Outcomes – Page 5 – The Health Care Blog

2010 Unplugged

Jan 4, 2011• 4

By BOB WACHTER, MD

For people like me, who, perversely enough, get a certain thrill from studying healthcare policy, there’s never been a more exciting, if also dizzying, year than 2010. Passage of the reform bill last March was only the start – and in some ways merely a marker – of the Shifting of the Paradigms: from provider to system; from pen to keyboard; from pay-for-piecework to pay-for-performance; from secrecy to transparency; from patient as passive actor to patient as star of our show.

I’ve been catching up on my reading during the holidays, so bear with me as I devote this blog – lengthier than usual – to a handful of articles, talks, and experiences that, while seeming unrelated, helped me better understand some of the threads of this vibrant healthcare tapestry we’re now weaving.

For decades, one of the defining characteristics of the American healthcare enterprise has been the remarkably poor value – quality divided by cost – it produces. Most of the changes afoot represent a push by a variety of stakeholders, using the tools at their disposal, to improve this value equation. And much of the push-back can be seen as the predictable acts of those who benefited from the old order. As the late William Safire once observed, when you zap a sacred cow, you need to brace yourself for the ensuing mooing. Welcome to Old MacDonald’s Farm.

Hospitalist Co-Management Of Neurosurgery Patients

Dec 24, 2010• 3

By ROBERT WACHTER, MD

In this month’s Archives of Internal Medicine, my colleagues and I report the results of our early experience with hospitalist co-management of neurosurgery patients. We found stratospheric satisfaction among neurosurgeons and nurses, as well as impressive cost reductions ($1400/admission). At the same time, there was no impact on quality or safety, at least as judged by hard end-points such as mortality and readmission rates.

While these results might seem like a mixed bag, I believe that the overall impact of this service has been fantastic, for patients, surgeons, and our own hospitalists. Let me explain, beginning with a brief history of hospitalist co-management, folding in the history of our neurosurgery co-management effort (which we call the “Co-Management with Neurosurgery Service”, or CNS), and ending with some of the more subtle outcomes that lead me to feel that this is one of the most important things our hospitalist program has done since its inception in 1995.

A Brief History of Co-Management

When the hospitalist field took off in the mid-1990s, we projected that its growth would largely reflect the degree to which hospitalists assumed the care of inpatient internal medicine (and later, pediatrics) patients: those with pneumonia, heart failure, sepsis, GI bleed, and the like. Sure, I recognized that there would be increased opportunities for traditional medical consultation – we come when you call us – but I completely underestimated the siren call of co-management.

It turns out that once there are hospitalists in the house, the notion of having them actively co-manage surgical patients is hard to resist, for several reasons. First, many of the problems such patients experience before and after surgery are really medical, not surgical. Secondly, just as a hospitalist can provide on-site availability that the primary care physician can’t match for medical patients, he or she can do the same for surgical patients. (In this case, it’s not that the primary care doc is stuck in the office, but rather the surgeon is stuck in the OR.) Third, in an era of more widespread quality measurement and reporting, it seems likely that a hospitalist will improve quality measures such as DVT prophylaxis and evidence-based management of CHF more than a surgeon, flying solo, would be able to.