Neurosurgeons and hospitalists are turning to comanagement arrangements to address medical problems in surgical patients. Compared with traditional medical consultation, comanagement lets the hospitalist share authority and responsibility for patient care. It is associated with improved provider satisfaction and more efficient care, but impact on clinical outcomes is uncertain. Shared responsibility for patient care requires careful planning to avoid conflicts and fragmentation of care.
Key points
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Comanagement is a rapidly growing care model that lets the hospitalist share the responsibility, authority, and accountability for the care of the surgical patient.
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Features of comanagement include advance negotiation of an agreement between hospitalists and surgeons, criteria for automatic hospitalist engagement, and broad scope of practice and for the hospitalist.
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Implementation of comanagement enhances provider satisfaction and the efficiency of care, but has not been shown to improve clinical outcomes.
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Potential pitfalls of comanagement include fragmented care and disengagement of the surgeon; careful planning prior to implementation of comanagement can reduce these risks.
Introduction
Surgeons have long depended on medical specialists (either general internists or subspecialists) to provide advice and assistance in caring for their patients. In this traditional consultation relationship, medical specialists have limited roles and responsibilities. They saw patients only at the surgeon’s request and focused on the narrow topic of the consultation question. They left recommendations for care but deferred to the surgeon to implement them. While traditional consultation still exists, a more collaborative comanagement model is gaining popularity.
Introduction
Surgeons have long depended on medical specialists (either general internists or subspecialists) to provide advice and assistance in caring for their patients. In this traditional consultation relationship, medical specialists have limited roles and responsibilities. They saw patients only at the surgeon’s request and focused on the narrow topic of the consultation question. They left recommendations for care but deferred to the surgeon to implement them. While traditional consultation still exists, a more collaborative comanagement model is gaining popularity.
Emergence of hospitalist comanagement
Growth of Comanagement
Comanagement is a negotiated relationship that lets the medical specialist share the responsibility, authority, and accountability for the care of the surgical patient. Although any medical specialty can comanage surgical patients, this role has largely fallen to hospitalists. Hospital medicine emerged in the 1990s and has become the fastest growing medical specialty. Because of their availability to care for inpatients, familiarity with the hospital’s operations, and capability of managing a broad range of medical problems, hospitalists are the natural providers of perioperative care. As a result, comanagement of surgical patients by hospitalists increased by over 11% per year between 2001 and 2006. Factors contributing to this growth include:
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Patients once deemed too old or medically complicated to undergo elective surgery are now routinely having operations. This requires more frequent and intensive involvement of physicians able to provide perioperative medical care.
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Competing responsibilities and financial incentives reduce the time surgeons can spend taking care of postoperative patients on the wards. In teaching hospitals, duty hour restrictions also limit resident availability.
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Surgeons are more willing to share responsibility for the management of their patients’ medical problems. A 2007 study found only a minority of surgeons believed that consultations should be limited to a specific question or that consultants should not write orders without prior discussion. A majority of surgeons desired a comanagement relationship.
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Medical centers have promoted hospitalist comanagement, hoping to improve efficiency and patient safety, as hospitalists have demonstrated in the care of medical patients.
Features of Comanagement
The specific features of a hospitalist comanagement service depend on the needs of the surgeons and resources available to the hospital medicine group. However, comanagement differs from consultation in several aspects ( Table 1 ).
| Traditional Consultation | Comanagement | |
|---|---|---|
| Relationship between surgeon and consultant | Informal, ad hoc | Formal, negotiated in advance |
| Patient selection | Only at surgeon’s request | Hospitalist sees all patients who meet predetermined clinical criteria |
| Consultant’s focus | Narrow consultation question chosen by surgeon | Comprehensive care of medical issues determined by surgeon or hospitalist |
| Consultant’s scope of practice | Leave recommendations | Write orders without prior approval in most circumstances |
| Discharge planning | Surgeon’s responsibility | Shared responsibility |
| Nonclinical roles | None | Surgeon and hospitalist may collaborate on quality improvement, research, and education projects |
Comanagement relationships are negotiated in advance
The surgeon and hospitalist must have a prior understanding of their respective roles and responsibilities. These are described in a comanagement agreement. This is particularly important for management issues that require shared responsibility, such as discharge planning.
Comanaging hospitalists can select which patients to see and what problems they will manage
The hospitalist can automatically see patients who meet predetermined clinical criteria, which were negotiated as part the comanagement agreement. These might include admitting diagnoses (eg, all patients with subarachnoid or subdural hemorrhage), medical comorbidities (eg, coronary artery disease or diabetes), or demographic features (eg, age over 70 years or admission to a critical care unit). Instead of depending on the surgeon to formulate a specific question, comanaging hospitalists have broad latitude to address most medical issues they identify.
Comanagement allows the hospitalist to write most orders without the surgeon’s approval
Exceptions to the hospitalist’s order writing privileges, such as initiation of anticoagulation, are delineated in the comanagement agreement.
Comanagement may include nonclinical collaboration
Although comanagement focuses on direct patient care, a successful relationship often evolves into a broader alliance between surgeons and hospitalists. Hospital medicine groups often play key roles in patient safety and hospital quality improvement endeavors. Surgeons who may have less experience or availability to address these concerns have collaborated with hospitalists to optimize their systems of care. Surgeons and hospitalists may also provide reciprocal education through conferences. In academic settings, comanagement relationships have also yielded joint research and publication.
Comanagement can occur whether a patient is under the care of the surgeon or hospitalist as the attending physician of record. In teaching hospitals, the surgeon typically remains the primary attending physician, with the hospitalist charting and billing as a consultant. In community hospitals, however, these roles are sometimes reversed. The hospitalist may have primary responsibility for the patient, and the surgeon’s role is limited to performing the operation and managing care directly related to the surgical diagnosis.
Comanagement experience for neurosurgical patients
A 2010 study found that comanagement by a generalist was most common among general and orthopedic surgery patients, among whom the incidence was 29% and 28% respectively. The incidence of comanagement among neurosurgical patients is unknown. Compared with orthopedic surgery in particular, there have been few published descriptions of comanagement services for these patients.
Description of a Hospitalist Comanagement with Neurosurgery Service
In 2007, the Department of Neurologic Surgery and the Department of Medicine’s Division of Hospital Medicine at the University of California, San Francisco (UCSF) collaborated to create the Comanagement with Neurosurgery Service (CNS). The service is staffed 365 days per year by faculty hospitalists, without the involvement of medicine trainees. In the first 18 months after implementation, CNS hospitalists provided care to 988 (29%) of the 3393 adult patients admitted to the neurologic surgery service.
Patient selection
In addition to seeing patients at the request of the neurosurgeons, the CNS hospitalist screens the chart of all patients within 24 hours of admission. Patients with any of the following conditions are automatically evaluated by the hospitalist: coronary artery disease, heart failure, chronic obstructive lung disease, chronic kidney disease, cirrhosis, dementia, diabetes requiring insulin, and treatment with anticoagulants. The hospitalist may also manage other patients without prior invitation based on their clinical judgment.
Scope of practice
The CNS hospitalist is generally responsible for their patients’ chronic or acute medical problems that are not directly related to the neurosurgical diagnosis. Some exceptions include hyponatremia, due to differences in management strategies between internal medicine and neurosurgery, and diabetes insipidis following transsphenoidal operations, which neurosurgical residents are trained to manage with the assistance of a neuroendocrinologist. Similarly, antiepileptic and glucocorticoid therapy remain the purview of the surgery team. The hospitalist writes orders directly and may consult other specialists without prior approval. Initiation of anticoagulant or antiplatelet therapy and invasive procedures require discussion with the surgical attending physician.
Care coordination
The CNS hospitalist routinely engages with ancillary staff, including rehabilitation therapists, clinical pharmacists, and case managers to provide advice and learn about their concerns. Completion of discharge materials remains the responsibility of the neurosurgical service, with input from the hospitalist as needed.
Other collaboration
Subsequent to the implementation of the CNS, neurosurgeons and hospitalists have conducted clinical research and published numerous manuscripts together. One hospitalist receives salary support from the Department of Neurosurgery to direct quality and safety efforts. In addition to having hospitalists participate in neurosurgery educational conferences, neurosurgery residents have rotated on the CNS to gain experience with perioperative medicine.
Related posts:
Quality Improvement in Neurosurgery
The Relationship Between National Health Care Policies and Quality Improvement in Neurosurgery
Quality Improvement Tools and Processes
Technology and Simulation to Improve Patient Safety
Electronic Medical Records and Quality Improvement
Recent Advances in the Patient Safety and Quality Initiatives Movement
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