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Improving Patient Care |

A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial

Brian W. Jack, MD; Veerappa K. Chetty, PhD; David Anthony, MD, MSc; Jeffrey L. Greenwald, MD; Gail M. Sanchez, PharmD, BCPS; Anna E. Johnson, RN; Shaula R. Forsythe, MA, MPH; Julie K. O'Donnell, MPH; Michael K. Paasche-Orlow, MD, MA, MPH; Christopher Manasseh, MD; Stephen Martin, MD, MEd; and Larry Culpepper, MD, MPH
[+] Article and Author Information

ClinicalTrials.gov registration number: NCT00252057.


From Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, and Brown University Alpert Medical School, Pawtucket, Rhode Island.


Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.

Acknowledgment: The authors thank Caroline Hesko, MPH, for data collection and Lynn Schipelliti, RN, and Mary Goodwin, RN, for implementing the intervention. The RED study employed Ms. Hesko, Ms. Schipelliti, and Ms. Goodwin.

Grant Support: By Agency for Healthcare Research and Quality grants 1UC1HS014289-01 and 1U18HS015905-01 (Dr. Jack) and National Heart, Lung, and Blood Institute, National Institutes of Health, grant 1 R01 HL081307-01 (Dr. Jack).

Potential Financial Conflicts of Interest:Grants received: B.W. Jack (Agency for Healthcare Research and Quality; National Heart, Lung, and Blood Institute, National Institutes of Health).

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Jack (e-mail, brian.jack@bmc.org). Data set: Available through written agreement with Dr. Jack (e-mail, brian.jack@bmc.org).

Requests for Single Reprints: Brian W. Jack, MD, Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, 1 BMC Place, Dowling 5 South, Boston, MA 02118; e-mail, brian.jack@bmc.org.

Current Author Addresses: Drs. Jack, Chetty, Manasseh, Martin, and Culpepper; Ms. Johnson; Ms. Forsythe; and Ms. O'Donnell: Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, 1 BMC Place, Dowling 5 South, Boston, MA 02118.

Dr. Anthony: Department of Family Medicine, Brown University Alpert Medical School, 111 Brewster Street, Pawtucket, RI 02860.

Dr. Greenwald: Hospital Medicine Unit, Department of Medicine, Boston University School of Medicine, Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118.

Dr. Sanchez: Boston Medical Center, 88 East Newton Street, Boston, MA 02118.

Dr. Paasche-Orlow: Section of General Internal Medicine, Boston University School of Medicine, Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118.

Author Contributions: Conception and design: B.W. Jack, V.K. Chetty, D. Anthony, J.L. Greenwald, G.M. Sanchez, C. Manasseh, L. Culpepper.

Analysis and interpretation of the data: B.W. Jack, V.K. Chetty, D. Anthony, J.L. Greenwald, A.E. Johnson, S.R. Forsythe, J.K. O'Donnell, M.K. Paasche-Orlow, S. Martin, L. Culpepper.

Drafting of the article: B.W. Jack, D. Anthony, J.L. Greenwald, G.M. Sanchez, A.E. Johnson, S.R. Forsythe, J.K. O'Donnell, M.K. Paasche-Orlow.

Critical revision of the article for important intellectual content: B.W. Jack, V.K. Chetty, J.L. Greenwald, G.M. Sanchez, A.E. Johnson, S.R. Forsythe, J.K. O'Donnell, M.K. Paasche-Orlow, L. Culpepper.

Final approval of the article: B.W. Jack, V.K. Chetty, J.L. Greenwald, G.M. Sanchez, A.E. Johnson, S.R. Forsythe, J.K. O'Donnell, M.K. Paasche-Orlow, C. Manasseh, S. Martin, L. Culpepper.

Provision of study materials or patients: B.W. Jack, A.E. Johnson, M.K. Paasche-Orlow, C. Manasseh.

Statistical expertise: V.K. Chetty, M.K. Paasche-Orlow.

Obtaining of funding: B.W. Jack, D. Anthony.

Administrative, technical, or logistic support: B.W. Jack, V.K. Chetty, D. Anthony, A.E. Johnson, J.K. O'Donnell, C. Manasseh.

Collection and assembly of data: B.W. Jack, G.M. Sanchez, A.E. Johnson, S.R. Forsythe, J.K. O'Donnell.


Ann Intern Med. 2009;150(3):178-187. doi:10.7326/0003-4819-150-3-200902030-00007
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The RED intervention decreased hospital utilization (combined emergency department visits and readmissions) within 30 days of discharge by about 30% among patients on a general medical service of an urban, academic medical center. More intervention group participants reported seeing their PCP for follow-up within 30 days and reported higher levels of preparedness for discharge. In addition, the intervention was successful in reducing hospital utilization among participants who frequently used hospital services. These data support implementation of a comprehensive program for hospital discharge among similar hospitals.

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Figures

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Figure 1.
Study flow diagram.

* Patients did not meet inclusion criteria if they were admitted from or planned discharge to an institutional setting (n = 74), planned hospitalization (n = 3) or discharge to a non-U.S. community (n = 5), were transferred to different hospital service (n = 8), did not speak English (n = 371) or have a telephone (n = 71), were on hospital precautions (n = 274) or suicide watch with a sitter (n = 10), were unable to consent (n = 181), had sickle cell disease as the admitting diagnosis (n = 38), had privacy status (n = 8), were deaf or blind (n = 2), or other (n = 4).

† Usual care participants did not meet eligibility criteria if they were discharged to a nursing facility (n = 28), were transferred to another hospital service (n = 1), were previously enrolled (n = 1), died during index admission (n = 2), requested to be removed (n = 5), or other (n = 3).

‡ Intervention participants did not meet eligibility criteria if they were discharged to a nursing facility (n = 21), were transferred to another hospital service (n = 6), died during index admission (n = 1), requested to be removed (n = 2), or other (n = 8).

§ 107 intervention participants did not receive a reinforcement call because they could not be reached by telephone (n = 93), they were readmitted the same or next day (n = 2), there was no staffing coverage (n = 8), or other (n = 4).

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Figure 2.
Cumulative hazard rate of hospital utilization for 30 days after index hospital discharge.

* The denominators for the events were 433 for usual care and 397 for intervention. This represents the number of discharges for each group, which includes index discharges and discharges from all subsequent admissions. At each discharge, the participant is returned to the risk pool. The denominator is thus constant during the entire 30 days.

† Two events for the usual care group and 6 events for the intervention group were removed from this analysis because the date of admission was missing.

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The cost and effect of patient discharge education
Posted on June 13, 2009
Hui-Ya Chan
National Taiwan University
Conflict of Interest: None Declared

The recent article by Jack and colleagues (1) reported that their Reengineered Hospital Discharge Program (RED) decreased re-hospitalization. Many of discharge plan depends nurses do the majority task, but the article present a different way to do follow up education. The results include time and cost analyses were also very impressive. Here I want to share my experience. I myself had done a similar simple investigation about consultancy phone call cost for different purpose. In 2005, nurses in our hospital still had to trace all patients one week after discharge by the policy established during SARS breaking out. We counted the phone call time and staff cost. The result was used to pursue the administrator to increase members of staff or to trace the high risk patients only. After showing the data, we change the policy to only offer the high risk patients phone call. The discussion part of the article indicated an important challenge for programs like RED is that health providers may have no financial incentive to do so. This is a very real issue. In the medical economical subject, we clearly knew that many programs are effective, but in cost this checkpoint still need more immediate and detail evidence to support any investment of program. I think we should cooperate with medical economist on related issue. In the future, along with the progress of network information and the growth of people's health knowledge, the discharge education and consult of those patients will also present the different change. This article remind us should attempt to study the cost-related factors among the research project, includes the cost as research indicators in the future.

References

1. Brian W. Jack, Veerappa K. Chetty, David Anthony, Jeffrey L. Greenwald, Gail M. Sanchez, Anna E. Johnson, Shaula R. Forsythe, Julie K. O'Donnell, Michael K. Paasche-Orlow, Christopher Manasseh, Stephen Martin, and Larry Culpepper A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial Ann Intern Med 2009; 150: 178-187

Conflict of Interest:

None declared

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