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A reengineered hospital discharge program to decrease rehospitalization: a randomized trial
Brian W Jack1, Veerappa K Chetty, David Anthony
1Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts 02118, USA. brian.jack@bmc.org
Insights
A discharge service intervention significantly reduced hospital utilization, including emergency department visits and rehospitalizations, within 30 days post-discharge. This program proved most effective for patients with a history of frequent hospital use.
Area of Science:
- Health Services Research
- Patient Outcomes
- Healthcare Management
Background:
- Hospital readmissions and emergency department (ED) visits post-discharge are significant healthcare burdens.
- Effective discharge planning is crucial to mitigate post-discharge adverse events and reduce hospital utilization.
- Existing discharge protocols may not adequately address patient needs, leading to recurrent hospitalizations.
Purpose of the Study:
- To evaluate the impact of a comprehensive discharge service intervention on minimizing hospital utilization.
- To assess the effectiveness of a multi-component intervention in reducing ED visits and rehospitalizations within 30 days of discharge.
- To identify patient subgroups that benefit most from enhanced discharge support.
Main Methods:
- A randomized controlled trial was conducted involving 749 hospitalized adults at an urban academic safety-net hospital.
- The intervention included a nurse discharge advocate and a clinical pharmacist to arrange follow-up, reconcile medications, educate patients, and reinforce the discharge plan.
- Primary outcomes measured were ED visits and hospitalizations within 30 days; secondary outcomes included patient-reported preparedness and primary care follow-up.
Main Results:
- The intervention group demonstrated a statistically significant reduction in hospital utilization compared to the usual care group (Incidence Rate Ratio: 0.695; P = 0.009).
- The intervention showed the greatest efficacy among patients with a history of hospital utilization in the six months preceding the index admission (P = 0.014).
- No adverse events were reported during the study period, though data analysis is ongoing.
Conclusions:
- A structured package of discharge services effectively reduces hospital utilization within 30 days of discharge.
- The intervention's success, particularly in high-utilization patients, highlights the importance of targeted post-discharge support.
- Further research should explore scalability and long-term effects across diverse healthcare settings.
Background:
Emergency department visits and rehospitalization are common after hospital discharge.
Objective:
To test the effects of an intervention designed to minimize hospital utilization after discharge.
Design:
Randomized trial using block randomization of 6 and 8. Randomly arranged index cards were placed in opaque envelopes labeled consecutively with study numbers, and participants were assigned a study group by revealing the index card.
Setting:
General medical service at an urban, academic, safety-net hospital.
Patients:
749 English-speaking hospitalized adults (mean age, 49.9 years).
Intervention:
A nurse discharge advocate worked with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education with an individualized instruction booklet that was sent to their primary care provider. A clinical pharmacist called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications. Participants and providers were not blinded to treatment assignment.
Measurements:
Primary outcomes were emergency department visits and hospitalizations within 30 days of discharge. Secondary outcomes were self-reported preparedness for discharge and frequency of primary care providers' follow-up within 30 days of discharge. Research staff doing follow-up were blinded to study group assignment.
Results:
Participants in the intervention group (n = 370) had a lower rate of hospital utilization than those receiving usual care (n = 368) (0.314 vs. 0.451 visit per person per month; incidence rate ratio, 0.695 [95% CI, 0.515 to 0.937]; P = 0.009). The intervention was most effective among participants with hospital utilization in the 6 months before index admission (P = 0.014). Adverse events were not assessed; these data were collected but are still being analyzed.
Limitation:
This was a single-center study in which not all potentially eligible patients could be enrolled, and outcome assessment sometimes relied on participant report.
Conclusion:
A package of discharge services reduced hospital utilization within 30 days of discharge.
Funding:
Agency for Healthcare Research and Quality and National Heart, Lung, and Blood Institute, National Institutes of Health.
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