The Impact of Medical Comanagement on Quality Care Metrics in Patients Undergoing InpatientLower Extremity Revascularization/Limb Salvage Procedures
John Denesopolis, M.D., John Phair, M.D., John Futchko, M.D., Eric Trestman, M.D., Matthew D. Shaines, M.D., Peter Shamamian, M.D., David P. Slovut, M.D., Evan C. Lipsitz, M.D., Jeffrey Indes, M.D..
Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA.
Objective: Patients with peripheral artery disease (PAD) and diabetes mellitus (DM) have many complex medical comorbidities that may affect their care. The goal of this study was to assess the effects of medical co-management by a hospitalist physician with adherence to AHA/ACCF guidelines in patients with PAD who underwent in-patient revascularization/limb salvage procedures when compared to a control group of these patients managed solely by vascular surgeons.
Methods: Using our institutionally maintained database, two cohorts were compared to evaluate the effects of quality of care metrics. We divided 637 patients into two cohorts for comparison: 326 between October 2012 and December 31 2013, before implementation of the hospitalist comanagement service, and 311 between January 2014 and December 31 2014, after implementation of the hospitalist comanagement service. The primary outcome investigated was compliance with the AHA/ACCF guidelines. Secondary outcomes included, mortality, readmissions, re-interventions, length of stay, and glycemic control.
Results: Adherence to AHA/ACCF guidelines for antiplatelet, statin, and ACE/ARB therapy at discharge was improved with implementation of comanagement (26.07% vs 27.01% p<0.05) with an improved absolute increase in adherence in the patients in the comanagement group (8.68% vs 5.83%). Length of stay was 6 days for the pre-comanagement group and 7 days for the comanagement group (p=0.269). Readmission rates at 30 days and 3 days were lower for the comanagement group (33.8% vs 39.9% p=0.1189 and 7.4% vs 13.5% p=<0.05). Reintervention rate was comparable with the implementation of comanagement (54% vs 56% p=0.577). Overall mortality and 30-day mortality were significantly improved with the implementation of comanagement (7%vs13% p=0.0157 and 19%vs29% p=0.074). There was no significant difference in hyperglycemic control as seen by comparing hemoglobin A1C after discharge between the two groups (7.9% vs 7.6% p=0.389).
Conclusion: We found that PAD patients undergoing inpatient revascularization/limb salvage procedures had an improvement in adherence to AHA/ACCF guidelines when they were medically co-managed by a hospitalist physician. Although they had similar outcomes with respect to re-intervention rates and glycemic control, these patients had significantly lower readmission rates and mortality when they were medically co-managed. Therefore, it may be paramount that institutions consider the implementation
of medical comanagement to improve the outcomes for patients undergoing in-patient revascularization/limb salvage procedures.
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