Clinical Outcomes of Orthopedic Surgery Comanagement by Internal Medicine Advanced Practice Clinicians: A Cohort Study.

OBJECTIVE: Compare clinical outcomes between advanced practice clinician-based comanagement and usual orthopedic care. BACKGROUND: Comanagement of orthopedic surgery patients by internal medicine hospitalists is associated with improvements in clinical outcomes including complications, length of stay, and cost. Clinical outcomes of orthopedic comanagement performed solely by internal medicine advanced practice clinicians have not been reported. METHODS: Retrospective cohort study in patients 18 years or older, hospitalized for orthopedic joint or spine surgery between May 1, 2014, and January 1, 2022. Outcomes assessed were length of stay, ICU transfer, return to operating room, inhospital and 30-day mortality, 30-day readmission, and total direct cost excluding surgical implants. Generalized boosted regression and propensity score weighting was used to compare clinical outcomes and healthcare cost between usual care and advanced practice clinician comanagement. RESULTS: Advanced practice clinician comanagement was associated with a 5% reduction in mean length of stay (RR=0.95, p=0.009), decreased odds of returning to the operating room (OR= 0.51, p=0.002), and a significant reduction in 30-day mortality (OR= 0.32, p=0.037) compared to usual orthopedic care in a weighted analysis. Need for ICU transfer was higher with advanced practice clinician comanagement (OR= 1.54, p=0.009), without significant differences in 30-day readmission or inhospital mortality. CONCLUSIONS: We observed reductions in length of stay, healthcare costs, return to the operating room, and 30-day mortality with advanced practice clinician comanagement compared to usual orthopedic care. Our findings suggest advanced practice clinician-based comanagement may represent a safe and cost-effective model for orthopedic comanagement.

Comparison of Resident, Advanced Practice Clinician, and Hospitalist Teams in an Academic Medical Center: Association With Clinical Outcomes and Resource Utilization.

BACKGROUND: Academic medical centers have expanded their inpatient medicine services with advanced practice clinicians (APCs) or nonteaching hospitalists in response to patient volumes, residency work hour restrictions, and recently, COVID-19. Reports of clinical outcomes, cost, and resource utilization differ among inpatient team structures. OBJECTIVE: Directly compare outcomes among resident, APC, and solo hospitalist inpatient general medicine teams. DESIGN: Retrospective cohort study using multivariable analysis adjusted for time of admission, interhospital transfer, and comorbidities that compares clinical outcomes, cost, and resource utilization. SUBJECTS: Patients 18 years or older discharged from an inpatient medicine service between July 2015 and July 2018 (N = 12,716). MAIN MEASURES: Length of stay (LOS), 30-day readmission, inpatient mortality, normalized total direct cost, discharge time, and consultation utilization. KEY RESULTS: Resident teams admitted fewer patients at night (32.0%; P < .001) than did APC (49.5%) and hospitalist (48.6%) teams. APCs received nearly 4% more outside transfer patients (P = .015). Hospitalists discharged patients 26 minutes earlier than did residents (mean hours after midnight [95% CI], 14.58 [14.44-14.72] vs 15.02 [14.97-15.08]). Adjusted consult utilization was 15% higher for APCs (adjusted mean consults per admission [95% CI], 1.00 [0.96-1.03]) and 8% higher for residents (0.93 [0.90-0.95]) than it was for hospitalists (0.85 [0.80-0.90]). No differences in LOS, readmission, mortality, or cost were observed between the teams. CONCLUSION: We observed similar costs, LOS, 30-day readmission, and mortality among hospitalist, APC, and resident teams. Our results suggest clinical outcomes are not significantly affected by team structure. The addition of APC or hospitalist teams represent safe and effective alternatives to traditional inpatient resident teams.

Impact of Hospitalist Team Structure on Patient-Reported Satisfaction with Physician Performance.

BACKGROUND: Patient experience is valuable because it reflects how patients perceive the care they receive within the healthcare system and is associated with clinical outcomes. Also, as part of the Hospital Value-Based Purchasing (HVBP) program, the Center for Medicare and Medicaid Services (CMS) rewards hospitals with financial incentives for patient experience as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. It is unclear how the addition of residents and advanced practice clinicians (APCs) to hospitalist-led inpatient teams affects patient satisfaction as measured by the HCAHPS and Press Ganey survey. OBJECTIVE: To compare patient satisfaction with hospitalists on resident, APC, and solo hospitalist teams measured by HCAHPS and Press Ganey physician performance domain survey results. DESIGN: Retrospective observational cohort study. PARTICIPANTS: All patients discharged from the Internal Medicine inpatient service between July 1, 2015, and July 1, 2018, who met HCAHPS survey eligibility criteria and completed a patient experience survey. MAIN MEASURES: HCAHPS and Press Ganey physician performance domain survey results. KEY RESULTS: No differences were observed in the selection of "top box" scores on the HCAHPS physician performance domain between resident, APC, and solo hospitalist teams. Adjusted Press Ganey physician performance domain survey results demonstrated significant differences between solo hospitalist and resident teams, with solo hospitalists having higher scores in three areas: time physician spent with you (4.58 vs. 4.38, p = 0.050); physician kept you informed (4.63 vs. 4.43, p = 0.047); and physician skill (4.80 vs. 4.63, p = 0.027). Solo hospitalists were perceived to have higher physician skill in comparison with hospitalist-APC teams (4.80 vs. 4.69, p = 0.042). CONCLUSION: While Press Ganey survey results suggest that patients have greater satisfaction with physicians on solo hospitalist teams, these differences were not observed on the HCAHPS physician performance survey domain, suggesting physician team structure does not impact HVBP incentive payments by CMS.

Residents examine factors associated with 30-day, same-cause hospital readmissions on an internal medicine service.

In recent years, there has been increased interest in stemming the tide of hospital readmissions in an attempt to improve quality of care. This study presents the Phase I results of a resident-led quality improvement initiative to determine the percentage of and risk factors for same-cause readmissions (SCRs; defined as hospital readmission within 30 days of hospital discharge for treatment of the same condition) to the internal medicine service of a multispecialty teaching hospital in central Texas. Results indicate that patients diagnosed with chronic obstructive pulmonary disease/asthma or anemia may be at increased risk for SCRs. Those patients who are insured by Medicaid and those who require assistance from social services also demonstrated an increased risk for SCRs. This study appears to be the first resident-led initiative in the field to examine 30-day SCRs to an internal medicine service for demographic and clinical risk factors.