Effects of hospitalist co-management on rate of initiation of osteoporosis treatment in patients with vertebral compression fractures: Retrospective cohort study.

BACKGROUND: Vertebral compression fractures are common in elderly people and most are due to osteoporosis. Osteoporosis treatment is effective for secondary prophylaxis, so initiation is recommended. Despite the clear benefits, the rate of initiation of osteoporosis treatment is very low. It is reported to be due to several factors including insufficient systems-based approaches for hospitals and post-acute care. Hospitalists, who are physicians dedicated to the treatment of patients in hospital and whose activity is generalist rather than specialized, are reported to be associated with higher-quality inpatient care because of, among other things, closer adherence to guidelines. Co-management by hospitalists for patients with vertebral compression fractures has potential benefits towards improving the outcomes. We compared the rate of initiation of osteoporosis treatment for patients with vertebral compression fractures between conventional orthopedic surgeon-led care (conventional group) and hospitalist co-management care (co-management group). METHODS: This is a single-center retrospective cohort study to evaluate the rate of initiation of osteoporosis treatment and reasons for non-initiation of osteoporosis treatment. Other clinical indicators were also evaluated, including length of hospital stay, preventable complications during hospitalization, and rate of 30-day readmission. RESULTS: We identified 55 patients in the conventional group and 93 patients in the co-management group. The rate of initiation of osteoporosis treatment was higher in the co-management group (45.2% vs. 3.6%, OR 21.5; 95%CI 5.12-192.0; P < 0.01). Most of the patients with non-initiation in the co-management group had reasons for it described in the medical records, but in the conventional group the reasons were unknown. There was no significant difference in length of hospital stay, preventable complications during hospitalization, or 30-day readmission between the groups. CONCLUSIONS: Hospitalist co-management of patients with vertebral compression fractures showed significantly higher rate of initiation of osteoporosis treatment than conventional orthopedic surgeon-led care.

Effects of hospitalist co-management for hip fractures.

BACKGROUND: Early surgery is recommended for patients with hip fractures. Average time to surgery in Japan is 3.8 days. Such delay could be caused by the burden of preoperative assessment and management of geriatric comorbidities upon orthopedic surgeons. Hospitalist co-management has potential benefits in comprehensive perioperative care that could positively affect time to surgery in patients with hip fractures. We compare clinical outcomes of patients with hip fractures managed by orthopedic surgeon-led care (conventional group) vs. those of patients with hip fractures managed by hospitalist co-management. METHODS: In this single-center retrospective cohort study, time to surgery was assessed with interrupted time series analyses. Whole length of hospital stay, length of hospital stay after surgery, complications during hospitalization, 30-day readmission, initiation of osteoporosis treatment and adherence to guidelines for deep vein thrombosis prophylaxis were also evaluated with Chi-square or Fisher's exact tests. RESULTS: The conventional group comprised 332 patients and the co-management group 418 patients. Interrupted time series analyses revealed an immediate reduction of time to surgery by 1.2 days (95%CI, -1.9 to -0.4, P = 0.003) with the start of co-management. Whole length of hospital stay and length of hospital stay after surgery tended to be shorter, but without statistical significance. Intermediate to severe complications and 30-day readmission were not significantly different between the groups. In the co-management group, the rate of initiation of osteoporosis treatment (46.4% vs. 6.3%, P < 0.001) and adherence rate to guidelines for deep vein thrombosis prophylaxis (99.3% vs. 88%, P < 0.001) were significantly higher than those in the conventional group. CONCLUSIONS: Hospitalist co-management for elderly patients with hip fractures led to significantly shorter time to surgery than conventional orthopedic surgeon-led care, and had advantages in other clinical indicators.

Deciduosis of the Appendix During Pregnancy.

Acute appendicitis is an important differential diagnosis in patients with right lower quadrant pain during pregnancy. Endometriosis, a hormone-related pathology, is another possibility. Patients with endometriosis are typically symptomatic before pregnancy. Stromal endometriosis is a variant of endometriosis that presents no symptoms before pregnancy but which occasionally presents with the new onset of symptoms during pregnancy. We report the case of a 35-year-old woman in her 8th month of pregnancy who presented with impending appendiceal rupture due to deciduosis of the appendix, a progesterone-related condition, during pregnancy. This case suggests that deciduosis/stromal endometriosis should be considered as a differential diagnosis of acute abdomen during pregnancy, even if the patient is asymptomatic before pregnancy.

Impact of the Hospitalist System in Japan on the Quality of Care and Healthcare Economics.

Objective The hospitalist system is considered successful with respect to the quality of care and cost effectiveness in the United States. Studies have consistently demonstrated an improved clinical efficiency with this system. In Japan, however, the efficacy of the hospitalist system has not yet been examined. As a "super-aged society", Japan has a high number of elderly patients with multiple comorbidities who may theoretically receive better care by the hospitalist system than by the conventional system. This study investigates the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population. Methods We analyzed 274 patients ≥65 years of age in whom the most resource-consuming diagnosis at admission was aspiration pneumonia over a 1-year period. We categorized patients as those managed by hospitalists and those managed by various departments (control group) and compared the groups. Propensity score matching was used to minimize selection bias. Results For matched pairs, the length of hospital stay in the hospitalist group was shorter than that in the control group. Care by the hospitalist system was associated with significantly lower hospital costs. The quality of care (rate of switching from intravenous to oral antibiotics, duration of antibiotics therapy, number of chest X-rays and blood tests during hospitalization) was also considered to be favorably impacted by the hospitalist system. There was no statistically significant difference in the mortality rate or readmission rate between the groups. Conclusion This study showed that the hospitalist system had a favorable impact on the quality of care and cost effectiveness, suggesting the potential utility of its implementation in the Japanese medical system.