Friday, December 24, 2010

Hospitalist comanagement of neurosurgical patients: loved by all and value neutral

One of my ortho colleagues gently taunts: “You're supposed to be the smart doctor. I'm just a dumb bone cruncher.” But I'm just as dumb about all that bone crunching surgical stuff as he claims to be about internal medicine. And so betwixt us both the bases get covered. Or so we hope.

Even in the days of old one of my close surgical colleagues and I were doing comanagement, long before anyone coined the term.  We didn't have cardiologists in those days, so I selected patients for pacemaker implantation and he performed the implants.  He would say "You take care of the tachyarrhythmias, I'll take care of the bradyarrhythmias."

Those are not very good definitions of hospitalist comanagement but it's about as precise as it gets. Which is why it's very difficult to draw conclusions from research evidence.

A recent issue of the Archives of Internal Medicine has published findings from the comanagement experience on the neurosurgical service at UCSF:

Results  During the study period, 7596 patients were admitted to the neurosurgery service: 4203 (55.3%) before July 1, 2007, and 3393 (44.7%) after comanagement began. Of those admitted during the postimplementation period, 988 (29.1%) were comanaged. After implementation of comanagement, no differences were found in patient mortality rate, readmission, or length of stay. No consistent improvements were seen in patient satisfaction, but strong perceived improvements occurred in care quality reported by nurses and nonnurse health care professionals. In addition, we observed a reduction in hospital costs of $1439 per admission.

But the more I dig into the body of the paper the more confusing it gets. There were lower costs in the post-comanagement as opposed to the pre-comanagement period (of only borderline statistical significance) but when comanaged patients were compared directly with non-comanaged patients (raw data not displayed in the paper) the comanaged patients had higher costs. To confuse things further, the authors say these were adjusted outcomes but in the same sentence imply that the difference was due to lower complexity in the non-comanaged patients. (OK, I'm very tired after a difficult few days of comanaging patients myself, so I may have missed something here).

And what about value? According to Skeptical Scalpel, quoting from an interview of one of the authors, the reimbursement to the comanagement service by the hospital was substantial.

Bob Wachter, one of the authors of the paper, gives an insider's view of the comanagement effort here.

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