Background: Two-thirds of surgical inpatients have at least 2 medical comorbidities, and 14% have six or more. Since 2001, there has been exponential growth of comanagement services, in which hospitalists embedded on surgical services take ownership over medical management. While advanced practice providers (APPs) increasingly manage surgical inpatients, successful comanagement models between hospitalists and APPs on surgical services have not been described.
Methods: Our novel comanagement model embeds a hospitalist within an APP-driven academic neurosurgical service. The hospitalist works 8am-5pm, Monday to Friday with the APPs with a daily rounding list of up to 12-15 patients (up to 40% of total service census). Primary process outcomes we sought to influence with the model were reduction in volume of subspecialty consultation (assessed pre-post) and improved neurosurgical multidisciplinary team member satisfaction (assessed by survey). We also compared patient-level outcomes using Chi-square tests between comanaged and non-comanaged patients using observed to expected hospital length of stay and mortality. Expected rates were calculated by Vizient and account for differences in the two groups.
Results: During the study period (July 1, 2019 to June 30, 2020) 492 patients (24% of the total 2047 inpatient neurosurgery patients) were seen by the hospitalists with an average daily census of 13.6 (36.3% of the total daily neurosurgical census). Of note there were substantially reduced volumes April through June due to deployment of comanagement hospitalists to emergency COVID staffing roles. Despite a higher case-mix index and longer length of stay in comanaged patients reflecting the fact that hospitalists were seeing sicker patients, observed length of stay (mean: 12.9 days) was still nearly a full day shorter than expected in comanaged patients (mean: 13.8 days) and observed to expected mortality was significantly lower in comanaged versus non-comanaged patients (0.43 vs. 0.63, p=<0.01). In addition, we observed a 46% reduction in additional medical subspecialty consultation primarily to cardiology, endocrinology, infectious disease and nephrology in available data from July 2019 to January 2020. After one year, all 63 neurosurgery nurses surveyed (100% response rate) agreed with the statement “The presence of a hospitalist improves care for neurosurgery patients.” All 31 APPs, residents, and faculty surveyed (100% response rate) agreed with the statement “Sick or clinically deteriorating patients receive adequate assessment and attention with regard to their medical problems.”
Conclusions: A neurosurgical advanced practice provider/hospitalist collaborative care comanagement model in an academic medical center has potential to improve patient care while having strong positive impacts on team dynamics and provider satisfaction across multiple disciplines.