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Medical and Surgical Comanagement after Elective Hip and Knee Arthroplasty: A Randomized, Controlled Trial

Jeanne M. Huddleston, MD; Kirsten Hall Long, PhD; James M. Naessens, MPH; David Vanness, PhD; Dirk Larson, MS; Robert Trousdale, MD; Matt Plevak, BS; Miguel Cabanela, MD; Duane Ilstrup, MS; Robert M. Wachter, MD, the Hospitalist–Orthopedic Team Trial Investigators
[+] Article, Author, and Disclosure Information

From Mayo Clinic College of Medicine, Rochester, Minnesota, and the University of California, San Francisco, San Francisco, California.

Acknowledgments: The authors thank Donna Lawson, LPN, and Danica Myhre, BS, for data collection, data entry, and project management; Marlené Boyd for administrative assistance; the Department of Medicine leadership, Kevin Whitford, MD, and other Inpatient Internal Medicine faculty and the Department of Orthopedic Surgery for their strong support, participation, and collaboration; the orthopedic surgical nurses at Rochester Methodist Hospital for their willingness to become crucial members of the Hospitalist–Orthopedic Team model of perioperative care; and Amy J. Markowitz for her editorial review.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Jeanne M. Huddleston, MD, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905; e-mail, huddleston.jeanne@mayo.edu.

Current Author Addresses: Drs. Huddleston, Long, Trousdale, Cabanela, and Naessens, Mr. Larson, Mr. Plevak, and Mr. Ilstrup: Mayo Clinic, 200 First Street SW, Rochester, MN 55905.

Dr. Vanness: University of Wisconsin-Madison, 785 WARF Building, 610 Walnut Street, Madison, WI 53726.

Dr. Wachter: University of California, San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143.

Ann Intern Med. 2004;141(1):28-38. doi:10.7326/0003-4819-141-1-200407060-00012
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We conducted a randomized, controlled trial at Rochester Methodist Hospital, a tertiary care, primarily surgical, teaching hospital with 794 beds and an average of more than 15 000 admissions per year. The Department of Orthopedic Surgery consists of 46 faculty surgeons and 50 residents. Twelve of the faculty surgeons perform lower-extremity major joint procedures at Rochester Methodist Hospital. The orthopedic residents rotate with the faculty for blocks of 3 months. We obtained institutional review board approval to conduct this study.

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Figure 1.
Flow of patients through the trial.

Twenty-one patients randomly assigned in the pilot study were not included in the analysis.

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Figure 2.
Surgeon (top) and nurse (bottom) preferences.

The 12 questions presented in the Care Model Assessment questionnaire were as follows (phrases and questions represent exact wording in the questionnaire): 1) general level of communication between all medical care providers; 2) recommendations and questions are brief and specific from the medical physicians; 3) ease of asking for advice from medical physicians at St. Mary's Hospital; 4) ease of providing high-quality medical care; 5) coordination of patients' postoperative medical care; 6) clarity of “who is in charge” of postoperative medical care; 7) coordination of patients' dismissal; 8) recognition of postoperative medical needs of the patient; 9) for medical physicians associated with the unit, general knowledge of perioperative care issues; 10) the patient receives better care; 11) promptness with which patients' postoperative medical care issues are addressed; and 12) results of tests, labs, and procedures are followed up on. HOT = Hospitalist–Orthopedic team.

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Impact of hospitalists on emergency hip surgery outcomes
Posted on July 26, 2004
Archana Roy
Mayo Clinic, Jacksonville
Conflict of Interest: None Declared

I congratulate Huddleston et al (Ann Intern Med. 2004; 141: 28-38) on their study documenting the benefit of orthopedist-hopsitalist comanagement approach for patients undergoing elective hip and knee surgery. As the authors discuss, additional research is needed to assess the clinical and economic impact of this model of care. It remains to be seen whether these findings will hold true in other situations (emergency surgery or other surgical patients). Further, the reason(s) for improved outcomes need to be investigated.

I would like to present our experience regarding the effect of hospitalist comanagement of patients undergoing emergency hip surgery. The setting of our study is at a community-based academic hospital where community physicians as well as physicians affiliated with an academic institution admit patients. This provided us a unique opportunity to compare the outcomes of emergency hip-surgery patients whose pre-operative medical evaluation and post-operative medical care was provided by traditional primary care physician (P), medical teaching service consisting of residents under the supervision of a faculty attending (T), or a dedicated faculty hospitalist (H). Data from 120 consecutive patients admitted from emergency department with hip fracture in 2002 were retrospectively analyzed. Patients in the H group were able to proceed to surgery after a mean (95% CI) of 0.9 day (0.7-1.2) compared to 1.2 (0.8- 1.5) in T and 1.4 (1.2-1.7) in P group, (p=0.03). There were significantly fewer post-operative complications in the H group compared to the other two groups; 27% (95% CI 15-41) vs 50% (27-72) in T and 45% (31-60) in P group, (p=0.04). Mean (95% CI) length of stay in H group was shorter, but not statistically significant, 5 days (4.5-6.0) compared to 6.5 (5-10) in T and 6 (5-7) in P group, (P=0.09). Mean time to completion of pre- operative evaluation consult in H group was 3.3 hr (95% CI 1.2-5.4), compared to 15hr (11.8 "“ 18.4) in T and 14.2hr.(12.2-16.4) in P group, (P = <0.001).

These observations, made in a different setting and patient population, compliment the findings reported by Huddleston et al, and suggest that the benefit of surgeon-hospitalist partnership may be generalizable. One reason for better outcome in the hospitalist group may be their round-the-clock availability. Clearly, that has financial implications. Further research is needed to better understand the mechanisms by which hospitalist model is beneficial, and to critically evaluate its cost-effectiveness.

Conflict of Interest:

None declared

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Summary for Patients

Team Care by Hospitalists with Surgeons after Hip or Knee Surgery

The summary below is from the full report titled “Medical and Surgical Comanagement after Elective Hip and Knee Arthroplasty. A Randomized, Controlled Trial.” It is in the 6 July 2004 issue of Annals of Internal Medicine (volume 141, pages 28-38). The authors are J.M. Huddleston, K. Hall Long, J.M. Naessens, D. Vanness, D. Larson, R. Trousdale, M. Plevak, M. Cabanela, D. Ilstrup, and R.M. Wachter, for the Hospitalist–Orthopedic Team Trial Investigators.


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