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A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.

ABSTRACT: 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.

SUBMITTER: Jack BW

PROVIDER: S-EPMC2738592 | biostudies-literature | 2009 Feb

REPOSITORIES: biostudies-literature

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A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.

Jack Brian W BW Chetty Veerappa K VK Anthony David D Greenwald Jeffrey L JL Sanchez Gail M GM Johnson Anna E AE Forsythe Shaula R SR O'Donnell Julie K JK Paasche-Orlow Michael K MK Manasseh Christopher C Martin Stephen S Culpepper Larry L

Annals of internal medicine 20090201 3

<h4>Background</h4>Emergency department visits and rehospitalization are common after hospital discharge.<h4>Objective</h4>To test the effects of an intervention designed to minimize hospital utilization after discharge.<h4>Design</h4>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.<h4>Setting</h4>General medical s ...[more]

PMID: 19189907

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Project description:ImportancePostdischarge outreach from the primary care practice is an important component of transitional care support. The most common method of contact is via telephone call, but calls are labor intensive and therefore limited in scope.ObjectiveTo test whether a 30-day automated texting program to support primary care patients after hospital discharge reduces acute care revisits.Design, setting, and participantsA 2-arm randomized clinical trial was conducted from March 29, 2022, through January 5, 2023, at 30 primary care practices within a single academic health system in Philadelphia, Pennsylvania. Patients were followed up for 60 days after discharge. Investigators were blinded to assignment, but patients and practice staff were not. Participants included established patients of the study practices who were aged 18 years or older, discharged from an acute care hospitalization, and considered medium to high risk for adverse health events by a health system risk score. All analyses were conducted using an intention-to-treat approach.InterventionPatients in the intervention group received automated check-in text messages from their primary care practice on a tapering schedule for 30 days following discharge. Any needs identified by the automated messaging platform were escalated to practice staff for follow-up via an electronic medical record inbox. Patients in the control group received a standard transitional care management telephone call from their practice within 2 business days of discharge.Main outcomes and measuresThe primary study outcome was any acute care revisit (readmission or emergency department visit) within 30 days of discharge.ResultsOf the 4736 participants, 2824 (59.6%) were female; the mean (SD) age was 65.4 (16.5) years. The mean (SD) length of index hospital stay was 5.5 (7.9) days. A total of 2352 patients were randomized to the intervention arm and 2384 were randomized to the control arm. There were 557 (23.4%) acute care revisits in the control group and 561 (23.9%) in the intervention group within 30 days of discharge (risk ratio, 1.02; 95% CI, 0.92-1.13). Among the patients in the intervention arm, 79.5% answered at least 1 message and 41.9% had at least 1 need identified.Conclusions and relevanceIn this randomized clinical trial of a 30-day postdischarge automated texting program, there was no significant reduction in acute care revisits.Trial registrationClinicalTrials.gov Identifier: NCT05245773.

Project description:ImportanceHip and knee arthroplasty are the most common inpatient surgical procedures for Medicare beneficiaries in the US, with substantial variation in cost and quality. Whether remote monitoring incorporating insights from behavioral science might help improve outcomes and increase value of care remains unknown.ObjectiveTo evaluate the effect of activity monitoring and bidirectional text messaging on the rate of discharge to home and clinical outcomes in patients receiving hip or knee arthroplasty.Design, setting, and participantsRandomized clinical trial conducted between February 7, 2018, and April 15, 2019. The setting was 2 urban hospitals at an academic health system. Participants were patients aged 18 to 85 years scheduled to undergo hip or knee arthroplasty with a Risk Assessment and Prediction Tool score of 6 to 8.InterventionsEligible patients were randomized evenly to receive usual care (n?=?153) or remote monitoring (n?=?147). Those in the intervention arm who agreed received a wearable activity monitor to track step count, messaging about postoperative goals and milestones, pain score tracking, and connection to clinicians as needed. Patients assigned to receive monitoring were further randomized evenly to remote monitoring alone or remote monitoring with gamification and social support. Remote monitoring?was offered before surgery, began at hospital discharge, and continued for 45 days postdischarge.Main outcomes and measuresThe primary outcome was discharge status (home vs skilled nursing facility or inpatient rehabilitation). Prespecified secondary outcomes included change in average daily step count and rehospitalizations.ResultsA total of 242 patients were analyzed (124 usual care, 118 intervention); median age was 66 years (interquartile range, 58-73 years); 78.1% were women, 45.5% were White, 43.4% were Black; and 81.4% in the intervention arm agreed to receive monitoring. There was no significant difference in the rate of discharge to home between the usual care arm (57.3%; 95% CI, 48.5%-65.9%) and the intervention arm (56.8%; 95% CI, 47.9%-65.7%) and no significant increase in step count in those receiving remote monitoring plus gamification and social support compared with remote monitoring alone. There was a statistically significant reduction in rehospitalization rate in the intervention arm (3.4%; 95% CI, 0.1%-6.7%) compared with the usual care arm (12.2%; 95% CI, 6.4%-18.0%) (P?=?.01).Conclusions and relevanceIn this study, the remote monitoring program did not increase rate of discharge to home after hip or knee arthroplasty, and gamification and social support did not increase activity levels. There was a significant reduction in rehospitalizations among those receiving the intervention, which may have resulted from goal setting and connection to the care team.Trial registrationClinicalTrials.gov Identifier: NCT03435549.

Project description:BackgroundDelays in starting physical therapy after hospital discharge worsen deconditioning in older adults. Intervening quickly can minimize the negative effects of deconditioning. Telerehabilitation is a strategy that increases access to rehabilitation, improves clinical outcomes, and reduces costs. This paper presents the protocol for a pragmatic clinical trial that aims to determine the effectiveness and cost-effectiveness of a multi-component intervention offered by telerehabilitation for discharged older adults awaiting physical therapy for any specific medical condition.MethodsThis is a pragmatic randomized controlled clinical trial with two groups: telerehabilitation and control. Participants (n=230) will be recruited among individuals discharged from hospitals who are in the public healthcare system physical therapy waiting lists. The telerehabilitation group will receive a smartphone app with a personalized program (based on individual's functional ability) of resistance, balance, and daily activity training exercises. The intervention will be implemented at the individuals' homes. This group will be monitored weekly by phone and monthly through a face-to-face meeting until they start physical therapy. The control group will adhere to the public healthcare system's usual flow and will be monitored weekly by telephone until they start physical therapy. The primary outcome will be a physical function (Timed Up and Go and 30-s Chair Stand Test). The measurements will take place in baseline, start, and discharge of outpatient physical therapy. The economic evaluations will be performed from the perspective of society and the Brazilian public healthcare system.DiscussionThe study will produce evidence on the effectiveness and cost-effectiveness of multi-component telerehabilitation intervention for discharged older adult patients awaiting physical therapy, providing input that can aid the implementation of similar proposals in other patient groups.Trial registrationBrazilian Registry of Clinical Trials (ReBEC), RBR-9243v7 . Registered on 24 August 2020.

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A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.

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A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.

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