Introduction
While the traditional model for medical consultation still exists in many hospitals, particularly at academic medical centers, many surgeons and hospitalists have expressed concerns about its limitations. Traditional consultation requires the referring physician to recognize when a patient requires a consultant’s input. However, a surgeon may not recognize when a patient is at high risk for medical complications, and thus fails to seek a consultation in a timely manner. Similarly, a hospitalist may identify important medical problems beyond the initial reason for consultation. The traditional consultation model, which limits the consultant to leaving recommendations, may also be inefficient if their implementation by the referring physician is delayed. To overcome these limitations, many hospitalists have taken on a more active role in caring for patients admitted for surgical or other specialty care. This new model has been termed comanagement.
A 2005 survey by the Society of Hospital Medicine (SHM) found that 85% of Hospital Medicine groups performed comanagement. Several factors are driving the growth of comanagement. Demographic changes in the surgical population have been a major impetus for surgeons’ demand for comanagement. As surgical volumes increase, surgeons must spend greater amounts of time in the operating room and have become less available to care for their patients on the floor. The availability of surgical house staff at teaching hospitals has also become increasingly limited due to tighter restrictions on resident duty hours. Simultaneously, surgical patients are older and sicker, and thus at greater risk for medical complications. Not surprisingly, many surgeons now feel that the traditional consultation model is too limiting. A study in 2007 found that only 41% of surgeons felt that consultants should limit their input to the initial consultation question, and only 37% believed that consultants should avoid writing orders without prior approval from the primary team. The majority of surgeons in this study desired a comanagement relationship with their consultant.
Medical centers have also pushed Hospital Medicine groups to adopt a comanagement role. Much of this impetus may arise from the desire to recruit and retain surgeons who demand medical comanagement. However, in some cases, hospital administrators have advocated for comanagement as a way to improve quality, safety, and cost efficiency in surgical patients, the same way that hospitalists have demonstrated these benefits in their own patients. Hospitals may also desire comanagement in response to nursing staff concerns about the limited availability of surgeons and specialists to respond to questions or address problems in their patients.
While not all hospitalists have been eager to pursue comanagement, many hospital medicine groups view it as a way to expand their role and demonstrate their value. Comanagement has also been seen as a potential source of revenue to hospitalist groups, both through increased professional fee collection as well as strategic support from the medical center.
Definition of Comanagement
There is no universally accepted definition of comanagement, and this moniker has been applied to a wide range of practice patterns. One definition, which encompasses most hospitalists’ practice, is that comanagement is a negotiated, collaborative relationship, which provides hospitalists with a broad scope of practice and also requires their increased responsibility for management of medical care in patients who are primarily being treated by a surgeon or other specialist.This definition does not assume that the surgeon or specialist will serve as the admitting physician. The term has also been applied to situations in which the hospitalist acts as the admitting physician for surgical patients, a practice that is especially common in nonteaching hospitals. While some have argued that it is the specialist who is comanaging the patient in that scenario, rather than the hospitalist, much of this discussion will still be relevant. The specific protocols and attributes of comanagement services vary. However, many comanagement services have common features that distinguish them from traditional medical consultation (Table 43-1).
| Traditional Medical Consultation | Comanagement | |
|---|---|---|
| Determination of hospitalist’s responsibilities and scope of practice | Determined at time of referral or based on informal understanding | Previously negotiated formal agreement between hospitalist and specialist |
| Identification of patients | Hospitalist only sees patients referred by specialist | Hospitalist may see patients selected by predetermined clinical criteria without specialist referral |
| Identification of problems | Hospitalist only addresses problems identified by specialist | Hospitalist may choose which problems to address |
| Communication of assessment and recommendations | Hospitalist only communicates assessment and recommendations to specialist | Hospitalist communicates directly with patient when appropriate |
| Communication with nurses and other providers | Hospitalist does not address questions or concerns from nurses | Hospitalist directly responds to questions and concerns from nurses |
| Permission to write orders and request additional consultation | Hospitalist must obtain permission from specialist first | Prior discussion with specialist rarely needed |
| Role in discharge planning | Hospitalist has limited or no role | Hospitalist addresses medical problems at time of discharge |
| Role of hospitalist beyond direct patient care | None | Hospitalist may work with specialist in quality improvement, education, and research projects |
Principles and Best Practices in Comanagement
Even when a comanagement relationship evolves organically over time, a formal agreement between the hospitalist and specialist is a key feature for success. This agreement should be negotiated between the Hospital Medicine group and a champion for comanagement among the specialists. A written policy or protocol provides shared expectations for the hospitalist’s roles and responsibilities. This is crucial for preventing disagreements and dissatisfaction that can arise from misunderstanding between hospitalist and specialist. If specialists become busier or if hospitalists demonstrate their value, the natural tendency is for both the number of comanaged patients and the depth of hospitalists involvement to grow. The formal agreement can provide the hospitalists with a degree of protection and predictability in terms of their workload by setting limits to the comanagement service’s census or require provision of additional resources as the service grows.
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Ensuring good patient care, however, is the most important reason to develop a formal comanagement agreement. By its nature, comanagement entails fragmentation of care. The primary physician’s responsibility to provide comprehensive care under a traditional care model is now being shared with another physician under comanagement. A formal, negotiated agreement helps to ensure that care is not omitted, duplicated, or in conflict. In some cases, these agreements must include multiple parties, such as when several subspecialists provide potentially overlapping care. For example, a neurosurgeon, a neurologist, and an intensivist, in addition to the comanaging hospitalist, will often jointly manage patients admitted with subarachnoid hemorrhage. The comanagement agreement should carefully define each specialist’s roles and responsibilities.
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Surgeons and other specialists may not recognize when a patient would benefit from medical consultation. Many comanagement protocols try to circumvent this problem by having the hospitalist follow patients who meet predetermined clinical criteria, even in the absence of a referral from the primary physician. Optimal patient selection criteria have not been elucidated, but they should be based on known risk factors for medical complications (Table 43-2). These risk factors may include specific admitting diagnoses or procedures (eg, hip fracture repair), demographic features (eg, over age 70), or the presence of specific medical comorbidities (eg, one or more revised cardiac risk index predictors). Determining appropriate selection criteria can be challenging. Comanagement probably has little benefit for healthy, low-risk patients, and overly inclusive criteria dilute the impact of hospitalists while overburdening them with work. Thus, attention should also be given to the projected number of patients that would be comanaged under the selection rules.
| Surgical Population | Selection Criteria for Comanagement | |
|---|---|---|
| Huddleston (2004) | Elective arthroplasty |
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