Systematic Review and Meta-analysis of the Impact of Surgeon–Physician Co-management Models on Short Term Outcomes for Vascular Surgery Inpatients

Objective: As the population ages, vascular surgeons are treating progressively older, multimorbid patients at risk of peri-operative complications. An embedded physician has been shown to improve outcomes in general and orthopaedic surgery. This systematic review and meta-analysis aimed to investigate the impact of surgeon–physician co-management models on morbidity and mortality rates in vascular inpatients. Data Sources: PubMed, Scopus, Embase, conference abstract listings, and clinical trial registries. Review Methods: Studies comparing adult vascular surgery inpatients under co-management with standard of care were eligible. The relative risks (RRs) of death, medical complications, and 30 day re-admission between co-management and standard care were calculated. The effect of co-management on the mean length of stay was calculated using weighted means. Risk of bias was assessed using the Methodological Index for Non-Randomised Studies, and certainty assessment with the GRADE analysis tools. Results: No randomised controlled trials were identified. Eight single institution studies between 2011 and 2020 with 7 410 patients were included. All studies were observational using before–after methodology. Studies were of high to moderate risk of bias, and outcomes were of very low GRADE certainty of evidence. Co-management was associated with a statistically significant lower relative risk of death (RR 0.64, 95% confidence interval [CI] 0.44 – 0.92; p = .02), cardiac complications (RR 0.47, 95% CI 0.25 – 0.87; p = .02), and infective complications (RR 0.49, 95% CI 0.35 – 0.67; p < .001) in vascular inpatients. No statistically significant differences in length of stay (standard mean difference –0.6 days, 95% CI –1.44 – 0.24 days; p = .16) and 30 day re-admission (RR 0.96, 95% CI 0.84 – 1.08; p = .49) were noted. Conclusion: Early results of physician and surgeon co-management for vascular surgery inpatients showed promising results from very low certainty data. Further well designed, prospective studies are needed to determine how to maximise the impact of physicians within a vascular service to improve patient outcomes while using hospital resources effectively.