A pragmatic randomized comparative effectiveness trial of transitional care for a socioeconomically diverse population: Design, rationale and baseline characteristics

Evaluation of the Impact of Discharge Clinic Follow-Up Interventions on 30-Day Readmission Rates

Care transition programs can result in cost avoidance and decreased resource utilization. This project aimed to determine whether implementation of a discharge clinic, referral to a community paramedicine program, or a second postdischarge call affected 30-day readmission rates. This single-center retrospective exploratory design study included 727 discharged patients without access to a primary care provider who were scheduled for a discharge clinic transitions appointment. Readmission rates were 17.7% for those who completed a discharge appointment and 24.7% for those who did not; 4% for those completing a second postdischarge call and 26% for those who did not; and 11.1% for those referred to a community paramedicine program and 24.9% for those not referred. A completed discharge clinic appointment resulted in 36% lower odds of readmission. A completed discharge clinic appointment was effective in reducing 30-day readmission rates as was a follow-up call.

Randomized Trial Evaluating Health System Expenditures with Transitional Care Services for Adults with No Usual Source of Care at Discharge

BACKGROUND

Multidisciplinary transitional care services reduce readmissions for high-risk patients, but it is unclear if health system costs to offer these intensive services are offset by avoidance of higher downstream expenditures.

OBJECTIVE

To evaluate net costs for a health system offering transitional care services DESIGN: One-year pragmatic, randomized trial PARTICIPANTS: Adults aged ≥ 18 without a usual source of follow-up care at the time of hospital discharge were enrolled through a high-volume, urban academic medical center in Chicago, IL, USA, from September 2015 through February 2016.

INTERVENTIONS

Eligible patients were silently randomized before discharge by an automated electronic health record algorithm allocating them in a 1:3 ratio to receive routine coordination of post-discharge care (RC) versus being offered intensive, multidisciplinary transitional care (TC) services.

MAIN MEASUREMENTS

Health system costs were collected from facility administrative systems and transformed to standardized costs using Medicare reference files. Multivariable generalized linear models estimated proportional differences in net costs over one year.

KEY RESULTS

Study patients (489 TC; 164 RC) had a mean age of 44 years; 34% were uninsured, 55% had public insurance, and 49% self-identified as Black or Latinx. Over 90 days, cost differences between groups were not statistically significant. Over 180 days, the TC group had 41% lower ED/observation costs (adjusted cost ratio [aCR], 0.59; 95% CI, 0.36-0.97), 50% lower inpatient costs (aCR, 0.50; 95% CI, 0.27-0.95), and 41% lower total healthcare costs (aCR, 0.59; 95% CI, 0.36-0.99) than the RC group. Over 365 days, total cost differences remained of similar magnitude but no longer were statistically significant.

CONCLUSIONS

Offering TC services for vulnerable adults at discharge reduced net health system expenditures over 180 days. The promising economic case for multidisciplinary transitional care interventions warrants further research.

TRIAL REGISTRATION

National Clinical Trials Registry (NCT03066492).

Primary Care-Led Transition Clinics Hold Promise in Improving Care Transitions for Cancer Patients Facing Social Disparities: A Commentary

Transitions in care are key junctions during which care coordination, communication, and individualized support are required to ensure optimal health outcomes for patients. This is particularly true for patients who face social disparities, such as poverty, limited health literacy, or belonging to a racial or ethnic minority, who are particularly at risk for experiencing poor care transitions. Interdisciplinary primary care-led transition clinics are an intervention that have shown promise in improving care transitions for diverse patient populations, including those that face social disparities, but their role in improving transitions in cancer care remains largely untapped. In this commentary we highlight why the time-limited support of an interdisciplinary primary care-led transition clinic that targets socially vulnerable cancer patients holds the promise of achieving more equitable healthcare access, healthcare quality, and ultimately more equitable health outcomes for cancer patients.

Effects of a Transitional Care Practice for a Vulnerable Population: a Pragmatic, Randomized Comparative Effectiveness Trial

BACKGROUND

There is limited experimental evidence on transitional care interventions beyond 30 days post-discharge and in vulnerable populations.

OBJECTIVE

Evaluate effects of a transitional care practice (TC) that comprehensively addresses patients' medical and psychosocial needs following hospital discharge.

DESIGN

Pragmatic, randomized comparative effectiveness trial.

PATIENTS

Adults discharged from an initial emergency, observation, or inpatient hospital encounter with no trusted usual source of care.

INTERVENTIONS

TC intervention included a scheduled post-discharge appointment at the TC practice, where a multidisciplinary team comprehensively assessed patients' medical and psychosocial needs, addressed modifiable barriers, and subsequent linkage to a new primary care source. Routine Care involved assistance scheduling a post-discharge appointment with a primary care provider that often partnered with the hospital where the initial encounter occurred.

MAIN MEASURES

The primary outcome was a binary indicator of death or additional hospital encounters within 90 days of initial discharge. Secondary outcomes included any additional hospital encounters, and counts of hospital encounters, over 180 days.

KEY RESULTS

Four hundred ninety patients were randomized to TC intervention and 164 to Routine Care; 34.6% were uninsured, 49.7% had Medicaid, and 57.4% were homeless or lived in a high-poverty area. There was no significant difference between arms in the 90-day probability of death or additional hospital encounters (relative risk [RR] 0.89; 0.91; 95% confidence interval [CI] 0.74-1.13). However, TC patients had 37% and 35% lower probability of any inpatient admission over 90 days (RR 0.63; 95% CI 0.43-0.91) and 180 days (RR 0.65; 95% CI 0.47-0.89), respectively. Over 180 days, TC patients had 42% fewer inpatient admissions (incidence rate ratio 0.58; 95% CI 0.37-0.90).

CONCLUSIONS

Among patients randomized to a patient-centered transitional care intervention, there was no significant reduction in 90-day probability of death or additional hospital encounters. However, there were significant decreases in measures of inpatient admissions over 180 days.

TRIAL REGISTRATION

clinicaltrials.gov identifier NCT03066492.