Abstract
Purpose
This study aimed to evaluate the use of active surgical co-management (SCM) by medical hospitalists for urology inpatient care.
Materials and Methods
Since March 2019, a hospitalist-SCM program was implemented at a tertiary-care medical center, and a retrospective cohort study was conducted among co-managed urology inpatients. We assessed the clinical outcomes of urology inpatients who received SCM and compared passive SCM (co-management of patients by hospitalists only on request; March 2019 to June 2020) with active SCM (co-management of patients based on active screening by hospitalists; July 2020 to October 2021). We also evaluated the perceptions of patients who received SCM toward inpatient care quality, safety, and subjective satisfaction with inpatient care at discharge or when transferred to other wards.
Results
We assessed 525 patients. Compared with the passive SCM group (n=205), patients in the active SCM group (n=320) required co-management for a significantly shorter duration (p=0.012) and tended to have a shorter length of stay at the urology ward (p=0.062) and less frequent unplanned readmissions within 30 days of discharge (p=0.095) while triggering significantly fewer events of rapid response team activation (p=0.002). No differences were found in the proportion of patients transferred to the intensive care unit, in-hospital mortality rates, or inpatient care questionnaire scores.
Conclusion
Active surveillance and co-management of urology inpatients by medical hospitalists can improve the quality and efficacy of inpatient care without compromising subjective inpatient satisfaction.
Keywords: Hospitalist, urology, inpatients, patient care, surgical co-management
Graphical Abstract
INTRODUCTION
Surgeons have long relied on medical specialists to provide advice and support in caring for patients. In most cases, medical specialists are required to identify comorbidities and provide risk stratification for surgical complications.1,2,3,4 Traditionally, the surgeon has the sole authority and responsibility to identify patients who would benefit from the consultant’s evaluation and determine the extent of involvement of internists.5,6 Medical specialists provide recommendations to surgeons, but the surgeon makes the final decision to implement them. Previous studies have shown that almost half of internists’ recommendations are ignored by the requesting physicians.7 In this model, patient medical conditions may not be optimized before surgery, and preventable complications may go overlooked.
The population of individuals aged 60 years or older is increasing significantly worldwide.8 Associated with such increases are increases in the prevalences of chronic diseases and complex medical conditions. Currently, patients with chronic conditions tend to live longer, and high-risk patients are exposed to more surgical interventions than that observed previously.9,10 Therefore, integrated medical care is necessary for most surgical patients.11 Surgical co-management (SCM) is a tested collaborative model between internists and surgeons to improve the healthcare outcomes of surgical patients.12 Under SCM care, the collaborating medical specialists share responsibility, authority, and accountability with the surgeons.12 Numerous studies have shown that SCM is associated with a reduction in medical complications, length of stay, 30-day readmissions, and cost of care without altering patient satisfaction.13,14,15,16,17,18 SCM has become a mainstay of hospital medicine, and according to a survey conducted by the Society of Hospital Medicine in the USA; approximately 85% of hospitalist groups are involved in a form of SCM.19
The hospitalist system in South Korea was first introduced in 2015, starting with the Department of Internal Medicine at Seoul National University Bundang Hospital (SNUBH), a 1300-bed tertiary referral hospital, to improve the quality of inpatient care and solve the problem of shortage of residents. Hospitalist service at SNUBH began with inpatient care in an acute medical unit and progressed to SCM in 2017 to address similar issues in surgical wards; a 3-month pilot program for urology inpatients (from March to May 2017) to evaluate the effectiveness and growth potential of SCM revealed satisfactory results in terms of perception changes of medical staff on the quality of patient care or safety. Based on these results, SCM was officially launched for inpatients in the urology department and for the first time in Korea in March 2019. Since July 2020, it has evolved from passive SCM, which is solely based on requests from urology surgeons, to active SCM, which involves active screening and assessment of all urology patients by medical hospitalists.
This study aimed to determine the effectiveness of SCM programs for urology inpatients and investigate whether active versus passive SCM interventions are associated with better clinical outcomes.
MATERIALS AND METHODS
Study design and setting
This retrospective cohort study was conducted at a 1300-bed tertiary referral teaching hospital in South Korea, where a hospitalist-SCM program for co-managing urology inpatients was launched on March 1, 2019. The SCM team consisted of eight urology faculty surgeons and 10 board-certified medical hospitalists. The medical hospitalists had an average of 12.3 years of clinical experience (range 4–18 years) and had worked in various specialties, including infectious diseases, pulmonology, critical care, gastroenterology, nephrology, endocrinology, rheumatology, and geriatrics. The surgeons were primarily accountable for the management of surgical and peri-surgical technical problems, and the hospitalists were responsible for patients’ medical problems or conditions.
Every day from 8:00 AM to 6:00 PM, a dedicated hospitalist collaboratively cared for urology inpatients requiring medical care. The co-managing hospitalist was available to address questions and concerns from the nurses and residents of the urology department concerning urology inpatients who were not being co-managed. During ward rounds for co-managed patients, the hospitalist ordered diagnostic or therapeutic interventions or consultations as needed and constantly communicated with urology surgeons concerning the medical problems of patients. If the co-managed patient became stabilized or did not require further medical management, the medical hospitalist terminated the co-management process. At night, residents and fellows at the urology department managed patients with active backup from internal medicine hospitalists. Ten medical hospitalists rotated through the SCM program monthly or bi-weekly. From March 2019 to June 2020, patients were co-managed by hospitalists based on requests by urology surgeons (passive SCM). From July 2020 to October 2021, hospitalists actively screened and assessed all urology inpatients for comorbidities and acute medical issues to initiate co-management spontaneously (active SCM).
Participants and data collection
All urology inpatients requiring medical consultation were eligible for the SCM program, regardless of whether they were admitted through the emergency department, outpatient department, or transferred from another department. Patients were withdrawn from SCM if they refused to participate in the SCM program. To compare SCM effectiveness between the two 16-month-periods (passive versus active SCM), demographic and clinical data, including route of admission, comorbid diseases, purpose of admission, urologic operations/procedures during admission, and reasons for SCM enrollment, were collected retrospectively from electronic medical records.
Survey on SCM quality and satisfaction
The participants were asked to complete a survey on SCM quality and satisfaction on the day of discharge or transfer to another department. The questionnaire consisted of the following five items: patient question (PQ)1, “Were you satisfied with the treatment provided by the medical hospitalist?”, PQ2, “Do you think you have received high-quality treatment from the medical hospitalist?”, PQ3, “Do you feel that your safety has improved because of the hospitalist’s inpatient care?”, PQ4, “If you are admitted to the urology department again, are you willing to reexperience the SCM with a medical hospitalist?”, and PQ5, “Would you want to be treated under the SCM with a medical hospitalist even if it requires paying for the service?”. Each question was scored on a 5-point Likert scale (1=disagree strongly, 2=disagree slightly, 3=neither agree, nor disagree, 4=agree slightly, and 5=agree strongly) to assess subjective satisfaction with the SCM provided by medical hospitalists.
Statistical analysis
Unless otherwise specified, the results are expressed as means with standard deviations for continuous variables and as percentages for categorical variables. Student’s t-test was used to compare continuous variables, and the chi-square or Fisher’s exact test was used to compare categorical variables. A logistic regression model by the enter method was used to adjust for confounding variables and to identify factors associated with clinical outcomes of the active SCM. Subgroup analyses of the clinical outcomes according to age (<65 years or ≥65 years), comorbidities by the Charlson comorbidity score (CCS) (CCS 0–2 or CCS 3–4 or CCS ≥5), and purpose of admission (planned procedures or cancer chemotherapy or treatment for urologic complications) were performed. Unless otherwise stated, all tests were two-sided and performed at a significance level of 0.05. Analyses were performed using IBM SPSS v. 21.0 (IBM Corp, Armonk, NY, USA).
Ethics statement
The Institutional Review Board of Seoul National University Bundang Hospital reviewed and approved this study design and waived the need for informed consent from the participants (B-2208-777-304). This study was conducted following the principles of the Declaration of Helsinki.
RESULTS
Patient characteristics
A total of 525 urology inpatients (205 and 320 were in the passive and active SCM groups, respectively) were co-managed by medical hospitalists. The baseline characteristics of the patients receiving SCM are presented in Table 1. Approximately 70% of the patients were male, and the mean age was 67.2 years. The mean age-weighted CCS value was 5.8. Demographic findings were not significantly different between patients in the passive and active SCM groups.
Table 1. Demographic and Clinical Characteristics of the Study Participants.
| Total (n=525) | Passive SCM (n=205) | Active SCM (n=320) | p value* | |||
|---|---|---|---|---|---|---|
| Sex, male | 367 (69.9) | 144 (70.2) | 223 (69.7) | 0.892 | ||
| Age, yr | 67.2±14.2 | 67.6±14.0 | 66.9±14.3 | 0.584 | ||
| Age group | 0.198 | |||||
| <50 years | 59 (11.2) | 17 (8.3) | 42 (13.1) | |||
| 50–59 years | 72 (13.7) | 35 (17.1) | 37 (11.6) | |||
| 60–69 years | 130 (24.8) | 49 (23.9) | 81 (25.3) | |||
| 70–79 years | 167 (31.8) | 63 (30.7) | 104 (32.5) | |||
| ≥80 years | 97 (18.5) | 41 (20.0) | 56 (17.5) | |||
| Admission route | 0.197 | |||||
| ER | 200 (38.1) | 87 (42.4) | 113 (35.3) | |||
| OPD | 324 (61.7) | 118 (57.6) | 206 (64.4) | |||
| Transfer from other departments | 1 (0.2) | 0 (0) | 1 (0.3) | |||
| Comorbid conditions | ||||||
| Diabetes mellitus | 0.389 | |||||
| Uncomplicated | 125 (23.8) | 54 (26.3) | 71 (22.2) | |||
| Complicated | 24 (4.6) | 11 (5.4) | 13 (4.2) | |||
| Liver disease | 0.139 | |||||
| Mild | 11 (2.1) | 2 (1.0) | 9 (2.8) | |||
| Moderate to severe | 7 (1.3) | 1 (0.5) | 6 (1.9) | |||
| CKD | 42 (8.0) | 15 (7.3) | 27 (8.4) | 0.644 | ||
| Heart disease | ||||||
| Prior MI | 49 (9.3) | 16 (7.8) | 33 (10.3) | 0.335 | ||
| CHF | 26 (5.0) | 6 (2.9) | 20 (6.3) | 0.087 | ||
| Cerebrovascular disease | 59 (11.2) | 24 (11.7) | 35 (10.9) | 0.785 | ||
| Dementia | 23 (4.4) | 11 (5.4) | 12 (3.8) | 0.378 | ||
| Chronic pulmonary disorder | 22 (4.2) | 5 (2.4) | 17 (5.3) | 0.109 | ||
| Hematologic malignancy | 1 (0.2) | 0 (0.0) | 1 (0.3) | 0.423 | ||
| Solid tumor | 0.153 | |||||
| Localized | 258 (49.1) | 91 (44.4) | 167 (52.2) | |||
| Metastatic | 132 (25.1) | 53 (25.9) | 79 (24.7) | |||
| Age-weighted CCS | 5.8±3.1 | 5.8±3.0 | 5.8±3.1 | 0.861 | ||
CCS, Charlson comorbidity score; CHF, chronic heart failure; CKD, chronic kidney disease; ER, emergency room; MI, myocardial infarction; OPD, outpatient department; SCM, surgical co-management.
Data are presented as numbers (%) or mean±SD.
*Significant differences between passive and active SCM patients were tested using the chi-square or Fisher’s exact test.
Most patients were admitted from the urology outpatient clinic because of surgical and infectious conditions, and the most common operation among patients was nephrectomy, followed by prostatectomy (Table 2). There were no significant differences in the type of surgery performed between the patients in the passive and active SCM groups.
Table 2. Purpose of Hospitalization and Details of Urology Operations and Procedures.
| Total (n=525) | Passive SCM (n=205) | Active SCM (n=320) | p value* | ||
|---|---|---|---|---|---|
| Purpose of admission | 0.597 | ||||
| Operation | 217 (41.4) | 91 (44.4) | 126 (39.5) | ||
| URO procedures | 24 (4.6) | 9 (4.4) | 15 (4.7) | ||
| URO cancer chemotherapy | 10 (1.9) | 2 (1.0) | 8 (2.5) | ||
| URO cancer w/u | 20 (3.8) | 6 (2.9) | 14 (4.4) | ||
| Infection | 151 (28.8) | 58 (28.3) | 93 (29.2) | ||
| Hematuria | 15 (2.9) | 3 (1.5) | 12 (3.8) | ||
| Obstruction/voiding problem | 15 (2.9) | 6 (2.9) | 9 (2.8) | ||
| Complicated conditions | 72 (13.7) | 30 (14.6) | 42 (13.2) | ||
| Urology operations or procedures | 0.500 | ||||
| Prostatectomy | 34 (14.7) | 12 (5.9) | 22 (6.9) | ||
| Nephrectomy | 80 (34.6) | 30 (14.6) | 50 (15.6) | ||
| Nephroureterectomy | 25 (10.8) | 14 (6.8) | 11 (3.4) | ||
| Radical cystectomy | 27 (11.7) | 10 (4.9) | 17 (5.3) | ||
| TUR-B | 22 (9.5) | 9 (4.4) | 13 (4.1) | ||
| Uretero-/nephrolithotomy | 22 (9.5) | 12 (5.9) | 10 (3.1) | ||
| Repair of urinary stress incontinence | 2 (0.9) | 1 (0.5) | 1 (0.3) | ||
| Others | 17 (7.4) | 9 (4.4) | 8 (2.5) | ||
SCM, surgical co-management; URO, urology, TUR-B, transurethral resection of the bladder.
Data are presented as numbers (%).
*Significant differences between passive and active SCM patients were tested using the chi-square or Fisher’s exact test.
Comparison of passive SCM and active SCM
The reasons for enrolling patients in the SCM program are summarized in Table 3. The most common reason was fever or infection-related problems, followed by renal failure and/or electrolyte imbalance. There was no significant difference between the two groups in their reasons for participating in SCM. However, patients who received passive SCM had more complex and multiple medical problems than those who received active SCM (p=0.014).
Table 3. Reasons for Enrolling Patients in the SCM Program.
| Total (n=525) | Passive SCM (n=205) | Active SCM (n=320) | p value* | ||
|---|---|---|---|---|---|
| Reasons for SCM | 0.699 | ||||
| Infection | 179 (50.7) | 63 (50.4) | 116 (50.9) | ||
| Changes in BP | 10 (2.8) | 6 (4.8) | 4 (1.8) | ||
| Changes in HR/rhythm | 5 (1.4) | 1 (0.8) | 4 (1.8) | ||
| Respiratory sx/sn | 17 (4.8) | 6 (4.8) | 11 (4.8) | ||
| AKI with electrolyte imbalance | 57 (16.1) | 23 (18.4) | 34 (14.9) | ||
| GI & hepatobiliary sx/sn | 18 (5.1) | 4 (3.2) | 14 (6.1) | ||
| Allergic sx/sn | 6 (1.7) | 2 (1.6) | 4 (1.8) | ||
| Opinions in cancer w/u & supportive care | 6 (1.7) | 1 (0.8) | 5 (2.2) | ||
| Endocrinologic care including BSL control | 5 (1.4) | 2 (1.6) | 3 (1.3) | ||
| Neurologic sx/sn | 6 (1.7) | 2 (1.6) | 4 (1.8) | ||
| Hematologic conditions | 12 (3.4) | 5 (4.0) | 7 (3.1) | ||
| Joint sx/sn | 1 (0.3) | 0 (0) | 1 (0.4) | ||
| Pain management | 5 (1.4) | 0 (0) | 5 (2.2) | ||
| Perioperative medical care | 17 (4.8) | 5 (4.0) | 12 (5.3) | ||
| Sx/sn suggesting HF & MI | 6 (1.7) | 3 (2.4) | 3 (1.3) | ||
| Others | 3 (0.8) | 2 (1.6) | 1 (0.4) | ||
| More than one reason for SCM | 172 (32.8) | 80 (39.0) | 92 (28.8) | 0.014 | |
AKI, acute kidney injury; BSL, blood sugar level; BP, blood pressure; GI, gastrointestinal; HR, heart rate; HF, heart failure; MI, myocardial infarction; SCM, surgical co-management; sx/sn, symptoms and signs; w/u, work up.
Data are presented as numbers (%).
*Significant differences between passive and active SCM patients were tested using the chi-square or Fisher’s exact test.
The clinical outcomes and SCM durations are presented in Table 4. Patients in the active SCM group tended to receive co-management earlier after admission than patients in the passive SCM group (p=0.361). However, this difference was not significant, and they received co-management for a significantly shorter duration (p=0.012). Under active SCM, the hospitalization period in the urology ward tended to be shorter (p=0.062), compared to the passive group, but there was no difference in the overall length of hospital stay between the two groups. The number of events triggering rapid response team (RRT) activation was significantly lower in the active SCM group (p=0.002) than in the passive SCM group; however, no differences were found in the proportion of patients transferred to the intensive care unit or in in-hospital mortality rates. Unplanned readmissions within 30 days of discharge tended to be less frequent among patients in the active SCM group than the passive SCM group (7.8% vs. 12.2%, p=0.095), but the difference was not statistically significant. In multivariate analysis, active SCM was associated with less frequent RRT trigger after adjusting for age, sex, and comorbidities (Table 5). No significant difference was detected among subgroups of age, comorbidities, and purpose of admission (Supplementary Table 1, only online).
Table 4. Comparison of Clinical Outcomes between Patients Who Received Passive and Active SCM.
| Total (n=525) | Passive SCM (n=205) | Active SCM (n=320) | p value* | ||
|---|---|---|---|---|---|
| Duration of URO hospitalization, days | 11.0±8.9 | 11.9±10.7 | 10.3±7.6 | 0.062 | |
| Duration of hospitalization, days | 12.7±10.6 | 13.2±10.4 | 12.3±10.8 | 0.341 | |
| Trigger of RRT among study patients | |||||
| Number of events | 44 | 27 | 17 | 0.002 | |
| Number of patients | 30 | 17 | 13 | 0.042 | |
| Patients with multiple events | 10 | 7 | 3 | 0.053 | |
| Trigger of RRT during the whole study period | |||||
| Number of events | 52 | 31 | 21 | 0.001 | |
| Number of patients | 39 | 22 | 17 | 0.021 | |
| Patients with multiple events | 10 | 7 | 3 | 0.043 | |
| Transfer to ICU | 28 (5.3) | 11 (5.4) | 17 (5.3) | 0.985 | |
| In-hospital mortality | 10 (1.9) | 5 (2.4) | 5 (1.6) | 0.477 | |
| Unplanned readmission within 30 days | 50 (9.5) | 25 (12.2) | 25 (7.8) | 0.095 | |
| SCM duration, days | 5.3±5.5 | 6.1±6.7 | 4.8±4.5 | 0.012 | |
| Time until SCM initiation, days | 3.8±5.3 | 4.1±6.0 | 3.6±4.8 | 0.361 | |
ICU, intensive care unit; RRT, rapid response team; SCM, surgical co-management; URO, urology; SD, standard deviation.
Data are presented as numbers (%) or mean±SD unless otherwise specified.
*Significant differences between passive and active SCM patients were tested using the chi-square or Fisher’s exact test.
Table 5. Multivariate Analyses of Factors Associated with RRT Trigger of Active SCM and Unplanned Readmission within 30 Days after Discharge.
| Factor | Univariate | p value | Multivariate | p value | |||||
|---|---|---|---|---|---|---|---|---|---|
| OR | 95% CI | aOR | 95% CI | ||||||
| RRT trigger of active SCM | |||||||||
| Age | 1.00 | 0.97–1.02 | 0.695 | 0.99 | 0.97–1.02 | 0.603 | |||
| Sex | |||||||||
| Female | 1.00 | ||||||||
| Male | 0.85 | 0.39–1.87 | 0.691 | 0.84 | 0.37–1.90 | 0.668 | |||
| Co-morbidities | |||||||||
| None | 1.00 | ||||||||
| Diabetes mellitus | 1.28 | 0.59–2.81 | 0.536 | ||||||
| Chronic liver disease | 0.00 | 0.998 | |||||||
| Chronic kidney disease | 1.85 | 0.61–5.58 | 0.274 | ||||||
| Congestive heart failure/prior MI | 1.85 | 0.73–4.71 | 0.198 | ||||||
| Cerebrovascular disease | 1.23 | 0.41–3.66 | 0.709 | ||||||
| Dementia | 0.74 | 0.10–5.70 | 0.774 | ||||||
| Chronic pulmonary disorder | 1.70 | 0.38–7.62 | 0.491 | ||||||
| Hematologic malignancy | 0.00 | >0.999 | |||||||
| Any solid malignancy | 0.58 | 0.27–1.25 | 0.162 | ||||||
| Connective tissue disorder | 2.40 | 0.29–20.20 | 0.419 | ||||||
| Charlson comorbidity score | 1.02 | 0.88–1.18 | 0.780 | 1.05 | 0.89–1.23 | 0.551 | |||
| Purpose of admission | 0.997 | ||||||||
| Operation | 1.00 | ||||||||
| URO procedures | 0.63 | 0.08–5.02 | 0.663 | ||||||
| URO cancer chemotherapy | 0.00 | 0.999 | |||||||
| URO cancer evaluation | 0.76 | 0.10–6.12 | 0.799 | ||||||
| Infection | 0.71 | 0.28–1.79 | 0.462 | ||||||
| Hematuria | 0.97 | 0.12–7.86 | 0.975 | ||||||
| Obstruction/voiding problem | 1.04 | 0.13–8.46 | 0.974 | ||||||
| Complicated conditions | 1.08 | 0.38–3.12 | 0.884 | ||||||
| SCM type | |||||||||
| Passive SCM | 1.00 | ||||||||
| Active SCM | 0.47 | 0.22–0.99 | 0.046 | 0.46 | 0.22–0.97 | 0.042 | |||
| Unplanned readmission within 30 days after discharge | |||||||||
| Age | 1.00 | 0.98–1.02 | 0.823 | 1.00 | 0.98–1.03 | 0.908 | |||
| Sex | |||||||||
| Female | 1.00 | ||||||||
| Male | 1.00 | 0.53–1.90 | 0.988 | 0.90 | 0.45–1.79 | 0.762 | |||
| Co-morbidities | |||||||||
| None | 1.00 | ||||||||
| Diabetes mellitus | 1.21 | 0.65–2.27 | 0.551 | ||||||
| Chronic liver disease | 1.96 | 0.55–7.01 | 0.302 | ||||||
| Chronic kidney disease | 0.45 | 0.11–1.93 | 0.285 | ||||||
| Congestive heart failure/prior MI | 0.96 | 0.39–2.35 | 0.931 | ||||||
| Cerebrovascular disease | 0.87 | 0.33–2.28 | 0.771 | ||||||
| Dementia | 2.09 | 0.68–6.40 | 0.198 | ||||||
| Chronic pulmonary disorder | 0.95 | 0.22–4.18 | 0.994 | ||||||
| Hematologic malignancy | 0.00 | >0.999 | |||||||
| Any solid malignancy | 1.43 | 0.69–2.94 | 0.333 | ||||||
| Connective tissue disorder | 1.36 | 0.16–11.32 | 0.773 | ||||||
| Charlson comorbidity score | 1.05 | 0.93–1.18 | 0.428 | 1.02 | 0.88–1.18 | 0.788 | |||
| Purpose of admission | 0.459 | 0.491 | |||||||
| Operation | 1.00 | 1.00 | |||||||
| URO procedures | 0.51 | 0.07–4.02 | 0.524 | 0.51 | 0.06–4.05 | 0.524 | |||
| URO cancer chemotherapy | 5.04 | 1.19–21.29 | 0.028 | 5.53 | 1.19–25.58 | 0.029 | |||
| URO cancer evaluation | 1.31 | 0.28–6.11 | 0.734 | 1.32 | 0.27–6.54 | 0.735 | |||
| Infection | 1.30 | 0.63–2.69 | 0.483 | 1.31 | 0.63–2.73 | 0.469 | |||
| Hematuria | 0.78 | 0.10–6.30 | 0.819 | 0.83 | 0.10–7.02 | 0.867 | |||
| Obstruction/voiding problem | 1.81 | 0.38–8.69 | 0.459 | 1.87 | 0.38–9.11 | 0.438 | |||
| Complicated conditions | 1.68 | 0.71–3.96 | 0.235 | 1.62 | 0.65–4.06 | 0.305 | |||
| SCM type | |||||||||
| Passive SCM | 1.00 | ||||||||
| Active SCM | 0.61 | 0.34–1.10 | 0.098 | 0.58 | 0.32–1.06 | 0.076 | |||
CI, confidence interval; MI, myocardial infarction; OR, odds ratio; RRT, rapid response team; SCM, surgical co-management; URO, urology.
Patient satisfaction with SCM
Among the 525 patients receiving SCM, 290 (55.2%) completed the questionnaire. Table 6 summarizes the results. Overall, patients were very much satisfied with the SCM provided by medical hospitalists and were confident that the SCM program could improve the quality and safety of inpatient care. Scores for the question “Would you want to be treated under the SCM by a medical hospitalist even if it requires paying for the service?” were slightly lower than those of the other questions. However, most patients were still willing to pay for SCM. No significant differences were observed in the questionnaire results between the passive and active SCM groups.
Table 6. Questionnaire on Patient Satisfaction with SCM.
| Total (n=290) | Passive SCM (n=81) | Active SCM (n=209) | p value* | |
|---|---|---|---|---|
| PQ1 | 4.17±0.80 | 4.12±0.91 | 4.19±0.75 | 0.547 |
| PQ2 | 4.07±0.82 | 4.09±0.83 | 4.06±0.82 | 0.788 |
| PQ3 | 4.08±0.80 | 4.09±0.87 | 4.08±0.77 | 0.925 |
| PQ4 | 4.08±0.82 | 4.15±0.81 | 4.06±0.82 | 0.396 |
| PQ5 | 3.93±0.90 | 3.90±1.02 | 3.94±0.86 | 0.744 |
PQ, patient question; SCM, surgical co-management.
Data are presented as mean±standard deviation.
PQ1: Were you satisfied with the treatment provided by the medical hospitalist? PQ2: Do you think you have received high-quality treatment from the medical hospitalist? PQ3: Do you feel that your safety has improved because of the hospitalist’s inpatient care? PQ4: If you are admitted to the urology department again, are you willing to reexperience SCM by a medical hospitalist? PQ5: Would you want to be treated under the SCM with a medical hospitalist even if it requires paying for the service?
*Significant differences between passive and active SCM patients were tested using the chi-square or Fisher’s exact test.
DISCUSSION
Collaborative inpatient care of surgical patients has been recognized as improving patient outcomes, and SCM is increasingly practiced by hospitalists.13,14,15,16,17,18,19 However, studies on the role and degree of hospitalist involvement during co-management are scarce, and only limited data are available concerning SCM in the field of urology. Therefore, in this study, we evaluated the use of active SCM (starting with active surveillance of patients who need SCM), compared with that of passive SCM (based on SCM request by surgeons), for urology inpatient care. Our results show that active SCM by medical hospitalists improved safety and care quality of urology inpatients, and patients were highly satisfied with our SCM program. To the best of our knowledge, this is the first study to report the results of SCM performed by internal medicine hospitalists in urology.
In previous studies on SCM in urology, co-management was limited to perioperative care. Stier, et al.20 reported the effect of perioperative hospitalist service provided by anesthesiologists in patients undergoing major urologic procedures, such as prostatectomy, cystectomy, and nephrectomy. This study reported significant reductions in complication rates, lengths of hospital stay, and total direct patient costs. Recently, Letica-Kriegel, et al.21 conducted a pilot study of a geriatric co-management program involving 59 patients aged 75 years and older undergoing radical cystectomy. All patients eligible for the program were referred to the geriatric clinic for preoperative geriatric consultation and were treated throughout their inpatient days. The geriatric team visited the patient, made recommendations regarding inpatient care, and assisted with discharge and post-surgical care planning. They reported that no patient had their surgery rescheduled because of the program and that urology practice providers expressed satisfaction with the program. In contrast, we launched a comprehensive SCM program for urology inpatients requiring medical care for various medical conditions, including infections, hemodynamic instabilities, and symptoms and signs of organ dysfunction, and co-management was provided by a dedicated, board-certified internal medicine hospitalist. Approximately half of the patients were admitted to the urology ward for reasons other than surgery. Our study demonstrated that SCM service provided by medical hospitalists improved the clinical prognosis of urology inpatients, even in areas other than perioperative care, and patients were highly satisfied with our SCM program. Our findings are in line with those of a recent systematic review and meta-analysis that suggested that internal medicine physician co-management might be associated with reduced length of stay and mortality of patients undergoing surgery.22
Regarding the degree of SCM involvement by hospitalists, active SCM when compared with passive SCM tended to improve the efficiency and safety of urology inpatients. Before implementing the SCM program, inpatient care for urology patients was provided by attending surgical physicians, urology residents, and nurses: during the daytime, a single resident stayed out of the operating room and responded to all urgencies in the ward. Managing acute and urgent issues was the responsibility of the cross-covering urology resident and the professor in charge of the patient. Medical problems, such as preoperative risk evaluation and management of acute deterioration, were solved by consulting subspecialty medical counterparts at the discretion of the surgical team. This traditional model frequently hinders the timely and prompt management of patients requiring medical treatment. Therefore, even with passive SCM, which was provided solely based on requests by urology surgeons, encouraging results were obtained regarding patient safety, quality of care, and patient and surgeon satisfaction (data not shown). However, for patients whose surgeons did not request co-management on time, their medical problems were often identified late, and their conditions worsened. After initiation of active SCM, where the co-managing hospitalist engaged actively in the whole process, from patient surveillance throughout medical treatment until termination of co-management, the number of patients receiving management increased by 56% when compared with those receiving passive SCM: 205 patients received passive SCM, and 320 received active SCM. Patients in the passive SCM group, compared with the active SCM group, had significantly more complex medical reasons for SCM. Compared with those receiving passive SCM, patients receiving active SCM tended to receive SCM earlier and for a shorter duration. It is likely that by actively surveilling urology inpatients, medical hospitalists could detect patients needing SCM earlier and thereby were more likely to provide timely medical interventions, leading to better prognoses for patients, including shorter length of stay and significantly fewer events triggering RRT activation.
As shown in the survey results, patients felt that they received high-quality care under the SCM, and their safety improved. Although there was no significant difference between passive SCM and active SCM in the degree of patient satisfaction, the results confirmed that patients were satisfied that the medical hospitalists treated them together. Positive results were also confirmed regarding the payment for SCM services, but it received the lowest score among those of other questions. The current Korean healthcare system requires out-of-pocket payments owing to low patient contributions relative to costs of care, low levels of reimbursement to healthcare providers, and incomplete coverage of medical services.23 Therefore, the SCM service could only be applied to patients who agreed to pay the additional fee for the service.24 For the SCM service to be less burdensome to patients and well established, it is necessary to not only set a reasonable and accurate fee table for the service but also for the government to provide financial support.
Our study has some limitations. First, as we aimed to compare the effects of passive and active SCM, focusing on whether the degree of hospitalist intervention in SCM affects the clinical outcomes of urologic patients, rather than the effect of SCM itself, a direct comparison with pre-SCM data was not included in this study. Moreover, as passive and active SCM programs were launched sequentially, a head-to-head comparison of the interventions could not be made. Second, this study included only inpatients in the urology department of a single tertiary-referral hospital. Although the effects of active SCM were apparent, follow-up studies are needed to confirm whether the same effect is confirmed in surgical departments other than urology and in other hospitals. In addition, a study on the effectiveness of surgical hospitalists was recently published in Korea,25 and further research on differences and similarities between surgical and medical hospitalists is warranted.
Nevertheless, this study is meaningful in that we analyzed the results of the first SCM system implemented in Korea. In addition, the study differs from previous studies in that board-certified internists provided the SCM service for all urology patients, who needed medical care and perioperative care. Finally, this study confirmed patient satisfaction with the SCM and reports its impact on clinical outcomes in detail.
In conclusion, active surveillance and co-management of urology inpatients by medical hospitalists could improve the quality and efficacy of inpatient care without compromising subjective inpatient satisfaction. Therefore, efforts are needed to expand and establish SCM services for inpatients in surgical wards.
ACKNOWLEDGEMENTS
This study was supported by a grant from the SNUBH Research Fund (no. 02-2016-041).
Footnotes
The authors have no potential conflicts of interest to disclose.
- Conceptualization: Eun Sun Kim, Jung Hun Ohn, and Nak-Hyun Kim.
- Data curation: all authors.
- Formal analysis: Nak-Hyun Kim and Eun Sun Kim.
- Funding acquisition: Eun Sun Kim.
- Supervision: Seok-Soo Byun and Hak Chul Jang.
- Writing—original draft: Eun Sun Kim and Nak-Hyun Kim.
- Writing—review & editing: all authors.
- Approval of final manuscript: all authors.
SUPPLEMENTARY MATERIALS
Summary of Subgroup Analyses of Patient Characteristics Potentially Influencing Outcomes of Active SCM
References
- 1.American College of Physicians. Guidelines for assessing and managing the perioperative risk from coronary artery disease associated with major noncardiac surgery. Ann Intern Med. 1997;127:309–312. doi: 10.7326/0003-4819-127-4-199708150-00011. [DOI] [PubMed] [Google Scholar]
- 2.Detsky AS, Abrams HB, Forbath N, Scott JG, Hilliard JR. Cardiac assessment for patients undergoing noncardiac surgery. A multifactorial clinical risk index. Arch Intern Med. 1986;146:2131–2134. [PubMed] [Google Scholar]
- 3.Detsky AS, Abrams HB, McLaughlin JR, Drucker DJ, Sasson Z, Johnston N, et al. Predicting cardiac complications in patients undergoing non-cardiac surgery. J Gen Intern Med. 1986;1:211–219. doi: 10.1007/BF02596184. [DOI] [PubMed] [Google Scholar]
- 4.Eagle KA, Brundage BH, Chaitman BR, Ewy GA, Fleisher LA, Hertzer NR, et al. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery. Circulation. 1996;93:1278–1317. [PubMed] [Google Scholar]
- 5.Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med. 1983;143:1753–1755. [PubMed] [Google Scholar]
- 6.Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: an update for the 21st-century consultant. Arch Intern Med. 2007;167:271–275. doi: 10.1001/archinte.167.3.271. [DOI] [PubMed] [Google Scholar]
- 7.Klein LE, Levine DM, Moore RD, Kirby SM. The preoperative consultation. Response to internists’ recommendations. Arch Intern Med. 1983;143:743–744. [PubMed] [Google Scholar]
- 8.United Nations Department of Economic and Social Affairs. World population ageing 2020 highlights: living arrangements of older persons. New York: United Nations; 2020. [Google Scholar]
- 9.Pearse RM, Moreno RP, Bauer P, Pelosi P, Metnitz P, Spies C, et al. Mortality after surgery in Europe: a 7 day cohort study. Lancet. 2012;380:1059–1065. doi: 10.1016/S0140-6736(12)61148-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Kim SW, Han HS, Jung HW, Kim KI, Hwang DW, Kang SB, et al. Multidimensional frailty score for the prediction of postoperative mortality risk. JAMA Surg. 2014;149:633–640. doi: 10.1001/jamasurg.2014.241. [DOI] [PubMed] [Google Scholar]
- 11.Tanriover MD, Guven G, Buldukoglu C, Diker O, Halacli B, Yildirim G, et al. Should every adult patient in the hospital have an internist? Sao Paulo Med J. 2013;131:283–284. doi: 10.1590/1516-3180.2013.1314719. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Siegal EM. Just because you can, doesn’t mean that you should: a call for the rational application of hospitalist comanagement. J Hosp Med. 2008;3:398–402. doi: 10.1002/jhm.361. [DOI] [PubMed] [Google Scholar]
- 13.Rohatgi N, Loftus P, Grujic O, Cullen M, Hopkins J, Ahuja N. Surgical comanagement by hospitalists improves patient outcomes: a propensity score analysis. Ann Surg. 2016;264:275–282. doi: 10.1097/SLA.0000000000001629. [DOI] [PubMed] [Google Scholar]
- 14.Montero Ruiz E, Rebollar Merino Á, Rivera Rodríguez T, García Sánchez M, Agudo Alonso R, Barbero Allende JM. Effect of comanagement with internal medicine on hospital stay of patients admitted to the service of otolaryngology. Acta Otorrinolaringol Esp. 2015;66:264–268. doi: 10.1016/j.otorri.2014.09.010. [DOI] [PubMed] [Google Scholar]
- 15.Della Rocca GJ, Moylan KC, Crist BD, Volgas DA, Stannard JP, Mehr DR. Comanagement of geriatric patients with hip fractures: a retrospective, controlled, cohort study. Geriatr Orthop Surg Rehabil. 2013;4:10–15. doi: 10.1177/2151458513495238. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Kammerlander C, Roth T, Friedman SM, Suhm N, Luger TJ, Kammerlander-Knauer U, et al. Ortho-geriatric service--a literature review comparing different models. Osteoporos Int. 2010;21(Suppl 4):S637–S646. doi: 10.1007/s00198-010-1396-x. [DOI] [PubMed] [Google Scholar]
- 17.Boddaert J, Cohen-Bittan J, Khiami F, Le Manach Y, Raux M, Beinis JY, et al. Postoperative admission to a dedicated geriatric unit decreases mortality in elderly patients with hip fracture. PLoS One. 2014;9:e83795. doi: 10.1371/journal.pone.0083795. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Simon TD, Eilert R, Dickinson LM, Kempe A, Benefield E, Berman S. Pediatric hospitalist comanagement of spinal fusion surgery patients. J Hosp Med. 2007;2:23–30. doi: 10.1002/jhm.144. [DOI] [PubMed] [Google Scholar]
- 19.Beresford L. The comanagement conundrum. Philadelphia, PA: The Hospitalist: Society of Hospital Medicine; 2011. [Google Scholar]
- 20.Stier G, Ramsingh D, Raval R, Shih G, Halverson B, Austin B, et al. Anesthesiologists as perioperative hospitalists and outcomes in patients undergoing major urologic surgery: a historical prospective, comparative effectiveness study. Perioper Med (Lond) 2018;7:13. doi: 10.1186/s13741-018-0090-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Letica-Kriegel AS, Tin AL, Nash GM, Benfante NE, McNeil N, Vickers AJ, et al. Feasibility of a geriatric comanagement (GERICO) pilot program for patients 75 and older undergoing radical cystectomy. Eur J Surg Oncol. 2022;48:1427–1432. doi: 10.1016/j.ejso.2022.02.023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Shaw M, Pelecanos AM, Mudge AM. Evaluation of internal medicine physician or multidisciplinary team comanagement of surgical patients and clinical outcomes: a systematic review and meta-analysis. JAMA Netw Open. 2020;3:e204088. doi: 10.1001/jamanetworkopen.2020.4088. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Chae W, Park EC, Lee KY, Kang HJ, Lee WY, Kim YM, et al. Development and evolution of hospital medicine in Korea. J Hosp Med. 2021;16:247–250. doi: 10.12788/jhm.3573. [DOI] [PubMed] [Google Scholar]
- 24.Jang SI. Korean hospitalist system implementation and development strategies based on pilot studies. J Korean Med Assoc. 2019;62:558–563. [Google Scholar]
- 25.Jung YB, Jung EJ, Lee KY. A surgical hospitalist system in Korea: a preliminary study of the effects on hospital costs and postoperative outcomes. Ann Surg Treat Res. 2021;100:298–304. doi: 10.4174/astr.2021.100.5.298. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Summary of Subgroup Analyses of Patient Characteristics Potentially Influencing Outcomes of Active SCM