Study Spots Patients Who Benefit From Early Postdischarge Care

Susan London

March 10, 2015

Hospital readmissions were significantly reduced when patients with multiple chronic conditions and a greater than 20% baseline risk for readmission received follow-up within 7 days of discharge, according to a study of 44,473 Medicaid recipients in North Carolina with 65,085 qualifying discharges.

The main findings, published in the March/April issue of the Annals of Family Medicine, showed that the one quarter of patients having the highest risk had a clinically meaningful reduction in the rate of readmission if they had an outpatient visit within 7 days of discharge. Others saw little, if any, reduction.

"Most patients do not meaningfully benefit from early outpatient follow-up. Transitional care resources would be best allocated toward ensuring that highest risk patients receive follow-up within 7 days," write Carlos Jackson, PhD, from Community Care of North Carolina, Raleigh, and colleagues.

"Even though it may be clinically intuitive that higher risk patients need earlier follow-up, common models for improving transitional care have not emphasized risk segmentation to inform the timing of the follow-up appointment, and there has been little evidence to date upon which to base such guidance," they note.

The investigators retrospectively analyzed state Medicaid claims data for patients discharged between April 2012 and March 2013, ascertaining when they received outpatient follow-up and whether they were readmitted within 30 days. Using the number and complexity of chronic conditions, they split patients into seven strata having different expected readmission rates.

Results of survival modeling showed that the benefit of earlier follow-up in terms of readmissions prevented increased with patients' baseline readmission risk.

In each risk stratum, patients had a significantly lower readmission rate if they had follow-up within 14 days of discharge, but the magnitude of reduction ranged from just 1.5 percentage points in the lowest stratum to 19.1 percentage points in the highest.

However, only slightly more than half of patients in the three highest-risk strata had received follow-up within 14 days, essentially the same as the proportion seen among patients in lower-risk strata.

Patients in the three highest-risk strata also had a clinically meaningful reduction in readmission rate, ranging from 6.2 to 7.7 percentage points, if they had follow-up within 7 days of discharge.

Findings were similar in sensitivity analyses that restricted the sample to adults only, that excluded behavioral health admissions, that looked at the sexes and various racial groups individually, or that considered only each patient's first discharge during the year.

"In current practice, one-size-fits-all discharge protocols may be determining a follow-up time frame more than evidence-based decision making or clinical need. Changing reimbursement policies are likely to further influence transitional care processes," the investigators point out.

"Further research is needed to determine how best to operationalize the practical application of risk segmentation to guide the timing of outpatient follow-up, which may include point-of-care decision support for physicians and personnel involved in discharge planning and scheduling in the hospital and outpatient practice. Risk segmentation may provide further value to inform optimal strategies for alternative models of follow-up contact with patients after discharge, such as nurse or pharmacist contact or other team-based approaches," they conclude.

The investigators have disclosed no relevant financial relationships.

Ann Fam Med. 2015;13:115-122. Full text

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