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The Burdens of Comanagement

From: The Hospitalist, October 2008

In some cases, sharing patients may hinder care

by Norra MacReady

It may be time for hospitalists to rethink their co-management relationships, says Eric Siegal, MD, chair of the Society of Hospital Medicine’s Public Policy Committee. Co-management is a mainstay of hospital medicine, but “recent, albeit limited evidence suggests hospitalist consultation and co-management may not be as effective as originally anticipated,” Dr. Siegal writes in this month’s Journal of Hospital Medicine.

He demonstrates his point with several studies, including the Hospitalist Orthopedic Team trial, which involved 526 patients who underwent elective hip or knee surgery at the Mayo Clinic. Hospitalist intervention reduced incidence of minor complications, such as urinary tract infections, but had no effect on more serious complications; it reduced adjusted length of stay (LOS) by a modest 0.5 days but did not affect actual LOS or cost per case. On the other hand, patients admitted to the Mayo Clinic for hip fractures derived a clear benefit from hospitalist co-management: Compared to the standard orthopedic service, the hospitalist team decreased time-to-surgery and lowered LOS by 2.2 days without compromising outcomes.

READ THIS EDITORIAL

Find this editorial, “Just Because You Can, Doesn’t Mean That You Should: A Call for the Rational Application of Hospitalist Comanagement,” in the September-October issue of the Journal of Hospital Medicine.

These and similar findings “support the common sense notion that hospitalists most benefit patients who are sick, frail, and medically or socially complex,” Dr. Siegal writes. “As a corollary, hospitalists probably offer relatively little benefit to surgical and specialty patients who are young or have compensated medical co-morbidities and/or straightforward disposition plans.”

Dr. Siegal says he wrote the article because he realized even though hospitalists share accountability and authority for patient care with other specialists, there’s rarely a clear line defining where one physician’s responsibilities end and the other’s begin. “My intention was to make people stop and think about what they were doing, rather than just doing it,” he tells The Hospitalist.

Co-management is a good example of the phenomenon known in the military as mission creep, Dr. Siegal explains. Mission creep occurs when a project originates with well-defined and perhaps limited goals, but then expands into areas for which it was never intended.

Co-management arose during California’s managed care heyday: Hospital administrators realized surgeons were having difficulty controlling patient length of stay and managing medical co-morbidities during surgery. Enter the hospitalist, charged with coordinating the care of the acutely ill in the most effective and efficient way possible. Surgeons and other specialists liked the idea of sharing responsibility with another physician, and administrators liked the effect on the bottom line.

Little by little, co-management evolved from a strategy for managing only the most complicated cases to a routine practice at many institutions—even when hospitalists actually added little to a patient’s care.

So, little by little, co-management evolved from a strategy for managing only the most complicated cases to a routine practice at many institutions—even when hospitalists actually added little to a patient’s care. For example, a “patient with a stable GI bleed who needs little more than an endoscopy I would argue does not need co-management,” Dr. Siegal says. In fact, he points out in his paper, inserting the hospitalist into the situation above might work against the patient if it delays the gastroenterologist’s involvement and the endoscopy. A gastroenterologist who assumes a hospitalist is running the show may pay insufficient attention to the patient, Dr. Siegal writes.

Worse than that, having more than one physician involved may actually increase the risk of medical errors if the doctors give conflicting or inconsistent orders that confuse hospital staff, patients, or their families. In many cases, the specialist is simply better qualified to do the admitting, Dr. Siegal says. When a patient comes in with a cranial bleed, “if it was my mother, I wouldn’t want me admitting her,” he says.

Unnecessary co-management also can negatively affect hospitalists themselves to the extent that the process engenders burnout or unhappiness on the job, Dr. Siegal adds. Without set parameters, specialists may assume that hospitalists will conduct all patient admits. This “devalues the hospitalist,” he writes. “People start seeing us as glorified residents,” leading to “huge job dissatisfaction.”

Co-management does offer some benefits, though they vary based on situation, he says. At institutions with a limited pool of surgeons, neurologists, or other specialists, sharing duties with hospitalists can free up specialists for cases that need their specific expertise. When specialist availability isn’t a problem, however, the real—if unspoken—purpose of co-management may be to lighten the burden for superstar specialists who attract patients, prestige, and money. The result can be overworked, stressed out hospitalists who may inadvertently neglect patients requiring care.

The solution is to give hospitalists more of a say in the types of cases they co-manage, and a clearer delineation of the responsibilities of each party involved, according to Dr. Siegal. “Sit down with the specialists and revisit where you are,” he says. He also suggests calling on hospital administrators, if necessary, to mollify specialists who might dislike the idea of a change.

After all, Dr. Siegal warns, “just showing up to co-manage doesn’t mean you’re doing anything to help the patient. You should have definable outcomes that can help you say, “‘This is better.’” TH

Norra MacReady is a medical writer based in California.


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