- Hugo Quinny Cheng, MD
Hugo Quinny Cheng, MD
- Clinical Professor of Medicine
- Division of Hospital Medicine
- Department of Medicine
- University of California, San Francisco
- Kevin J Bozic, MD, MBA
Kevin J Bozic, MD, MBA
- Chair of the Department of Surgery and Perioperative Care
- Professor of Orthopedic Surgery
- The Dell Medical School at the University of Texas at Austin
- Section Editors
- Andrew D Auerbach, MD, MPH
Andrew D Auerbach, MD, MPH
- Section Editor - Hospital Medicine
- Professor of Medicine
- University of California, San Francisco
- Hilary Sanfey, MD
Hilary Sanfey, MD
- Section Editor — General Surgical Principles; Quality and Safety
- Professor of Surgery
- SIU School of Medicine
Comanagement is a model that allows the generalist, typically a hospitalist, to share the responsibility, authority, and accountability for the care of surgical patients. The popularity of comanagement has grown in parallel with the hospitalist movement. Between 2001 and 2006, the comanagement of surgical patients by hospitalists increased by over 11 percent per year . This increase is due to several factors, including an increasing number of patients with advance aged or serious medical disease undergoing surgery [2,3].
This topic will provide an overview of the principles of surgical comanagement. The principles of traditional medical consultation are discussed elsewhere. (See "Overview of the principles of medical consultation and perioperative medicine".)
Medical comanagement of surgical patients can take a variety of forms. Often, the surgeon remains the attending of record, while the comanaging physician is given wide latitude to manage the perioperative care of surgical patients. Alternatively, these roles are reversed, and the surgical patient is admitted to the comanaging physician, who assumes primary responsibility for care. In this case, the surgeon is often only responsible for managing issues related to the surgical diagnosis and procedure. Regardless of the specific arrangement, comanagement has features that distinguishes it from traditional medical consultation (table 1).
Negotiated relationship — In traditional medical consultation, the role of the consultant is either defined at the time the consultation is requested or based upon presumed mutual understanding . Comanagement relationships are far more formal . Protocols and expectations are negotiated between the primary and comanaging physician and often delineated in a written comanagement agreement prior to initiating patient care. They involve not only the individual surgeon and comanaging physician but the entire surgical and hospital medicine groups as well as other potential partners, such as hospital administrators.
Selection of patients and reasons for referral — With traditional consultation, the surgeon retains sole authority and responsibility for identifying patients who would benefit from evaluation by the consultant. The surgeon also determines the scope of the consultant's involvement. Consultation etiquette constrains the ability of the consultant to address issues beyond those specified by the referring provider [4,6]. (See "Overview of the principles of medical consultation and perioperative medicine", section on 'Performing the consultation'.)
- Sharma G, Kuo YF, Freeman J, et al. Comanagement of hospitalized surgical patients by medicine physicians in the United States. Arch Intern Med 2010; 170:363.
- Whinney C, Michota F. Surgical comanagement: a natural evolution of hospitalist practice. J Hosp Med 2008; 3:394.
- Siegal EM. Just because you can, doesn't mean that you should: A call for the rational application of hospitalist comanagement. J Hosp Med 2008; 3:398.
- Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med 1983; 143:1753.
- Mendelson DA, Friedman SM. Principles of comanagement and the geriatric fracture center. Clin Geriatr Med 2014; 30:183.
- Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: an update for the 21st-century consultant. Arch Intern Med 2007; 167:271.
- Klein LE, Levine DM, Moore RD, Kirby SM. The preoperative consultation. Response to internists' recommendations. Arch Intern Med 1983; 143:743.
- Ferguson RP, Rubinstien E. Preoperative medical consultations in a community hospital. J Gen Intern Med 1987; 2:89.
- Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med 2004; 141:28.
- Tadros RO, Faries PL, Malik R, et al. The effect of a hospitalist comanagement service on vascular surgery inpatients. J Vasc Surg 2015; 61:1550.
- Rohatgi N, Loftus P, Grujic O, et al. Surgical Comanagement by Hospitalists Improves Patient Outcomes: A Propensity Score Analysis. Ann Surg 2016; 264:275.
- Montero Ruiz E, Rebollar Merino Á, Rivera Rodríguez T, et al. Effect of comanagement with internal medicine on hospital stay of patients admitted to the Service of Otolaryngology. Acta Otorrinolaringol Esp 2015; 66:264.
- Della Rocca GJ, Moylan KC, Crist BD, et al. Comanagement of geriatric patients with hip fractures: a retrospective, controlled, cohort study. Geriatr Orthop Surg Rehabil 2013; 4:10.
- Kammerlander C, Roth T, Friedman SM, et al. Ortho-geriatric service--a literature review comparing different models. Osteoporos Int 2010; 21:S637.
- Hinami K, Feinglass J, Ferranti DE, Williams MV. Potential role of comanagement in "rescue" of surgical patients. Am J Manag Care 2011; 17:e333.
- Phy MP, Vanness DJ, Melton LJ 3rd, et al. Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med 2005; 165:796.
- Batsis JA, Phy MP, Melton LJ 3rd, et al. Effects of a hospitalist care model on mortality of elderly patients with hip fractures. J Hosp Med 2007; 2:219.
- Auerbach AD, Wachter RM, Cheng HQ, et al. Comanagement of surgical patients between neurosurgeons and hospitalists. Arch Intern Med 2010; 170:2004.
- Society for Hospital Medicine. A Guide to building a Co-Managment Program. http://www.hospitalmedicine.org/Web/Practice_Management/Co-Management/program_building_guide.aspx.
- Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA 2002; 287:487.
- Center for Medicare and Medicaid Services. Hospital CAHPS. 2009. Available at: http://www.hcahpsonline.org/home.aspx (Accessed on January 12, 2011).
- GENERAL PRINCIPLES
- Negotiated relationship
- Selection of patients and reasons for referral
- Broad scope of practice
- Clinical outcomes
- Efficiency of care
- Fragmented care
- Disengagement of the surgeon
- Provider dissatisfaction
- KEYS TO SUCCESS
- Identify obstacles and challenges
- Clarify roles and responsibilities
- Identify champions
- Address financial issues
- Measure performance
- SUMMARY AND RECOMMENDATIONS