Team Care by Hospitalists with Surgeons after Hip or Knee Surgery

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The summary below is from the full report titled "Medical and Surgical Comanagement after Elective Hip and Knee Arthroplasty. A Randomized, Controlled Trial." It is in the 6 July 2004 issue of Annals of Internal Medicine (volume 141, pages 28-38). The authors are J.M. Huddleston, K. Hall Long, J.M. Naessens, D. Vanness, D. Larson, R. Trousdale, M. Plevak, M. Cabanela, D. Ilstrup, and R.M. Wachter, for the Hospitalist–Orthopedic Team Trial Investigators.

What is the problem and what is known about it so far?

Hospitalists are doctors (usually trained in internal medicine) who specialize in providing medical care to hospital patients. Recently, they have started partnering with surgeons to provide care for patients who have had surgery. This approach differs from standard postoperative care, in which a surgeon manages the patient's care after the operation. No studies have assessed the benefits or costs of team care by internists with surgeons.

Why did the researchers do this particular study?

To determine whether team care by hospitalists with surgeons improves outcomes and decreases costs in older patients having hip or knee surgery.

Who was studied?

516 patients at a single hospital, each of whom who had elective joint surgery on the hip or knee. All patients were older than 75 years of age and had at least 1 medical illness, such as diabetes or heart failure.

How was the study done?

Patients were randomly assigned to either standard care (surgeons alone) or team care (surgeons together with hospitalists). Doctors training to be bone surgeons (orthopedic residents) managed patients receiving standard care. Orthopedic faculty supervised those residents. Faculty hospitalists with board certification in internal medicine managed patients receiving team care. The hospitalists communicated regularly with the orthopedic residents. The same nurses and physical therapists cared for both groups of patients. Residents and hospitalists could consult doctors with special expertise (subspecialists) if specific complications arose. Research nurses reviewed medical records and laboratory data to assess problems that occurred after surgery. The researchers then compared numbers and types of problems and length of hospital stay between the 2 groups. They also used administrative data to estimate costs of care for the 2 groups.

What did the researchers find?

About 10% of the patients in both groups had a surgical complication, such as a wound infection or blood in the joint. About 1% in both groups had a major medical complication, such as a heart attack or kidney failure. About 30% of the patients receiving team care and 44% of the patients receiving standard care had minor medical complications, such as fever, urinary tract infection, or abnormal blood mineral (electrolyte) test results. In addition, almost 62% of the patients receiving team care and 50% of those receiving standard care left the hospital with no complications. Patients in both groups usually went home within 5 to 6 days after surgery and had similar costs of care. Nurses and surgeons preferred team care, whereas patients in both groups were equally satisfied with care.

What were the limitations of the study?

Participants were older patients with medical problems who had elective hip or knee surgery at a single hospital. Surgeons were orthopedic residents supervised by orthopedic faculty, and hospitalists were all academic faculty. Results may not apply to younger lower-risk patients, other surgeries, other hospitals, or other doctors. The doctors providing the care knew that they were participating in the study, which may have affected how they treated the patients. Some costs, such as those for the amount of time the doctor spent with the patient, were not measured.

What are the implications of the study?

In a single academic hospital, team care by hospitalists with orthopedic surgeons reduced minor medical complications in older patients having elective hip or knee surgery but did not affect major complications, length of stay, or costs.