Integrated post-discharge transition care in a
hospitalist system: disease-specific care and referral
Chin-Chung Shu, M.D.1,2; Nin-Chieh Hsu, M.D.1,2; Yu-Feng Lin, M.D.1,2;
Jann-Yuan Wang, M.D., Ph.D.2; Jou-Wei Lin, M.D., Ph.D.3; and Wen-Je Ko,
M.D., Ph.D.1,4
Correspondence to:
Wen-Je Ko, MD, PhD
Department of Traumatology
National Taiwan University Hospital
No. 7, Chung-Shan South Road, Taipei 100, Taiwan
E-mail: Kowj@ntu.edu.tw
Tel: +886-2-23123456 ext 63098
Fax: +886-2-23952333
Running title: Post-discharge transition care in a hospitalist system
Word count: Abstract-261; Main text-2145
Key words: Hospitalist, post-discharge transition care, Taiwan
____________________
1Department of Traumatology, National Taiwan University Hospital, Taipei city,
Taiwan
2Department of Internal Medicine, National Taiwan University Hospital, Taipei
city, Taiwan
3Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin
Branch, Yun-Lin county, Taiwan
4Department of Surgery, National Taiwan University Hospital, Taipei city,
Taiwan
1
Abstract
Background: The post-discharge period is a vulnerable time for patients with
high rates of adverse events that may lead to unnecessary re-admissions,
especially in older populations. Because care discontinuity is easily interrupted
after hospitalist care hospitalist care, close follow-up may decrease
re-admission. This study aimed to investigate the impact of an integrated
post-discharge transition care (PDTC) in Taiwan’s hospitalist system.
Methods: From December 2009 to May 2010, patients admitted to the
hospitalist ward of a medical center in Taiwan, and discharged alive to home
care were included. Under quality improvement initiative, an observation group
was recruited in the first two months of the study period. Intervention of PDTC,
including disease-specific care plan, telephone monitoring, hotline counseling,
and hospitalist-run clinic visit were performed in the latter four months
(intervention group). The primary endpoint was unplanned re-admission and
death within 30 days after discharge.
Results: There were 94 and 219 patients in the observation and intervention
groups respectively. Both groups had similar characteristics on admission and
discharge. In the intervention group, 18 patients who had worsening
disease-specific indicators by telephone monitoring and 21 who reported
2
new/worsening symptoms by hotline counseling were associated with
unplanned re-admission (p=0.031 and 0.019, respectively). Those who
received PDTC had lower rates of re-admission and death within 30 days
post-discharge than the observation group (15% vs. 25%, p=0.021). No-use of
hospitalist-run clinic and presence of underlying malignancy were other
independent factors for 30-day post-discharge readmission and death.
Conclusion: The integrated PDTC using disease-specific care, telephone
monitoring, hotline counseling and a hospitalist-run cliniccan reduce
post-discharge readmissions and deaths.
3
Introduction
The hospitalist system has grown worldwide in recent decades.1-3 even
though its pros and cons are still under debate. While the hospitalist system
may save on hospitalization costs, a major concern is interruption of patient
care w provided by the primary care physician.4 In fact, short-term
post-discharge re-admission rates are very high in the elderly, approaching
20% within one month after discharge.5 Reasons for this include poor
compliance, instability of chronic disease, and insufficient communication
between in- and out-patient physicians.6 Home visits and telemedicine have
been studied in post-discharge care, but the reports are limited to those with
congestive
heart
failure,
chronic
obstructive
pulmonary
disease
or
post-surgery. 7-9
In a particular referral center, the one-month re-admission rate after
discharge from the hospitalist ward is 22% (unpublished data). Based on a
concept of care transition intervention,10 post-discharge transition care (PDTC)
is important in extending the care continuity after discharge from a hospitalist
ward.11-12 Close follow-up and communication may prevent adverse events
and decrease re-admission rates before the primary care physician takes over
care continuity.13
4
Although the experience of post-discharge transition care (PDTC) has
been studied extensively, the integrated model using telephone service has
not been well studied in a hospitalist system.10, 14 Given the success of care
transitions in decreasing post-discharge adverse events and reducing
re-admission rates,10 this study aimed to investigate if a comprehensive PDTC
program consisting of establishing a disease-specific care plan on discharge, a
daily patient hotline, scheduled follow-up calls, and a hospitalist-run clinic can
reduce re-admission rates and post-discharge mortality.
5
Methods
Study subjects
This prospective study was conducted in National Taiwan University
Hospital, a tertiary-care referral center in northern Taiwan, and was approved
by the Institutional Review Board of the hospital (200900012023R). From
December 2009 to May 2010, all patients >18 years old and admitted to the
hospitalist-care ward from emergency department were consecutively
screened. Those who were discharged alive to home were enrolled them
according to the designated general medical diseases (Table 1). The
disease-based sub-groups were clearly monitored by specific care plans.
Other inclusion criteria included a telephone line at home and caregiver/patient
who could speak Chinese or Taiwanese language.
Patients were excluded if they were electively admitted, previously
enrolled, died during hospitalization, transferred to a subspecialty ward or
other institutions, refused consent, or had an anticipated life expectancy <30
days. Patients without underlying chronic illness and a Barthel score >60 were
also excluded for presumably not requiring monitoring.15
For quality improvement initiative during the first two months of study
period, the patients received no other active intervention except a follow-up
6
call 30 days after discharge to confirm the patient’s status of readmission,
emergency department visit, and survival (observation group). In the latter four
months of the study, the patients received integrated PDTC within 30 days
after discharge (intervention group).
For every patient, the hospital doctors made a discharge plan. The ward
staff educated the patients and their caregivers regarding the usual discharge
care plan, which included chest care, inhaler use, tube/wound care skills,
diet/drug compliance and other disease-specific elements of discharge
teaching. Caregivers were taught if the patients were illiterate or had cognitive
deficits or Barthel score <35.
The patients were referred back to the clinic of theirprimary care
physician for continuity of care. A primary care physician was defined if the
patient had visited the same doctor three times or more within one year prior to
admission.4 If there was no primary care physician, the patients were
followed-up at the hospitalist-run clinic.
Integrated PDTC protocol
For the intervention group, the study nurses and hospital physician made
a PDTC plan, which consisted of
a disease-specific care plan, scheduled
follow-up calls, and a hotline in order to monitoring disease status and their
7
indicators (Table 1) aside from the usual discharge care plan. The
disease-specific indicators were initially chosen and then modified by their
hospital care physician according to the patient’s condition.16 The study nurses
and physicians explained and educated the patients and their caregivers as
regards measuring and reporting the indicators, and adhering to the discharge
plan and medication use.
After discharge, the study nurse contacted and cared for the patients
regularly by telephone on post-discharge days 1, 3, 7, 14 and 30. Using a
standardized case report form, the content of telephone calls service included:
1) monitoring disease-specific indicators; 2) enhancing drug compliance; and 3)
confirming adherence to the discharge care plan, including diet/life
modification and tube/wound care skill. A designated telephone line was also
opened from 8am to 9pm daily for call-in counseling for the intervention group.
Once there was disease worsening found (see online supplement), the
study nurses reported to and discussed with the subject’s hospitalist for further
management. Our ward clinic was opened between 8AM and 9PM daily and
managed by a hospitalist.
Clinical characteristics
The study patients’ clinical characteristics, laboratory data, hospital course
8
and outcomes were recorded. The Charlson index and Barthel scores were
calculated as in previous studies.17-18 Patients were followed up for 30 days
after discharge or until death, re-admission or loss of follow-up. Loss of
follow-up was defined if the patient/caregiver could not be contacted for two
consecutive two times.
The primary endpoint was unplanned readmission and unexpected death
within 30 days after discharge. Secondary endpoints included unplanned visits
to the emergency department (ED) or hospitalist-run clinic. An urgent or
unplanned clinic visit was defined as <24 hours duration from appointment to
clinic visit.
Statistics analysis
Inter-group differences were compared by independent t test for numerical
variables and chi-square test for categorical variables. Curves of probability of
re-admission and death were generated using the Kaplan-Meier method and
compared by the log-rank test. Multivariate Cox proportional hazard regression
was used to identify factors associated with 30-day primary outcome by
forward conditional method. A two-sided p<0.05 was considered significant. All
analyses were performed using the SPSS (Version 13.0, Chicago, IL).
9
Results
From December 2009 to May 2010, a total of 2932 patients were
admitted to general ward from the emergency department. Of the 737 patients
who were admitted to the hospitalist ward, only 551 were discharged alive for
home care (Fig. 1). Of them, 139 patients did not match the enrolment
diseases, 95 declined to join, and 4 were defined as “not requiring PDTC”.
Among the 313 patients finally enrolled, 94 patients were recruited into the
observation group and 219 into the intervention group with PDTC.
The clinical characteristics were similar between the two groups including
age, gender, underlying comorbidities, and presence of a primary care
physician (Table 2). Results of laboratory examinations on admission were
also similar. Upon discharge, the patients in the observation group were most
frequently cared for by their children (40% vs. 27%, p=0.009) whereas those of
the intervention group were commonly cared for by their spouses (42% vs.
31%, p=0.084).
Both groups had comparable activity of daily living by Barthel scores,
length of hospitalization, and defined diseases (see online supplement).
Extraordinary care including tubes (e.g. nasogastric tube, tracheostomy tube,
and draining tube), catheters (e.g. Foley catheter, catheter for dialysis, and
10
draining tube), was similar between the two groups. Wounds, mostly bedsores,
which needed regular cleaning and dressing at home were noted in 11.8% of
the study patients.
In the post-discharge course, 843 calls were recorded, with an average of
6.10 ± 2.96 minutes per call. Among 219 patients receiving PDTC, 134
received all of the calls and the remaining 85 were terminated earlier, including
53 lost to follow-up and 32 re-admissions/death. Eighteen had worsening
disease-specific indicators, six of whom were referred to the ED and 12 to the
clinic appointments (only 2 attended the hospitalist-run clinic). Six (five from
the ED and one from the clinic) were re-admitted within 30 days after
discharge. Those with worsening indicators had significantly higher risk of
re-admission than those without (p=0.031 by the Fisher’s exact test). Another
four cases had wrong tube or wound care that was corrected after further
education. All patients except two had good drug compliance.
Forty-four (20%) patients in the intervention group contacted us 105 times
through the designated telephone line. Of them, 29 calls from 21 patients
reported new or worsening symptoms. Four were referred to the ED and 11 to
the outpatient clinic, while the remaining six had counseling only. Seven (33%)
were re-admitted (4 from the ED and 3 from the clinic). Those reporting new or
11
worsening symptoms had higher risk of re-admission than those without new
or worsened symptoms (p=0.019, Fisher’s exact test). The other 76 patients
with counseling all asked for minor medical help such as health education, skill
confirmation, and drug/diet consultation.
In terms of post-discharge clinic appointment, there were more scheduled
appointments at the hospitalist-run clinic, either regular (27% vs. 14%, p=0.008)
or unplanned visits (9% vs. 2%, p=0.005) and less with the primary-care
physician (72% vs. 83%, p=0.038) in the observation group than in the
intervention group. Visits of the hospitalist-run clinic were associated with less
re-admissions (p=0.088) than no visits, whereas that of the primary care
physician clinic were not significant (p=0.890). The numbers of ED visits were
not different between the observation and intervention groups (23% vs. 17%,
p=0.212).
Within 30 days after discharge, the observation group had significantly
higher rates of re-admission and death than the intervention group (25% vs.
15%, p=0.021, Fig. 2). Further analysis revealed that the observation group
had borderline higher re-admission rate (22% vs. 14%, p=0.075) and
significantly higher death rate (3% vs. 1%, p=0.048). In contrast, the
re-admission rate of the overall patients in the general wards of the hospital
12
were similar during the observation and the intervention periods (17.0% vs.
17.2%, p=0.913, chi-square test; see online supplement).
Multivariate
Cox
proportional
hazard
regression
revealed
three
independent factors for primary outcome within 30 days after discharge,
including underlying malignancy (HR: 2.34, 95% CI: 1.33~4.11), not visiting the
hospitalist-run clinic after discharge (HR: 2.65, 95% CI: 1.04~6.73), and not
receiving PDTC (HR: 2.05, 95% CI: 1.16~3.65) (Table 5). Artificial tubes and
catheters, wounds requiring dressing change, age >65 years, Barthel score
<60, and longer hospitalization stay (≥14 days) were not associated with
post-discharge re-admission and death.
13
Discussion
This study investigates experiences with a multi-faceted PDTC program
consisting of a disease-specific care plan, follow-up phone calls, and referral to
a hospitalist-run clinic to decrease 30-day re-admissions and mortality. In
addition to the outpatient clinic, a PDTC program is important for patients after
discharge. Absence of underlying malignancy and visits to the hospitalist-run
clinic are also associated with better outcome.
The best method of care transition after discharge has not been
well-established, although several modes have been studied including
telephone-call follow-up, telehealth communication and monitoring and home
visits by nursing staff.8, 19-21 A integrated PDTC program using telephone-call
follow-up is easy to implement and has minimal equipment requisites.20 The
telephone service in the current study included active regular contact, to detect
disease worsening earlier, and stand-by counseling service.8 In addition, the
service monitors patient medication compliance and lifestyle modifications.22
The standby counseling service was also helpful, especially for care related
questions and unpredicted events.23-24 However, the number of ED visits is not
significantly reduced, probably because the service is only available from 8am
to 9pm, and some aspects of the ED are irreplaceable.
14
The findings in the current study suggests that outpatient clinics run by
hospitalists may play important roles in improving post-discharge outcomes.11
Outpatient follow-up by a hospitalist that is familiar with the patients’ disease
status can provide continuous care for discharged patients and complements
the PDTC. Extraordinary hospitalist care after discharge is very important,
because 20~30% of patients do not have a primary care doctor. As such, the
frequency of hospitalist-run clinic visits in the study increases in those without
PDTC and decreases in the intervention group. Continuity of post-discharge
patient care can be transitioned and covered by an integrated PDTC and
hospitalist-run clinics.
The study has several limitations to our study. First, the study used quality
improvement initiative design without randomization. This may not be a
serious concern because of the similarity in clinical characteristics among the
two study groups and in the re-admission rate of patients discharged from the
general wards. Second, telephone monitoring may be biased by the patient or
caregiver’s expression. Third, in a multi-faceted PDTC, it is hard to distinguish
where the strength comes from which piece of intervention. Fourth, the number
of patients excluded is considerable and may bias the result. Lastly, because
this study was performed in a tertiary referral center and the patients had
15
multiple co-morbidities, the results cannot easily be generalized to the regional
or district hospitals.
The hospitalist system has become widely accepted in recent decades,25
with advances developed to cope with any discontinuity from in-patient to
out-patient care.3,
12
However, hospitalist PDTC guidelines are lacking at
present. Apart from discharge summary and planning,6, 26-27 the current study
shows that an integrated PDTC is effective in care transition and may be
applied to general medical patients, who require an ever-increasing amount of
resources within the currently ageing society.28-29
16
Competing Interests
The authors declare that they have no competing interests.
Authors’ Contributions
Dr. W.J. Ko designed the study. Drs. C.C. Shu, N.C. Hsu, and Y.F. Lin
were involved in the project execution, clinical data collection, analysis and the
manuscript writing. Dr. J.W. Lin also participated in data analysis and J.Y.
Wang contributed to manuscript writing.
Acknowledgements
The authors thank the support of research assistants from the Ministry of
Economic Affairs (program number 98-EC-17-A-19-S2-0134).
17
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22
Table 1. Disease-associated indicators designated for post-discharge care by
telephone-call follow-up
Disease
Indicator 1
Indicator 2
Indicator 3
CHF with acute exacerbation
Body weight
Leg edema*
Dyspnea index†
Liver cirrhosis with decompensation
Body weight
Consciousness
COPD with acute exacerbation
Fever
Dyspnea index†
DM with poor control
Blood glucose
Hypertension with poor control
Blood pressure
Acute on chronic renal failure
Body weight
Urine output
Terminal cancer
Consciousness
Pain scale#
Ischemic stroke
Barthel’s score
Consciousness
UGI bleeding
Stool character
Heart rate
Pneumonia
Fever
Dyspnea index
Urinary tract infection
Fever
Dysuria
Cellulitis
Size of lesion
Local pain#
Intra-abdominal infection
Fever
Abdominal pain#
Chronic disease with acute change
Sputum character
Dyspnea index†
Acute illness
Fever
Abbreviations: CHF, congestive heart failure; COPD, chronic obstructive
pulmonary disease; DM, Diabetes mellitus; UGI, upper gastrointestinal
*measured
by grading developed for cancer treatment30
†measured by the Medical Research Council dyspnea scale 31
#measured by the Numerical Rating Scale32
23
Table 2. Clinical characteristics and laboratory data on initial admission
compared between the observation and intervention groups
Observation
group (n=94)
Intervention
group (n=219)
p value
Age, years
71 ± 15
69 ± 16
0.207
Gender, Male
42 (45)
115 (53)
0.204
3.5 ± 3.2
3.1 ± 3.1
0.210
Primary care physician, presence
66 (70)
173 (79)
0.094
Underlying malignancy
30 (32)
57 (26)
0.287
10079 ± 5011
10903 ± 5588
0.232
Hemoglobin, g/dL
13.2 ± 18.3
11.2 ± 2.6
0.228
Creatinine, mg/dL
2.6 ± 5.1
1.9 ± 2.0
0.284
Albumin, g/dL
3.4 ± 0.4
3.3 ± 0.8
0.630
38 (40)
58 (27)
0.009
3 (3)
5 (2)
0.617
Spouse
29 (31)
92 (42)
0.084
Non-relative caregiver
21 (22)
62 (28)
0.321
Barthel score at discharge
62 ± 35
66 ± 37
0.378
Length of hospital stay, days
8.5 ± 8.0
8.9 ± 6.1
0.660
Artificial tube/catheter at discharge
22 (23)
51 (23)
0.982
Wound needing change dressing
10 (11)
27 (12)
0.671
Charlson Score
Laboratory data at the initial admission
Leukocyte count, /µL
Care-giver at home
Child generation
Parental generation
Data are no. (%) or mean ± standard deviation unless otherwise indicated.
24
Table 3. Multivariate analysis for factors possibly associated with re-admission
and unexpected death within 30 days after discharge
Multivariate
Characteristics
p value
Age: years
≥ 65
HR (95% C.I.)
0.980
< 65 years
Gender
Male
0.423
Female
Artificial tube/catheter
At least one
0.880
None
Wound needed change of
dressing
Presence
0.404
Absence
Charlson score
Barthel score at discharge
<2
2~4
0.580
>4
0.418
< 60
0.208
≥ 60
Primary care physician
Presence
0.710
Absence
Underlying malignancy
Yes
0.003
2.34 (1.33 ~ 4.11)
No
Length of hospital stay
< 14 days
0.188
≥ 14 days
Blood leukocyte count (/µL)
6000 ~ 11000
0.494
< 6000, >11000
Post-discharge transition care
Not received
0.014
Received
Post-discharge disease item
Chronic illness
Acute illness
25
0.172
2.05 (1.16 ~ 3.65)
Visit of integrated clinic by
hospital physician
Not received
0.041
Received
Care-giver at home
Not spouse
Spouse
26
0.465
2.65 (1.04 ~ 6.73)
LEGEND
Figure 1. Flow chart of patient enrolment: “Not required”, patients with no
chronic illness and Barthel score ≥60; “Dx, not matched”, patient’s
diagnosis did not match the enrolled disease items; “Patient refused”,
patient refused enrolment
Figure 2. The probability of re-admission and unexpected death within 30 days
after discharge was plotted by the Kaplan Meier method and compared
using log-rank test. PDTC, post-discharge transition care
27