The impact of follow-up telephone calls to patients after hospitalization

Mobile Technology Use in Clinical Research Examining Challenges and Implications for Health Promotion in South Africa: Mixed Methods Study

BACKGROUND

The use of mobile technologies in fostering health promotion and healthy behaviors is becoming an increasingly common phenomenon in global health programs. Although mobile technologies have been effective in health promotion initiatives and follow-up research in higher-income countries and concerns have been raised within clinical practice and research in low- and middle-income settings, there is a lack of literature that has qualitatively explored the challenges that participants experience in terms of being contactable through mobile technologies.

OBJECTIVE

This study aims to explore the challenges that participants experience in terms of being contactable through mobile technologies in a trial conducted in Soweto, South Africa.

METHODS

A convergent parallel mixed methods research design was used. In the quantitative phase, 363 young women in the age cohorts 18 to 28 years were contacted telephonically between August 2019 and January 2022 to have a session delivered to them or to be booked for a session. Call attempts initiated by the study team were restricted to only 1 call attempt, and participants who were reached at the first call attempt were classified as contactable (189/363, 52.1%), whereas those whom the study team failed to contact were classified as hard to reach (174/363, 47.9%). Two outcomes of interest in the quantitative phase were "contactability of the participants" and "participants' mobile number changes," and these outcomes were analyzed at a univariate and bivariate level using descriptive statistics and a 2-way contingency table. In the qualitative phase, a subsample of young women (20 who were part of the trial for ≥12 months) participated in in-depth interviews and were recruited using a convenience sampling method. A reflexive thematic analysis approach was used to analyze the data using MAXQDA software (version 20; VERBI GmbH).

RESULTS

Of the 363 trial participants, 174 (47.9%) were hard to reach telephonically, whereas approximately 189 (52.1%) were easy to reach telephonically. Most participants (133/243, 54.7%) who were contactable did not change their mobile number. The highest percentage of mobile number changes was observed among participants who were hard to reach, with three-quarters of the participants (12/16, 75%) being reported to have changed their mobile number ≥2 times. Eight themes were generated following the analysis of the transcripts, which provided an in-depth account of the reasons why some participants were hard to reach. These included mobile technical issues, coverage issues, lack of ownership of personal cell phones, and unregistered number.

CONCLUSIONS

Remote data collection remains an important tool in public health research. It could, thus, serve as a hugely beneficial mechanism in connecting with participants while actively leveraging the established relationships with participants or community-based organizations to deliver health promotion and practice.

Piloting an opioid callback program in community pharmacies

BACKGROUND

Although opioid prescribing has recently trended downward, opioid-related overdoses and deaths have drastically increased. Community pharmacists are accessible health care providers who are well positioned to disseminate information on opioid safety and to educate and counsel on medication use, managing adverse events, and proper medication disposal. Patient callbacks facilitate appropriate medication usage. We developed an opioid callback program that provides a framework for pharmacists to follow up with patients with an opioid prescription.

OBJECTIVES

This study aimed to (1) describe the development of the opioid callback initiative and (2) report results from a pilot test in 2 community pharmacies.

METHODS

The opioid callback process and data collection forms were collaboratively developed with community pharmacists at each site. Data recorded on the opioid callback forms were descriptively analyzed and chi-square test of independence explored differences by pain durations related to opioid disposal, security, and safety. Participating pharmacy staff were interviewed to identify facilitators and barriers to implementation, as well as opportunities for improvement.

RESULTS

Forty-one opioid callbacks were attempted and 36 were completed (87.8%). Pharmacists were statistically significantly more likely to discuss naloxone with patients with chronic pain (89.5%) than those with acute pain (46.2%). Pharmacists reported that the program successfully raised awareness of opioid disposal opportunities and safe opioid practices, including storage and naloxone ownership. They expressed patients' willingness to answer questions and appreciation for the extra attention and care.

CONCLUSION

Community pharmacists are well positioned to address the opioid crisis as access points for medication questions, opioid safety education, opioid disposal, naloxone, and medications for people with an opioid use disorder. This study presents a proof of concept for a pharmacist-led opioid callback program. Expansion could help inform patients about how to use opioids safely, how to treat an opioid overdose, and where to dispose of unused medications.

Postdischarge Video Visits for Adherence to Hospital Discharge Recommendations: A Randomized Clinical Trial

Objective

To determine whether a postdischarge video visit with patients, conducted by hospital medicine advanced practice providers, improves adherence to hospital discharge recommendations.

Patients and Methods

We conducted a single-institution 2-site randomized clinical trial with 1:1 assignment to intervention vs control, with enrollment from August 10, 2020, to June 23, 2022. Hospital medicine patients discharged home or to an assisted living facility were randomized to a video visit 2-5 days postdischarge in addition to usual care (intervention) vs usual care (control). During the video visit, advanced practice providers reviewed discharge recommendations. Both intervention and control groups received telephone follow-up 3-6 days postdischarge to ascertain the primary outcome of adherence to all discharge recommendations for new and chronic medication management, self-management and action plan, and home support.

Results

Among 1190 participants (594 intervention; 596 control), the primary outcome was ascertained in 768 participants (314 intervention; 454 control). In intervention vs control, there was no difference in the proportion of participants with the primary outcome (76.7% vs 72.5%; P=.19) or in the individual domains of the primary outcome: new and chronic medication management (94.1% vs 92.8%; P=.50), self-management and action plan (76.5% vs 71.5%; P=.18), and home support (94.1% vs 94.3%; P=.94). Women receiving intervention vs control had higher adherence to recommendations (odds ratio, 1.77; 95% CI, 1.08-2.91).

Conclusion

In hospital medicine patients, a postdischarge video visit did not improve adherence to discharge recommendations. Potential gender differences in adherence require further investigation.Clinicaltrials.gov number, NCT04547803.

Patient Perspectives of the Hospital Discharge Process: A Qualitative Study

Care transitions after hospitalization require communication across care teams, patients, and caregivers. As part of a quality improvement initiative, we conducted qualitative interviews with a diverse group of 53 patients who were recently discharged from a hospitalization within a safety net hospital to explore how patient preferences were included in the hospital discharge process and differences in the hospital discharge experience by race/ethnicity. Four themes emerged from participants regarding desired characteristics of interactions with the discharge team: (1) to feel heard, (2) inclusion in decision-making, (3) to be adequately prepared to care for themselves at home through bedside teaching, (4) and to have a clear and updated discharge timeline. Additionally, participants identified patient-level factors the discharge planning team should consider, including the social context, family involvement, health literacy, and linguistic barriers. Lastly, participants identified provider characteristics, such as a caring and empathetic bedside manner, that they found valuable in the discharge process. Our findings highlight the need for shared decision-making in the discharge planning process to improve both patient safety and satisfaction.

Effectiveness of Transition Care Intervention Targeted to High-Risk Patients to Reduce Readmissions: Study Protocol for the TARGET-READ Multicenter Randomized-Controlled Trial

Hospital readmissions within 30 days represent a burden for the patients and the entire health care system. Improving the care around hospital discharge period could decrease the risk of avoidable readmissions. We describe the methods of a trial that aims to evaluate the effect of a structured multimodal transitional care intervention targeted to higher-risk medical patients on 30-day unplanned readmissions and death. The TARGET-READ study is an investigator-initiated, pragmatic single-blinded randomized multicenter controlled trial with two parallel groups. We include all adult patients at risk of hospital readmission based on a simplified HOSPITAL score of ≥4 who are discharged home or nursing home after a hospital stay of one day or more in the department of medicine of the four participating hospitals. The patients randomized to the intervention group will receive a pre-discharge intervention by a study nurse with patient education, medication reconciliation, and follow-up appointment with their referring physician. They will receive short follow-up phone calls at 3 and 14 days after discharge to ensure medication adherence and follow-up by the ambulatory care physician. A blind study nurse will collect outcomes at 1 month by phone call interview. The control group will receive usual care. The TARGET-READ study aims to increase the knowledge about the efficacy of a bundled intervention aimed at reducing 30-day hospital readmission or death in higher-risk medical patients.

Factors Correlated With Successful Pediatric Post-Discharge Phone Call Attempt and Connection

OBJECTIVES

Postdischarge phone calls can identify discharge errors and gather information following hospital-to-home transitions. This study used the multisite Project IMPACT (Improving Pediatric Patient Centered Care Transitions) dataset to identify factors associated with postdischarge phone call attempt and connectivity.

METHODS

This study included 0- to 18-year-old patients discharged from 4 sites between January 2014 and December 2017. We compared demographic and clinical factors between postdischarge call attempt and no-attempt and connectivity and no-connectivity subgroups and used mixed model logistic regression to identify significant independent predictors of call attempt and connectivity.

RESULTS

Postdischarge calls were attempted for 5528 of 7725 (71.6%) discharges with successful connection for 3801 of 5528 (68.8%) calls. Connection rates varied significantly among sites (52% to 79%, P < .001). Age less than 30 days (P = .03; P = .01) and age 1 to 6 years (P = .04; P = .04) were independent positive predictors for both call attempt and connectivity, whereas English as preferred language (P < .001) and the chronic noncomplex clinical risk group (P = .02) were independent positive predictors for call attempt and connectivity, respectively. In contrast, readmission within 3 days (P = .004) and federal or state payor (P = .02) were negative independent predictors for call attempt and call connectivity, respectively.

CONCLUSIONS

This study suggests that targeted interventions may improve postdischarge call attempt rates, such as investment in a reliable call model or improvement in interpreter use, and connectivity, such as enhanced population-based communication.

Home to Stay: A randomized controlled trial protocol to assess use of a mobile app to reduce readmissions following colorectal surgery

AIM

Patients undergoing colorectal surgery face high rates of emergency room visits and readmission to hospital. These unplanned hospital visits lead to both increased patient anxiety and health care costs. The aim of this study is to evaluate the use of mobile application to support patients undergoing colorectal surgery following discharge from hospital.

METHOD

This study is a randomized controlled trial in which the control group will receive standard follow-up care following discharge after surgery and the intervention group will receive standard follow-up care in addition to the mobile application. The primary outcome is the proportion of patients with unplanned hospital visits within 30 days of discharge. The secondary outcomes are patient-reported outcomes on validated scales evaluating their quality of recovery following discharge. A sample size of 670 subjects is planned. For the primary outcome, the control and intervention groups will be compared using a generalized linear model to account for clustering of patients within centres. For the secondary outcomes, the overall scores on the Quality of Recovery 15 and Patient Activation Measure will be analysed using a linear regression model.

RESULTS

It is expected that the results of this study will show that the mobile app will lead to significant improvements in unplanned hospital visits as well as improved quality of recovery for patients.

CONCLUSION

If the trial is successful, the mobile app can be easily adopted more widely into clinical practice to support patients at home following surgery.

Articulation of postsurgical patient discharges: coordinating care transitions from hospital to home

BACKGROUND

Cardiac surgery patients are at high risk for readmissions after hospital discharge- few of these readmissions are preventable by mitigating barriers underlying discharge care transitions. An in-depth evaluation of the nuances underpinning the discharge process and the use of tools to support the process, along with insights on patient and clinician experiences, can inform the design of evidence-based strategies to reduce preventable readmissions.

OBJECTIVE

The study objectives are 3-fold: elucidate perceived factors affecting the postsurgical discharge care transitions of cardiac surgery patients going home; highlight differences among clinician and patient perceptions of the postsurgical discharge experiences, and ascertain the impact of these transitions on patient recovery at home.

METHODS

We conducted a prospective multi-stakeholder study using mixed methods, including general observations, patient shadowing, chart reviews, clinician interviews, and follow-up telephone patient and caregiver surveys/interviews. We followed thematic and content analyses.

FINDINGS

Participants included 49 patients, 6 caregivers, and 27 clinicians. We identified interdependencies between the predischarge preparation, discharge education, and postdischarge follow-up care phases that must be coordinated for effective discharge care transitions. We identified several factors that could lead to fragmented discharges, including limited preoperative preparation, ill-defined discharge education, and postoperative plans. To address these, clinicians often performed behind-the-scenes work, including offering informal preoperative preparation, tailoring discharge education, and personalizing postdischarge follow-up plans. As a result, majority of patients reported high satisfaction with care transitions and their positive impact on their home recovery.

DISCUSSION AND CONCLUSIONS

Articulation work by clinicians (ie, behind the scenes work) is critical for ensuring safety, care continuity, and overall patient experience during care transitions. We discuss key evidence-based considerations for re-engineering postsurgical discharge workflows and re-designing discharge interventions.

Protocol for the MobiMD trial: A randomized controlled trial to evaluate the effect of a self-monitoring mobile app on hospital readmissions for complex surgical patients

BACKGROUND

Hospital readmissions are estimated to cost $17.4 billion per year in the Medicare population alone, with readmission rates as high as 30% for patients undergoing complex abdominal surgery. Improved transitional care and self-monitoring may reduce preventable readmissions for such high-risk populations. In this study, we will conduct a single-institution randomized controlled trial (RCT) to assess the effect of a novel transitional care mobile app, MobiMD, on hospital readmission in complex abdominal surgery patients.

METHODS

Three hundred patients will be randomized 1:1 to standard of care (SOC) versus SOC plus MobiMD app in a parallel, single-blinded, two-arm RCT. Eligible patients are those who undergo complex abdominal surgery in the division of Surgical Oncology, Colorectal Surgery or Transplant Surgery. The MobiMD app provides push notification reminders directly to the patient's smart device, prompting them to enter clinical data and patient-reported outcomes. Clinical data collected via the MobiMD app include vital signs, red flag symptoms, daily wound and surgical drain images, ostomy output, drain output, medication compliance, and wound care compliance. These data are reviewed daily by a physician. The primary outcome is the proportion of participants readmitted to the hospital within 30 days of surgery. Secondary outcomes are 90-day hospital readmission, emergency department and urgent care visits, complication severity, and total readmission cost.

DISCUSSION

If effective, mobile health apps such as MobiMD could be routinely integrated into surgical transitional care programs to minimize unnecessary hospital readmissions, emergency department visits and healthcare resource utilization. Clinical trials identifier: NCT04540315.

Factorial Analysis Quantifies the Effects of Pediatric Discharge Bundle on Hospital Readmission

BACKGROUND AND OBJECTIVES

Factorial design of a natural experiment was used to quantify the benefit of individual and combined bundle elements from a 4-element discharge transition bundle (checklist, teach-back, handoff to outpatient providers, and postdischarge phone call) on 30-day readmission rates (RRs).

METHODS

A 2⁴ factorial design matrix of 4 bundle element combinations was developed by using patient data (N = 7725) collected from January 2014 to December 2017 from 4 hospitals. Patients were classified into 3 clinical risk groups (CRGs): no chronic disease (CRG1), single chronic condition (CRG2), and complex chronic condition (CRG3). Estimated main effects of each bundle element and their interactions were evaluated by using Study-It software. Because of variation in subgroup size, important effects from the factorial analysis were determined by using weighted effect estimates.

RESULTS

RR in CRG1 was 3.5% (n = 4003), 4.1% in CRG2 (n = 1936), and 17.6% in CRG3 (n = 1786). Across the 3 CRGs, the number of subjects in the factorial groupings ranged from 16 to 674. The single most effective element in reducing RR was the checklist in CRG1 and CRG2 (reducing RR by 1.3% and 3.0%) and teach-back in CRG3 (by 4.7%) The combination of teach-back plus a checklist had the greatest effect on reducing RR in CRG3 by 5.3%.

CONCLUSIONS

The effect of bundle elements varied across risk groups, indicating that transition needs may vary on the basis of population. The combined use of teach-back plus a checklist had the greatest impact on reducing RR for medically complex patients.

Effectiveness of Pharmacist Intervention to Reduce Medication Errors and Health-Care Resources Utilization After Transitions of Care: A Meta-analysis of Randomized Controlled Trials

OBJECTIVES

Medication errors are common during transitions of care. The main objective of the current investigation was to examine the effectiveness of pharmacist-based transition of care interventions on the reduction of medication errors after hospital discharge.

METHODS

A systematic search was conducted to detect published reports of randomized trials using the National Library of Medicine's PubMed database, the Cochrane Database of Systematic Reviews, and Google Scholar inclusive to July 1, 2015. Search terms included pharmacist, medication, errors, readmission, transition, and discharge. A priori main outcomes included medication errors and health-care resources utilization (hospital readmission and/or emergency room visits). Quantitative analysis was performed using a random effect method.

RESULTS

Thirteen randomized trials examining 3503 patients were included in the final analysis. The aggregate effect of the 10 studies evaluating the effect of pharmacists intervention on the incidence of medication errors during transitions of care favored pharmacist over control with an odds ratio (95% confidence interval [CI]) of 0.44 (0.31-0.63). The overall effect of 4 studies evaluating the effect of a pharmacist intervention on the incidence of emergency room visits compared with control favored the pharmacist intervention, odds ratio (95% CI) of 0.42 (0.22-0.78), number needed to treat (95% CI) of 6.2 (3.4-31.4).

CONCLUSIONS

Pharmacist transition of care intervention is an effective strategy to reduce medication errors after hospital discharge. In addition, a pharmacist intervention also reduces subsequent emergency room visits. Hospitals should consider implementing this intervention to improve patient safety and quality during transitions of care.

Effect of a Real-Time Risk Score on 30-day Readmission Reduction in Singapore

OBJECTIVE

To develop a risk score for the real-time prediction of readmissions for patients using patient specific information captured in electronic medical records (EMR) in Singapore to enable the prospective identification of high-risk patients for enrolment in timely interventions.

METHODS

Machine-learning models were built to estimate the probability of a patient being readmitted within 30 days of discharge. EMR of 25,472 patients discharged from the medicine department at Ng Teng Fong General Hospital between January 2016 and December 2016 were extracted retrospectively for training and internal validation of the models. We developed and implemented a real-time 30-day readmission risk score generation in the EMR system, which enabled the flagging of high-risk patients to care providers in the hospital. Based on the daily high-risk patient list, the various interfaces and flow sheets in the EMR were configured according to the information needs of the various stakeholders such as the inpatient medical, nursing, case management, emergency department, and postdischarge care teams.

RESULTS

Overall, the machine-learning models achieved good performance with area under the receiver operating characteristic ranging from 0.77 to 0.81. The models were used to proactively identify and attend to patients who are at risk of readmission before an actual readmission occurs. This approach successfully reduced the 30-day readmission rate for patients admitted to the medicine department from 11.7% in 2017 to 10.1% in 2019 (p < 0.01) after risk adjustment.

CONCLUSION

Machine-learning models can be deployed in the EMR system to provide real-time forecasts for a more comprehensive outlook in the aspects of decision-making and care provision.

Using Intern-Led Quality Improvement to Reduce Readmissions for Specialty Service Patients Within an Academic Medical Center

Introduction

Postdischarge patient calls are an effective intervention to decrease unplanned readmissions. Despite its efficacy, calls are time consuming and compete with other clinical obligations. The purpose of this study was to evaluate the viability of intern-led quality improvement (QI) on conducting initial postdischarge calls to filter patients who require clinical or nurse follow-up.

Methods

QI interns from an academic medical center's QI program completed postdischarge patient calls within 72 hours of patient discharge from a neurosurgery service between June 2018 and July 2019. QI interns filtered patients who required follow-up calls from a clinical service or nurse department. The departments called patients within 48 hours of requests. Unplanned readmission rate was compared between the cohort of patients who requested and received a follow-up call versus a cohort of patients who requested and did not receive a follow-up call (control).

Results

QI interns completed 83.8% postdischarge patient calls within 72 hours of discharge. Reasons for unsuccessful calls included patient unresponsiveness (74.6%), wrong phone number on file (13.9%), and request to be called at a different time (11.5%). Nurses completed 57.2% follow-up requests within the targeted 48 hours and completed remaining requests within 7 days. QI intern postdischarge follow-up calls, in conjunction with nurse follow-up intervention, showed a significant (risk ratio = -3.31, p = 0.012) preventive effect on unplanned readmission rate.

Conclusions

QI interns are a viable alternative to nurses to conduct the first contact of postdischarge patient follow-up calls. This system of QI interns filtering calls to the correct clinical service or nurse department increased postdischarge patient follow-up calls success rate and decreased readmission rates.

Advanced Medication Reconciliation: A Systematic Review of the Impact on Medication Errors and Adverse Drug Events Associated with Transitions of Care

OBJECTIVE

The goal of this study was to conduct a systematic review on the impact of in-hospital electronic/enhanced medication reconciliation compared to basic medication reconciliation on medication errors, discrepancies, and adverse drug events (ADEs).

METHODS

The study team searched for peer-reviewed English-language articles in EMBASE, OVID, and Scopus databases up to October 2019. Included were randomized controlled trials (RCTs), pre-post, or interrupted time series designs with medication errors, discrepancies, or ADEs as an outcome, and medication reconciliation applied at hospital discharge. Basic medication reconciliation was defined as using a paper-based format, electronic medication reconciliation as using an electronic format, and enhanced medication reconciliation as incorporating additional interventions to reduce medication errors.

RESULTS

Ten studies (three RCTs, one retrospective cohort study, two interrupted time series studies, three pre-post studies, and one longitudinal study) were identified, with six and four studies comparing basic medication reconciliation to electronic and enhanced medication reconciliation, respectively. The overall risk of bias of the included studies was low (three), unclear (two), moderate (three), and serious/high (two). In general, studies demonstrated that electronic medication reconciliation reduced the odds of a medication discrepancy or ADE and may reduce the mean number of medication discrepancies. Enhanced medication reconciliation was more equivocal, with some studies showing improvement; however, risk of bias was generally significant.

CONCLUSION

Electronic medication reconciliation tends to reduce the risk of ADE; however, these conclusions were limited due to a lack of consistency in study settings, interventions, and outcome definitions. Future studies with more rigorous designs and standardized outcome definitions would provide clarity on this topic.

Association of pharmacist counseling with adherence, 30-day readmission, and mortality: A systematic review and meta-analysis of randomized trials

OBJECTIVE(S)

To determine the association of pharmacist medication counseling with medication adherence, 30-day hospital readmission, and mortality.

METHODS

The initial search identified 21,590 citations. After applying the inclusion and exclusion criteria, 62 randomized controlled trials (RCTs) (49 for the meta-analysis) were included in the final analysis. Data were pooled using a random-effects model.

RESULTS

The participants in most of the studies were older patients with chronic diseases who, therefore, were taking many drugs. The overall methodologic quality of evidence ranged from low to very low. Pharmacist medication counseling versus no such counseling was associated with a statistically significant 30% increase in relative risk (RR) for medication adherence, a 24% RR reduction in 30-day hospital readmission (number needed to treat = 4.2), and a 30% RR reduction in emergency department visits. RR reductions for primary care visits and mortality were not statistically significant.

CONCLUSION

The evidence supports pharmacist medication counseling to increase medication adherence and to reduce 30-day hospital readmissions and emergency department visits. However, higher-quality RCT studies are needed to confirm or refute these findings.

Implementation of podiatry telephone appointments for people with rheumatic and musculoskeletal diseases

BACKGROUND

Foot health problems are common in the general population, and particularly so in people with rheumatic and musculoskeletal disorders (RMD). Several clinical guidelines state that people with RMDs should have access to foot health services, although service capacity is often limited. The current COVID-19 pandemic has increased the need for alternative ways to provide patient care. The aim of this clinical audit was to review a newly implemented telephone follow-up appointment service conducted within the Rheumatology Podiatry Department in Leeds, UK.

METHODS

Fifty-eight patients attending the Rheumatology Podiatry Department at Leeds Teaching Hospitals NHS Trust were contacted by telephone approximately 6-8 weeks following initial intervention. During the telephone consultation, all patients were asked pre-defined questions relating to their symptoms, intervention efficacy, the need for further appointments and their preference for the type of consultation. To assess the cost of the telephone consultation the number of attempts needed in order to make successful contact, the duration of the call and the number of telephone follow-up appointments completed in a working day were also recorded.

RESULTS

Twenty-five patients (43%) were successfully contacted within the 6-8 weeks stipulated time frame and were included in the analysis. Of the 25 contacted, twelve (48%) patients were successfully contacted on the first attempt. Ten (40%) were successfully contacted on the second attempt. The remaining three patients (12%) required 3 or more attempts to make successful contact. Telephone consultations were estimated not to last longer than 10 min, including notes screening and documentation. Eleven patients (44%) reported an improvement in their symptoms, thirteen (52%) reported no change and one patient (4%) reported their symptoms to be worse.

CONCLUSION

Telephone follow-up consultations may be a potentially cost-effective alternative to face-to-face appointments when implemented in a Rheumatology Podiatry Department, and provide an alternative way of providing care, especially when capacity for face-to-face contact is limited. The potential cost saving and efficiency benefits of this service are likely to be enhanced when telephone consultations are pre-arranged with patients.

Phone Calls to Retain Research Participants and Determinants of Reachability in an African Setting: Observational Study

Background

Long-term retention of research participants in studies is challenging. In research in sub-Saharan Africa, phone calls are the most frequently used method to distantly engage with participants.

Objective

We aimed to get insight into the effectiveness of phone calls to retain contact with participants and evaluated determinants of reachability.

Methods

A cross-sectional study was performed using the databases of two randomized controlled trials investigating different kinds of antiretroviral therapy in HIV-positive patients. One trial finished in 2018 (study 1), and the other finished in 2015 (study 2). A random sample size of 200 participants per study was obtained. There were up to 3 phone numbers available per participant collected during the studies. Participants received a maximum of 3 phone calls on every available number on different days and at different times. Voicemails were left, and emails sent wherever possible. We documented how many calls were answered, who answered, as well as after how many attempts participants were reached. To further increase our understanding of reachability, we conducted a short questionnaire assessing factors contributing to reachability. The study was approved by the Research Ethics Committee of the University of Witwatersrand, Johannesburg, South Africa (reference number M1811107).

Results

In our sample size of n=200 per study, study 1, with a median time of 11 months since the last visit at the research site, had a response rate of 70.5% (141/200) participants while study 2, with a median duration of 55 months since the last visit, had a response rate of 50.0% (100/200; P<.001). In study 1, 61.5% (123/200) of calls were answered directly by the participant while this was 36.0% (72/200) in study 2 (P=.003). The likelihood of reaching a participant decreased with time (odds ratio [OR] 0.73, 95% CI 0.63 to 0.84) for every year since the last face-to-face visit. Having more phone numbers per participant increased reachability (OR 2.32, 95% CI 1.24 to 4.36 for 2 phone numbers and OR 3.03, 95% CI 1.48 to 6.22 for 3 phone numbers compared with 1 number). A total of 141 of 241 reached participants responded to the questionnaire. Of the 93 participants who had changed phone numbers, 5% (50/93) had changed numbers because their phone was stolen. The most preferred method of being contacted was direct calling (128/141) with participants naming this method followed by WhatsApp (69/141).

Conclusions

Time since last visit and the number of phone numbers listed were the only determinants of reachability. Longer follow-up time is accompanied with a decrease in reachability by phone while more listed phone numbers increases the likelihood that someone can be reached.

Trial Registration

ClinicalTrials.gov NCT02671383; https://clinicaltrials.gov/ct2/show/NCT02671383 and ClinicalTrials.gov NCT02670772; https://clinicaltrials.gov/ct2/show/NCT02670772

Impact of a Follow-up Telephone Call Program on 30-Day Readmissions (FUTR-30): A Pragmatic Randomized Controlled Real-world Effectiveness Trial

BACKGROUND

Telephone call programs are a common intervention used to improve patients' transition to outpatient care after hospital discharge.

OBJECTIVE

To examine the impact of a follow-up telephone call program as a readmission reduction initiative.

RESEARCH DESIGN

Pragmatic randomized controlled real-world effectiveness trial.

SUBJECTS

We enrolled and randomized all patients discharged home from a hospital general medicine service to a follow-up telephone call program or usual care discharge. Patients discharged against medical advice were excluded. The intervention was a hospital program, delivering a semistructured follow-up telephone call from a nurse within 3-7 days of discharge, designed to assess understanding and provide education, and assistance to support discharge plan implementation.

MEASURES

Our primary endpoint was hospital inpatient readmission within 30 days identified by the electronic health record. Secondary endpoints included observation readmission, emergency department revisit, and mortality within 30 days, and patient experience ratings.

RESULTS

All 3054 patients discharged home were enrolled and randomized to the telephone call program (n=1534) or usual care discharge (n=1520). Using a prespecified intention-to-treat analysis, we found no evidence supporting differences in 30-day inpatient readmissions [14.9% vs. 15.3%; difference -0.4 (95% confidence interval, 95% CI), -2.9 to 2.1; P=0.76], observation readmissions [3.8% vs. 3.6%; difference 0.2 (95% CI, -1.1 to 1.6); P=0.74], emergency department revisits [6.1% vs. 5.4%; difference 0.7 (95% CI, -1.0 to 2.3); P=0.43], or mortality [4.4% vs. 4.9%; difference -0.5 (95% CI, -2.0 to 1.0); P=0.51] between telephone call and usual care groups.

CONCLUSIONS

We found no evidence of an impact on 30-day readmissions or mortality due to the postdischarge telephone call program.

Patient Continuity of Care Questionnaire in a cardiac sample: A Confirmatory Factor Analysis

OBJECTIVE

Even though continuity is essential after discharge, there is a lack of reliable questionnaires to measure and assess patients' perceptions of continuity of care. The Patient Continuity of Care Questionnaire (PCCQ) addresses the period before and after discharge from hospital. However, previous studies show that the factor structure needs to be confirmed and validated in larger samples, and the aim of this study was to evaluate the psychometric properties of the PCCQ with focus on factor structure, internal consistency and stability.

DESIGN

A psychometric evaluation study. The questionnaire was translated into Swedish using a forward-backward technique and culturally adapted through cognitive interviews (n=12) and reviewed by researchers (n=8).

SETTING

Data were collected in four healthcare settings in two Swedish counties.

PARTICIPANTS

A consecutive sampling procedure included 725 patients discharged after hospitalisation due to angina, acute myocardial infarction, heart failure or atrial fibrillation.

MEASUREMENT

To evaluate the factor structure, confirmatory factor analyses based on polychoric correlations were performed (n=721). Internal consistency was evaluated by ordinal alpha. Test-retest reliability (n=289) was assessed with intraclass correlation coefficient (ICC).

RESULTS

The original six-factor structure was overall confirmed, but minor refinements were required to reach satisfactory model fit. The standardised factor loadings ranged between 0.68 and 0.94, and ordinal alpha ranged between 0.82 and 0.95. All subscales demonstrated satisfactory test-retest reliability (ICC=0.76-0.94).

CONCLUSION

The revised version of the PCCQ showed sound psychometric properties and is ready to be used to measure perceptions of continuity of care. High ordinal alpha in some subscales indicates that a shorter version of the questionnaire can be developed.

Reducing ER Visits and Readmissions after Head and Neck Surgery Through a Phone-based Quality Improvement Program

Objective:

Evaluate the impact of a patient phone calls and virtual wound checks within 72 hours of discharge on reducing emergency room (ER) visits and readmissions.

Methods:

Single arm trial with comparison to historical control data of patients undergoing multi subsite head and neck cancer operations or laryngectomy between July 2017 and June 2018 at a tertiary academic medical center. Patients were contacted within 72 hours of hospital discharge. As a supplement to the call, patients were given the opportunity to video conference with and/or send pictures to the provider with additional questions via a designated wound care phone.

Results:

Ninety-one patients met inclusion criteria, of whom 83 (91.2%) were contacted. Six patients (7%) were readmitted, of whom three had not been able to be reached. The patients who had been unable to be contacted were readmitted for dysphagia (2), and a urinary tract infection (1). The contacted patients were advised to go the ER during the call for concerns for postoperative bleeding (2) and gastrointestinal bleeding (1). Twenty-five patients (30%) utilized the wound care phone. 18 patients (21.7%) reported that the phone call survey prevented them from going to the ER. When compared to the prior year, there was as statistically significant decrease in ER visits ( P < .05), and no change in readmissions.

Conclusions:

Implementation of a phone call in the early postoperative period has the potential to decrease unnecessary ER visits and enhance patient satisfaction. This may decrease strain on the health care system and improve patient care.

Level of Evidence:

4

Hospital readmissions after pulmonary resection: post-discharge nursing telephone assessment identifies high risk patients

Background

We previously reported that post-discharge nursing telephone assessments identified a frequent number of patient complaints. Our aim was to determine if telephone assessments can identify patients at risk for emergency room (ER) visits or hospital readmissions.

Methods

A single-institution, retrospective review was performed on all patients undergoing pulmonary resection over a 12-month period. Standardized nursing telephone calls were conducted and records were reviewed to determine postoperative issues. ER visits and readmissions within 30 and 90 days were recorded.

Results

In total, 521 patients underwent pulmonary resection and 245 (47%) were reached for telephone assessment. ER visits within 30/90 days were 8.1% (n=42) and 12.1% (n=63). Readmissions within 30/90 days were 3.1% (n=16) and 6% (n=31). For those reached by telephone assessment, patients with major issue demonstrated increased 30-day ER visits: 22.6% (n=7) vs. 8.0% (n=17), P=0.019. For all patients, those with 90-day ER visit and/or readmission were more likely to have pulmonary complications during initial admission (43.8% vs. 21.2%, P<0.001). Among patients who were reached by telephone, independent predictors of ER visit or readmission within 30 days were: major issue identified on telephone assessment (P=0.007), discharge with chest tube (<0.001), and reintubation postoperatively (P=0.047).

Conclusions

Standardized nursing telephone assessments were able to identify a high-risk population more likely to need ER visit or readmission. However, telephone assessments did not decrease ER visits or readmissions. Improved post-discharge protocols are needed for these high-risk patients in order to ensure patient safety, optimize patient experience, and limit unnecessary resource utilization.

Home to Stay: An Integrated Monitoring System Using a Mobile App to Support Patients at Home Following Colorectal Surgery

Background:

Patients undergoing colorectal surgery are vulnerable during their transition from hospital to home and require increased support following discharge from hospital. Study objectives were to perform an initial assessment of patient uptake, outcomes, and satisfaction with an integrated discharge monitoring system called Home to Stay.

Methods:

The intervention was an integrated discharge monitoring system that uses a mobile app platform. Patients downloaded the app prior to discharge from hospital and received a Daily Health Check day #1 to #14, #21, and #30. Patient responses’ were accessed by the health-care team via secure web site, and extreme responses were “flagged” to indicate that a follow-up telephone call was necessary. Primary outcomes were patient uptake, Quality of Recovery scores and satisfaction with the program. Secondary outcomes were 30-day emergency room (ER) visits and readmissions.

Results:

One hundred and thirty-two patients were invited to participate and 106 accepted. Of these, 93 used the app at least once. The mean overall score on the Quality of Recovery Scale increased significantly from day 1 to day 14. Patient satisfaction with the app was high, with 92% of patients reporting overall satisfaction as good or excellent. The 30-day readmission rate was 6% and was lower than the 30-day readmission rate of 18% reported for the 4 months prior to the start of the study.

Conclusions:

The Home to Stay Program to support patients at home after colorectal surgery is feasible with high patient uptake and satisfaction. This program has the potential to reduce 30-day readmissions, however further studies are required.

Implementation of a Discharge Education Program to Improve Transitions of Care for Patients at High Risk of Medication Errors

Background: Transitions of care (TOC) points are those where patient outcomes can be affected, especially patients at high risk for medication errors. Pharmacist-led postdischarge telephone counseling positively affects patient outcomes, though challenges exist relating to successful patient contact. Objective: The objective of this study was to develop and evaluate a discharge education service bridging the inpatient and outpatient setting to increase successful patient contact points during the TOC process from hospital to home. Methods: This prospective, single-centered observational study examined the impact of a discharge medication education program on successful telephone follow-up contact. The primary outcome was the percentage of high-risk patients educated at hospital discharge who were successfully reached via follow-up telephone contact within 2 business days of discharge. Secondary end points included hospital readmission rates and patient survey responses. Results: A total of 50 patients were included in the initial evaluation of this service; 78% of patients were successfully contacted within 2 business days after discharge, an increase from a 20% success rate prior to service implementation. At follow-up telephone calls, patients reported taking an average of 16 medications. The 30-day readmission rate was 10% for patients receiving this service, compared with 19% prior to implementation. When asked if they understood the medication component of their care and if they found the TOC service to be satisfactory, 100% and 96% of patients strongly agreed or agreed with these statements, respectively, and none disagreed. Conclusion and Relevance: This service demonstrates how pharmacists can interact with a high-risk population and increase contact points to optimize care at crucial health care transition points.

Assessment of pharmacy-driven transitional interventions in hospitalized patients with psychiatric disorders

OBJECTIVE

Pharmacy-driven transitions of care (TOC) services for psychiatric patient populations have not been systematically evaluated. The primary objective was to assess pharmacy TOC services for patients hospitalized for psychiatric care at an academic medical center. The secondary objectives were to evaluate the incidence of psychiatric-associated readmission, emergency department (ED) presentations, or both and outpatient clinic follow-up 30 days after discharge, in addition to characterizing the types and frequencies of psychotropic medications prescribed at discharge.

DESIGN

Retrospective, double-cohort study.

SETTING AND PARTICIPANTS

This study compares adult patients who received at least 1 pharmacy-driven TOC intervention before discharge from a psychiatric unit between June 1, 2017, and June 30, 2018, with a historical control group that was discharged between June 1, 2016, and May 31, 2017. Interventions included discharge education on selected high-risk medications, medication barriers assessment, TOC notes to outpatient providers, postdischarge telecommunication, and bedside medication delivery.

OUTCOME MEASURES

The percentage of pharmacy TOC services provided for patients hospitalized for psychiatric care at an academic medical center and the incidence of psychiatric-associated readmission, ED presentations, or both and outpatient clinic follow-up 30 days after discharge.

RESULTS

Fifty-three and 104 electronic health records were reviewed within the control and intervention groups, respectively. The most common interventions were discharge education (22.7%), bedside delivery of medications (22.7%), and medication barrier assessments (22.2%). Adherence (26.8%) and cost (19.5%) were the most common medication barriers. Thirty-day psychiatric-associated readmissions, ED presentations, or both occurred in 32.4% and 15.4% of patients in the control and intervention groups, respectively (P < 0.001). Of the patients, 15.1% and 20.1% presented for outpatient follow-up in the control and intervention groups, respectively (P < 0.001). Statistically, more patients in the control group were prescribed antidepressants at discharge (41.8% vs. 13.1%), whereas more patients in the intervention group were prescribed lithium (10.9% vs. 4.3%) and antipsychotics other than clozapine (40.0% vs. 25.9%).

CONCLUSION

The findings show significant differences in clinical outcomes between patients receiving and not receiving pharmacy-driven transitional interventions. Future prospective studies are warranted to further elucidate these observations.

Medication histories documentation at the community pharmacy setting: A study from Jordan

Objectives

The main objective of this study was to evaluate community pharmacists’ awareness and perception about medication reconciliation service and to assess the completeness of collecting patients’ medication histories in the community pharmacy setting.

Methods

A cross-sectional study was conducted between February to March 2018 in Amman-Jordan. During the study period, 150 community pharmacists were invited to participate in the study. Each pharmacist completed a validated structured questionnaire evaluating their awareness, current practice, perceived attitude and perceived barriers towards the implementation of medication reconciliation and the collection of medication histories at the community pharmacy setting.

Results

A total of 121 pharmacists agreed to participate and filled the questionnaire. Our results showed that only 13.2% of the pharmacists were able to define “medication reconciliation” correctly, and around 31% have a misconception that the medication reconciliation process should be performed only at the inpatient setting.

Only 19.8% (n = 24) of the participating pharmacists stated that they ask all patients for a complete current medication list of medications when they arrive at the pharmacy site. Medication histories for most patients were lacking information about the dosage, route, frequency, and time of the last refill for each medication listed. “Patients lack of awareness about all the medications they are receiving” was the main barrier discouraging community pharmacists from collecting medication histories and participating in reconciliation service.

Conclusion

Community pharmacists in Jordan showed a low awareness about the medication reconciliation concept and demonstrated a modest role in obtaining medication histories in community pharmacies. But still, they showed a positive attitude towards their role in implementing the different steps of medication reconciliation. This suggests that educational workshops to increase pharmacists’ awareness about their role and responsibilities in collecting a complete and accurate medication history are warrented.

Use of a Bidirectional Text Messaging System for Emergency Department Follow-Up Versus Usual Follow-Up

Background: The use of text messaging is a growing trend. Usual care for follow-up with patients (no dedicated communication) has proven unreliable, and alternative communication methods may be beneficial. Introduction: The objective was to evaluate the effect of text messaging as a means of follow-up communication compared to usual care on patient satisfaction among patients discharged from the emergency department (ED). Materials and Methods: Participants completed a baseline survey about their text message usage and ED visit satisfaction. The participants completed a follow-up survey 2 weeks later. Participants randomized to text messaging received a text message at 24 h, 1 week, and 2 weeks after discharge. Control participants received usual care (typically no dedicated communication). Bivariate analyses were performed, and intent-to-treat and per protocol analyses were completed to examine follow-up satisfaction with ED communication/care. Results: A total of 802 subjects were recruited (text messaging-398 subjects, usual care-404 subjects). In the intent-to-treat analysis, text messaging subjects were not more likely to report satisfaction with follow-up communication (adjusted odds ratio [aOR] 0.90 [0.46-1.75]) or follow-up care (aOR 0.66 [0.30-1.46]) than usual care subjects. In per-protocol analysis, text messaging subjects had 2.95 (1.52-5.73) higher odds of reporting satisfaction with follow-up communication and 3.24 (1.46-7.16) higher odds of reporting satisfaction with follow-up care. Discussion: The use of text messaging for follow-up, when comparing satisfaction with follow-up communication and follow-up care after discharge, performs at least equally as well as usual follow-up. Conclusions: Text messaging is a provider time-saving and resource-conserving technology allowing health care providers to potentially reach a larger proportion of patients, making it a valuable form of follow-up communication.

Effects of Pharmacist-Conducted Medication Reconciliation at Discharge on 30-Day Readmission Rates of Patients With Chronic Obstructive Pulmonary Disease

PURPOSE

To analyze effect of pharmacist-conducted medication reconciliation on 30-day readmission rates in chronic obstructive pulmonary disease (COPD) and identify common medication errors among patient with readmissions.

METHODS

Pharmacists were educated on discharge medication reconciliation for patients with COPD. A retrospective chart review was conducted on patients who underwent pharmacist-conducted discharge medication reconciliation to determine 30-day readmissions. Medication errors analyzed included medication omissions and dose or frequency errors. Previously collected internal research without pharmacist-conducted medication reconciliation served as the control.

RESULTS

There were 65 patients in the control group and 50 in the intervention group. About 25% of patients in the control group and 26% of patients in the intervention group had any cause readmissions within 30 days of discharge (P = .87). Both the control and the intervention group had similar COPD-related readmissions of 12.3% and 12.6%, respectively. Medication dose or frequency errors consisted of 68.9% and 46.7% of total errors in the control and the intervention groups, respectively. Long-acting muscarinic antagonist (LAMA) or long-acting beta 2-agonist (LABA) were the most common drug classes to be incorrectly dosed or omitted at discharge. In the intervention group, 30 errors were identified. Due to inability to coordinate discharges, pharmacists intervened on 13 errors, 7 of which were accepted by the prescriber.

CONCLUSION

Pharmacist-conducted medication reconciliation at discharge did not affect 30-day readmission rates of patients with COPD. Confounding factors included a small sample size, passive pharmacist education, and discharge issues. The most common medication errors at discharge were dosing or frequency errors of LABAs or LAMAs.

Reducing Medication Therapy Problems in the Transition from Hospital to Home: A Pre- & Post-Discharge Pharmacist Collaboration

BACKGROUND

With 30-day Medicare readmission rates reaching 20%, a heightened focus has been placed on improving the transition process from hospital to home. For many institutions, this charge has identified medication-use safety as an area where pharmacists are well-positioned to improve outcomes by reducing medication therapy problems (MTPs).

METHODS

This system-wide (425 bed community hospital plus 18 primary care clinics) prospective study recruited inpatient and ambulatory pharmacists to provide comprehensive medication management before and after hospital discharge. The results analyzed were the success rate and timing of the inpatient to ambulatory pharmacist handoff, as well as the number, type, and severity of MTPs resolved in both settings.

RESULTS

Of the 105 eligible patients who received a pharmacist evaluation before discharge, 61 (58%) received follow-up with an ambulatory pharmacist an average of 2.88 days after discharge (range 1-8 days). An average of 5 and 1.4 MTPs per patient were identified and resolved in the inpatient vs. ambulatory setting, respectively. Although average MTP severity ratings were higher in the inpatient setting, the highest severity rating was seen most frequently in the ambulatory setting.

CONCLUSIONS

In the transition from hospital to home, pharmacist evaluation in both the inpatient and ambulatory settings are necessary to resolve medication therapy problems.

Reducing readmission rates through a discharge follow-up service

Approximately 15% of elderly patients are readmitted within 28 days of discharge. This costs the NHS and patients. Previous studies show telephone contact with patients -post-discharge can reduce readmission rates. This service -evaluation used a cohort design and compared 30-day emergency readmission rate in patients identified to receive a community nurse follow-up with patients where no attempt was made. 756 patients across seven hospital wards were -identified; 303 were identified for the intervention and 453 in a -comparison group. Hospital admission and readmission data was extracted over 6 months. Where an attempt to contact a patient was made post-discharge, the readmission rate was 9.24% compared to 15.67% where no attempt to -contact was made (p=0.011). After adjustment for -confounding using logistic regression, there was evidence of reduced readmissions in the 'attempt to contact' group odds ratio = 1.93 (95% c-onfidence interval = 1.06-3.52, p=0.033). Of the patients who community nurses attempted to contact, 288 were contacted, and 202 received a home visit with general practitioner -referral and medications advice being the most common -interventions initiated. This service evaluation shows that a simple intervention where community nurses attempt to contact and visit geriatric patients after discharge causes a significant reduction in 30-day hospital readmissions.

Parents welcome follow-up using mobile devices: A survey of acceptability at an Australian tertiary paediatric centre

Follow-up for ongoing management and monitoring of patients is important in clinical practice and research. While common, telephone follow-up is resource intensive and, in our experience, yields low success rates. Electronic communication using mobile devices including smartphones and tablets can provide efficient alternatives - including SMS (text), online forms and mobile apps. To assess attitudes towards electronic follow-up, we surveyed 642 parents and carers at Perth Children's Hospital, targeting demographics, device ownership and attitudes towards electronic follow-up. Mobile phone ownership was effectively universal. Almost all respondents were happy to communicate electronically with the hospital. Promisingly, 93.2% of respondents were happy to receive follow-up SMSs from the hospital and 80.3% were happy to reply to SMS questions. There was less enthusiasm regarding other modalities, with 59.9% happy to use a website and 69.0% happy to use a mobile app. The results support the introduction of electronic communication for follow-up in our paediatric population.

Implementation of postdischarge follow-up telephone calls at a comprehensive cancer center

PURPOSE

The development and implementation of a pharmacy-driven, postdischarge follow-up telephone call program to assess medication adherence, provide education, and address medication-related concerns are discussed.

SUMMARY

Many readmissions are avoidable through effective discharge planning and patient follow-up after hospitalization. However, there is limited information on how to effectuate this process. To address this barrier, a team consisting of a clinical pharmacy specialist, a clinical pharmacy manager, a postgraduate year 1 pharmacy resident, and an education specialist at The University of Texas MD Anderson Cancer Center collaborated to create a postdischarge telephone call program within a transitions-of-care (TOC) pilot program. Various education and training materials were created to ensure trainees were competent. As of February 2016, 23 outpatient pharmacists and students have completed training, earning a median pretest and posttest score of 6 and 9, respectively, out of 10. There have been 206 calls completed; 150 patients (73%) were successfully reached, and 20 patients (9%) declined the telephone call. Medication adherence assessed during the telephone follow-up identified that 134 patients (89%) received their new medications within 72 hours, and 87 patients (58%) were recognized as having one or more discrepancies.

CONCLUSION

Developing a TOC program similar to this pilot program requires several resources including time, collaboration, and support from the management team. Pharmacy is well positioned to complete an accurate medication review and conduct postdischarge telephone calls to address medication-related issues. By providing these services, patients will receive continuity of care and positively impact emergency room visitation rates and hospital readmission rates.

Tele-Follow-Up of Older Adult Patients from the Geriatric Emergency Department Innovation (GEDI) Program

The objective of this study was to characterize the content and interventions performed during follow-up phone calls made to patients discharged from the Geriatrics Emergency Department Innovation (GEDI) Program and to demonstrate the benefit of these calls in the care of older adults discharged from the emergency department (ED). This study utilizes retrospective chart review with qualitative analysis. It was set in a large, urban, academic hospital emergency department utilizing the Geriatric Emergency Department Innovations (GEDI) Program. The subjects were adults aged 65 and over who visited the emergency department for acute care. Follow-up telephone calls were made by geriatric nurse liaisons (GNLs) at 24–72 h and 10–14 days post-discharge from the ED. The GNLs documented the content of the phone calls, and these notes were analyzed through a constant comparative method to identify emergent themes. The results showed that the most commonly arising themes in the patients’ questions and nurses’ responses across time-points included symptom management, medications, and care coordination (physician appointments, social services, therapy, and medical equipment). Early follow-up presented the opportunity for nurses to address needs in symptom management and care coordination that directly related to the ED admission; later follow-up presented a unique opportunity to resolve sub-acute issues that were not addressed by the initial discharge plan and to manage newly arising symptoms and patient needs. Thus, telephone follow-up after emergency department discharge presents an opportunity to better connect older adults with appropriate outpatient care and to address needs arising shortly after discharge that may not have otherwise been detected. By following up at two discrete time-points, this intervention identifies and addresses distinct patient needs.

Ensuring continuity of patient care across the healthcare interface: Telephone follow-up post-hospitalization

AIMS

To implement pharmacist-led, postdischarge telephone follow-up (TFU) intervention and to evaluate its impact on rehospitalization parameters in polypharmacy patients, via comparison with a well-matched control group.

METHOD

Pragmatic, prospective, quasi-experimental study. Intervention patients were matched by propensity score techniques with a control group. Guided by results from a pilot study, clinical pharmacists implemented TFU intervention, added to routine integrated medicines management service.

RESULTS

Using an intention to treat approach, reductions in 30- and 90-day readmission rates for intervention patients compared with controls were 9.9% [odds ratio = 0.57; 95% confidence interval (CI): 0.36-0.90; P < 0.001] and 15.2% (odds ratio = 0.53; 95% CI: 0.36-0.79; P = 0.021) respectively. Marginal mean time to readmission was 70.9 days (95% CI: 66.9-74.9) for intervention group compared with 60.1 days (95% CI: 55.4-64.7) for controls. Mean length of hospital stay compared with control was (8.3 days vs. 6.7 days; P < 0.001). Benefit: cost ratio for 30-day readmissions was 29.62, and 23.58 for 90-day interval. Per protocol analyses gave more marked improvements. In intervention patients, mean concern scale score, using Beliefs about Medicine Questionnaire, was reduced 3.2 (95% CI: -4.22 to -2.27; P < 0.001). Mean difference in Medication Adherence Report Scale was 1.4 (22.7 vs. 24.1; P < 0.001). Most patients (83.8%) reported having better control of their medicines after the intervention.

CONCLUSIONS

Pharmacist-led postdischarge structured TFU intervention can reduce 30- and 90-day readmission rates. Positive impacts were noted on time to readmission, length of hospital stay upon readmission, healthcare costs, patient beliefs about medicines, patient self-reported adherence and satisfaction.

Automated Postdischarge Trauma Patient Call Program

Postdischarge phone calls have been shown to improve communications between patients and health care providers, potentially reducing readmission rates, medication errors, and emergency department (ED) visits. Given the complexity of social and medical issues associated with trauma, we studied the utility of an automated phone call system as a method of identifying gaps in trauma care. The Trauma Program and the Health Management and Education Department at a Level 1 academic trauma center engaged in a collaborative quality improvement effort using the CipherHealth LLC platform to provide automated phone calls to trauma patients 2-3 days after discharge. Automated questions to patients focused upon symptoms, equipment and medications, discharge instruction comprehension, and follow-up needs. When indicated, the automated system sent an alert and prompted the timely return phone call to the patient from a registered nurse with the intent of addressing the specified issue. During the 4-month study period, 1,382 patients were discharged from the trauma service. Three hundred thirty-two calls were attempted, with 186 completed. Twenty-seven percent of the completed calls prompted a nurse to make a personalized callback to the patient. Most calls were for symptoms (26%), follow-up appointments (22%), medication issues (21%), and discharge instruction clarification (15%). Just over 25% of trauma patients requested further clarification after discharge from the hospital. The results of this pilot indicate that further follow-up is warranted to determine whether outpatient follow-up calls in the trauma population have any impact upon mitigating complications and quality measures such as reduced ED visits, readmission, and patient safety and satisfaction.

Interventions to reduce readmissions: can complex adaptive system theory explain the heterogeneity in effectiveness? A systematic review

Background

Successfully transitioning patients from hospital to home is a complex, often uncertain task. Despite significant efforts to improve the effectiveness of care transitions, they remain a challenge across health care systems. The lens of complex adaptive systems (CAS) provides a theoretical approach for studying care transition interventions, with potential implications for intervention effectiveness. The aim of this study is to examine whether care transition interventions that are congruent with the complexity of the processes and conditions they are trying to improve will have better outcomes.

Methods

We identified a convenience sample of high-quality care transition intervention studies included in a care transition synthesis report by Kansagara and colleagues. After excluding studies that did not meet our criteria, we scored each study based on (1) the presence or absence of 5 CAS characteristics (learning, interconnections, self-organization, co-evolution, and emergence), as well as system-level interdependencies (resources and processes) in the intervention design, and (2) scored study readmission-related outcomes for effectiveness.

Results

Forty-four of the 154 reviewed articles met our inclusion criteria; these studies reported on 46 interventions. Nearly all the interventions involved a change in interconnections between people compared with care as usual (96% of interventions), and added resources (98%) and processes (98%). Most contained elements impacting learning (67%) and self-organization (69%). No intervention reflected either co-evolution or emergence. Almost 40% of interventions were rated as effective in terms of impact on hospital readmissions. Chi square testing for an association between outcomes and CAS characteristics was not significant for learning or self-organization, however interventions rated as effective were significantly more likely to have both of these characteristics (78%) than interventions rated as having no effect (32%, p = 0.005).

Conclusions

Interventions with components that influenced learning and self-organization were associated with a significant improvement in hospital readmissions-related outcomes. Learning alone might be necessary but not be sufficient for improving transitions. However, building self-organization into the intervention might help people effectively respond to problems and adapt in uncertain situations to reduce the likelihood of readmission.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3712-7) contains supplementary material, which is available to authorized users.

Measuring the Impact of Medication-Related Interventions on 30-Day Readmission Rates in a Skilled Nursing Facility

BACKGROUND

There is a lack of published literature that measures the impact of transitional care pharmacist (TCP) medication-related interventions within the skilled nursing facility (SNF) setting.

OBJECTIVES

To evaluate the impact of TCP medication-related interventions on 30-day hospital readmissions among SNF patients compared to current standard of care.

METHODS

This was a retrospective pilot study. All patients included in the study were discharged from an inpatient facility to a SNF. The control group received transitional services from a care team with no pharmacist. The intervention group received transitional services from a care team plus a pharmacist.

RESULTS

The 30-day readmission rates in the intervention group were 14 (12%)/116 compared to the control group, 19 (16%)/116; however, the difference was not statistically significant (P = .35). The median time to readmission was statistically significantly longer in the intervention group, 17.5 days, compared to the control group, 10 days (P = .02). One hundred seventy-four medication-related interventions were performed in the intervention group during the study period.

CONCLUSION

This study demonstrates that TCP interventions in an SNF are associated with a significant delay in readmission. A continuation of the pilot program may show a role in reducing all-cause 30-day readmission and ED visit rates.

Post-discharge Medication Reconciliation: Reduction in Readmissions in a Geriatric Primary Care Clinic

Objectives: This study aimed to evaluate hospital utilization and characterize interventions of pharmacist-led telephonic post-discharge medication reconciliation. Method: A retrospective analysis was conducted, including 833 index events in 586 geriatric patients receiving the intervention. Medicare claims were used to capture 30-day hospital utilization (admission to the emergency department, observation unit, or inpatient hospitalization) following discharge from any of these locations. Medication-related interventions were described. Results: Hospital utilization within 30 days after discharge from any location was greater for patients receiving usual care compared with the intervention (32.5% vs. 22.2%; odds ratio [OR] = 1.69, 95% confidence interval [CI] = [1.06, 2.68]). Inpatient admission within 30 days after discharge from any location was greater for those receiving usual care (14.7% vs. 6.4%; OR = 2.54, 95% CI = [1.18, 5.44]). At least one medication-related problem was identified and addressed in 89.8% of patients receiving the intervention. Discussion: A telephonic post-discharge medication reconciliation program can lead to reduction in hospital utilization in a geriatric population.

Budget Impact Analysis of a Pharmacist-Provided Transition of Care Program

BACKGROUND

Postdischarge medication management services have been shown to reduce the incidence of medication-related problems during the transition from inpatient to outpatient care. A pharmacist-run transition of care (TOC) program has been developed to reduce the unplanned readmissions of a high-risk managed Medicaid population after hospitalization.

OBJECTIVE

To estimate the budget impact of adding an outpatient pharmacy-based TOC program to a medical benefit from the payer perspective.

METHODS

A budget impact analysis was conducted using a decision-tree model developed in Microsoft Excel. The effect on inpatient and total health care costs from the payer perspective was estimated for the 2-year period following initial hospital discharge. Inputs were based on a total plan population of 240,000 lives, with a high-risk population of 7.5%, of whom 37% were hospitalized and potentially qualified for TOC services, resulting in an eligible population of 6,660 patients. The TOC program was assumed to initially cover 30% of the eligible population, with expansion to 60% over the 2 years. We previously reported that this program reduced the risk of readmission by 32% within 6 months and saved the health plan $2,139 per patient referred to the program, inclusive of program cost, compared with patients receiving usual discharge care. Sensitivity analyses were performed to test the impact of uncertainty of model inputs on the results, with the cost of TOC services ranging from $99 to $2,000 per patient referred.

RESULTS

The model showed that the TOC program was cost saving at over $3 per member per month in the first 6 months, which translates to over $25 million in total health care cost savings over 2 years. These results were primarily driven by the estimated reduction in inpatient costs associated with the program, which were estimated at $20 million over the 2 years. Sensitivity analyses illustrated that within all the reasonable ranges of model input parameters, including the upper limit of TOC services set to $2,000 per patient referred, the TOC program resulted in cost savings to the health plan.

CONCLUSIONS

The TOC program resulted in potential cost savings of over $25 million to the managed Medicaid plan over a period of 2 years, corresponding to over $4 per member per month.

DISCLOSURES

Funding for this study was contributed by the Komoto Family Foundation, which provided fellowships to Ni and McCombs during the time of this study. Colayco is employed by Synergy Pharmacy Solutions and by the Komoto Family Foundation. Hashimoto and Komoto are employed by Synergy Pharmacy Solutions. Gowda and Wearda report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. Study concept and design were contributed by Ni, Colayco, and McCombs, along with the other authors. Hashimoto, Komoto, and Wearda took the lead in data collection, assisted by Ni, Colayco, and Gowda. Data interpretation was performed by Ni, Colayco, and McCombs, along with the other authors. The manuscript was written by Ni and Colayco and revised by Gowda and McCombs, along with the other authors.

Pharmacist Clinical Interventions and Discharge Counseling in Medical Rehabilitation Wards in a Local Hospital: A Prospective Trial

Patients undergoing rehabilitation experience numerous changes in medication regimens during care transitions, exposing these patients to an increased risk of drug-related problems (DRPs). A prospective, non-randomized, quasi-experimental study was conducted in medical rehabilitation wards to evaluate the impact of pharmacist-delivered interventions and counseling on 30-day unplanned health care utilization and medication adherence for selected rehabilitation patients. A pharmacist provided medication reconciliation and counseling before discharge. Phone follow-up was completed 30 days after discharge to assess for unplanned health care utilization rate and medication adherence. A total of 85 patients (n = 43 in prospective intervention group and n = 42 in historical usual care group) were included. Among the intervention group, 23 DRPs were identified in 14 (32.6%) patients, resulting in 51 interventions. The intervention group had a significantly lower unplanned health care utilization rate than the usual care group (25.6% vs. 47.6%, p = 0.035). The risk of unplanned health care utilization was reduced by over 60% (Odds ratio (OR) = 0.378; 95% CI = 0.15-0.94). Patients reporting medium to high medication adherence increased from 23.6% to 88.4% 30 days after counseling (p < 0.05). Pharmacist medication reconciliation and discharge counseling reduced unplanned health care utilization 30 days after discharge and improved medication adherence.

Thirty-day unplanned hospital readmission in ovarian cancer patients undergoing primary or interval cytoreductive surgery: systematic literature review

OBJECTIVES

Thirty-day readmission rate has been proposed as metric of quality and remains an ongoing clinical concern in the primary treatment of patients with advanced-stage ovarian epithelial ovarian cancer. We conducted a review of the literature to identify rates, risk factors, and predictors for 30-day readmission in this population.

METHODS

A 10-year period MEDLINE (PubMed) search of English literature studies published between January 01, 2008-January 01, 2018 was performed to identify appropriate studies for review.

RESULTS

Thirty -day readmission rates for ovarian cancer patients undergoing primary treatment ranged from 2.5-19.3%. Neoadjuvant chemotherapy and interval cytoreductive surgery (NACT-ICS) surgery was associated with lower readmission rates, when compared to primary debulking surgery (PDS). The most frequently reported adverse events resulting in readmission include inpatient management of ileus/small bowel obstruction, wound-related complications, and thromboembolic events. Readmission predictors included the presence of other medical comorbidities, re-operation, and major complications occurring after initial hospital discharge. Some studies reported lower rates of readmission and survival in patients treated by NACT-ICS.

CONCLUSIONS

Policies and programs should be designed to measure short- and long-term outcomes in this patient population to avoid bias in assigning patients to NACT-ICS to maintain low 30-day readmission rates.

Thirty-day hospital readmission and emergency department visits after vascular surgery: a Canadian prospective cohort study

BACKGROUND

Rates of hospital readmission following surgery can serve as a marker for quality of care. The aim of this study was to establish the rates and causes of readmission and emergency department visits after vascular surgery and to understand how these patients are managed.

METHODS

We conducted a prospective observational cohort study including all inpatients who underwent major vascular surgery between September 2015 and June 2016 at a tertiary vascular care centre in Toronto. Patients were followed at 30 days after discharge via telephone interview.

RESULTS

We enrolled 133 patients (94 men [70.7%] and 39 women [29.3%] with a mean age of 65.3 years). The most common index admission diagnosis was peripheral artery disease (67 patients [50.4%]). At 30 days, 19 patients (14.8%) had been readmitted or had visited the emergency department, most commonly after lower extremity revascularization (19.4%). Ten patients were readmitted a mean of 16.8 days following discharge; surgical site infection was the most common cause for readmission (3 patients). The most common treatment was antimicrobial therapy (4 patients). The mean hospital length of stay was 14.4 days. Nine patients presented to the emergency department a mean of 10.6 days after discharge; 6 reported a wound issue, and most (6 of 9) were managed with oral antibiotic treatment.

CONCLUSION

Early readmission/emergency department visits after lower extremity revascularization surgery in patients with peripheral artery disease are common and are often due to surgical site infection or wound-related issues. Follow-up within 7-10 days and a specialized wound care team may help reduce the occurrence of these events.

Analysis of Patient Follow-Up at a Level I Trauma Center in Ohio

Trauma patients report being unprepared for hospital discharge. The purpose of this study was to identify follow-up compliance rates at our trauma clinic and identify factors associated with trauma patients' adherence to follow-up appointment. We recruited patients 15 years and older who were discharged from the trauma service between December 2014 and August 2015. Demographic information and injury-related variables were obtained from the trauma registry for patients who attended their follow-up and those who did not attend. Follow-up appointment weather data were collected. All patients were surveyed regarding barriers to compliance. There was no difference in demographics, number of intensive care unit days, length of stay, or distance to the clinic. On days with rain or snow, patients were less likely to follow-up. Patients were more likely to follow-up on warmer days, and maximum daily air temperature was an independent predictor of follow-up compliance. Mechanism of injury and trauma activations were associated with higher follow-up compliance. Trauma patients are overall compliant with postdischarge follow-up appointments. There are no consistent factors related to trauma follow-up when compared with similar follow-up studies.