Surgical comanagement

INTRODUCTION — Comanagement is a model that allows the generalist, frequently a hospitalist, to share the responsibility, authority, and accountability for the inpatient medical care of surgical patients.

This topic will provide an overview of the principles and evidence regarding surgical comanagement. The principles of traditional medical consultation are discussed elsewhere. (See "Overview of the principles of medical consultation and perioperative medicine".)

EXPANSION OF THE COMANAGEMENT MODEL — The popularity of comanagement has expanded in parallel with the hospitalist movement. Between 2001 and 2006, the comanagement of surgical patients by hospitalists increased by over 11 percent per year [1]. The rising prevalence of surgical comanagement is due to several factors, including an increasing number of patients with advanced age or serious medical disease undergoing surgery [2,3]. In a cohort of patients undergoing total hip replacement or colectomy between 2007 and 2010, half of the patients were followed by a general medicine consultant [4]. A cross-sectional analysis of 11 United States academic medical centers found that requests for surgical comanagement by orthopedic and neurosurgery departments comprised the most common reasons for general medicine consultations [5].

GENERAL PRINCIPLES — Medical comanagement of surgical patients can take a variety of forms. Often, the surgeon remains the attending of record, while the comanaging physician is given wide latitude to manage the nonsurgical aspects of perioperative care. Alternatively, the surgical patient is admitted to the comanaging physician, who assumes primary responsibility for care but with the surgeon primarily responsible for managing perioperative surgical issues including surgical complications. Regardless of the specific arrangement, comanagement has features that distinguish it from traditional medical consultation (table 1).

Negotiated relationship — In traditional medical consultation, the role of the consultant is either defined at the time the consultation is requested or based upon presumed mutual understanding [6]. Comanagement relationships are far more formal [7]. Protocols and expectations are negotiated between the primary and comanaging physician and often delineated in a written comanagement agreement prior to initiating patient care. More complex comanagement agreements may be multidisciplinary, involving nursing, physical therapy, social work, and/or occupational therapy team members. Other potential partners, such as hospital administrators, may be factored into the agreements as well.

Selection of patients and reasons for referral — With traditional consultation, the surgeon retains sole authority and responsibility for identifying patients who would benefit from consultant evaluation. The surgeon also determines the latitude of the consultant's involvement. Consultation etiquette constrains the ability of the consultant to address issues beyond those specified by the referring provider [6,8]. (See "Overview of the principles of medical consultation and perioperative medicine", section on 'Performing the consultation'.)

Comanagement relationships usually give the comanaging physician greater leeway in selecting patients and determining which problems to address. Many comanagement agreements identify clinical criteria that automatically prompt the comanaging physician's involvement without requiring a formal consult request from the surgeon. The comanagement agreement may also describe areas of perioperative care that will be the responsibility of the comanaging physician, who is then free to address any issues within those domains.

Patient selection criteria for comanagement should ideally identify patients at higher risk for perioperative medical complications; commonly used criteria may include diagnoses (eg, hip fracture), demographic features (eg, advanced age), or medical comorbidity (eg, dysfunction of specific organ systems). Despite general adherence to this principle, patient selection methods vary between comanagement programs [9]. The development of a patient selection algorithm that balances value added and resource stewardship is a focus of ongoing research [10,11].

Broad scope of practice — In contrast to traditional medical consultation services, comanagement relationships provide the comanaging physician with a broad scope of practice, allowing them to write most orders, consult additional specialists, and otherwise manage patients as they deem necessary. The comanagement agreement may, however, indicate some restrictions on this scope of practice. For example, the comanaging physician might not be permitted to order antiplatelet agents or anticoagulants without the surgeon's approval, due to the risk of surgical site hemorrhage.

Communication — Also in contrast to traditional medical consultation, lines of communication are much more open and fluid with comanagement. Whereas all communication with the patient and other providers is routed through the referring surgeon with traditional consultation [6], the comanaging physician is generally free to communicate directly with the patient and can expect to be contacted by any care provider who has concerns about the patient. (See "Overview of the principles of medical consultation and perioperative medicine", section on 'Review with the patient'.)

BENEFITS — Despite its growing popularity, comanagement has not been proven to universally improve clinical outcomes, although it may be associated with improved clinician satisfaction and efficiency of care.

Clinical outcomes — Although it seems reasonable to expect that patients at higher risk for complications will derive greater benefit from medical comanagement, the clinical outcomes of comanagement are mixed:

●In a randomized trial, over 500 adult patients with medical comorbidities undergoing elective hip or knee arthroplasty were assigned to traditional medicine consultation service or a hospitalist-led comanagement service [12]. Comanaged patients were more likely to be discharged without a complication (62 versus 50 percent). The difference was driven by a reduction in minor complications, such as electrolyte abnormality, fever, or urinary tract infection. There was no difference in the incidence of more serious complications, such as myocardial infarction, pulmonary embolism, or pneumonia.

●In a 2020 meta-analysis including 14 prospective studies of surgical patients, comanagement was not associated with a reduction in mortality [9]. There was wide variability among the individual studies included, such as the structure of their comanagement services (eg, multidisciplinary team collaboration, internist versus hospitalist involvement), the nature of patient selection, and elective versus emergency surgical procedures. In a subgroup analysis, only comanagement with involvement of a multidisciplinary care team was associated with a reduction in mortality (odds ratio [OR] 0.67, 95% CI 0.51-0.88).

●In a meta-analysis including 4 studies (two randomized trials and two nonrandomized controlled trials) and almost 1000 adult noncardiac surgery patients, postoperative comanagement did not reduce in-hospital mortality [13].

●In a prospective study, over 200 older adults with acute hip fracture were assigned to orthogeriatric comanagement or to an orthopedic team with the support of a geriatric consultant service. A group of patients managed with usual orthopedic care was used as a historical control group. Those in the orthogeriatric comanagement group, but not the geriatric consult group, had a lower one-year mortality rate (OR 0.31, 95% CI 0.10-0.96) [14].

Although a number of additional observational studies reported that comanagement improves patient outcomes, including decreasing mortality, complications, and patient-reported pain scores [15-22], several observational studies involving orthopedic and neurosurgical patients [23-26] found that comanagement is not associated with improved patient outcomes. In fact, in a retrospective cohort analysis from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) including approximately 20,000 hip fracture patients, comanagement was associated with increased mortality, even after adjusting for differences in age and comorbidities (OR 1.36, 95% CI 1.02-1.81) [26].

Satisfaction

●Clinician – Surgeons and nurses are consistently more satisfied with comanagement than traditional medical consultation. In one trial, 90 percent of surgeons and nurses felt that comanagement improved care of orthopedic surgery patients [12]. Similarly, over 90 percent of surgeons and nurses caring for neurosurgical patients felt that hospitalist comanagement improved patient care and made it easier for them to provide care [25]. This study also found a marked increase in the perception that unstable patients were promptly identified and treated, medical problems were addressed after discharge, and communication between clinicians was improved.

●Patient – Several studies of comanagement have not found any meaningful impact on patient satisfaction [12,15,25]. However, one study of joint replacement patients found that after implementation of comanagement with a hospitalist, patient satisfaction scores improved in three of eight measures [27].

Efficiency of care — Comanagement by hospitalists tends to improve efficiency of care, as measured by length of hospital stay and hospital costs [15-19,23,25,27].

In observational studies of hip fracture patients, comanagement was associated with decreased time between admission and surgery and shorter length of stay [14,17,23]. However, in a meta-analysis including prospective studies across several surgical specialties, length of stay was similar with and without surgical comanagement [9]. Among the four studies that included a multidisciplinary team, comanagement was associated with a two-day reduction in length of stay (95% CI, -4.05 to -0.01 days).

A 2020 review of eight surgical comanagement studies including orthopedic, neurosurgical, vascular, and general surgery patients found an average savings of USD $4132 per patient [28]. However, varied results on overall hospital costs were noted, and three of the eight studies reported a cost increase. In the studies reporting cost savings, cost reduction did not reduce care quality, as measured either by mortality, complication rates, or readmission.

RISKS — Shared responsibility can lead to fragmented care and disengagement of the surgeon from direct perioperative care. A poorly negotiated agreement that devalues the comanaging physician's role can also lead to career dissatisfaction [3].

Fragmented care — Comanagement entails dividing care responsibilities between two providers. While some tasks (such as wound care) are obviously the purview of the surgeon, and others (such as management of electrolyte derangements) will fall to the comanaging physician, there are large areas of potential overlap. Without coordination of efforts, tasks can be omitted or duplicated. For example, a surgeon and comanaging physician may both fail to order a red blood cell transfusion for a severely anemic patient, as each assumed it was the other provider's responsibility. Furthermore, the actions of one provider may conflict with that of their counterpart, such as when a hospitalist orders insulin, unaware that the surgeon has restricted the patient’s oral intake.

Fragmented care also complicates the lines of communication. Nurses or other providers caring for comanaged patients may be uncertain as to whether to contact the surgeon or comanaging physician with questions or concerns. As a result, important information can be delayed or omitted. Patients may also be confused by the comanagement arrangement and have difficulty directing their questions appropriately.

Disengagement of the surgeon — Although the presence of a comanaging physician frees up the surgeon to spend more time in the operating room or clinic, this can have the unintended consequence of disengaging the surgeon from responsibilities of managing the perioperative medical care of their patients [3]. This disengagement can leave the comanaging physician to care for problems beyond their training and experience.

Clinician dissatisfaction — While studies have found that surgeons prefer medical comanagement to consultation, less is known about the comanaging physician satisfaction with this model. Career satisfaction will suffer if much of the work assigned to the comanaging physician is noncognitive or mundane. Comanaging stable, low-risk patients may also be perceived as unrewarding. Comanagement can lead to an unequal relationship, typically with the comanaging physician as the more burdened partner. This may be exacerbated by arrangements that place the comanaging physician under the supervision of the surgeon. Excessive workloads may also impair satisfaction with comanagement.

KEYS TO SUCCESS — Comanagement is far more complicated than traditional medical consultation and requires considerable advanced planning. The Society for Hospital Medicine (SHM) has developed a guide for building a comanagement program. While actual implementation of comanagement will vary according to the needs and capabilities of the hospital medicine group and surgical service at each hospital, the SHM guide lists six basic steps to forging a successful comanagement service:

●Identify obstacles and challenges

●Clarify roles and responsibilities

●Identify champions

●Address financial issues

●Measure performance

●Establish quality improvement initiatives

Identify obstacles and challenges — Before embarking on comanagement, consideration should be given to potential obstacles, challenges, and risks to the service. When contemplating the creation of a comanagement relationship, planners should ask:

●Who are the key stakeholders (eg, surgeons, comanaging physician/hospitalists, hospital administrators, other specialists, nonphysician providers)?

●What are the goals of comanagement?

●What are the risk to patients and providers if the service is unsuccessful?

●Are there unrealistic assumptions about the effects of comanagement?

Clarify roles and responsibilities — Given the complexity of comanagement arrangements, the specific roles and responsibilities of the surgeons and comanaging physician must be delineated in a written comanagement agreement. This helps to prevent errors that can arise from fragmented care and to ensure ongoing provider engagement throughout the hospital course. Common questions to address are:

●How will patients be selected for comanagement?

●Who will be the attending of record for comanaged patients?

●Which problems and complications will the comanaging physician address versus the surgeon?

●What is the role of each party in patient admission and discharge planning?

●What restrictions will be placed on the comanaging physician's scope of practice?

●What are the protocols for communication, eg, how should nursing (and other ancillary service) calls be directed? When is direct communication between the surgeon and comanaging physician required? How will management disagreements be resolved?

Identify champions — Both the surgical and medical groups involved in comanagement should identify individuals with strong leadership and interpersonal skills who are committed to the success of the service. The champions will represent their groups when negotiating the comanagement agreement but should also be willing to compromise and act as voice of moderation. Champions should expect to help resolve conflicts. They should meet regularly after implementation to evaluate and improve the service, modifying the comanagement agreement as needed.

Comanagement works best when surgical and medical providers are equal stakeholders. The champions must advocate for the service to their colleagues, as well as to the hospital, which may be asked to provide financial or logistical support. The champions must understand the needs and capabilities of their groups. For instance, the surgical group champion should recognize what problems are beyond the surgeons' capabilities to manage, and the comanaging medicine group champion should know how many patients a comanaging physician can comanage at once.

Address financial issues — The vast majority of hospital medicine programs cannot meet their financial obligations without support, which typically comes from the hospital [29]. Before agreeing to create a comanagement service, stakeholders should estimate the revenue that the combined medical-surgical comanagement service will generate and agree on how any deficit will be funded.

Measure performance — In addition to tracking census data and case mix, the service champions should determine if comanagement has improved clinical outcomes, satisfaction, and efficiency of care.

●Clinical outcomes – Commonly measured clinical outcomes include:

•Mortality rates.

•Surgical and medical complications.

•Unplanned transfers to an intensive care unit.

•30-day readmission rates.

•Process outcomes that reflect quality of care. These may include a combination of condition-specific patient-reported outcomes, laboratory findings, and/or standardized, clinical examination metrics. The specific process outcomes selected should be those commonly used to assess the condition of interest to facilitate comparisons across different comanagement programs. As an example, for in-hospital geriatric comanagement programs, a 2018 expert consensus identified the following as the most relevant quality indicators: cognition/delirium, functionality/mobility, falls, pain, medication and pressure ulcers [30]. (See "Measuring quality in hospitals in the United States", section on 'Reported measures of hospital quality'.)

●Satisfaction – Satisfaction with comanagement should be assessed in patients, surgeons, hospitalists, nurses and other stakeholders. Patient satisfaction is usually evaluated using standard survey, such as those developed by Press Ganey or the Hospital Consumer Assessment of Healthcare Providers and Systems [31]. Providers can be surveyed on satisfaction with issues such as:

•Quality and promptness of communication

•Availability of the surgeon or hospitalist to address complications

•Quality of discharge planning

•Impact of comanagement on the provider's ability to deliver care

•Overall quality of medical care

●Cost and Efficiency – Efficiency of care is of particular concern to the hospital. Typical measurements include:

•Overall length of stay, as well as time from admission to surgery and from surgery to discharge

•Direct hospital costs per admission

•Surgery cancellation rates

Establish quality improvement initiatives — The complex and dynamic nature of comanagement programs requires continuous and intentional quality improvement efforts. The most effective quality improvement efforts are those that are intentional, structured, and iterative, such as the “Plan-Do-Study-Act” (PDSA) or the Deming cycle [32].

Quality-improvement teams, led by program champions, should meet regularly to review internal performance measures, evaluate the applicability of all available evidence, and identify areas of improvement. In addition, for comanagement programs that include multidisciplinary teams, representatives from each discipline should have a voice in this process.

Such initiatives have been demonstrated to improve quality measures. As examples, two studies on the longitudinal performance of surgical comanagement programs found improvement in program quality measures over a five-year period starting at program conception [33,34].

SUMMARY AND RECOMMENDATIONS

●Definition – Comanagement is a model that allows the generalist, frequently a hospitalist, to share the responsibility, authority, and accountability for the medical care of surgical patients. (See 'Introduction' above.)

●General principles – Compared with traditional medical consultants, comanaging physicians provide care under protocols established in a negotiated agreement with the surgeons (table 1). Often, the surgeon remains the attending of record, while the comanaging physician is given wide latitude to manage the nonsurgical aspects of perioperative care. Alternatively, these roles may be reversed, and the surgical patient is admitted to the comanaging physician, who assumes primary responsibility for care. (See 'Negotiated relationship' above and 'General principles' above.)

●Benefits – Despite its growing popularity, comanagement has not been proven to universally improve clinical outcomes, although it may be associated with improved provider satisfaction and efficiency of care. The involvement of a multidisciplinary team may improve clinical outcomes. (See 'Benefits' above.)

●Risks – Potential risks associated with comanagement include fragmentation of care, disengagement of the surgeon, dissatisfaction of the comanaging physician, and patient confusion. (See 'Risks' above.)

●Keys to success – Creation of a successful comanagement program requires identification of potential obstacles to implementation, clarification of roles and responsibilities of each provider in the relationship, identification of strong champions committed to the program’s success, performance measurements, and the establishment of continuous quality improvement initiatives. (See 'Keys to success' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Vincent Galea, who contributed to the most recent revision of this topic.