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Effectiveness of a chronic care model-based transitional care program for patients with biliary drainage: a
Ting Zhang1, Long Zhang2, Huiling Zhou3
1Department of Hepatobiliary and Pancreatic Surgery, The Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China.
Objectives:
Patients undergoing biliary drainage are at high risk of readmission. We evaluated a Chronic Care Model (CCM)-based transitional care program designed to improve post-discharge outcomes.
Methods:
This prospective, two-center randomized controlled trial assigned 300 patients requiring biliary drainage to an intervention (CCM-based transitional care) or control (usual care) group. Primary outcomes were 90-day hospital readmission and complication rates. Time-to-readmission was analyzed using the Kaplan-Meier method. Secondary outcomes included patient-reported readiness for hospital discharge, self-care behavior, and quality of life. Predictive models, including logistic regression and support vector machine (SVM), were developed to identify risk factors for readmission.
Results:
The intervention group had significantly lower 90-day readmission rates (16.3% vs. 37.1%; P = 0.001) and complication rates (12.1% vs. 26.5%; P = 0.010). Intervention patients reported higher mean scores (all P < 0.001) for discharge readiness (88.09 vs. 60.49), self-care behavior (88.04 vs. 59.95), and quality of life (88.16 vs. 60.84). Logistic regression confirmed that these patient-reported scores predicted lower readmission risk (OR: 0.97, 95% CI: 0.95-0.99). Furthermore, the SVM model demonstrated high discriminatory ability (AUC: 0.93; 95% CI: 0.89-0.95).
Conclusions:
A structured, CCM-based transitional care program effectively reduces readmissions and complications while prolonging community-based stability for patients with biliary drainage. Furthermore, patient-reported metrics integrated into an SVM model accurately predict readmission risk, enabling targeted interventions.
