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Evaluation of Internal Medicine Physician or Multidisciplinary Team Comanagement of Surgical Patients and Clinical Outcomes: A Systematic Review and Meta-analysis.

ABSTRACT: Importance: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. Objective:To evaluate the association of IM physician involvement with clinical and health system outcomes compared with usual surgical care among adults who undergo surgery. Data Sources:MEDLINE, Embase, CINAHL, and CENTRAL databases were searched for studies published in English from database inception to April 2, 2019. Study Selection:Prospective randomized or nonrandomized clinical studies comparing IM physician consultation or comanagement with usual surgical care were selected by consensus of 2 reviewers. Data Extraction and Synthesis: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. Main Outcomes and Measures:The prespecified primary outcome was length of stay; other outcomes included 30-day readmissions, inpatient mortality, medical complications, functional outcomes, and costs. Results: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. Conclusions and Relevance: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.

SUBMITTER: Shaw M

PROVIDER: S-EPMC7201311 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BACKGROUND: Morbidity and mortality (M&M) conferences provide a forum for discussing adverse events and systems-based practice (SBP) issues; however, few models for implementing multidisciplinary, systems-focused M&M conferences exist. OBJECTIVE: To implement a new systems-focused M&M conference and evaluate success in focusing on adverse events and systems issues in a nonpunitive, multidisciplinary manner. METHODS: We implemented a new M&M conference into our large university-based internal medicine residency program. Using content analysis, we qualitatively analyzed audio recordings of M&M conferences from the first year of implementation (2010-2011) to determine the frequency of adverse events (injury resulting from medical care), SBP discussion, and allocation of blame. Multidisciplinary attendance was evaluated by attendance logs. Surveys assessed change in interns' perceptions of M&M conferences before and after the conference series (measured by median Likert-scale response) and trainee/faculty attitudes regarding the goal of M&M conferences. RESULTS: There were 226 attendees (66 faculty, 160 residents/fellows) at 9 M&M conferences. Average attendance per conference was 71, with representation from 16 disciplines. All M&M conferences (100%) included adverse events, SBP discussion, and lacked explicit individual blame. Interns' perceptions improved, including their belief that the M&M conference's purpose is systems improvement (4.35 versus 4.71, P = .02) and complications are discussed without blame (3.81 versus 4.34, P = .01). After experiencing M&M conferences, trainees/faculty reported favorable ratings, including beliefs that the M&M conference is important for education (97%) and the purpose is systems improvement (95%). CONCLUSIONS: The implementation of a new systems-focused M&M conference resulted in a conference series focusing on adverse events and associated system issues in a nonpunitive, multidisciplinary context.

Project description:ImportanceThe human patient simulators that are currently used in multidisciplinary operating room team training scenarios cannot simulate surgical tasks because they lack a realistic surgical anatomy. Thus, they eliminate the surgeon's primary task in the operating room. The surgical trainee is presented with a significant barrier when he or she attempts to suspend disbelief and engage in the scenario.ObjectiveTo develop and test a simulation-based operating room team training strategy that challenges the communication abilities and teamwork competencies of surgeons while they are engaged in realistic operative maneuvers.Design, setting, and participantsThis pre-post educational intervention pilot study compared the gains in teamwork skills for midlevel surgical residents at Wake Forest Baptist Medical Center after they participated in a standardized multidisciplinary team training scenario with 3 possible levels of surgical realism: (1) SimMan (Laerdal) (control group, no surgical anatomy); (2) "synthetic anatomy for surgical tasks" mannequin (medium-fidelity anatomy), and (3) a patient simulated by a deceased donor (high-fidelity anatomy).InterventionsParticipation in the simulation scenario and the subsequent debriefing.Main outcomes and measuresTeamwork competency was assessed using several instruments with extensive validity evidence, including the Nontechnical Skills assessment, the Trauma Management Skills scoring system, the Crisis Resource Management checklist, and a self-efficacy survey instrument. Participant satisfaction was assessed with a Likert-scale questionnaire.ResultsScenario participants included midlevel surgical residents, anesthesia providers, scrub nurses, and circulating nurses. Statistical models showed that surgical residents exposed to medium-fidelity simulation (synthetic anatomy for surgical tasks) team training scenarios demonstrated greater gains in teamwork skills compared with control groups (SimMan) (Nontechnical Skills video score: 95% CI, 1.06-16.41; Trauma Management Skills video score: 95% CI, 0.61-2.90) and equivalent gains in teamwork skills compared with high-fidelity simulations (deceased donor) (Nontechnical Skills video score: 95% CI, -8.51 to 6.71; Trauma Management Skills video score: 95% CI, -1.70 to 0.49).Conclusions and relevanceIncluding a surgical task in operating room team training significantly enhanced the acquisition of teamwork skills among midlevel surgical residents. Incorporating relatively inexpensive, medium-fidelity synthetic anatomy in human patient simulators was as effective as using high-fidelity anatomies from deceased donors for promoting teamwork skills in this learning group.

Project description:BackgroundUS healthcare organizations increasingly use physician satisfaction and attitudes as a key performance indicator. Further, many health care organizations also have an academically oriented mission. Physician involvement in research and teaching may lead to more positive workplace attitudes, with subsequent decreases in turnover and beneficial impact on patient care. This article aimed to understand the influence of time spent on academic activities and perceived quality of care in relation to job attitudes among internal medicine physicians in the Veterans Health Administration (VHA).MethodsA cross-sectional survey was conducted with inpatient attending physicians from 36 Veterans Affairs Medical Centers. Participants were surveyed regarding demographics, practice settings, workplace staffing, perceived quality of care, and job attitudes. Job attitudes consisted of three measures: overall job satisfaction, intent to leave the organization, and burnout. Analysis used a two-level hierarchical model to account for the nesting of physicians within medical centers. The regression models included organizational-level characteristics: inpatient bed size, urban or rural location, hospital teaching affiliation, and performance-based compensation.ResultsA total of 373 physicians provided useable survey responses. The majority (72%) of respondents reported some level of teaching involvement. Almost half (46%) of the sample reported some level of research involvement. Degree of research involvement was a significant predictor of favorable ratings on physician job satisfaction and intent to leave. Teaching involvement did not have a significant impact on outcomes. Perceived quality of care was the strongest predictor of physician job satisfaction and intent to leave. Perceived levels of adequate physician staffing was a significant contributor to all three job attitude measures.ConclusionsExpanding opportunities for physician involvement with research may lead to more positive work experiences, which could potentially reduce turnover and improve system performance.

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Evaluation of Internal Medicine Physician or Multidisciplinary Team Comanagement of Surgical Patients and Clinical Outcomes: A Systematic Review and Meta-analysis.

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