L. Elizabeth Goldman, MD, MCR *; Urmimala Sarkar, MD, MPH *; Eric Kessell, PhD; David Guzman, MS; Michelle Schneidermann, MD; Edgar Pierluissi, MD; Barbara Walter, RN, MSN; Eric Vittinghoff, PhD, MPH; Jeff Critchfield, MD; Margot Kushel, MD
Acknowledgment: The authors thank Sue Currin, MS, RN, Chief Executive Officer of San Francisco General Hospital Medical Center, for helping to secure funding for this study; San Francisco General Hospital for providing in-kind support; Michael Paasche-Orlow, MD, for his collaboration; and Jenna Kruger, MS, for helping to prepare and submit the manuscript. They thank Richard Santana, RN; Catheryn Williams, RN; Tip Tam, RN, for implementing the intervention. The authors also thank the study nurse practitioners and research assistants for their invaluable contribution to this study.
Grant Support: The Gordon and Betty Moore Foundation (grant 1836), the Agency for Healthcare Research and Quality (grant K08 HS018090-01), and the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through the University of California, San Francisco Clinical and Translational Science Institute (grant KL2 RR024130).
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0094.
Reproducible Research Statement:Study protocol: Available from Dr. Goldman (email, email@example.com). Statistical code and data set: Not available.
Requests for Single Reprints: L. Elizabeth Goldman, MD, MCR, Department of Internal Medicine, Division of General Medicine, San Francisco General Hospital, University of California, San Francisco, 1001 Potrero Avenue, Box 1364, San Francisco, CA, 94110; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Goldman, Sarkar, and Kushel and Mr. Guzman: Department of Internal Medicine, Division of General Medicine, San Francisco General Hospital, University of California, San Francisco, 1001 Potrero Avenue, Box 1364, San Francisco, CA, 94110.
Drs. Kessell, Schneidermann, Pierlussi, and Critchfield: Department of Medicine, Division of General Medicine, San Francisco General Hospital, University of California, San Francisco, 1001 Potrero Avenue, Room 5H17, San Francisco, CA 94110.
Ms. Walter: HealthWorks4U, RN Healthcare Consultants, 115 Third Street, Suite 2, San Rafael, CA 94904.
Dr. Vittinghoff: Division of Biostatistics, Department of Epidemiology and Biostatistics, University of California, San Francisco, 185 Berry Street, Lobby 5, Suite 5700, San Francisco, CA 94107.
Author Contributions: Conception and design: L.E. Goldman, U. Sarkar, E. Kessell, M. Schneidermann, E. Pierluissi, B. Walter, J. Critchfield, M. Kushel.
Analysis and interpretation of the data: L.E. Goldman, U. Sarkar, E. Kessell, D. Guzman, E. Pierluissi, E. Vittinghoff, J. Critchfield, M. Kushel.
Drafting of the article: L.E. Goldman, U. Sarkar, E. Kessell, D. Guzman, M. Schneidermann, J. Critchfield, M. Kushel.
Critical revision of the article for important intellectual content: L.E. Goldman, E. Kessell, D. Guzman, M. Schneidermann, E. Pierluissi, E. Vittinghoff, J. Critchfield, M. Kushel.
Final approval of the article: L.E. Goldman, U. Sarkar, J. Critchfield, M. Kushel.
Provision of study materials or patients: M. Schneidermann, B. Walter, J. Critchfield.
Statistical expertise: D. Guzman, E. Vittinghoff.
Obtaining of funding: J. Critchfield.
Administrative, technical, or logistic support: E. Kessell, M. Schneidermann, B. Walter, J. Critchfield.
Collection and assembly of data: L.E. Goldman, U. Sarkar, E. Kessell, D. Guzman, M. Schneidermann, B. Walter, J. Critchfield, M. Kushel.
Hospitals are implementing discharge support programs to reduce readmissions, and these programs have had mixed success.
To examine whether a peridischarge, nurse-led intervention decreased emergency department (ED) visits or readmissions among ethnically and linguistically diverse older patients admitted to a safety-net hospital.
Randomized, controlled trial using computer-generated randomization with 1:1 allocation, stratified by language. (Clinical Trials.gov: NCT01221532)
Publicly funded urban hospital in Northern California.
Hospitalized adults aged 55 years or older with anticipated discharge to the community who spoke English, Spanish, or Chinese (Mandarin or Cantonese).
Usual care versus in-hospital, one-on-one, self-management education given by a dedicated language-concordant registered nurse combined with a telephone follow-up after discharge from a nurse practitioner.
Staff blinded to the study groups determined ED visits or readmissions to any facility at 30, 90, and 180 days after initial hospital discharge using administrative data from several hospitals.
There were 700 low-income, ethnically and linguistically diverse patients with a mean age of 66.2 years (SD, 9.0). The primary outcome of ED visits or readmissions did not differ between the intervention and usual care groups (hazard ratio, 1.26 [95% CI, 0.89 to 1.78] at 30 days, 1.21 [CI, 0.91 to 1.62] at 90 days, and 1.11 [CI, 0.86 to 1.43] at 180 days).
This study was done at a single acute-care hospital. There were fewer outcomes than expected, which may have caused the study to be underpowered.
A nurse-led, in-hospital discharge support intervention did not show a reduction in readmissions or ED visits among diverse, low-income older adults at a safety-net hospital. Although wide CIs preclude firm conclusions, the intervention may have increased ED visits. Alternative readmission prevention strategies should be tested in this population.
Gordon and Betty Moore Foundation.
Goldman LE, Sarkar U, Kessell E, et al. Support From Hospital to Home for Elders: A Randomized Trial. Ann Intern Med. 2014;161:472–481. doi: 10.7326/M14-0094
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Published: Ann Intern Med. 2014;161(7):472-481.
Geriatric Medicine, Hospital Medicine.
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