Musculoskeletal disorders and diseases are the leading cause of disability in the United States and account for more than one-half of all chronic conditions in people over 50 years of age in developed countries. More than one in four Americans have a musculoskeletal condition requiring medical attention. Annual direct and indirect costs for bone and joint health are $849 billion, 7.7% of the gross domestic product.
Based on this data it is little wonder that orthopedic surgery will have increasing volumes of patient visits and operative interventions in the coming years, especially in the setting of an aging population with increasing expectations for functional recovery and quality of life. The challenge associated with this growth will be the increasing number of medical comorbidities in these older patients and the need for a systematic evaluation of such comorbidities to optimize the perioperative course. It is estimated that surgery-related costs will rise 50% and surgical complications 100% in the United States in the next two decades.
From the beginning hospitalists have filled a collaborative role, assuming care of primary care physicians' patients in the hospital. Just as primary care physicians (PCPs) cannot feasibly be in two places at once (the office and the hospital), surgeons cannot simultaneously manage complex inpatients and perform surgeries. Combining limited surgical availability with restricted surgical resident work hours, which creates added pressure for surgical residents to maximize operating room time, the active involvement of a medical comanager makes great practical and economic sense if it is planned well and actively managed.
Early literature on orthopedic comanagement focused on geriatrician collaboration with surgeons. Despite inconsistent data on length of hospital stay and mortality, these studies and more recent ones demonstrate that systematic geriatric evaluation and management can decrease the incidence of common postoperative medical complications such as congestive heart failure, arrhythmias, venous thromboembolism (VTE), and delirium, and improve compliance with antiosteoporotic therapy and VTE prophylaxis. More recent literature has focused on hospitalist collaboration with orthopedics and has shown lower adjusted length of hospital stay and decreased complication rates in some studies, although mortality and readmission rates were not changed. In one study of hip fracture patients, delirium was diagnosed more often in the comanagement group, but this was associated with an earlier discharge after surgery. This may reflect greater attention to the presence of delirium, better documentation, and more prompt treatment.
In practice, comanagement is becoming a more prominent practice pattern especially as an integrated part of hospitalist practice. A recent retrospective study of Medicare beneficiaries has shown an 11.4% per year rise in comanagement practice by generalist physicians between 2001 and 2006. Thus, in all likelihood, the practice of comanagement by hospitalists will not wane, and more surgeons, especially orthopedists, will call on hospitalists in this collaborative spirit. The 2005–2006 Society of Hospital Medicine (SHM) survey indicated that 85% of hospital medicine groups did a form of comanagement.