Medical and Surgical Comanagement after Elective Hip and Knee Arthroplasty

A Randomized, Controlled Trial

6 July 2004 | Volume 141 Issue 1 | Pages 28-38

Background: Hospitalists are assuming an increasing role in the care of surgical patients, but the impact of this model of care on postoperative outcomes is unknown.

Objective: To determine the impact of providing a collaborative, hospitalist-led model of care on postoperative outcomes and costs among patients having hip or knee arthroplasty.

Design: Randomized, controlled trial.

Setting: Academic medical center.

Participants: 526 patients having elective orthopedic surgery who are at elevated risk for postoperative morbidity.

Measurements: Length of stay, inpatient postoperative medical complications, health care provider satisfaction, and inpatient costs.

Interventions: A comanagement medical Hospitalist–Orthopedic Team compared with standard postoperative care by orthopedic surgeons with medical consultation.

Results: More patients in the hospitalist group were discharged from the hospital with no complications (61.6% vs. 49.8%; difference, 11.8 percentage points [95% CI, 2.8 to 20.7 percentage points]). Fewer minor complications were observed among hospitalist patients (30.2% vs. 44.3%; difference, –14.1 percentage points [CI, –22.7 to –5.3 percentage points]). Observed length of stay was not statistically different between treatment groups. However, when adjusted for discharge delays, mean length of stay for patients in the hospitalist model of care was shorter (5.1 days vs. 5.6 days; difference, –0.5 day [CI, –0.8 to –0.1 day]). Total costs did not differ between groups. Orthopedic surgeons and nurses preferred the hospitalist model.

Limitations: Care providers and patients were aware of intervention assignments, and the study could not capture all costs associated with the hospitalist model.

Conclusions: The comanagement medical Hospitalist–Orthopedic Team model reduced minor postoperative complication rates with no statistically significant difference in length of stay or cost. The nurses and surgeons strongly preferred the comanagement hospitalist model. Additional research on the clinical and economic impact of the hospitalist model in other surgical populations is warranted.

Editors' Notes Context No large studies evaluate potential benefits and costs of internists and surgeons comanaging postoperative patients. Contribution In this single-center trial, high-risk patients undergoing elective hip or total knee arthroplasty were randomly assigned to either standard surgical care or comanagement care by a team of general internal medicine faculty and orthopedic physicians and nurses. Compared with standard care, comanagement care reduced the number of postoperative complications but did not affect overall length of stay or costs. Clinicians strongly preferred comanagement care. Cautions Costs of comanagement were not captured fully because physician–patient interaction time was not tracked. –The Editors

 

Author and Article Information

From Mayo Clinic College of Medicine, Rochester, Minnesota, and the University of California, San Francisco, San Francisco, California.

Acknowledgments: The authors thank Donna Lawson, LPN, and Danica Myhre, BS, for data collection, data entry, and project management; Marlené Boyd for administrative assistance; the Department of Medicine leadership, Kevin Whitford, MD, and other Inpatient Internal Medicine faculty and the Department of Orthopedic Surgery for their strong support, participation, and collaboration; the orthopedic surgical nurses at Rochester Methodist Hospital for their willingness to become crucial members of the Hospitalist–Orthopedic Team model of perioperative care; and Amy J. Markowitz for her editorial review.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Jeanne M. Huddleston, MD, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905; e-mail, huddleston.jeanne{at}mayo.edu.

Current Author Addresses: Drs. Huddleston, Long, Trousdale, Cabanela, and Naessens, Mr. Larson, Mr. Plevak, and Mr. Ilstrup: Mayo Clinic, 200 First Street SW, Rochester, MN 55905.

Dr. Vanness: University of Wisconsin-Madison, 785 WARF Building, 610 Walnut Street, Madison, WI 53726.

Dr. Wachter: University of California, San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143.

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