Musculoskeletal disorders and diseases are the leading cause of disability in the United States and account for more than one-half of all chronic conditions in people over 50 years of age in developed countries. More than one in four Americans have a musculoskeletal condition requiring medical attention. Annual direct and indirect costs for bone and joint health are $849 billion, 7.7% of the gross domestic product.

Based on this data it is little wonder that orthopedic surgery will have increasing volumes of patient visits and operative interventions in the coming years, especially in the setting of an aging population with increasing expectations for functional recovery and quality of life. The challenge associated with this growth will be the increasing number of medical comorbidities in these older patients and the need for a systematic evaluation of such comorbidities to optimize the perioperative course. It is estimated that surgery-related costs will rise 50% and surgical complications 100% in the United States in the next two decades.

From the beginning hospitalists have filled a collaborative role, assuming care of primary care physicians’ patients in the hospital. Just as primary care physicians (PCPs) cannot feasibly be in two places at once (the office and the hospital), surgeons cannot simultaneously manage complex inpatients and perform surgeries. Combining limited surgical availability with restricted surgical resident work hours, which creates added pressure for surgical residents to maximize operating room time, the active involvement of a medical comanager makes great practical and economic sense if it is planned well and actively managed.

Early literature on orthopedic comanagement focused on geriatrician collaboration with surgeons. Despite inconsistent data on length of hospital stay and mortality, these studies and more recent ones demonstrate that systematic geriatric evaluation and management can decrease the incidence of common postoperative medical complications such as congestive heart failure, arrhythmias, venous thromboembolism (VTE), and delirium, and improve compliance with antiosteoporotic therapy and VTE prophylaxis. More recent literature has focused on hospitalist collaboration with orthopedics and has shown lower adjusted length of hospital stay and decreased complication rates in some studies, although mortality and readmission rates were not changed. In one study of hip fracture patients, delirium was diagnosed more often in the comanagement group, but this was associated with an earlier discharge after surgery. This may reflect greater attention to the presence of delirium, better documentation, and more prompt treatment.

In practice, comanagement is becoming a more prominent practice pattern especially as an integrated part of hospitalist practice. A recent retrospective study of Medicare beneficiaries has shown an 11.4% per year rise in comanagement practice by generalist physicians between 2001 and 2006. Thus, in all likelihood, the practice of comanagement by hospitalists will not wane, and more surgeons, especially orthopedists, will call on hospitalists in this collaborative spirit. The 2005–2006 Society of Hospital Medicine (SHM) survey indicated that 85% of hospital medicine groups did a form of comanagement.

Comanagement of surgical (and medical subspecialty) patients has rapidly evolved with much initial enthusiasm. However, when proposals do not clearly delineate the nature of these relationships, great potential for confusion of roles, miscommunication, suboptimal patient care, and dissatisfaction of both parties can result as the service expands and staffing becomes more of an issue.

Based on the author’s experience and on other hospitalists’ successful collaborations, this chapter will suggest specific steps that can be taken to initiate a potential orthopedic comanagement effort and avoid common pitfalls. Institutional support for this activity is paramount and the medical administration should be involved in these initial meetings from the outset. Initially, ask the following questions:

1. 
   

   Why are we doing this?

   
   

   To start out, it is best to clarify explicitly the motivation for starting such a program: Are the surgeons stretched thin between operating room (OR) time and patient care responsibilities on the floors and in the office? Are orthopedic residents more limited by duty hour restrictions and therefore less able to focus on patient care on the floors? Are there concerns with care quality within the standard structure of medical subspecialty consultation? Are nursing and ancillary staff having issues with access to practitioners for patient medical needs and issues? Do they want someone to take on the burden of doing histories and physicals and discharge notes and summaries? These are just a few questions that might help to focus the expectations of the proposing orthopedists.

   
   
2. 
   

   Is the hospitalist service the best solution to this problem?

   
   

   Once it becomes clear what your orthopedic colleagues desire, then clarify how hospitalist services and skills can (or should) address these issues. Is a hospitalist the best solution to this problem? Certainly hospitalists are adept at addressing medical issues in hospitalized patients as medical consultants, but to what degree should they assume the detailed minutia of patient care (ie, acetaminophen orders, renewing intravenous (IV) fluids)? This presents the potential to become a “glorified resident” in the care of these patients, which many hospitalists abhor. In addition, issues like surgical wound care and drain management may be pushed upon hospitalists despite concerns that their scope of practice exceeds their internal medicine training. Similar concerns have been raised when hospitalists assume primary responsibility for patients with intracranial bleeds for neurosurgeons.

   
   
3. 
   

   What other solutions have been considered?

   
   

   If the first call from nursing for a problem traditionally has gone to orthopedic residents and/or staff who now are tied up elsewhere, is the hospitalist the next logical call in an equitable “comanagement” relationship? Some newer hospitalists or hospitalist groups may accept this as part of their growth and cultivation of their practice; whereas others fear the mission creep to becoming a “glorified resident,” as described previously. In our institution, nurses channel most first calls for a variety of issues to one nurse practitioner (NP) and one physician’s assistant (PA), both stationed on the dedicated orthopedic ward. If relevant medical issues arise that require hospitalist involvement, they will find us on the ward and relay the information to us. This allows us as hospitalists to focus on the more sophisticated medical issues that are more consistent with our scope of practice; in addition, we can also serve as the gatekeeper to further subspecialty consultation when needed, avoiding superfluous consultations and testing.

   
   
4. 
   

   Will a comanagement service jeopardize other relationships, such as with subspecialty consultants and with other medical groups in a community hospital setting?

   
   
5. 
   

   Should the hospitalist service initially limit comanagement to specific patient demographics for the orthopedist, such as for certain PCPs who admit their patients?

Analysis of the current structure of care delivery in orthopedics serves a useful measurement both as a baseline and after the intervention. In our analysis at the Cleveland Clinic, we found that there were significant differences in the delivery of care on medical services and on orthopedic services due to the following factors:

• Limited supervision of medical care provided by the NP and PA.
  
• Competing responsibilities of orthopedic residents providing backup for other providers or assisting in the OR.
  
• Lack of internal medicine training of orthopedic residents to address complicated medical issues.
  
• Significant medical comorbidities of patients requiring routine medical surveillance to prevent, detect, and intervene during their hospitalization.
  
• Limitations of general medical consultation service that typically “reacts” to consultation requests when problems have already been identified and lacks the capacity to prospectively affirm or develop a medical plan of care for high-risk or complicated medical patients.