Best Practice for Older Patients Fails to Curb Readmissions

Marcia Frellick

May 22, 2017

SAN ANTONIO — Having a nurse phone older adults discharged from the emergency department to help with medication use and appointment scheduling had no effect on readmission rates or on whether the patient followed up with a physician, according to a study of 2000 patients.

The intervention "did not work. It most emphatically did not work," said lead investigator Kevin Biese, MD, a geriatrician and associate professor of emergency and internal medicine at the University of North Carolina at Chapel Hill.

"We felt that if healthcare systems on a wide-scale basis were going to implement a follow-up phone-call intervention, they were likely to do something similar to this — get their callback center to call patients using a scripted survey — he explained here at the American Geriatrics Society (AGS) 2017 Annual Scientific Meeting.

This study shows that they might not want to invest resources in such an intervention, he explained.

The randomized controlled trial had the power to detect a 5% absolute decrease in 30-day readmission rates, which was the primary outcome of the study.

A nurse who worked at the hospital's callback center was trained to phone patients 65 years and older who were discharged from the emergency department in the previous 1 to 3 days.

It most emphatically did not work.

During the call, which took an average of 20 minutes, the nurse reviewed medication instructions, other instructions, such as wound care, and postdischarge instructions, and helped the patient make follow-up appointments.

Similar patients, who served as the control group, got a call from the nurse asking how they felt about their care.

The readmission rates were similar in the intervention and control groups. When Dr Biese showed a graph of the data, he quipped that "if I made those lines red and blue, you'd see purple."

Secondary outcomes were whether patients had trouble getting medications or follow-up appointments in the 30 days after discharge.

"Were they more likely to see a doctor because of the call? No," Dr Biese reported. "Almost 80% in each group saw a doctor within 30 days, and they were not more likely to see that doctor at any point in the time stretch."

In both groups, about 15% of patients said they had difficulty getting a new medication prescribed in the emergency department, he said.

Assuming that this work is validated during the prepublication peer-review process, it "should cause us to move on," said Laura Hanson, MD, chair of the AGS committee that selected the top abstracts for the meeting.

The committee felt this was a well-designed randomized controlled trial with rigorous research methods, she told Medscape Medical News, noting that she recused herself from the selection process because she is also a geriatrician at the University of North Carolina.

The fact that Dr Biese and his team were able to study 2000 patients in a short period of time shows it was powered well, she added.

"Because it's being tried all over the country and people are investing resources and passion in these phone follow-up interventions, it's important for us to know that this just isn't efficient," she explained.

Poor Use of Resources

Checking in to make sure that patients are getting their medications, that they understand the medical instructions, and that they schedule follow-up appointments are "are all considered best practices, and that didn't work," Dr Hanson pointed out.

It might be that "older adults need more than this to dissuade them from feeling that their only recourse is to come back to the emergency department or the hospital," she explained.

A home visit — by a nurse or by a team that includes a nurse, physician, pharmacist, and social worker who can support the patient — might be a better use of resources, Dr Hanson said.

Currently, the rate of older people presenting to the emergency department is greater than the rate of growth of the population, so the situation is urgent, Dr Biese said.

And a recent analysis determined that 57.3% of patients 65 and older admitted to the hospital came through the emergency department (Am J Emerg Med. 2016;34:943-947).

"Any older adult is more likely to find themselves in an emergency department today than 5 or 10 years ago," he said. And they are being taken care of, for the most part, by physicians who don't specialize in the complexities of older adults.

"In our current paradigm of care, whether we admit patients to the hospital or discharge them to the community, they are at high risk," Dr Biese added. "We need to figure out ways to transition the older adults we take care of in the emergency department more safely."

This work is supported by the John A. Hartford Foundation. Dr Biese and Dr Hanson have disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2017 Annual Scientific Meeting. Presented May 18, 2017.

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