Abstract
Older patients who undergo surgery may benefit from geriatrician comanagement. It is unclear whether other internal medicine (IM) physician involvement improves outcomes for adults who undergo surgery. To evaluate the association of IM physician involvement with clinical and health system outcomes compared with usual surgical care among adults who undergo surgery. MEDLINE, Embase, CINAHL, and CENTRAL databases were searched for studies published in English from database inception to April 2, 2019. Prospective randomized or nonrandomized clinical studies comparing IM physician consultation or comanagement with usual surgical care were selected by consensus of 2 reviewers. Data were extracted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline by 2 authors independently. Intervention characteristics were described using existing indicators. Risk of bias was assessed using Risk of Bias 2.0 and Risk of Bias in Nonrandomized Studies of Interventions tools. Studies were pooled when appropriate in meta-analysis using random-effects models. Prespecified subgroups included IM physician-only vs multidisciplinary team interventions and patients undergoing elective vs emergency procedures. The prespecified primary outcome was length of stay; other outcomes included 30-day readmissions, inpatient mortality, medical complications, functional outcomes, and costs. Of 6027 records screened, 14 studies (with 1 randomized clinical trial) involving 35 800 patients (13 142 [36.7%] in intervention groups) were eligible for inclusion. Interventions varied substantially among studies and settings; most interventions described comanagement by a hospitalist or internist; 7 (50%) included a multidisciplinary team, and 9 (64%) studied predominantly patients who had elective procedures. Risk of bias in 10 studies (71%) was serious. Meta-analysis showed no significant association with length of stay (mean difference, -1.02 days; 95% CI, -2.09 to 0.04 days; P = .06) or mortality (odds ratio, 0.79; 95% CI, 0.56 to 1.11; P = .18), but multidisciplinary team involvement was associated with significant reduction in length of stay (mean difference, -2.03 days; 95% CI, -4.05 to -0.01 days; P = .05) and mortality (odds ratio, 0.67; 95% CI, 0.51 to 0.88; P = .004). There was no difference in 30-day readmissions (odds ratio, 0.89; 95% CI, 0.68 to 1.16; P = .39). Data could not be pooled for complications or costs. Only 1 study (7%) reported functional outcomes. The findings of this study suggest that IM physician comanagement that includes multidisciplinary team involvement may be associated with reduced length of stay and mortality in adults undergoing surgery. Evidence was low quality, and well-designed prospective studies are still needed.
Highlights
As surgical techniques advance, more medically complex patients have become candidates for surgical interventions, including those who are older, are frail, or have multiple comorbidities and are at higher risk for poor outcomes.[1,2] The increase in the medical complexity of patients undergoing surgery has prompted increased involvement of internal medicine (IM) physicians in all aspects of perioperative care, including preoperatively optimizing the management of comorbidities, such as anemia, postoperatively managing complications, and maximizing functional recovery.[3]
The findings of this study suggest that IM physician comanagement that includes multidisciplinary team involvement may be associated with reduced length of stay and mortality in adults undergoing surgery
Of 6027 articles identified in initial searches, 73 underwent full-text assessment and 16 studies were identified for inclusion, including 1 (6%) randomized clinical trials (RCTs),[24 1] (6%) comparative cohort study,[25] and 14 (88%) pre-post studies,[23,26,27,28,29,30,31,32,33,34,35,36,37,38 3] (21%) of which included a concurrent control group.[26,32,33]
Summary
More medically complex patients have become candidates for surgical interventions, including those who are older, are frail, or have multiple comorbidities and are at higher risk for poor outcomes.[1,2] The increase in the medical complexity of patients undergoing surgery has prompted increased involvement of internal medicine (IM) physicians in all aspects of perioperative care, including preoperatively optimizing the management of comorbidities, such as anemia, postoperatively managing complications, and maximizing functional recovery.[3]. A 2010 literature review[7] identified 21 studies encompassing 4 different models of orthogeriatric service, while a 2015 meta-analysis of randomized clinical trials (RCTs) for patients with hip fracture[8] included 15 studies describing a range of models of integrated geriatric care. The meta-analysis concluded that a comprehensive geriatric care model was associated with greater functional improvement and an increased proportion of patients discharged back to their premorbid place of residence but found no significant difference in mortality or length of stay (LOS).[8] Another systematic review[9] examined geriatrician comanagement across different specialties, including elective orthopedic surgery and older general medical inpatients as well as patients with hip fracture. An international Delphi study[10] recently developed quality structure and process indicators for inpatient geriatric comanagement programs, which are increasingly becoming the standard of care
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
