Evaluation of Internal Medicine Physician or Multidisciplinary Team Comanagement of Surgical Patients and Clinical Outcomes

Abstract

IMPORTANCE Older patients who undergo surgery may benefit from geriatrician comanagement. It is unclear whether other internal medicine (IM) physician involvement improves outcomes for adults who undergo surgery. OBJECTIVE To evaluate the association of IM physician involvement with clinical and health system outcomes compared with usual surgical care among adults who undergo surgery. DATA SOURCES MEDLINE, Embase, CINAHL, and CENTRAL databases were searched for studies published in English from database inception to April 2, 2019. STUDY SELECTION Prospective randomized or nonrandomized clinical studies comparing IM physician consultation or comanagement with usual surgical care were selected by consensus of 2 reviewers. DATA EXTRACTION AND SYNTHESIS Data were extracted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline by 2 authors independently. Intervention characteristics were described using existing indicators. Risk of bias was assessed using Risk of Bias 2.0 and Risk of Bias in Nonrandomized Studies of Interventions tools. Studies were pooled when appropriate in meta-analysis using random-effects models. Prespecified subgroups included IM physician-only vs multidisciplinary team interventions and patients undergoing elective vs emergency procedures. MAIN OUTCOMES AND MEASURESThe prespecified primary outcome was length of stay; other outcomes included 30-day readmissions, inpatient mortality, medical complications, functional outcomes, and costs. RESULTSOf 6027 records screened, 14 studies (with 1 randomized clinical trial) involving 35 800 patients (13 142 [36.7%] in intervention groups) were eligible for inclusion. Interventions varied substantially among studies and settings; most interventions described comanagement by a hospitalist or internist; 7 (50%) included a multidisciplinary team, and 9 (64%) studied predominantly patients who had elective procedures. Risk of bias in 10 studies (71%) was serious.

Enhanced Recovery After Surgery: An Orthopedic Perspective

“…Across the United States, advances in surgical technique and multidisciplinary care [38] have been shown to improve outcomes after elective TJA. The average hospital LOS in the United States after THA was 1.9 days, and it was just 1.0 day following TKA in 2020 [39].…”

How to Set Up a Perioperative BNP/NTproBNP and Troponin Screening Program

“…Surgical patient co-management provided by IMPCT has been an essential part of implementing perioperative biomarker testing, and this model may confer addition benefits for patients, colleagues, and budgetary considerations. While co-management has not shown universal improvement in outcomes, 18 metaanalyses of shared care by geriatricians and orthopedic surgeons have showed decreased mortality and shorter length of stay (LOS). 19,20 Similarly, a meta-analysis of surgical patients with IM co-management demonstrated decreased LOS and mortality.…”

“…19,20 Similarly, a meta-analysis of surgical patients with IM co-management demonstrated decreased LOS and mortality. 18 An RCT looking at co-management by hospitalists and surgeons versus a consultation care model showed decreased minor, but not major, complications and fewer discharge delays. 21 Studies have also shown that shared care models increase prescribing of evidence-based treatment, 22 increase surgeon and nurse satisfaction, 21 decrease LOS 19,20,23 , and decrease readmissions resulting in overall cost savings.…”

Sharing the helm: medical co‐management for the older surgical patient

“…Collaborative care models have shown better care coordination, 29,31 decreased complications including delirium and functional decline, 31,32 shorter hospital stays 31,32 and potential cost savings 33 . Observational data from the National Emergency Laparotomy Audit (NELA) in the United Kingdom (UK) show that postoperative geriatrician review is associated with lower mortality in older emergency laparotomy patients, 34,35 while meta‐analyses of studies of co‐management of surgical patients by geriatricians 36 or general physicians 37 suggest that mortality benefits accrue in models including a multidisciplinary team in addition to the medical specialist. There are also concerted efforts on improving perioperative care for older people undergoing elective surgery, proactively identify issues in the preoperative setting to predict and reduce complications postoperatively.…”