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Original Investigation | Health Care Reform

Comanagement of Hospitalized Surgical Patients by Medicine Physicians in the United States FREE

Gulshan Sharma, MD, MPH; Yong-Fang Kuo, PhD; Jean Freeman, PhD; Dong D. Zhang, PhD; James S. Goodwin, MD
[+] Author Affiliations

Author Affiliations: Department of Internal Medicine and Sealy Center of Aging, University of Texas Medical Branch, Galveston.


Arch Intern Med. 2010;170(4):363-368. doi:10.1001/archinternmed.2009.553.
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Published online

Background  Comanagement of surgical patients by medicine physicians (generalist physicians or internal medicine subspecialists) has been shown to improve efficiency and to reduce adverse outcomes. We examined the extent to which comanagement is used during hospitalizations for common surgical procedures in the United States.

Methods  We conducted a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for 1 of 15 inpatient surgical procedures from 1996 to 2006 (n = 694 806). We also calculated the proportion of Medicare beneficiaries comanaged by medicine physicians (generalist physicians or internal medicine subspecialists) during hospitalization. Comanagement was defined by relevant physicians (generalist or internal medicine subspecialist) submitting a claim for evaluation and management services on 70% or more of the days that the patients were hospitalized.

Results  Between 1996 and 2006, 35.2% of patients hospitalized for a common surgical procedure were comanaged by a medicine physician: 23.7% by a generalist physician and 14% by an internal medicine subspecialist (2.5% were comanaged by both). The percentage of patients experiencing comanagement was relatively unchanged from 1996 to 2000 and then increased sharply. The increase was entirely attributable to a surge in comanagement by generalist physicians. In a multivariable multilevel analysis, comanagement by generalist physicians increased 11.4% per year from 2001 to 2006. Patients with advanced age, with more comorbidities, or receiving care in nonteaching, midsize (200-499 beds), or for-profit hospitals were more likely to receive comanagement. All of the growth in comanagement was attributed to increased comanagement by hospitalist physicians.

Conclusions  Medical comanagement of Medicare beneficiaries hospitalized for a surgical procedure is increasing because of the increasing role of hospitalists. To meet this growing need for comanagement, training in internal medicine should include medical management of surgical patients.

Figures in this Article

Comanagement of surgical patients refers to patient care in which the medicine physician (generalist physician or internal medicine subspecialist) daily assesses acute issues, addresses medical comorbidities, communicates with surgeons, and facilitates patient care transition from the acute care hospital setting.1 The benefits of comanagement include increased prescribing of evidence-based treatments2; reduced time to surgery3; fewer transfers to an intensive care unit for acute medical deterioration4; fewer postoperative complications46; increased likelihood of discharge to home4; reduced length of stay7; improved nurse and surgeon satisfaction5; and a lower 6-month readmission rate.2

Using a 5% national Medicare sample, we examined the rate of comanagement of surgical patients by generalist physicians or internal medicine subspecialists in US hospitals from 1996 through 2006. We also examined how comanagement by medicine physicians varied by type of surgery as well as by patient and hospital characteristics.

The study cohort consisted of 694 806 hospital admissions in the 5% Medicare sample who underwent inpatient surgery between 1996 and 2006 and were discharged with a surgical diagnosis related group (DRG) code associated with at least 1 of the following procedures: cholecystectomy (DRG 493, 195, 196, 197, and 198); resection for colorectal cancer (DRG 148 and 149); abdominal aortic aneurysm repair (DRG 110); lower-extremity revascularization (DRG 553, 554, and 478); major leg amputation (DRG 113, 213, and 285); coronary artery bypass grafting surgery (DRG 105, 547, 548, 549, and 550); aortic/mitral valve replacement (DRG 104 and 105); lung resection for cancer (DRG 75); radical prostatectomy (DRG 334); transurethral resection of the prostate for benign prostatic hypertrophy (DRG 476 and 306); radical nephrectomy for renal cancer (DRG 303); back surgery (DRG 496, 497, 498, and 499); knee replacement (DRG 544); hip replacement (DRG 544); and repair of hip fracture (DRG 210, 211, and 544). The surgical DRGs selected were those used by the Dartmouth Atlas of Healthcare7 for benchmarking US hospitals and associated with a mean length of stay of more than 3 days.

We identified 2 types of comanagement: that by a generalist physician (ie, general internist, geriatrician, family practitioner, or general practitioner) and that by an internal medicine subspecialist. Comanagement was defined by the relevant physician (generalist or internal medicine subspecialist) submitting a claim for evaluation and management services on 70% or more of the days that the patient was hospitalized, including partial days (ie, admission and discharge days). Inpatient physician claims were identified using American Medical Association–Common Procedure Terminology–Evaluation and Management codes 99221 to 99223 (initial hospital visit), 99251 to 99255 (inpatient consultation), and 99231 to 99233 (subsequent hospital visit). We also analyzed the effect of various cut points for the minimum percentage of total hospital days for which a medicine physician provided care. In some analyses, we examined the comanagement of surgical patients by hospitalist physicians, as previously defined.8

The proportion of admissions comanaged by any medicine physician was calculated and then stratified by patient and hospital characteristics. Linear trend in the percentage of patients comanaged from 1996 to 2006 was tested using a likelihood ratio test. Two trends were identified: during 1996 to 2000 and during 2001 to 2006. Hierarchical generalized linear models with a logistic link, after adjustment for clustering of admissions (level 1) within hospitals (level 2), were constructed to evaluate comanagement during 2001 to 2006 with any medicine physician or generalist physician. Analyses were performed with SAS version 9.1 (SAS Institute Inc, Cary, North Carolina); GLIMMIX (SAS Institute Inc) was used to conduct multilevel analyses.

Between 1996 and 2006, 35.2% of patients hospitalized for a common surgical procedure were comanaged by medicine physicians: 23.7% by a generalist physician and 14% by an internal medicine subspecialist (2.5% were comanaged by both). Comanagement by any medicine physician for patients hospitalized for a surgical procedure increased from 33.3% in 1996 to 40.8% in 2006 (P < .001). A likelihood ratio test showed 2 distinct time trends (P < .001). The percentage of surgical patients receiving comanagement changed little during the late 1990s and then increased in 2001 (Figure 1). The increase in comanagement was limited to comanagement by generalist physicians. Comanagement by generalist physicians increased from 20.5% in 1996 to 31.3% in 2006 (P < .001). This increase was entirely attributable to an increase in comanagement by generalist physicians who were hospitalists. Comanagement by hospitalists increased from 1.7% of patients in 1996 to 12.5% in 2006.

Place holder to copy figure label and caption
Figure 1.

Trends in comanagement of patients hospitalized for a surgical procedure between 1996 and 2006 by a generalist physician, internal medicine subspecialist, or any medicine physician. A patient is defined as having comanagement if any medicine physician submitted evaluation and management claims for at least 70% of the days during the patient's hospital stay for a surgical procedure. A medicine physician is defined as either a generalist physician or an internal medicine subspecialist; a generalist physician is defined as an internal medicine physician, a geriatrician, a family practitioner, or a general practitioner; and an internal medicine subspecialist includes pulmonary, cardiology, gastroenterology, endocrinology, rheumatology, nephrology, infectious disease, and hematology/oncology specialties. For all point estimates, the 95% confidence intervals are less than 0.5% and are not shown.

Graphic Jump Location

The percentage of patients comanaged by a medicine physician varied by type of surgery (Figure 2). For example, comanagement by a medicine physician increased from 28.6% in 1996 to 41.7% in 2006 (P < .001) for patients hospitalized for orthopedic surgery but actually decreased from 43.0% in 1996 to 39.9% in 2006 (P < .001) for patients hospitalized for cardiothoracic surgery.

Place holder to copy figure label and caption
Figure 2.

Trends in medical comanagement by type of surgery for patients hospitalized for a surgical procedure between 1996 and 2006. Orthopedic surgery includes back surgery (diagnosis related group [DRG] codes 496, 497, 498, 499), knee replacement (DRG 544), hip replacement (DRG 544), and repair for hip fracture (DRG 210, 211, and 544); vascular surgery includes abdominal aortic aneurysm repair (DRG 110), lower-extremity revascularization (DRG 553, 554, and 478), and major leg amputation (DRG 113, 213, and 285); cardiothoracic surgery includes coronary artery bypass grafting (DRG 105, 547, 548, 549, and 550), aortic/mitral valve replacement (DRG 104 and 105), and lung resection for cancer (DRG 75); general surgery includes cholecystectomy (DRG 493, 195, 196, 197, and 198) and resection for colorectal cancer (DRG 148 and 149); and urologic surgery includes radical prostatectomy (DRG 334), transurethral resection of the prostrate for benign prostatic hypertrophy (DRG 476 and 306), and radical nephrectomy for renal cancer (DRG 303).

Graphic Jump Location

Table 1 shows how comanagement varied by patient and hospital characteristics. Older adults, women, persons with low socioeconomic status, and those with more comorbidities were more likely to receive comanagement. Most comanaged patients were seen by a generalist physician, except for those undergoing cardiothoracic surgery, who were more likely to be comanaged by internal medicine subspecialists (almost entirely cardiologists or pulmonologists). Surgical patients cared for in nonteaching, midsize, and for-profit hospitals were more likely to receive medical comanagement.

Table Graphic Jump LocationTable 1. Percentage of Surgical Patients Comanaged by Any Medicine Physiciana or a Generalist Physicianb Stratified by Selected Patient and Hospital Characteristics,c 1996-2006

After other variables were adjusted for, comanagement by a generalist physician increased at 11.4% per year and overall comanagement by any medicine physician increased 7.8% per year during 2001 to 2006 (Table 2). Advanced age, emergency admissions, and increasing comorbidities were all strong predictors of comanagement. Patients cared for in major teaching hospitals were substantially less likely to receive comanagement. Comanagement varied widely by region, with patients in New England much less likely than others to be comanaged.

Table Graphic Jump LocationTable 2. Multilevel Analyses of Odds of Comanagement With a Generalist Physiciana and With Any Medicine Physicianb for a Patient Hospitalized for a Surgical Procedure Between 2001 and 2006

In these analyses, we defined comanagement as participation of a medicine physician on 70% or more of total hospital days. Using different cut points (eg, ≥50% or ≥80% of hospital days) changed the estimates of the percentage of patients receiving comanagement. However, the pattern of increase in comanagement over time and the association of comanagement with patient and hospital characteristics did not change appreciably by cut point.

We found a rapid rise in the percentage of hospitalized surgical patients who were comanaged by a medicine physician. The increase, begun in 2001, was caused by more comanagement by generalist physicians who are hospitalists. The percentage of patients who were comanaged by internal medicine subspecialists or nonhospitalist generalist physicians was essentially unchanged from 1996 through 2006. Orthopedic surgery patients experienced the fastest growth in medical comanagement as well as the greatest overall use of comanagement by generalist physicians. Almost all studies of comanagement are in orthopedic patients.26,9 Indeed, the rapid growth in medical comanagement coincided with the first randomized controlled trials published in 2001, showing benefits of comanagement in orthopedic patients.9 Clearly, prospective trials of medical comanagement are needed in other surgical disciplines.

The growth in care of surgical patients by medicine physicians raises the issue of appropriate training. A cross-sectional survey of generalist physicians who devoted 25% or more time to inpatient care revealed that perioperative management was underemphasized during their training.10 The American Council of Graduate Medical Education currently does not list competencies in perioperative management as a core requirement for internal medicine training.11 The growth in comanagement by medicine physicians in our study was attributed to increased care by hospitalist physicians. Hospitalists are well suited to respond quickly to changes in postoperative patients. A recent survey found that 91% of hospitalists have cared for surgical patients.12 The Society of Hospital Medicine recognizes perioperative management as a key skill for hospitalists and lists competencies in perioperative medicine as core requirements.13

Older adults and persons with comorbidities are more likely to receive comanagement. These patients are at higher risk for complications of surgery and will more likely benefit from comanagement. In a recent study of Medicare beneficiaries, of patients rehospitalized within 30 days of a surgical discharge, 70.5% were rehospitalized for a medical condition.14 Closer attention to medical comorbidities during the initial hospitalization might be expected to reduce this rate. The increase in comanagement of surgical patients by hospitalists has implications for the number of hospitalists that are needed. If we assume that 100% of Medicare patients who are hospitalized for surgical procedures are to be followed up by hospitalists, and taking into account the current workload of hospitalists, an additional 2500 to 3000 full-time equivalent hospitalists would be required.15

Our study has several limitations. First, we examined comanagement only in a fee-for-service Medicare population, and our findings may not be generalizable to non-Medicare patients. We studied 15 common inpatient surgical procedures that were performed in this population, and the results may not apply to other types of surgical procedures. These 15 procedures represent 39.1% of all operations performed in this population. Our definition of comanagement—evaluation and management claims submitted on at least 70% of all hospital days by a medicine physician—is arbitrary. Using different cut points changed the proportion of patients comanaged but not the increasing trend. A further limitation is that we did not assess processes or outcomes of care and therefore cannot comment on any benefits of comanagement.

In summary, comanagement of surgical patients by medicine physicians is increasing. To meet this need, training in internal medicine should include medical management of surgical patients. Further prospective trials of comanagement in surgical patients in specialties other than orthopedic surgery are clearly needed.

Correspondence: Gulshan Sharma, MD, MPH, Department of Internal Medicine, 301 University Blvd, JSA-5.112, University of Texas Medical Branch, Galveston, TX 77555-0561 (gulshan.sharma@utmb.edu).

Accepted for Publication: November 15, 2009.

Author Contributions:Study concept and design: Sharma, Kuo, Freeman, and Goodwin. Acquisition of data: Kuo, Freeman, Zhang, and Goodwin. Analysis and interpretation of data: Sharma, Kuo, Zhang, and Goodwin. Drafting of the manuscript: Sharma, Kuo, Freeman, and Goodwin. Critical revision of the manuscript for important intellectual content: Sharma, Kuo, Freeman, Zhang, and Goodwin. Statistical analysis: Sharma, Kuo, and Zhang. Obtained funding: Goodwin. Administrative, technical, and material support: Sharma, Kuo, Zhang, and Goodwin. Study supervision: Sharma, Kuo, Freeman, and Goodwin.

Financial Disclosure: None reported.

Funding/Support: This work was supported by grants R01 AG 033134, K05 CA 134923, K08 AG 031583, and P30 AG 024832 from the National Institutes of Health.

Additional Contributions: Sarah Toombs Smith, PhD, helped in the preparation of the manuscript.

Whinney  CMichota  F Surgical comanagement: a natural evolution of hospitalist practice. J Hosp Med 2008;3 (5) 394- 397
PubMed Link to Article
Fisher  AADavis  MWRubenach  SESivakumaran  SSmith  PNBudge  MM Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare. J Orthop Trauma 2006;20 (3) 172- 180
PubMed Link to Article
Phy  MPVanness  DJMelton  LJ  III  et al.  Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med 2005;165 (7) 796- 801
PubMed Link to Article
Zuckerman  JDSakales  SRFabian  DRFrankel  VH Hip fractures in geriatric patients. Results of an interdisciplinary hospital care program. Clin Orthop Relat Res 1992; (274) 213- 225
PubMed
Huddleston  JMLong  KHNaessens  JM  et al. Hospitalist-Orthopedic Team Trial Investigators, Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med 2004;141 (1) 28- 38
PubMed Link to Article
Friedman  SMMendelson  DABingham  KWKates  SL Impact of a comanaged Geriatric Fracture Center on short-term hip fracture outcomes. Arch Intern Med 2009;169 (18) 1712- 1717
PubMed Link to Article
 The Dartmouth Atlas of Healthcare: ICD-9 procedure codes for inpatient surgery. www.dartmouthatlas.org/faq/SxICD9codes.pdf. Accessed March 1, 2009
Kuo  YFSharma  GFreeman  JLGoodwin  JS Growth in the care of older patients by hospitalists in the United States. N Engl J Med 2009;360 (11) 1102- 1112
PubMed Link to Article
Marcantonio  ERFlacker  JMWright  RJResnick  NM Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 2001;49 (5) 516- 522
PubMed Link to Article
Plauth  WH  IIIPantilat  SZWachter  RMFenton  CL Hospitalists' perceptions of their residency training needs: results of a national survey. Am J Med 2001;111 (3) 247- 254
PubMed Link to Article
 ACGME program requirements for graduate medical education in internal medicine. http://www.acgme.org/acWebsite/downloads/RRC_progReq/140_internal_medicine_07012009.pdf. Accessed July 10, 2009
Vasilevskis  EKnebel  JWachter  RAuerbach  A The Rise of the Hospitalists in California.  Oakland California Healthcare Foundation2007;
Society of Hospital Medicine, The core competencies in hospital medicine: a framework for curriculum development by the Society of Hospital Medicine. J Hosp Med 2006;1 ((suppl 1)) 2- 95
PubMed Link to Article
Jencks  SFWilliams  MVColeman  EA Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009;360 (14) 1418- 1428
PubMed Link to Article
 2007-2008 Bi-annual survey. Society of Hospital Medicine Web site. http://www.hospitalmedicine.org/AM/Template.cfm?Section=Survey&Template=/CM/HTMLDisplay.cfm&ContentID=18412. Accessed June 1, 2009

Figures

Place holder to copy figure label and caption
Figure 1.

Trends in comanagement of patients hospitalized for a surgical procedure between 1996 and 2006 by a generalist physician, internal medicine subspecialist, or any medicine physician. A patient is defined as having comanagement if any medicine physician submitted evaluation and management claims for at least 70% of the days during the patient's hospital stay for a surgical procedure. A medicine physician is defined as either a generalist physician or an internal medicine subspecialist; a generalist physician is defined as an internal medicine physician, a geriatrician, a family practitioner, or a general practitioner; and an internal medicine subspecialist includes pulmonary, cardiology, gastroenterology, endocrinology, rheumatology, nephrology, infectious disease, and hematology/oncology specialties. For all point estimates, the 95% confidence intervals are less than 0.5% and are not shown.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Trends in medical comanagement by type of surgery for patients hospitalized for a surgical procedure between 1996 and 2006. Orthopedic surgery includes back surgery (diagnosis related group [DRG] codes 496, 497, 498, 499), knee replacement (DRG 544), hip replacement (DRG 544), and repair for hip fracture (DRG 210, 211, and 544); vascular surgery includes abdominal aortic aneurysm repair (DRG 110), lower-extremity revascularization (DRG 553, 554, and 478), and major leg amputation (DRG 113, 213, and 285); cardiothoracic surgery includes coronary artery bypass grafting (DRG 105, 547, 548, 549, and 550), aortic/mitral valve replacement (DRG 104 and 105), and lung resection for cancer (DRG 75); general surgery includes cholecystectomy (DRG 493, 195, 196, 197, and 198) and resection for colorectal cancer (DRG 148 and 149); and urologic surgery includes radical prostatectomy (DRG 334), transurethral resection of the prostrate for benign prostatic hypertrophy (DRG 476 and 306), and radical nephrectomy for renal cancer (DRG 303).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Percentage of Surgical Patients Comanaged by Any Medicine Physiciana or a Generalist Physicianb Stratified by Selected Patient and Hospital Characteristics,c 1996-2006
Table Graphic Jump LocationTable 2. Multilevel Analyses of Odds of Comanagement With a Generalist Physiciana and With Any Medicine Physicianb for a Patient Hospitalized for a Surgical Procedure Between 2001 and 2006

References

Whinney  CMichota  F Surgical comanagement: a natural evolution of hospitalist practice. J Hosp Med 2008;3 (5) 394- 397
PubMed Link to Article
Fisher  AADavis  MWRubenach  SESivakumaran  SSmith  PNBudge  MM Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare. J Orthop Trauma 2006;20 (3) 172- 180
PubMed Link to Article
Phy  MPVanness  DJMelton  LJ  III  et al.  Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med 2005;165 (7) 796- 801
PubMed Link to Article
Zuckerman  JDSakales  SRFabian  DRFrankel  VH Hip fractures in geriatric patients. Results of an interdisciplinary hospital care program. Clin Orthop Relat Res 1992; (274) 213- 225
PubMed
Huddleston  JMLong  KHNaessens  JM  et al. Hospitalist-Orthopedic Team Trial Investigators, Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med 2004;141 (1) 28- 38
PubMed Link to Article
Friedman  SMMendelson  DABingham  KWKates  SL Impact of a comanaged Geriatric Fracture Center on short-term hip fracture outcomes. Arch Intern Med 2009;169 (18) 1712- 1717
PubMed Link to Article
 The Dartmouth Atlas of Healthcare: ICD-9 procedure codes for inpatient surgery. www.dartmouthatlas.org/faq/SxICD9codes.pdf. Accessed March 1, 2009
Kuo  YFSharma  GFreeman  JLGoodwin  JS Growth in the care of older patients by hospitalists in the United States. N Engl J Med 2009;360 (11) 1102- 1112
PubMed Link to Article
Marcantonio  ERFlacker  JMWright  RJResnick  NM Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 2001;49 (5) 516- 522
PubMed Link to Article
Plauth  WH  IIIPantilat  SZWachter  RMFenton  CL Hospitalists' perceptions of their residency training needs: results of a national survey. Am J Med 2001;111 (3) 247- 254
PubMed Link to Article
 ACGME program requirements for graduate medical education in internal medicine. http://www.acgme.org/acWebsite/downloads/RRC_progReq/140_internal_medicine_07012009.pdf. Accessed July 10, 2009
Vasilevskis  EKnebel  JWachter  RAuerbach  A The Rise of the Hospitalists in California.  Oakland California Healthcare Foundation2007;
Society of Hospital Medicine, The core competencies in hospital medicine: a framework for curriculum development by the Society of Hospital Medicine. J Hosp Med 2006;1 ((suppl 1)) 2- 95
PubMed Link to Article
Jencks  SFWilliams  MVColeman  EA Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009;360 (14) 1418- 1428
PubMed Link to Article
 2007-2008 Bi-annual survey. Society of Hospital Medicine Web site. http://www.hospitalmedicine.org/AM/Template.cfm?Section=Survey&Template=/CM/HTMLDisplay.cfm&ContentID=18412. Accessed June 1, 2009

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