Anesthesiologists as perioperative hospitalists and outcomes in patients undergoing major urologic surgery: a historical prospective, comparative effectiveness study

Gary Stier,Robert Martin,Briahnna Austin,Ronak Raval,Joseph Soo,Herbert Ruckle,Gary Shih,Bryan Halverson,Davinder Ramsingh

doi:10.1186/s13741-018-0090-y

Abstract

BackgroundPerioperative care has been identified as an area of wide variability in quality, with conflicting models, and involving multiple specialties. In 2014, the Loma Linda University Departments of Anesthesiology and Urology implemented a perioperative hospitalist service (PHS), consisting of anesthesiology-trained physicians, to co-manage patients for the entirety of their perioperative period. We hypothesized that implementation of this PHS model would result in an improvement in patient recovery.MethodsAs a quality improvement (QI) initiative, the PHS service was formed of selected anesthesiologists who received training on the core competencies for hospitalist medicine. The service was implemented following a co-management agreement to medically manage patients undergoing major urologic procedures (prostatectomy, cystectomy, and nephrectomy). Impact was assessed by comparisons to data from the year prior to PHS service implementation. Data was compared with and without propensity matching. Primary outcome marker was a reduction in length of stay. Secondary outcome markers included complication rate, return of bowel function, number of consultations, reduction in total direct patient costs, and bed days saved.ResultsSignificant reductions in length of stay (p < 0.05) were demonstrated for all surgical procedures with propensity matching and were demonstrated for cystectomy and nephrectomy cases without. Significant reductions in complication rates and ileus were also observed for all surgical procedures post-PHS implementation. Additionally, reductions in total direct patient costs and frequency of consultations were also observed.ConclusionsAnesthesiologists can safely function as perioperative hospitalists, providing appropriate medical management, and significantly improving both patient recovery and throughput.

Highlights

Perioperative care has been identified as an area of wide variability in quality, with conflicting models, and involving multiple specialties
Meaning Anesthesiologists can safely function as perioperative hospitalists for patients undergoing urologic surgery
Since the study was initiated as a quality improvement (QI) project, it is reported following the Standards for Quality Improvement Reporting Excellence (SQUIRE guidelines) (Davidoff et al 2009; Ogrinc et al 2008) and is presented as a historical prospective comparative effectiveness format following the GRACE (Good Research for Comparative Effectiveness) initiative principles and checklist (Dreyer 2013; Dreyer et al 2010)

Summary

Introduction

Perioperative care has been identified as an area of wide variability in quality, with conflicting models, and involving multiple specialties. Perioperative care, in particular, has been identified as an area of high cost with a wide variability in quality (Kain et al 2014; Lilot et al 2015). Anesthesiologists in the U.S have investigated a larger role in the patient’s surgical experience as part of the concept of the perioperative surgical home (PSH), which is a patient-centered, physician led, interdisciplinary, and team-based system of coordinated care (Kain et al 2014). While the concepts of PSH and ERAS provide the tools to improve perioperative care, the decision of which, and how, various health care providers should be involved remains unresolved. The question of which provider should be medically managing these patients is of debate

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