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Tele-transitions of care. A 12-month, parallel-group, superiority randomized controlled trial protocol, evaluating the use of telehealth versus standard transitions of care in the prevention of avoidable hospital readmissions.

ABSTRACT: Introduction:Comprehensive transitions of care, reduce dangerous hospital readmissions. Telehealth offers promise, however few guidelines aid clinicians in introducing it in a feasible way while addressing the needs of a multi-comorbid population. Physician adoptability remains a significant barrier to the use of Telehealth due to data overload, concerns for disruptive workflows and uncertain practices. The methods proposed aid clinicians in implementing Telehealth training and research with limited resources to reach patients who need clinical surveillance most. This study introduces a new workflow for addressing tele-transitions of care, using risk stratification, remote patient monitoring, and patient-centered virtual visits. We propose a new communication tool which facilitates adoption. We take a clinically meaningful approach in assessing avoidable hospital readmissions, which can lead to further quality improvements and improved patient care. Methods:This study design is a parallel-group, superiority, randomized controlled trial in which 180 patients are enrolled in the standard of care or Telehealth arms and evaluated for 30-days post hospitalization. The Telehealth group receives daily vitals surveillance with a "teledoc", a senior resident physician, who performs weekly virtual visits. The endpoint is 30-day hospital readmission. Patient data is collected on hospital utilization, patient self-management, physician and patient experience. Discussion:Our protocol introduces a novel study design with existing clinical trainees, to provide comprehensive tele-transitions of care to reduce avoidable readmissions.

SUBMITTER: Noel K

PROVIDER: S-EPMC6129734 | biostudies-literature | 2018 Dec

REPOSITORIES: biostudies-literature

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Tele-transitions of care. A 12-month, parallel-group, superiority randomized controlled trial protocol, evaluating the use of telehealth versus standard transitions of care in the prevention of avoidable hospital readmissions.

Noel Kimberly K Yagudayev Shamuel S Messina Catherine C Schoenfeld Elinor E Hou Wei W Kelly Gerald G

Contemporary clinical trials communications 20180817

<h4>Introduction</h4>Comprehensive transitions of care, reduce dangerous hospital readmissions. Telehealth offers promise, however few guidelines aid clinicians in introducing it in a feasible way while addressing the needs of a multi-comorbid population. Physician adoptability remains a significant barrier to the use of Telehealth due to data overload, concerns for disruptive workflows and uncertain practices. The methods proposed aid clinicians in implementing Telehealth training and research ...[more]

PMID: 30211339

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Project description:BACKGROUND:Poor transitions of care leads to increased health costs, over-utilization of emergency room departments, increased re-hospitalizations and causes poor patient experiences and outcomes. This study evaluated Telehealth feasibility in improving transitions of care. METHODS:This is a 12-month randomized controlled trial, evaluating the use of telehealth (remote patient monitoring and video visits) versus standard transitions of care with the primary outcomes of hospital readmission and emergency department utilization and secondary outcomes of access to care, medication management and adherence and patient engagement. Electronic Medical Record data, Health Information Exchange data and phone survey data was collected. Multi-variable logistic regression models were created to evaluate the effect of Telehealth on hospital readmission, emergency department utilization, medication adherence. Chi-square tests or Fisher's exact tests were used to compare the percentages of categorical variables between the Telehealth and control groups. T tests or Wilcoxon rank sum tests were used to compared means and medians between the two randomized groups. RESULTS:The study conducted between June 2017 and 2018, included 102 patients. Compared with the standard of care, Telehealth patients were more likely to have medicine reconciliation (p?=?0.013) and were 7 times more likely to adhere to medication than the control group (p?=?0.03). Telehealth patients exhibited enthusiasm (p?=?0.0001), and confidence that Telehealth could improve their healthcare (p?=?0.0001). Telehealth showed no statistical significance on emergency department utilization (p?=?0.691) nor for readmissions (p?=?0.31). 100% of Telehealth patients found the intervention to be valuable, 98% if given the opportunity, reported they would continue using telehealth to manage their healthcare needs, and 94% reported that the remote patient monitoring technology was useful. CONCLUSIONS:Telehealth can improve transitions of care after hospital discharge improving patient engagement and adherence to medications. Although this study was unable to show the effect of Telehealth on reduced healthcare utilization, more research needs to be done in order to understand the true impact of Telehealth on preventing avoidable hospital readmission and emergency department visits. TRIAL REGISTRATION:ClinicalTrials.Gov ID: NCT03528850 Date Registered (Retrospective): 5/18/2018. Status: Completed. IRB #: 970227.

Project description:BackgroundUrgent, unplanned hospital readmissions are increasingly being used to gauge the quality of care. We reviewed urgent readmissions to determine which were potentially avoidable and compared rates of all-cause and avoidable readmissions.MethodsIn a multicentre, prospective cohort study, we reviewed all urgent readmissions that occurred within six months among patients discharged to the community from 11 teaching and community hospitals between October 2002 and July 2006. Summaries of the readmissions were reviewed by at least four practising physicians using standardized methods to judge whether the readmission was an adverse event (poor clinical outcome due to medical care) and whether the adverse event could have been avoided. We used a latent class model to determine whether the probability that each readmission was truly avoidable exceeded 50%.ResultsOf the 4812 patients included in the study, 649 (13.5%, 95% confidence interval [CI] 12.5%-14.5%) had an urgent readmission within six months after discharge. We considered 104 of them (16.0% of those readmitted, 95% CI 13.3%-19.1%; 2.2% of those discharged, 95% CI 1.8%-2.6%) to have had a potentially avoidable readmission. The proportion of patients who had an urgent readmission varied significantly by hospital (range 7.5%-22.5%; χ(2) = 92.9, p < 0.001); the proportion of readmissions deemed avoidable did not show significant variation by hospital (range 1.2%-3.7%; χ(2) = 12.5, p < 0.25). We found no association between the proportion of patients who had an urgent readmission and the proportion of patients who had an avoidable readmission (Pearson correlation 0.294; p = 0.38). In addition, we found no association between hospital rankings by proportion of patients readmitted and rankings by proportion of patients with an avoidable readmission (Spearman correlation coefficient 0.28, p = 0.41).InterpretationUrgent readmissions deemed potentially avoidable were relatively uncommon, comprising less than 20% of all urgent readmissions following hospital discharge. Hospital-specific proportions of patients who were readmitted were not related to proportions with a potentially avoidable readmission.

Project description:Identification of patients at a high risk of potentially avoidable readmission allows hospitals to efficiently direct additional care transitions services to the patients most likely to benefit.To externally validate the HOSPITAL score in an international multicenter study to assess its generalizability.International retrospective cohort study of 117?065 adult patients consecutively discharged alive from the medical department of 9 large hospitals across 4 different countries between January 2011 and December 2011. Patients transferred to another acute care facility were excluded.The HOSPITAL score includes the following predictors at discharge: hemoglobin, discharge from an oncology service, sodium level, procedure during the index admission, index type of admission (urgent), number of admissions during the last 12 months, and length of stay.30-day potentially avoidable readmission to the index hospital using the SQLape algorithm.Overall, 117?065 adults consecutively discharged alive from a medical department between January 2011 and December 2011 were studied. Of all medical discharges, 16?992 of 117?065 (14.5%) were followed by a 30-day readmission, and 11?307 (9.7%) were followed by a 30-day potentially avoidable readmission. The discriminatory power of the HOSPITAL score to predict potentially avoidable readmission was good, with a C statistic of 0.72 (95% CI, 0.72-0.72). As in the derivation study, patients were classified into 3 risk categories: low (n?=?73?031 [62.4%]), intermediate (n?=?27?612 [23.6%]), and high risk (n?=?16?422 [14.0%]). The estimated proportions of potentially avoidable readmission for each risk category matched the observed proportion, resulting in an excellent calibration (Pearson ?2 test P?=?.89).The HOSPITAL score identified patients at high risk of 30-day potentially avoidable readmission with moderately high discrimination and excellent calibration when applied to a large international multicenter cohort of medical patients. This score has the potential to easily identify patients in need of more intensive transitional care interventions to prevent avoidable hospital readmissions.

Project description:BACKGROUND:Care transitions programs have been shown to reduce hospital readmissions. OBJECTIVES:The main objective of this study was to evaluate effects of the Mayo Clinic Care Transitions (MCCTs) Program on potentially preventable and nonpreventable 30-day unplanned readmissions among high-risk elders. RESEARCH DESIGN:This was a retrospective cohort study of patients enrolled in MCCT following hospitalization and propensity score-matched controls receiving usual primary care. SUBJECTS:The subjects were primary care patients, who were 60 years or older, at high-risk for readmission, and hospitalized for any cause between January 1, 2011 and June 30, 2013. MEASURES:Hospital readmission within 30 days. The 3M algorithm was used to identify potentially preventable readmissions. Readmissions for ambulatory care sensitive conditions, a subset of preventable readmissions identified by the 3M algorithm, were also assessed. RESULTS:The study cohort included 365 pairs of MCCT enrollees and propensity score-matched controls. Patients were similar in age (mean 83?y) and other baseline demographic and clinical characteristics, including reason for index hospitalization. MCCT enrollees had a significantly lower all-cause readmission rate [12.4% (95% confidence interval: CI, 8.9-15.7) vs. 20.1% (15.8-24.1); P=0.004] resulting from a decrease in potentially preventable readmissions [8.4% (95% CI, 5.5-11.3) vs. 14.3% (95% CI, 10.5-17.9); P=0.01]. Few potentially preventable readmissions were for ambulatory care sensitive conditions (6.7% vs. 12.0%). The rates of nonpotentially preventable readmissions were similar [4.3% (95% CI, 2.2-6.5) vs. 6.7% (95% CI, 4.0-9.4); P=0.16]. Potentially preventable readmissions were reduced by 44% (hazard ratio, 0.56; 95% CI, 0.36-0.88; P=0.01) with no change in other readmissions. CONCLUSIONS:The MCCT significantly reduces preventable readmissions, suggesting that access to multidisciplinary care can reduce readmissions and improve outcomes for high-risk elders.

Project description:ObjectiveTo investigate the effect of pharmacist-led medicines management in multimorbid, hospitalised patients on long-term hospital readmissions and survival.DesignParallel-group, randomised controlled trial.SettingRecruitment from an internal medicine hospital ward in Oslo, Norway. Patients were enrolled consecutively from August 2014 to the predetermined target number of 400 patients. The last participant was enrolled March 2016. Follow-up until 31 December 2017, that is, 21-40 months.ParticipantsAcutely admitted multimorbid patients ≥18 years, using minimum four regular drugs from minimum two therapeutic classes. 399 patients were randomly assigned, 1:1, to the intervention or control group. After excluding 11 patients dying in-hospital and 2 erroneously included, the primary analysis comprised 386 patients (193 in each group) with median age 79 years (range 23-96) and number of diseases 7 (range 2-17).InterventionIntervention patients received pharmacist-led medicines management comprising medicines reconciliation at admission, repeated medicines reviews throughout the stay and medicines reconciliation and tailored information at discharge, according to the integrated medicines management model. Control patients received standard care.Primary and secondary outcome measuresThe primary endpoint was difference in time to readmission or death within 12 months. Overall survival was a priori the clinically most important secondary endpoint.ResultsPharmacist-led medicines management had no significant effect on the primary endpoint time to readmission or death within 12 months (median 116 vs 184 days, HR 0.82, 95% CI 0.64 to 1.04, p=0.106). A statistically significantly increased overall survival was observed during 21-40 months follow-up (HR 0.66, 95% CI 0.48 to 0.90, p=0.008).ConclusionsPharmacist-led medicines management had no statistically significant effect on time until readmission or death. A statistically significant increased overall survival was seen. Further studies should be conducted to investigate the effect of such an intervention on a larger scale.Trial registration numberNCT02336113.

Dataset Information

Tele-transitions of care. A 12-month, parallel-group, superiority randomized controlled trial protocol, evaluating the use of telehealth versus standard transitions of care in the prevention of avoidable hospital readmissions.

Publications

Tele-transitions of care. A 12-month, parallel-group, superiority randomized controlled trial protocol, evaluating the use of telehealth versus standard transitions of care in the prevention of avoidable hospital readmissions.

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