Hospitalist-Comanagement in Orthopedic Surgery in Spain: Experience of an Academic Medical Center

Background:

Hospitalist-comanagement model in surgical patients has demonstrated good results in terms of length of hospital stay, readmissions, quality of care and costs in the American Medical System. However, results from international cohorts are very limited. The objective of our study is to assess the impact of hospitalist-comanagement with orthopedic surgeons for patients who underwent knee and hip arthroplasty in a single academic medical center from Spain.

Methods:

A retrospective observational case-control study was performed. The case group was constituted by patients over 65 year-old who underwent hip or knee surgery in the period of 2011-2013 with hospitalist co-management. This cohort was compared to a historical group of patients with knee and hip arthroplasty in 2009, in the same medical center, without hospitalist care. The impact of the hospitalist-comanagement was assessed in terms of length of hospital stay, general complications (infection, hematoma/seroma, delirium), differences in APR-DRG and detection of new cardiovascular risk factors. In the hospitalist group, new diagnosis of hypertension was considered when systolic blood pressure over 140 mmHg or diastolic blood pressure over 90 mmHg was detected in 3 different days. New diabetes mellitus was diagnosed when fasting glucose over 126 mg/dL was detected twice. 

Results:

The case cohort was constituted by 102 patients. The mean age of the cohort was 75 years, with 50 % male and 52 % with hip arthroplasty. Principal comorbidities in this group where hypertension (76 %), obesity (39 %) and diabetes mellitus (17 %). Forty-four percent of this patients were ASA II and 51 % ASA III. Mean APR-DRG was 1.91 ± 0.20. Median length of hospital stay was 7 (IQR 6-9). Postoperative complications were found in 28 % of patients.

Fifty patients constituted the control group. The mean age of the cohort was 77 years, with 58 % male and 50 % with hip arthroplasty. Principal comorbidities in this group where hypertension (54 %), obesity (26 %) and diabetes mellitus (16 %). Sixty percent of this patients were ASA II and 34 % ASA III. Mean APR-DRG was 1.73 ± 0.10. Median length of stay was 7 (IQR 7-8). Postoperative complications were found in 24% of patients.

A higher complexity of patients according to APR-DRG (p < 0.01) and a trend to a higher anesthetic risk according to ASA (p = 0.08) was found in the hospitalist group, while there were no differences between case and controls in length of hospital stay and global complication rate. Moreover, 24 % (7/29) of patients were newly diagnosed of hypertension and 6 % (5/84) of type 2-diabetes mellitus in the hospitalist cohort. There were no thromboembolic complications in both groups.

Conclusions:

Hospitalist-comanagement in orthopedic surgery in Spain, could offer perioperative care to more complex patients without differences in length of hospital stay or complications. This model could also provide a better postoperative control due to new cardiovascular risk factor detection.