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Care Coordination and Hospitalization in Older Adults With or at Risk for Cardiovascular Disease: A Randomized
Lisa M Kern1, Joselyne E Aucapina1, Samprit Banerjee2
1Department of Medicine, Weill Cornell Medicine, New York, New York.
Insights
Proactive care coordination for cardiovascular disease (CVD) patients did not reduce hospitalizations compared to usual post-hospitalization care. Many patients declined the proactive outreach, preferring to manage their own care.
Area of Science:
- Cardiovascular Disease Management
- Healthcare Coordination
- Health Services Research
Background:
- Patients with cardiovascular disease (CVD) often experience fragmented care due to multiple ambulatory physicians.
- Care coordinators can improve communication but are scarce for all patients who could benefit.
Purpose of the Study:
- To compare the effectiveness of two strategies for allocating patients with or at risk for CVD to care coordination.
- Investigate proactive vs. post-hospitalization care coordination.
Main Methods:
- Randomized clinical trial involving 400 patients (≥65 years) with CVD or risk factors and fragmented care.
- Intervention group received proactive care coordination offers; control group received usual post-hospitalization coordination.
- Primary outcome: emergency department visits or hospitalizations.
Main Results:
- No significant difference in emergency department visits or hospitalizations between proactive and usual care groups.
- Acceptance of proactive care coordination was low (26.5%) as many patients managed their own care.
- 100% of eligible patients in the control group accepted post-hospitalization coordination.
Conclusions:
- Proactive outreach for care coordination did not improve outcomes compared to usual post-hospitalization care.
- Patient preference and self-management influenced the low uptake of proactive coordination.
- Future strategies may need to consider patient preferences for care coordination timing and delivery.
Importance:
Patients with or at risk for cardiovascular disease (CVD) often see many ambulatory physicians who may not communicate with each other. Care coordinators can bridge gaps in communication among physicians, but there are too few of them for all patients who might benefit.
Objective:
To compare the effectiveness of 2 strategies for allocating patients with or at risk for CVD to care coordination.
Design, Setting, And Participants:
This randomized clinical trial performed randomization and outreach from May 15 to November 30, 2023, and completed follow-up on May 31, 2024, in an accountable care organization in New York, New York. Participants included patients who were 65 years or older, had CVD or at least 1 CVD risk factor, had highly fragmented ambulatory care the previous year (fragmentation score ≥0.85), and had been attributed by Medicare to the accountable care organization.
Intervention:
Usual care assigned patients to care coordinators after any hospitalization. The intervention moved the time of care coordination earlier, offering care coordination proactively (without respect to hospitalization) to those who reported problems with care coordination on a telephone survey.
Main Outcomes And Measures:
The primary outcome was emergency department (ED) visits or hospitalizations during follow-up. The main secondary outcome was acceptability of the intervention, followed by appropriateness, fidelity, and efficiency.
Results:
A total of 400 participants (202 in the intervention group and 198 in the control group) were included in the analysis. The mean (SD) age of participants was 75.8 (7.0) years; 287 (71.8%) were female. Participants had a median of 14 (IQR, 9-22) visits to 8 (IQR, 6-11) physicians during the previous year. In the intervention group, 13 participants of 49 eligible (26.5%) accepted care coordination, compared with 17 of 17 (100%) in the control group. The most common reason for declining care coordination was that participants were coordinating care themselves. There was no difference in ED visits or hospitalizations (0.25 [95% CI, 0.21-0.31] events per 100 person-days alive in the intervention group vs 0.21 [95% CI, 0.17-0.27] events per 100 person-days alive in the control group; P = .29).
Conclusions And Relevance:
In this randomized clinical trial, proactive outreach for offering care coordination in advance of hospitalization did not result in better outcomes compared with usual care offering posthospitalization coordination. Many participants declined the proactive outreach offer.
Trial Registration:
ClinicalTrials.gov Identifier: NCT05820295.
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