Evaluation of post-discharge follow-up and clinical outcomes in patients

Hospital discharge is a vulnerable moment often marked by poor communication and limited patient education. Information and Communication Technologies, like instant messaging, offer scalable tools to improve continuity of care and reduce rehospitalizations.

To evaluate the effectiveness of an intervention designed to improve medication adherence, survival, and prevent rehospitalization through a post-discharge follow-up program.

A quasi-experimental study was conducted in adults discharged from general hospitalization or ambulatory surgery. The intervention group received four weekly educational messages via instant messaging; the pre-intervention group received only a follow-up form. Measured outcomes included response rate, medication adherence, appointment attendance, rehospitalization, and quality of life.

278 patients were included (154 pre-intervention, 124 intervention), with no major differences in age, sex, or residence. Orthopedics was the most common discharging specialty. Follow-up attendance was similar (84.03%). At 30 days, the probability of avoiding rehospitalization was 95.92% in the intervention group (95% CI: 89.49%-98.45%; p = 0.776). However, the intervention group showed a higher rate of non-response (20.97% vs. 5.19%; p < 0.001) and lower contact effectiveness (79.03% vs. 94.81%; p < 0.001). A significant shift toward messaging apps was observed during the intervention period (p < 0.001).

While messaging showed potential, findings underscore the continued importance of phone-based follow-up and the need for hybrid, patient-centered communication strategies. Future interventions should tackle engagement barriers and consider risk-based approaches with extended follow-up to maximize impact.