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A New Era in Vascular Surgery Inpatient Care: Results of a Vascular Surgeon-Hospitalist Co-management Service
Rami O. Tadros, MD, Peter L. Faries, Rajesh Malik, Ageliki G. Vouyouka, Windsor Ting, Andrew Dunn, Michael L. Marin, Alan Briones.
The Icahn School of Medicine at Mount Sinai, New York, NY, USA.
OBJECTIVES:
Vascular surgery patients have increased medical co-morbidities that amplify the complexity of care. We aim to assess the impact of a hospitalist co-management service (HCS) on inpatient vascular surgery outcomes.
METHODS:
1059 patients were divided into two cohorts for comparison: 515 between January, 2012 and December, 2012 prior to the implementation of a HCS, and 544 between January, 2013 and October, 2013 after the initiation of a HCS. Nine vascular surgeons and ten hospitalists participated in the HCS. Endpoints measured were in-hospital mortality (IHM), length-of-stay (LOS), 30-day readmission rates (RAR), 0-10 visual analog scale pain scale scores, in-patient adult safety assessments using the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI), and resident perceptions assessed by survey.
RESULTS:
The IHM rate decreased from 1.75% to 0.37% after the implantation of the HCS, p=0.016, with a decrease in the observed: expected (O:E) ratio from 0.89 to 0.22. The risk adjusted IHM decreased from 1.56% to 0.0008%, p=0.003. Mean LOS was lower in the base period, 5.1days vs. 5.5 days, p<0.001, with an O:E ratio of 0.83 and 0.78, respectively. The risk adjusted LOS increased from 4.2 days to 4.3 days, p<0.001. The overall 30-day RAR was unchanged, 23.1% compared to 22.8%, p=0.6. The related 30-day RAR was also similar, 11.5% compared to 11.4%, p=0.5. Patients reporting no pain during hospitalization increased from 72.8% prior to the HCS to 77.8% after, p=0.04. Reports of moderate pain decreased from 14% to 9.6%, p=0.016. Mild and severe pain scores were similar between the two groups. Adult safety measured by AHRQ demonstrated a decrease in the number of deaths among surgical patients with treatable complications from 3 to 0 patients, p=0.04. Most house staff reported that the co-management program had a positive impact on patient care and education.
CONCLUSIONS:
The hospitalist co-management service has resulted in a significant decrease in in-hospital mortality rates, improved patient safety as measured by AHRQ, and lower pain scores. Resident surveys demonstrated perceived improvement in patient care and education. Continued observation will be necessary to assess the long-term impact of the HCS on quality metrics.
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