Affiliations
Divisions of Health Care Policy and Research, University of Colorado Denver, Denver, Colorado
General Internal Medicine, University of Colorado Denver, Denver, Colorado
Email
Gregory.misky@ ucdenver.edu
Given name(s)
Gregory J.
Family name
Misky
Degrees
MD

Pathway Reduces Utilization and Disparities

Article Type
Article
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Implementation of an acute venous thromboembolism clinical pathway reduces healthcare utilization and mitigates health disparities
Author(s)
Gregory J. Misky, MD
Todd Carlson, MD
Elaina Thompson, RN, MBA
Toby Trujillo, Pharm D, FCCP, FAHA, BCPS (AQ Cardiology)
Kristen Nordenholz, MD, MSc

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is common, costly, and often fatal. Annual VTE incidence in the United States is over 1 million, including over 220,000 PE patients who have an average hospital length of stay (LOS) of 8 days, with a rising per‐patient cost of over $40,000.[1, 2] Nearly half of all PE readmissions occur within 30 days; recurrent DVT events are 21% more costly than the initial event.[3] Likewise, 30‐day PE mortality is 8%, with most deaths occurring within 1 hour of initial presentation.[4, 5]

Rapid implementation of therapeutic anticoagulation has reduced morbidity and mortality in VTE. Ineffective and untimely treatment increases disease progression, significant medication‐related adverse events, and cost. The Joint Commission recognized this risk and included National Patient Safety Goal 3.5.01 to reduce adverse events.[6] Appropriate use of anticoagulation was further emphasized by national quality initiatives through Joint Commission VTE core measures endorsed by the National Quality Forum and the Centers for Medicare and Medicaid Services.[7]

Many models of outpatient VTE care pathways exist. Early models focused on the feasibility of low‐molecular‐weight heparins (LMWH) in the ambulatory setting, with transition to long‐term warfarin. Focus shifted to comprehensive disease pathway implementation aimed at reducing healthcare resource utilization. These pathways have reduced cost and unnecessary hospital stays and minimized complications through enrolling low‐risk patients. To our knowledge, results of an interdisciplinary VTE care pathway have not been published from a large urban academic institution, where a substantial uninsured population exists.

Examining baseline VTE practices and care delivered at our institution provided critical knowledge in effectively developing a novel model of care. Prior to pathway development, acute VTE patients were typically admitted for initiation of therapeutic anticoagulation and appropriate overlap of injectable anticoagulants with warfarin. Significant healthcare disparities were seen among VTE patients at our institution: uninsured patients stayed in the hospital 2 additional days and accumulated twice the rate of 30‐day emergency department (ED) reutilization and cost than insured patients.[8] Discharged VTE patients were managed through a pharmacy‐run anticoagulation clinic pending primary care provider (PCP) follow‐up. We speculated many uninsured VTE patients lacked sufficient disease and treatment information, and lacked surveillance and timely access to medical care following hospitalization. We hypothesized that through (1) targeted education of patients and providers, (2) coordination of timely follow‐up for at‐risk patients, and (3) posthospital monitoring, we could achieve standardized care for all acute DVT and low‐risk PE patients. As a result, we aimed to decrease hospital LOS and produce fewer return visits and readmissions.

METHODS

Study Setting and Population

Acute medical VTE patients were targeted, where they were either discharged directly from the ED or admitted to a medicine service. Acute VTE was defined as primary or secondary diagnosis of new, lower extremity DVT, PE or concurrent DVT, and PE. Patients were identified and tracked by a professional research assistant (PRA) using our electronic medical record (EMR) search filter of all 120 discharge diagnoses for acute DVT and PE.

Our hospital is a 375‐bed, academic medical center in a metropolitan area of under 3 million people. ED volume is approximately 55,000 patients per year.

Exclusion Criteria

We excluded patients classified as surgical/postoperative/admitted to a surgery service, pregnant/postpartum/admitted to an obstetrical service, hospital direct admissions (including outside hospital transfers), and oncology service admissions. Clinically unstable patients requiring intensive care unit admission and/or thrombolytic therapy, and patients with upper extremity, recurrent, or catheter‐associated VTE were also excluded. To allow for comparative data, exclusion criteria were similar to those used in the historical, retrospective chart review performed previously at our institution.[8]

VTE Clinical Care Pathway

The pathway was developed as a quality improvement project through a multidisciplinary, collaborative effort, including pharmacists (inpatient and outpatient), administrative staff in the anticoagulation clinic, nurse leaders and educators, physician faculty (ED, inpatient and outpatient), case managers (inpatient and ED), and providers from local community health clinics, who provide the majority of follow‐up care for our uninsured patients.

We sought care standardization and system‐wide education for all acute, medical, lower‐extremity DVT and low‐risk PE patients, with a focus on coordination of transitional care. All pathway patients were provided education, lab testing, and outpatient medications including LMWH and warfarin. For patients lacking insurance, medications were provided through a medication assistance program at no cost to the patient. Timely outpatient clinic follow‐up and posthospital phone calls were targeted safety net features to facilitate timely hospital discharge and program success. We also aimed to meet nationally mandated quality of care measures and benchmarks. Funding for this project, obtained through a quality improvement (QI) grant from the hospital supported a PRA and educational materials.

The Colorado Multiple Institutional Review Board approved the protocol prior to study implementation. Specific elements of the care pathway have been outlined (see Supporting Information, Figure 1, in the online version of this article). The initial rollout of the program occurred as a pilot in the ED for patients presenting with DVT only to assess feasibility. Based on this success, the pathway team expanded the program to inpatients, including those with PE, and augmented the educational program.

Measures

Evaluation of the intervention was completed by real‐time chart extraction and phone interviews within 72 hours of hospital discharge and a chart review at 6 weeks following discharge. Chart review determined the number of follow‐up visits within 30 days to the anticoagulation clinic and episodes of recidivism. Study data (n=241) were obtained from February 1, 2011 to June 30, 2012 and compared to previously published retrospective data on VTE patients at our institution (n=234) from December 1, 2007 to April 4, 2009.8

We obtained patient demographics (age, gender, ethnicity, insurance category) and admission status from the EMR. We collected data on ED recidivism within 30 days (for VTE‐related issues), LOS, and readmissions within 30 days of discharge. We also collected total cost data for all VTE care from hospital administrative billing data including initial presentation and VTE‐related return visits to the ED and readmissions.

Outcomes

Descriptive information, including demographics, admission status and type of VTE event are summarized for the VTE care pathway. Pathway patients, stratified by payer status (uninsured vs insured), were compared to previously described historical controls.[8] Primary outcomes included comparisons of total costs, LOS, and 30‐day ED recidivism and hospital readmission rates. Further comparisons were made between insured and uninsured patients on these same outcomes.

Data Analysis

Data are presented as proportions or meanstandard deviation unless indicated otherwise. Categorical data were compared using the Fisher exact test or 2 test, where appropriate. Continuous variables were compared using the Student t test. All tests were 2‐tailed. Statistical analyses of the results were performed using GraphPad Prism 4.0 (GraphPad Software, San Diego, CA) and InStat 3.06 (GraphPad Software). A P value <0.05 was considered statistically significant for this study.

RESULTS

Care Pathway Cohort

We enrolled 241 medical patients with acute VTE during the 19‐month study period (Table 1). Of these, 107 (44.4%) presented with DVT alone, whereas the remaining 134 (55.6%) had PE. Eighty‐eight of the 241 VTE patients were uninsured (36.5%). Uninsured patients were younger on average (46.7 vs 55.5 years; P<0.0001) and more commonly presented with DVT only (58.0% vs 36.7%; P=0.036).

Demographics of VTE Care Pathway Patients
 Patients, N=241Uninsured, N=88Insured, N=153P Value

  • NOTE: Abbreviations: DVT, deep vein thrombosis; ED, emergency department; IQR, interquartile range; PE, pulmonary embolism; SD, standard deviation; VTE, venous thromboembolism.

Mean age, y (SD)52.4 (15.8)46.7 (13.9)55.5 (16.1)<0.0001
Median age, y (IQR)53 (4263.5)56 (44.367)49 (35.358.5) 
Gender, male, n (%)113 (46.9)44 (50.0)69 (45.1)0.548
Pulmonary embolism, n (%)134 (55.6)37 (42.0)97 (63.3)0.036
All VTE, hospital admission, n (%)179 (74.3)58 (65.9)121 (79.1)0.032
PE, hospital admission, n (%)132 (54.8)37 (42.0)95 (97.9)1.00

Utilizing the pathway, the majority of VTE patients (179; 74.3%) were admitted to the hospital. Among the uninsured, 58 of 88 (65.9%) patients were admitted compared to 121 of 153 (79.1%) among the insured (P=0.032). Among 107 DVT patients, 47 were admitted (43.9%), including 20 of 51 uninsured DVT patients (39.2%) compared to 27 of 56 insured DVT patients (48.2%). Nearly all PE patients (132 of 134; 98.5%) were admitted. Two insured PE patients were not admitted.

Care Pathway Versus Historical Cohort

Comparing VTE care pathway patients to historical VTE patients (prior to intervention), the age and gender, as well as number of VTE events, VTE type, and admission status were similar (Table 2).

Clinical Care Pathway Versus Historical VTE
OutcomeHistorical VTE, N=234Pathway VTE, N=241P Value

  • NOTE: Categorical data were compared using the Fisher exact test or 2 test, where appropriate. Continuous variables were compared using the Student t test. All tests were 2‐tailed. Abbreviations: DVT, deep vein thrombosis; LOS, length of stay; PE, pulmonary embolism; SD, standard deviation; VTE, venous thromboembolism.

Age, y, mean53.152.40.64
Male, n (%)125 (53.4)113 (47.0)0.46
DVT (%)106 (45.3)107 (44.4)0.92
Uninsured (%)38 (35.8)51 (47.7)0.93
PE (%)128 (54.7)134 (55.6)0.92
Uninsured (%)29 (22.7)38 (28.4)0.11
Admitted (%)171 (73.1)179 (74.3)0.85
DVT (%)43 (40.6)47 (43.9)0.91
Uninsured (%)17 (39.6)20 (42.6)0.94
PE (%)128 (100)132 (98.5)0.91
Uninsured (%)29 (100)38 (100)0.32
LOS, d, mean (SD)4.4 (3.8)3.1 (2.9)<0.001
Uninsured5.9 (5.1)3.1 (2.9)<0.001
Insured3.8 (3.1)3.1 (2.9)0.69
ED revisit, n (%)26 (11.1)27 (11.2)0.974
Uninsured, n (%)12 (17.9)12 (13.6)0.59
Readmission, n (%)16 (9.4)10 (5.6)0.25
Uninsured, n (%)5 (10.9)2 (3.4)0.24
Total cost, $, mean (SD)7610 (9988)5295 (7975)0.005
Uninsured9953 (14211)4304 (6596)0.001
Insured6698 (7564)5875 (8650)0.36
Cost, admitted, $, mean (SD)10324 (8988)7038 (8965)0.044
Uninsured14420 (13351)6375 (7462)0.005
Insured8843 (6565)7353 (9288)0.599

Average hospital LOS for an admitted care pathway patient was 3.1 days versus 4.4 days in an historical VTE patient (P=0.0001; Table 2). When stratified by insurance, uninsured pathway patients had a LOS of 3.1, decreased from a prepathway LOS of 5.9 days (P=0.0006), whereas this did not change among insured patients (3.1 from 3.8 days [P=0.688]).

For all VTE care pathway patients, 30‐day ED recidivism was 11.2%, similar to prepathway data (11.1%; Table 2). This was true regardless of insurance status. Thirty‐day readmission rates trended from 9.4% prepathway to 5.6% postpathway (P=0.254) (Table 2). Compared to historical VTE patients, uninsured pathway patients had readmission rates of 3.4% from 10.9% (P=0.237), whereas readmission rates for insured patients were 6.6% from 8.8% (P=0.686).

Average cost for a VTE care pathway patient was $5295 compared to an historical cost of $7610 per VTE patient (P <0.005). Among uninsured pathway patients, the cost of VTE care was $4304 compared to $9953 historically (P=0.001). Among insured pathway patients, the cost of VTE care was $5875 compared to an historical cost of $6698 (P=0.365).

The average VTE cost of care for an admitted pathway patient was $7038 versus $10,324 per admitted historical patient (P=0.044). For an admitted uninsured VTE pathway patient, cost was $6375 versus $14,420 per historical VTE patient (P=0.005). For an admitted insured VTE pathway patient, the cost was $7353 versus $8843 per historical VTE patient (P=0.599).

Patient satisfaction scores with the care pathway averaged 4.5 (15 Likert scale).

DISCUSSION

Development and implementation of a multidisciplinary VTE clinical care pathway at our institution represents success across multiple domains. As a QI project, we standardized care and delivered system‐wide education, and provided solutions to existing gaps in posthospital care. This pathway for a common, dangerous disease requiring high‐risk medications magnifies the importance of care delivered at vulnerable points. Results of our study are the first to our knowledge to mitigate healthcare disparities and reduce healthcare utilization through a care pathway across diverse populations. Hospital LOS for all VTE patients was significantly decreased, wile lowering hospital reutilization patterns, particularly among the uninsured. Hospital admission rates are now lower specifically for the uninsured patients, because ED and inpatient providers now have increased confidence in the follow‐up arrangements with the safety‐net clinics.

Many clinical care pathways for VTE are proven, safe, and cost‐effective.[9, 10, 11, 12] Outpatient DVT treatment delivers significant cost savings and averts unnecessary hospital stays.[13, 14] A hospital‐based program providing outpatient DVT treatment among inner‐city patients in New York demonstrated a lower incidence of adverse events and substantial cost savings, but excluded PE patients.[15] We intentionally sought to expand our VTE program by including both PE and vulnerable uninsured patients.

Lack of health insurance and routine primary care is a major challenge to successful implementation of any care pathway. Access to timely posthospital follow‐up care is far more limited in patients lacking private insurance.[16, 17] Uninsured patients are less likely to receive necessary medical care and more likely to have delayed care.[18, 19] Uninsured patients also have poorer short‐term health and are nearly 3 times more likely to have an ED revisit following hospital discharge than insured patients.[16, 20, 21] At our own institution, many discharged medical patients lack timely PCP follow‐up, especially the uninsured, leading to higher rates of hospital reutilization.[22] Interventions directed at the uninsured VTE patient to mitigate such disparities were specifically targeted. These included coordination of timely follow‐up care in community health clinics and provision of posthospital phone calls.

Efforts to improve transitional care for vulnerable patients have proven successful. Patients linked from the ED to community health clinics through scheduled follow‐up have improved frequency of follow‐up, receive routine care, and have reduced hospital utilization and rehospitalization.[23, 24, 25] Conversely, fewer care disparities are realized by patients within integrated systems such as the Veterans Administration.[26] Thus, the ultimate development of a VTE care pathway at our nonintegrated hospital required an innovative paradigm to deliver acute DVT and PE care. Through examining existing processes of our VTE care, we hypothesized that the main contributors of baseline care deficiencies included inadequate system‐wide education, fragmented care, and significant barriers to timely follow‐up.

Education of providers, patients, and system‐wide process change were key elements in pathway implementation. Provider educational opportunities concerning VTE disease and treatment were identified, including safe and effective outpatient management options. We anticipated provider reluctance prescribing potentially dangerous anticoagulation medications to otherwise stable patients who might lack close posthospital supervision (eg, ED clinicians accustomed to admitting patients and inpatient teams cautious in discharging patients). We postulated that patients received inadequate VTE education and lacked appropriate skills to effectively and safely manage their new disease and medications. The diverse educational components outlined within the pathway significantly contributed to improved provider confidence in their patients' follow‐up care as well as their patients' comprehension of their disease.

Timely posthospital care follow‐up for all VTE patients significantly impacted our pathway results. Historically, uninsured patients lacked primary care follow‐up, often waiting 3 months for an initial clinic visit. Through timely care coordination with local community health clinics, uninsured VTE care pathway patients discharged from our facility are routinely scheduled to be seen within 72 hours. Posthospital care is further addressed through follow‐up phone calls, which monitor patient understanding and care, and identify how and where potential medical needs are best met. Such calls increase patient satisfaction, resolve medication issues, and result in fewer ED return visits.[27] With our intervention, patient satisfaction scores averaged 4.5 (15 Likert scale), reflecting strong support for phone calls and overall experience.

Direct institutional annual cost savings realized with the VTE care pathway was $452,460. This occurred primarily as a result of nearly 50% fewer inpatient days required for admitted VTE patients. Indirect cost savings were further accomplished through increased availability of high‐demand outpatient anticoagulation visits given improved timely PCP follow‐up. Prior to pathway implementation, uninsured patients frequently had multiple, often unreimbursed, visits to this clinic while awaiting PCP follow‐up. Additional future cost savings may occur as healthcare reimbursement patterns are likely to include methods to penalize inefficient and high‐resource usage.

There are several limitations to our study. This was a single‐institution quality program with relatively small numbers. Comparison of pathway data with historical data provides an interval lag that may miss temporal changes in medical practice and disease trends. However, we believe the practice of VTE treatment changed minimally between the 2 time periods. We identified virtually the same number and type of patients in each cohort. Physician and PRA staff turnover complicated tracking patients and challenged continuous system‐wide education. However, we believe consistent education and feedback to PRA faculty throughout the study period minimized variability. Although we could not verify VTE presentations to outside hospitals other than by patient self‐report, it is likely that our patient population would have re‐presented to our institution for follow‐up VTE needs or bleeding concerns. As a result of timely follow‐up phone calls, the number of return visits to the hospital may have been magnified, because more educated patients may have overreacted to mild symptom changes. Prior to the intervention, discharged VTE patients may not have recognized signs and symptoms of worsening disease or may not have returned to our institution for follow‐up needs. Last, we did not control for comorbidities in either cohort, which may affect hospital utilization patterns, as younger patients may be less likely to be admitted or insured.

As a result of a comprehensive VTE clinical care pathway developed by key stakeholders, acute VTE patients who present to our hospital are therapeutically anticoagulated and monitored in a timely, uniform, and safe manner. We believe success reflects system‐wide education and standardization of care through reducing variation, including the high‐risk posthospital period. In an era of fragmented medical care, this program closes existing gaps in care and addresses the needs of vulnerable patients through strong collaboration and efficient coordination with local community health clinics. This is especially important in a dynamic healthcare landscape with an evolving payer mix that demands the medical establishment seek innovative ways to improve quality of care while reducing cost. Future research should explore etiologies and impacts of outcome variability based on insurance status, and identify other conditions and institutions demonstrating care disparities. Ultimately, implementation of this pathway provides strong evidence for improving care, meeting Joint Commission anticoagulation patient safety goals, and conserving limited resources for a common and deadly disease.

Acknowledgements

The authors thank Sancia Tonn, PRA, Carol Kemp‐Jackson from University of Colorado outpatient anticoagulation clinic, and the Metro Community Provider Network Clinics.

Disclosures

This project was funded by University of Colorado Hospital QI Small Grants Program. Preliminary results of this pathway were previously presented at the 2012 Society of Hospital Medicine Annual Meeting, San Diego, California, April 14, 2012.

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Supplementary information (1)
References
  1. MacDougall DA, Feliu AL, Boccuzzi SJ, et al. Economic burden of deep‐vein thrombosis, pulmonary embolism, and post‐thrombotic syndrome. Am J Health Syst Pharm. 2006;63(20 suppl 6):S5–S15.
  2. Park B, Messina L, Dargon P, et al. Recent trends in clinical outcomes and resource utilization for pulmonary embolism in the United States: findings from the nationwide inpatient sample. Chest. 2009;136(4):983–990.
  3. Spyropoulos AC, Lin J. Direct medical costs of venous thromboembolism and subsequent hospital readmission rates: an administrative claims analysis from 30 managed care organizations. J Manag Care Pharm. 2007;13(6):475–486.
  4. Smith S, Geske J, Maguire J, Zane N, Carter R, Morgenthaler T. Early anticoagulation is associated with reduced mortality for acute pulmonary embolism. Chest. 2010;137(6):1382–1390.
  5. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999;353(9162):1386–1389.
  6. University of North Carolina Air Care website. Available at: http://www.unchealthcare.org/site/Nursing/servicelines/aircare/2009npsg. National Patient Safety Goal/NPSG.03.05.01. http://www.unchealthcare.org/site/Nursing/servicelines/aircare/. Accessed November 1, 2013.
  7. National consensus standards for the prevention and care of deep vein thrombosis (DVT) project between The Joint Commission and the National Quality Forum (NQF) 2008. Available at: http://www.jointcommission.org/venous_thromboembolism. Accessed November 1, 2013.
  8. Misky GJ, Manheim JC, Zehnder N, et al. Health Care disparities on venous thromboembolism based on insurance status in the United States. J Thromb Thrombolysis. 2011:32(4):393–398.
  9. Hyers TM, Spyropolous AC; INNOVATE Investigators. Community‐based treatment of venous thromboembolism with a low‐molecular weight heparin and warfarin. J Thromb Thrombolysis. 2007;24(3):225–232.
  10. Kidney R, Hosny G, Canning MB, et al. Implementation of a clinical pathway for emergency department out‐patient management of deep vein thrombosis. Ir Med J. 2010;103(8):246–248.
  11. Spyropoulos AC. Outpatient‐based treatment protocols in the management of venous thromboembolic disease. Am J Manag Care. 2000;6(20 suppl):S1034–S1044.
  12. Lee M, Pao D, Hsu T, et al. Cost savings and effectiveness of outpatient treatment with low molecular weight heparin of deep vein thrombosis in a community hospital. Can J Clin Pharmacol. 2004;11(1):e17–e27.
  13. Vinson DR, Berman DA. Outpatient treatment of deep venous thrombosis: a clinical care pathway managed by the emergency department. Ann Emerg Med. 2001;37(3):251–258.
  14. Tillman DJ, Charland SL, Witt DM. Effectiveness and economic impact associated with a program for outpatient management of acute deep vein thrombosis in a group model health maintenance organization. Arch Intern Med. 2000;160(19):2926–2932.
  15. Dunn AS, Schechter C, Gotlin A, et al. Outpatient treatment of deep venous thrombosis in diverse inner‐city patients. Am J Med. 2001;110(6):458–462.
  16. Asplin BR, Rhodes KV, Levy H, et al. Insurance status and access to urgent ambulatory care follow‐up appointments. JAMA. 2005;294(10):1248–1254.
  17. Kerr EA, Siu AL. Follow‐up after hospital discharge: does insurance make a difference? J Health Care Poor Underserved. 1993;4(2):133–142.
  18. Burt CW, McCaig LF, Simon AE. Emergency department visits by persons recently discharged from U.S. hospitals. Natl Health Stat Report. 2008;(6):1–9.
  19. Hadley J. Insurance coverage, medical care use, and short‐term health changes following an unintentional injury or the onset of a chronic condition. JAMA. 2007;297(10):1073–1084.
  20. Baker DW, Shapiro MF, Schur CL. Health insurance and access to care for symptomatic conditions. Arch Intern Med. 2000;160(9):1269–1274.
  21. Weissman JS, Stern R, Fielding SL, et al. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med. 1991;114(4):325–331.
  22. Misky GJ, Wald H, Coleman EA. Post‐hospitalization transitions: examining the effects of timing of primary care provider follow‐up. J Hosp Med. 2010;5:392–397.
  23. Rothkopf J, Brookler K, Wadhwa S, et al. Medicaid patients seen at federally qualified health centers use hospital services less than those seen by private providers. Health Aff (Millwood). 2011;30(7):1335–1342.
  24. Robbins JM, Valdmanis VG, Webb DA. Do public health clinics reduce rehospitalizations?: the urban diabetes study. J Health Care Poor Underserved. 2008;19(2):562–573.
  25. Chan TC, Killeen JP, Castillo EM, et al. Impact of an internet‐based emergency department appointment system to access primary care at safety net community clinics. Ann Emerg Med. 2009;54(2):279–284.
  26. Shimada SL, Montez‐Rath ME, Loveland SA, et al. Racial disparities in patient safety indicator (psi) rates in the veterans health administration. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches. Vol. 1: Assessment. Rockville, MD: Agency for Healthcare Research and Quality; 2008. Available at: http://www.ncbi.nlm.nih.gov/books/NBK43651, Accessed November 1, 2013.
  27. Dudas V, Bookwalter T, Kerr KM, et al. The impact of follow‐up telephone calls to patients after hospitalization. Dis Mon. 2002;48(4):239–248.
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Author(s)
Gregory J. Misky, MD
Todd Carlson, MD
Elaina Thompson, RN, MBA
Toby Trujillo, Pharm D, FCCP, FAHA, BCPS (AQ Cardiology)
Kristen Nordenholz, MD, MSc
Author(s)
Gregory J. Misky, MD
Todd Carlson, MD
Elaina Thompson, RN, MBA
Toby Trujillo, Pharm D, FCCP, FAHA, BCPS (AQ Cardiology)
Kristen Nordenholz, MD, MSc
Files
Supplementary information (1)
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Supplementary information (1)
Article PDF
jhm2186.pdf
Article PDF
jhm2186.pdf

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is common, costly, and often fatal. Annual VTE incidence in the United States is over 1 million, including over 220,000 PE patients who have an average hospital length of stay (LOS) of 8 days, with a rising per‐patient cost of over $40,000.[1, 2] Nearly half of all PE readmissions occur within 30 days; recurrent DVT events are 21% more costly than the initial event.[3] Likewise, 30‐day PE mortality is 8%, with most deaths occurring within 1 hour of initial presentation.[4, 5]

Rapid implementation of therapeutic anticoagulation has reduced morbidity and mortality in VTE. Ineffective and untimely treatment increases disease progression, significant medication‐related adverse events, and cost. The Joint Commission recognized this risk and included National Patient Safety Goal 3.5.01 to reduce adverse events.[6] Appropriate use of anticoagulation was further emphasized by national quality initiatives through Joint Commission VTE core measures endorsed by the National Quality Forum and the Centers for Medicare and Medicaid Services.[7]

Many models of outpatient VTE care pathways exist. Early models focused on the feasibility of low‐molecular‐weight heparins (LMWH) in the ambulatory setting, with transition to long‐term warfarin. Focus shifted to comprehensive disease pathway implementation aimed at reducing healthcare resource utilization. These pathways have reduced cost and unnecessary hospital stays and minimized complications through enrolling low‐risk patients. To our knowledge, results of an interdisciplinary VTE care pathway have not been published from a large urban academic institution, where a substantial uninsured population exists.

Examining baseline VTE practices and care delivered at our institution provided critical knowledge in effectively developing a novel model of care. Prior to pathway development, acute VTE patients were typically admitted for initiation of therapeutic anticoagulation and appropriate overlap of injectable anticoagulants with warfarin. Significant healthcare disparities were seen among VTE patients at our institution: uninsured patients stayed in the hospital 2 additional days and accumulated twice the rate of 30‐day emergency department (ED) reutilization and cost than insured patients.[8] Discharged VTE patients were managed through a pharmacy‐run anticoagulation clinic pending primary care provider (PCP) follow‐up. We speculated many uninsured VTE patients lacked sufficient disease and treatment information, and lacked surveillance and timely access to medical care following hospitalization. We hypothesized that through (1) targeted education of patients and providers, (2) coordination of timely follow‐up for at‐risk patients, and (3) posthospital monitoring, we could achieve standardized care for all acute DVT and low‐risk PE patients. As a result, we aimed to decrease hospital LOS and produce fewer return visits and readmissions.

METHODS

Study Setting and Population

Acute medical VTE patients were targeted, where they were either discharged directly from the ED or admitted to a medicine service. Acute VTE was defined as primary or secondary diagnosis of new, lower extremity DVT, PE or concurrent DVT, and PE. Patients were identified and tracked by a professional research assistant (PRA) using our electronic medical record (EMR) search filter of all 120 discharge diagnoses for acute DVT and PE.

Our hospital is a 375‐bed, academic medical center in a metropolitan area of under 3 million people. ED volume is approximately 55,000 patients per year.

Exclusion Criteria

We excluded patients classified as surgical/postoperative/admitted to a surgery service, pregnant/postpartum/admitted to an obstetrical service, hospital direct admissions (including outside hospital transfers), and oncology service admissions. Clinically unstable patients requiring intensive care unit admission and/or thrombolytic therapy, and patients with upper extremity, recurrent, or catheter‐associated VTE were also excluded. To allow for comparative data, exclusion criteria were similar to those used in the historical, retrospective chart review performed previously at our institution.[8]

VTE Clinical Care Pathway

The pathway was developed as a quality improvement project through a multidisciplinary, collaborative effort, including pharmacists (inpatient and outpatient), administrative staff in the anticoagulation clinic, nurse leaders and educators, physician faculty (ED, inpatient and outpatient), case managers (inpatient and ED), and providers from local community health clinics, who provide the majority of follow‐up care for our uninsured patients.

We sought care standardization and system‐wide education for all acute, medical, lower‐extremity DVT and low‐risk PE patients, with a focus on coordination of transitional care. All pathway patients were provided education, lab testing, and outpatient medications including LMWH and warfarin. For patients lacking insurance, medications were provided through a medication assistance program at no cost to the patient. Timely outpatient clinic follow‐up and posthospital phone calls were targeted safety net features to facilitate timely hospital discharge and program success. We also aimed to meet nationally mandated quality of care measures and benchmarks. Funding for this project, obtained through a quality improvement (QI) grant from the hospital supported a PRA and educational materials.

The Colorado Multiple Institutional Review Board approved the protocol prior to study implementation. Specific elements of the care pathway have been outlined (see Supporting Information, Figure 1, in the online version of this article). The initial rollout of the program occurred as a pilot in the ED for patients presenting with DVT only to assess feasibility. Based on this success, the pathway team expanded the program to inpatients, including those with PE, and augmented the educational program.

Measures

Evaluation of the intervention was completed by real‐time chart extraction and phone interviews within 72 hours of hospital discharge and a chart review at 6 weeks following discharge. Chart review determined the number of follow‐up visits within 30 days to the anticoagulation clinic and episodes of recidivism. Study data (n=241) were obtained from February 1, 2011 to June 30, 2012 and compared to previously published retrospective data on VTE patients at our institution (n=234) from December 1, 2007 to April 4, 2009.8

We obtained patient demographics (age, gender, ethnicity, insurance category) and admission status from the EMR. We collected data on ED recidivism within 30 days (for VTE‐related issues), LOS, and readmissions within 30 days of discharge. We also collected total cost data for all VTE care from hospital administrative billing data including initial presentation and VTE‐related return visits to the ED and readmissions.

Outcomes

Descriptive information, including demographics, admission status and type of VTE event are summarized for the VTE care pathway. Pathway patients, stratified by payer status (uninsured vs insured), were compared to previously described historical controls.[8] Primary outcomes included comparisons of total costs, LOS, and 30‐day ED recidivism and hospital readmission rates. Further comparisons were made between insured and uninsured patients on these same outcomes.

Data Analysis

Data are presented as proportions or meanstandard deviation unless indicated otherwise. Categorical data were compared using the Fisher exact test or 2 test, where appropriate. Continuous variables were compared using the Student t test. All tests were 2‐tailed. Statistical analyses of the results were performed using GraphPad Prism 4.0 (GraphPad Software, San Diego, CA) and InStat 3.06 (GraphPad Software). A P value <0.05 was considered statistically significant for this study.

RESULTS

Care Pathway Cohort

We enrolled 241 medical patients with acute VTE during the 19‐month study period (Table 1). Of these, 107 (44.4%) presented with DVT alone, whereas the remaining 134 (55.6%) had PE. Eighty‐eight of the 241 VTE patients were uninsured (36.5%). Uninsured patients were younger on average (46.7 vs 55.5 years; P<0.0001) and more commonly presented with DVT only (58.0% vs 36.7%; P=0.036).

Demographics of VTE Care Pathway Patients
 Patients, N=241Uninsured, N=88Insured, N=153P Value

  • NOTE: Abbreviations: DVT, deep vein thrombosis; ED, emergency department; IQR, interquartile range; PE, pulmonary embolism; SD, standard deviation; VTE, venous thromboembolism.

Mean age, y (SD)52.4 (15.8)46.7 (13.9)55.5 (16.1)<0.0001
Median age, y (IQR)53 (4263.5)56 (44.367)49 (35.358.5) 
Gender, male, n (%)113 (46.9)44 (50.0)69 (45.1)0.548
Pulmonary embolism, n (%)134 (55.6)37 (42.0)97 (63.3)0.036
All VTE, hospital admission, n (%)179 (74.3)58 (65.9)121 (79.1)0.032
PE, hospital admission, n (%)132 (54.8)37 (42.0)95 (97.9)1.00

Utilizing the pathway, the majority of VTE patients (179; 74.3%) were admitted to the hospital. Among the uninsured, 58 of 88 (65.9%) patients were admitted compared to 121 of 153 (79.1%) among the insured (P=0.032). Among 107 DVT patients, 47 were admitted (43.9%), including 20 of 51 uninsured DVT patients (39.2%) compared to 27 of 56 insured DVT patients (48.2%). Nearly all PE patients (132 of 134; 98.5%) were admitted. Two insured PE patients were not admitted.

Care Pathway Versus Historical Cohort

Comparing VTE care pathway patients to historical VTE patients (prior to intervention), the age and gender, as well as number of VTE events, VTE type, and admission status were similar (Table 2).

Clinical Care Pathway Versus Historical VTE
OutcomeHistorical VTE, N=234Pathway VTE, N=241P Value

  • NOTE: Categorical data were compared using the Fisher exact test or 2 test, where appropriate. Continuous variables were compared using the Student t test. All tests were 2‐tailed. Abbreviations: DVT, deep vein thrombosis; LOS, length of stay; PE, pulmonary embolism; SD, standard deviation; VTE, venous thromboembolism.

Age, y, mean53.152.40.64
Male, n (%)125 (53.4)113 (47.0)0.46
DVT (%)106 (45.3)107 (44.4)0.92
Uninsured (%)38 (35.8)51 (47.7)0.93
PE (%)128 (54.7)134 (55.6)0.92
Uninsured (%)29 (22.7)38 (28.4)0.11
Admitted (%)171 (73.1)179 (74.3)0.85
DVT (%)43 (40.6)47 (43.9)0.91
Uninsured (%)17 (39.6)20 (42.6)0.94
PE (%)128 (100)132 (98.5)0.91
Uninsured (%)29 (100)38 (100)0.32
LOS, d, mean (SD)4.4 (3.8)3.1 (2.9)<0.001
Uninsured5.9 (5.1)3.1 (2.9)<0.001
Insured3.8 (3.1)3.1 (2.9)0.69
ED revisit, n (%)26 (11.1)27 (11.2)0.974
Uninsured, n (%)12 (17.9)12 (13.6)0.59
Readmission, n (%)16 (9.4)10 (5.6)0.25
Uninsured, n (%)5 (10.9)2 (3.4)0.24
Total cost, $, mean (SD)7610 (9988)5295 (7975)0.005
Uninsured9953 (14211)4304 (6596)0.001
Insured6698 (7564)5875 (8650)0.36
Cost, admitted, $, mean (SD)10324 (8988)7038 (8965)0.044
Uninsured14420 (13351)6375 (7462)0.005
Insured8843 (6565)7353 (9288)0.599

Average hospital LOS for an admitted care pathway patient was 3.1 days versus 4.4 days in an historical VTE patient (P=0.0001; Table 2). When stratified by insurance, uninsured pathway patients had a LOS of 3.1, decreased from a prepathway LOS of 5.9 days (P=0.0006), whereas this did not change among insured patients (3.1 from 3.8 days [P=0.688]).

For all VTE care pathway patients, 30‐day ED recidivism was 11.2%, similar to prepathway data (11.1%; Table 2). This was true regardless of insurance status. Thirty‐day readmission rates trended from 9.4% prepathway to 5.6% postpathway (P=0.254) (Table 2). Compared to historical VTE patients, uninsured pathway patients had readmission rates of 3.4% from 10.9% (P=0.237), whereas readmission rates for insured patients were 6.6% from 8.8% (P=0.686).

Average cost for a VTE care pathway patient was $5295 compared to an historical cost of $7610 per VTE patient (P <0.005). Among uninsured pathway patients, the cost of VTE care was $4304 compared to $9953 historically (P=0.001). Among insured pathway patients, the cost of VTE care was $5875 compared to an historical cost of $6698 (P=0.365).

The average VTE cost of care for an admitted pathway patient was $7038 versus $10,324 per admitted historical patient (P=0.044). For an admitted uninsured VTE pathway patient, cost was $6375 versus $14,420 per historical VTE patient (P=0.005). For an admitted insured VTE pathway patient, the cost was $7353 versus $8843 per historical VTE patient (P=0.599).

Patient satisfaction scores with the care pathway averaged 4.5 (15 Likert scale).

DISCUSSION

Development and implementation of a multidisciplinary VTE clinical care pathway at our institution represents success across multiple domains. As a QI project, we standardized care and delivered system‐wide education, and provided solutions to existing gaps in posthospital care. This pathway for a common, dangerous disease requiring high‐risk medications magnifies the importance of care delivered at vulnerable points. Results of our study are the first to our knowledge to mitigate healthcare disparities and reduce healthcare utilization through a care pathway across diverse populations. Hospital LOS for all VTE patients was significantly decreased, wile lowering hospital reutilization patterns, particularly among the uninsured. Hospital admission rates are now lower specifically for the uninsured patients, because ED and inpatient providers now have increased confidence in the follow‐up arrangements with the safety‐net clinics.

Many clinical care pathways for VTE are proven, safe, and cost‐effective.[9, 10, 11, 12] Outpatient DVT treatment delivers significant cost savings and averts unnecessary hospital stays.[13, 14] A hospital‐based program providing outpatient DVT treatment among inner‐city patients in New York demonstrated a lower incidence of adverse events and substantial cost savings, but excluded PE patients.[15] We intentionally sought to expand our VTE program by including both PE and vulnerable uninsured patients.

Lack of health insurance and routine primary care is a major challenge to successful implementation of any care pathway. Access to timely posthospital follow‐up care is far more limited in patients lacking private insurance.[16, 17] Uninsured patients are less likely to receive necessary medical care and more likely to have delayed care.[18, 19] Uninsured patients also have poorer short‐term health and are nearly 3 times more likely to have an ED revisit following hospital discharge than insured patients.[16, 20, 21] At our own institution, many discharged medical patients lack timely PCP follow‐up, especially the uninsured, leading to higher rates of hospital reutilization.[22] Interventions directed at the uninsured VTE patient to mitigate such disparities were specifically targeted. These included coordination of timely follow‐up care in community health clinics and provision of posthospital phone calls.

Efforts to improve transitional care for vulnerable patients have proven successful. Patients linked from the ED to community health clinics through scheduled follow‐up have improved frequency of follow‐up, receive routine care, and have reduced hospital utilization and rehospitalization.[23, 24, 25] Conversely, fewer care disparities are realized by patients within integrated systems such as the Veterans Administration.[26] Thus, the ultimate development of a VTE care pathway at our nonintegrated hospital required an innovative paradigm to deliver acute DVT and PE care. Through examining existing processes of our VTE care, we hypothesized that the main contributors of baseline care deficiencies included inadequate system‐wide education, fragmented care, and significant barriers to timely follow‐up.

Education of providers, patients, and system‐wide process change were key elements in pathway implementation. Provider educational opportunities concerning VTE disease and treatment were identified, including safe and effective outpatient management options. We anticipated provider reluctance prescribing potentially dangerous anticoagulation medications to otherwise stable patients who might lack close posthospital supervision (eg, ED clinicians accustomed to admitting patients and inpatient teams cautious in discharging patients). We postulated that patients received inadequate VTE education and lacked appropriate skills to effectively and safely manage their new disease and medications. The diverse educational components outlined within the pathway significantly contributed to improved provider confidence in their patients' follow‐up care as well as their patients' comprehension of their disease.

Timely posthospital care follow‐up for all VTE patients significantly impacted our pathway results. Historically, uninsured patients lacked primary care follow‐up, often waiting 3 months for an initial clinic visit. Through timely care coordination with local community health clinics, uninsured VTE care pathway patients discharged from our facility are routinely scheduled to be seen within 72 hours. Posthospital care is further addressed through follow‐up phone calls, which monitor patient understanding and care, and identify how and where potential medical needs are best met. Such calls increase patient satisfaction, resolve medication issues, and result in fewer ED return visits.[27] With our intervention, patient satisfaction scores averaged 4.5 (15 Likert scale), reflecting strong support for phone calls and overall experience.

Direct institutional annual cost savings realized with the VTE care pathway was $452,460. This occurred primarily as a result of nearly 50% fewer inpatient days required for admitted VTE patients. Indirect cost savings were further accomplished through increased availability of high‐demand outpatient anticoagulation visits given improved timely PCP follow‐up. Prior to pathway implementation, uninsured patients frequently had multiple, often unreimbursed, visits to this clinic while awaiting PCP follow‐up. Additional future cost savings may occur as healthcare reimbursement patterns are likely to include methods to penalize inefficient and high‐resource usage.

There are several limitations to our study. This was a single‐institution quality program with relatively small numbers. Comparison of pathway data with historical data provides an interval lag that may miss temporal changes in medical practice and disease trends. However, we believe the practice of VTE treatment changed minimally between the 2 time periods. We identified virtually the same number and type of patients in each cohort. Physician and PRA staff turnover complicated tracking patients and challenged continuous system‐wide education. However, we believe consistent education and feedback to PRA faculty throughout the study period minimized variability. Although we could not verify VTE presentations to outside hospitals other than by patient self‐report, it is likely that our patient population would have re‐presented to our institution for follow‐up VTE needs or bleeding concerns. As a result of timely follow‐up phone calls, the number of return visits to the hospital may have been magnified, because more educated patients may have overreacted to mild symptom changes. Prior to the intervention, discharged VTE patients may not have recognized signs and symptoms of worsening disease or may not have returned to our institution for follow‐up needs. Last, we did not control for comorbidities in either cohort, which may affect hospital utilization patterns, as younger patients may be less likely to be admitted or insured.

As a result of a comprehensive VTE clinical care pathway developed by key stakeholders, acute VTE patients who present to our hospital are therapeutically anticoagulated and monitored in a timely, uniform, and safe manner. We believe success reflects system‐wide education and standardization of care through reducing variation, including the high‐risk posthospital period. In an era of fragmented medical care, this program closes existing gaps in care and addresses the needs of vulnerable patients through strong collaboration and efficient coordination with local community health clinics. This is especially important in a dynamic healthcare landscape with an evolving payer mix that demands the medical establishment seek innovative ways to improve quality of care while reducing cost. Future research should explore etiologies and impacts of outcome variability based on insurance status, and identify other conditions and institutions demonstrating care disparities. Ultimately, implementation of this pathway provides strong evidence for improving care, meeting Joint Commission anticoagulation patient safety goals, and conserving limited resources for a common and deadly disease.

Acknowledgements

The authors thank Sancia Tonn, PRA, Carol Kemp‐Jackson from University of Colorado outpatient anticoagulation clinic, and the Metro Community Provider Network Clinics.

Disclosures

This project was funded by University of Colorado Hospital QI Small Grants Program. Preliminary results of this pathway were previously presented at the 2012 Society of Hospital Medicine Annual Meeting, San Diego, California, April 14, 2012.

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is common, costly, and often fatal. Annual VTE incidence in the United States is over 1 million, including over 220,000 PE patients who have an average hospital length of stay (LOS) of 8 days, with a rising per‐patient cost of over $40,000.[1, 2] Nearly half of all PE readmissions occur within 30 days; recurrent DVT events are 21% more costly than the initial event.[3] Likewise, 30‐day PE mortality is 8%, with most deaths occurring within 1 hour of initial presentation.[4, 5]

Rapid implementation of therapeutic anticoagulation has reduced morbidity and mortality in VTE. Ineffective and untimely treatment increases disease progression, significant medication‐related adverse events, and cost. The Joint Commission recognized this risk and included National Patient Safety Goal 3.5.01 to reduce adverse events.[6] Appropriate use of anticoagulation was further emphasized by national quality initiatives through Joint Commission VTE core measures endorsed by the National Quality Forum and the Centers for Medicare and Medicaid Services.[7]

Many models of outpatient VTE care pathways exist. Early models focused on the feasibility of low‐molecular‐weight heparins (LMWH) in the ambulatory setting, with transition to long‐term warfarin. Focus shifted to comprehensive disease pathway implementation aimed at reducing healthcare resource utilization. These pathways have reduced cost and unnecessary hospital stays and minimized complications through enrolling low‐risk patients. To our knowledge, results of an interdisciplinary VTE care pathway have not been published from a large urban academic institution, where a substantial uninsured population exists.

Examining baseline VTE practices and care delivered at our institution provided critical knowledge in effectively developing a novel model of care. Prior to pathway development, acute VTE patients were typically admitted for initiation of therapeutic anticoagulation and appropriate overlap of injectable anticoagulants with warfarin. Significant healthcare disparities were seen among VTE patients at our institution: uninsured patients stayed in the hospital 2 additional days and accumulated twice the rate of 30‐day emergency department (ED) reutilization and cost than insured patients.[8] Discharged VTE patients were managed through a pharmacy‐run anticoagulation clinic pending primary care provider (PCP) follow‐up. We speculated many uninsured VTE patients lacked sufficient disease and treatment information, and lacked surveillance and timely access to medical care following hospitalization. We hypothesized that through (1) targeted education of patients and providers, (2) coordination of timely follow‐up for at‐risk patients, and (3) posthospital monitoring, we could achieve standardized care for all acute DVT and low‐risk PE patients. As a result, we aimed to decrease hospital LOS and produce fewer return visits and readmissions.

METHODS

Study Setting and Population

Acute medical VTE patients were targeted, where they were either discharged directly from the ED or admitted to a medicine service. Acute VTE was defined as primary or secondary diagnosis of new, lower extremity DVT, PE or concurrent DVT, and PE. Patients were identified and tracked by a professional research assistant (PRA) using our electronic medical record (EMR) search filter of all 120 discharge diagnoses for acute DVT and PE.

Our hospital is a 375‐bed, academic medical center in a metropolitan area of under 3 million people. ED volume is approximately 55,000 patients per year.

Exclusion Criteria

We excluded patients classified as surgical/postoperative/admitted to a surgery service, pregnant/postpartum/admitted to an obstetrical service, hospital direct admissions (including outside hospital transfers), and oncology service admissions. Clinically unstable patients requiring intensive care unit admission and/or thrombolytic therapy, and patients with upper extremity, recurrent, or catheter‐associated VTE were also excluded. To allow for comparative data, exclusion criteria were similar to those used in the historical, retrospective chart review performed previously at our institution.[8]

VTE Clinical Care Pathway

The pathway was developed as a quality improvement project through a multidisciplinary, collaborative effort, including pharmacists (inpatient and outpatient), administrative staff in the anticoagulation clinic, nurse leaders and educators, physician faculty (ED, inpatient and outpatient), case managers (inpatient and ED), and providers from local community health clinics, who provide the majority of follow‐up care for our uninsured patients.

We sought care standardization and system‐wide education for all acute, medical, lower‐extremity DVT and low‐risk PE patients, with a focus on coordination of transitional care. All pathway patients were provided education, lab testing, and outpatient medications including LMWH and warfarin. For patients lacking insurance, medications were provided through a medication assistance program at no cost to the patient. Timely outpatient clinic follow‐up and posthospital phone calls were targeted safety net features to facilitate timely hospital discharge and program success. We also aimed to meet nationally mandated quality of care measures and benchmarks. Funding for this project, obtained through a quality improvement (QI) grant from the hospital supported a PRA and educational materials.

The Colorado Multiple Institutional Review Board approved the protocol prior to study implementation. Specific elements of the care pathway have been outlined (see Supporting Information, Figure 1, in the online version of this article). The initial rollout of the program occurred as a pilot in the ED for patients presenting with DVT only to assess feasibility. Based on this success, the pathway team expanded the program to inpatients, including those with PE, and augmented the educational program.

Measures

Evaluation of the intervention was completed by real‐time chart extraction and phone interviews within 72 hours of hospital discharge and a chart review at 6 weeks following discharge. Chart review determined the number of follow‐up visits within 30 days to the anticoagulation clinic and episodes of recidivism. Study data (n=241) were obtained from February 1, 2011 to June 30, 2012 and compared to previously published retrospective data on VTE patients at our institution (n=234) from December 1, 2007 to April 4, 2009.8

We obtained patient demographics (age, gender, ethnicity, insurance category) and admission status from the EMR. We collected data on ED recidivism within 30 days (for VTE‐related issues), LOS, and readmissions within 30 days of discharge. We also collected total cost data for all VTE care from hospital administrative billing data including initial presentation and VTE‐related return visits to the ED and readmissions.

Outcomes

Descriptive information, including demographics, admission status and type of VTE event are summarized for the VTE care pathway. Pathway patients, stratified by payer status (uninsured vs insured), were compared to previously described historical controls.[8] Primary outcomes included comparisons of total costs, LOS, and 30‐day ED recidivism and hospital readmission rates. Further comparisons were made between insured and uninsured patients on these same outcomes.

Data Analysis

Data are presented as proportions or meanstandard deviation unless indicated otherwise. Categorical data were compared using the Fisher exact test or 2 test, where appropriate. Continuous variables were compared using the Student t test. All tests were 2‐tailed. Statistical analyses of the results were performed using GraphPad Prism 4.0 (GraphPad Software, San Diego, CA) and InStat 3.06 (GraphPad Software). A P value <0.05 was considered statistically significant for this study.

RESULTS

Care Pathway Cohort

We enrolled 241 medical patients with acute VTE during the 19‐month study period (Table 1). Of these, 107 (44.4%) presented with DVT alone, whereas the remaining 134 (55.6%) had PE. Eighty‐eight of the 241 VTE patients were uninsured (36.5%). Uninsured patients were younger on average (46.7 vs 55.5 years; P<0.0001) and more commonly presented with DVT only (58.0% vs 36.7%; P=0.036).

Demographics of VTE Care Pathway Patients
 Patients, N=241Uninsured, N=88Insured, N=153P Value

  • NOTE: Abbreviations: DVT, deep vein thrombosis; ED, emergency department; IQR, interquartile range; PE, pulmonary embolism; SD, standard deviation; VTE, venous thromboembolism.

Mean age, y (SD)52.4 (15.8)46.7 (13.9)55.5 (16.1)<0.0001
Median age, y (IQR)53 (4263.5)56 (44.367)49 (35.358.5) 
Gender, male, n (%)113 (46.9)44 (50.0)69 (45.1)0.548
Pulmonary embolism, n (%)134 (55.6)37 (42.0)97 (63.3)0.036
All VTE, hospital admission, n (%)179 (74.3)58 (65.9)121 (79.1)0.032
PE, hospital admission, n (%)132 (54.8)37 (42.0)95 (97.9)1.00

Utilizing the pathway, the majority of VTE patients (179; 74.3%) were admitted to the hospital. Among the uninsured, 58 of 88 (65.9%) patients were admitted compared to 121 of 153 (79.1%) among the insured (P=0.032). Among 107 DVT patients, 47 were admitted (43.9%), including 20 of 51 uninsured DVT patients (39.2%) compared to 27 of 56 insured DVT patients (48.2%). Nearly all PE patients (132 of 134; 98.5%) were admitted. Two insured PE patients were not admitted.

Care Pathway Versus Historical Cohort

Comparing VTE care pathway patients to historical VTE patients (prior to intervention), the age and gender, as well as number of VTE events, VTE type, and admission status were similar (Table 2).

Clinical Care Pathway Versus Historical VTE
OutcomeHistorical VTE, N=234Pathway VTE, N=241P Value

  • NOTE: Categorical data were compared using the Fisher exact test or 2 test, where appropriate. Continuous variables were compared using the Student t test. All tests were 2‐tailed. Abbreviations: DVT, deep vein thrombosis; LOS, length of stay; PE, pulmonary embolism; SD, standard deviation; VTE, venous thromboembolism.

Age, y, mean53.152.40.64
Male, n (%)125 (53.4)113 (47.0)0.46
DVT (%)106 (45.3)107 (44.4)0.92
Uninsured (%)38 (35.8)51 (47.7)0.93
PE (%)128 (54.7)134 (55.6)0.92
Uninsured (%)29 (22.7)38 (28.4)0.11
Admitted (%)171 (73.1)179 (74.3)0.85
DVT (%)43 (40.6)47 (43.9)0.91
Uninsured (%)17 (39.6)20 (42.6)0.94
PE (%)128 (100)132 (98.5)0.91
Uninsured (%)29 (100)38 (100)0.32
LOS, d, mean (SD)4.4 (3.8)3.1 (2.9)<0.001
Uninsured5.9 (5.1)3.1 (2.9)<0.001
Insured3.8 (3.1)3.1 (2.9)0.69
ED revisit, n (%)26 (11.1)27 (11.2)0.974
Uninsured, n (%)12 (17.9)12 (13.6)0.59
Readmission, n (%)16 (9.4)10 (5.6)0.25
Uninsured, n (%)5 (10.9)2 (3.4)0.24
Total cost, $, mean (SD)7610 (9988)5295 (7975)0.005
Uninsured9953 (14211)4304 (6596)0.001
Insured6698 (7564)5875 (8650)0.36
Cost, admitted, $, mean (SD)10324 (8988)7038 (8965)0.044
Uninsured14420 (13351)6375 (7462)0.005
Insured8843 (6565)7353 (9288)0.599

Average hospital LOS for an admitted care pathway patient was 3.1 days versus 4.4 days in an historical VTE patient (P=0.0001; Table 2). When stratified by insurance, uninsured pathway patients had a LOS of 3.1, decreased from a prepathway LOS of 5.9 days (P=0.0006), whereas this did not change among insured patients (3.1 from 3.8 days [P=0.688]).

For all VTE care pathway patients, 30‐day ED recidivism was 11.2%, similar to prepathway data (11.1%; Table 2). This was true regardless of insurance status. Thirty‐day readmission rates trended from 9.4% prepathway to 5.6% postpathway (P=0.254) (Table 2). Compared to historical VTE patients, uninsured pathway patients had readmission rates of 3.4% from 10.9% (P=0.237), whereas readmission rates for insured patients were 6.6% from 8.8% (P=0.686).

Average cost for a VTE care pathway patient was $5295 compared to an historical cost of $7610 per VTE patient (P <0.005). Among uninsured pathway patients, the cost of VTE care was $4304 compared to $9953 historically (P=0.001). Among insured pathway patients, the cost of VTE care was $5875 compared to an historical cost of $6698 (P=0.365).

The average VTE cost of care for an admitted pathway patient was $7038 versus $10,324 per admitted historical patient (P=0.044). For an admitted uninsured VTE pathway patient, cost was $6375 versus $14,420 per historical VTE patient (P=0.005). For an admitted insured VTE pathway patient, the cost was $7353 versus $8843 per historical VTE patient (P=0.599).

Patient satisfaction scores with the care pathway averaged 4.5 (15 Likert scale).

DISCUSSION

Development and implementation of a multidisciplinary VTE clinical care pathway at our institution represents success across multiple domains. As a QI project, we standardized care and delivered system‐wide education, and provided solutions to existing gaps in posthospital care. This pathway for a common, dangerous disease requiring high‐risk medications magnifies the importance of care delivered at vulnerable points. Results of our study are the first to our knowledge to mitigate healthcare disparities and reduce healthcare utilization through a care pathway across diverse populations. Hospital LOS for all VTE patients was significantly decreased, wile lowering hospital reutilization patterns, particularly among the uninsured. Hospital admission rates are now lower specifically for the uninsured patients, because ED and inpatient providers now have increased confidence in the follow‐up arrangements with the safety‐net clinics.

Many clinical care pathways for VTE are proven, safe, and cost‐effective.[9, 10, 11, 12] Outpatient DVT treatment delivers significant cost savings and averts unnecessary hospital stays.[13, 14] A hospital‐based program providing outpatient DVT treatment among inner‐city patients in New York demonstrated a lower incidence of adverse events and substantial cost savings, but excluded PE patients.[15] We intentionally sought to expand our VTE program by including both PE and vulnerable uninsured patients.

Lack of health insurance and routine primary care is a major challenge to successful implementation of any care pathway. Access to timely posthospital follow‐up care is far more limited in patients lacking private insurance.[16, 17] Uninsured patients are less likely to receive necessary medical care and more likely to have delayed care.[18, 19] Uninsured patients also have poorer short‐term health and are nearly 3 times more likely to have an ED revisit following hospital discharge than insured patients.[16, 20, 21] At our own institution, many discharged medical patients lack timely PCP follow‐up, especially the uninsured, leading to higher rates of hospital reutilization.[22] Interventions directed at the uninsured VTE patient to mitigate such disparities were specifically targeted. These included coordination of timely follow‐up care in community health clinics and provision of posthospital phone calls.

Efforts to improve transitional care for vulnerable patients have proven successful. Patients linked from the ED to community health clinics through scheduled follow‐up have improved frequency of follow‐up, receive routine care, and have reduced hospital utilization and rehospitalization.[23, 24, 25] Conversely, fewer care disparities are realized by patients within integrated systems such as the Veterans Administration.[26] Thus, the ultimate development of a VTE care pathway at our nonintegrated hospital required an innovative paradigm to deliver acute DVT and PE care. Through examining existing processes of our VTE care, we hypothesized that the main contributors of baseline care deficiencies included inadequate system‐wide education, fragmented care, and significant barriers to timely follow‐up.

Education of providers, patients, and system‐wide process change were key elements in pathway implementation. Provider educational opportunities concerning VTE disease and treatment were identified, including safe and effective outpatient management options. We anticipated provider reluctance prescribing potentially dangerous anticoagulation medications to otherwise stable patients who might lack close posthospital supervision (eg, ED clinicians accustomed to admitting patients and inpatient teams cautious in discharging patients). We postulated that patients received inadequate VTE education and lacked appropriate skills to effectively and safely manage their new disease and medications. The diverse educational components outlined within the pathway significantly contributed to improved provider confidence in their patients' follow‐up care as well as their patients' comprehension of their disease.

Timely posthospital care follow‐up for all VTE patients significantly impacted our pathway results. Historically, uninsured patients lacked primary care follow‐up, often waiting 3 months for an initial clinic visit. Through timely care coordination with local community health clinics, uninsured VTE care pathway patients discharged from our facility are routinely scheduled to be seen within 72 hours. Posthospital care is further addressed through follow‐up phone calls, which monitor patient understanding and care, and identify how and where potential medical needs are best met. Such calls increase patient satisfaction, resolve medication issues, and result in fewer ED return visits.[27] With our intervention, patient satisfaction scores averaged 4.5 (15 Likert scale), reflecting strong support for phone calls and overall experience.

Direct institutional annual cost savings realized with the VTE care pathway was $452,460. This occurred primarily as a result of nearly 50% fewer inpatient days required for admitted VTE patients. Indirect cost savings were further accomplished through increased availability of high‐demand outpatient anticoagulation visits given improved timely PCP follow‐up. Prior to pathway implementation, uninsured patients frequently had multiple, often unreimbursed, visits to this clinic while awaiting PCP follow‐up. Additional future cost savings may occur as healthcare reimbursement patterns are likely to include methods to penalize inefficient and high‐resource usage.

There are several limitations to our study. This was a single‐institution quality program with relatively small numbers. Comparison of pathway data with historical data provides an interval lag that may miss temporal changes in medical practice and disease trends. However, we believe the practice of VTE treatment changed minimally between the 2 time periods. We identified virtually the same number and type of patients in each cohort. Physician and PRA staff turnover complicated tracking patients and challenged continuous system‐wide education. However, we believe consistent education and feedback to PRA faculty throughout the study period minimized variability. Although we could not verify VTE presentations to outside hospitals other than by patient self‐report, it is likely that our patient population would have re‐presented to our institution for follow‐up VTE needs or bleeding concerns. As a result of timely follow‐up phone calls, the number of return visits to the hospital may have been magnified, because more educated patients may have overreacted to mild symptom changes. Prior to the intervention, discharged VTE patients may not have recognized signs and symptoms of worsening disease or may not have returned to our institution for follow‐up needs. Last, we did not control for comorbidities in either cohort, which may affect hospital utilization patterns, as younger patients may be less likely to be admitted or insured.

As a result of a comprehensive VTE clinical care pathway developed by key stakeholders, acute VTE patients who present to our hospital are therapeutically anticoagulated and monitored in a timely, uniform, and safe manner. We believe success reflects system‐wide education and standardization of care through reducing variation, including the high‐risk posthospital period. In an era of fragmented medical care, this program closes existing gaps in care and addresses the needs of vulnerable patients through strong collaboration and efficient coordination with local community health clinics. This is especially important in a dynamic healthcare landscape with an evolving payer mix that demands the medical establishment seek innovative ways to improve quality of care while reducing cost. Future research should explore etiologies and impacts of outcome variability based on insurance status, and identify other conditions and institutions demonstrating care disparities. Ultimately, implementation of this pathway provides strong evidence for improving care, meeting Joint Commission anticoagulation patient safety goals, and conserving limited resources for a common and deadly disease.

Acknowledgements

The authors thank Sancia Tonn, PRA, Carol Kemp‐Jackson from University of Colorado outpatient anticoagulation clinic, and the Metro Community Provider Network Clinics.

Disclosures

This project was funded by University of Colorado Hospital QI Small Grants Program. Preliminary results of this pathway were previously presented at the 2012 Society of Hospital Medicine Annual Meeting, San Diego, California, April 14, 2012.

References
  1. MacDougall DA, Feliu AL, Boccuzzi SJ, et al. Economic burden of deep‐vein thrombosis, pulmonary embolism, and post‐thrombotic syndrome. Am J Health Syst Pharm. 2006;63(20 suppl 6):S5–S15.
  2. Park B, Messina L, Dargon P, et al. Recent trends in clinical outcomes and resource utilization for pulmonary embolism in the United States: findings from the nationwide inpatient sample. Chest. 2009;136(4):983–990.
  3. Spyropoulos AC, Lin J. Direct medical costs of venous thromboembolism and subsequent hospital readmission rates: an administrative claims analysis from 30 managed care organizations. J Manag Care Pharm. 2007;13(6):475–486.
  4. Smith S, Geske J, Maguire J, Zane N, Carter R, Morgenthaler T. Early anticoagulation is associated with reduced mortality for acute pulmonary embolism. Chest. 2010;137(6):1382–1390.
  5. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999;353(9162):1386–1389.
  6. University of North Carolina Air Care website. Available at: http://www.unchealthcare.org/site/Nursing/servicelines/aircare/2009npsg. National Patient Safety Goal/NPSG.03.05.01. http://www.unchealthcare.org/site/Nursing/servicelines/aircare/. Accessed November 1, 2013.
  7. National consensus standards for the prevention and care of deep vein thrombosis (DVT) project between The Joint Commission and the National Quality Forum (NQF) 2008. Available at: http://www.jointcommission.org/venous_thromboembolism. Accessed November 1, 2013.
  8. Misky GJ, Manheim JC, Zehnder N, et al. Health Care disparities on venous thromboembolism based on insurance status in the United States. J Thromb Thrombolysis. 2011:32(4):393–398.
  9. Hyers TM, Spyropolous AC; INNOVATE Investigators. Community‐based treatment of venous thromboembolism with a low‐molecular weight heparin and warfarin. J Thromb Thrombolysis. 2007;24(3):225–232.
  10. Kidney R, Hosny G, Canning MB, et al. Implementation of a clinical pathway for emergency department out‐patient management of deep vein thrombosis. Ir Med J. 2010;103(8):246–248.
  11. Spyropoulos AC. Outpatient‐based treatment protocols in the management of venous thromboembolic disease. Am J Manag Care. 2000;6(20 suppl):S1034–S1044.
  12. Lee M, Pao D, Hsu T, et al. Cost savings and effectiveness of outpatient treatment with low molecular weight heparin of deep vein thrombosis in a community hospital. Can J Clin Pharmacol. 2004;11(1):e17–e27.
  13. Vinson DR, Berman DA. Outpatient treatment of deep venous thrombosis: a clinical care pathway managed by the emergency department. Ann Emerg Med. 2001;37(3):251–258.
  14. Tillman DJ, Charland SL, Witt DM. Effectiveness and economic impact associated with a program for outpatient management of acute deep vein thrombosis in a group model health maintenance organization. Arch Intern Med. 2000;160(19):2926–2932.
  15. Dunn AS, Schechter C, Gotlin A, et al. Outpatient treatment of deep venous thrombosis in diverse inner‐city patients. Am J Med. 2001;110(6):458–462.
  16. Asplin BR, Rhodes KV, Levy H, et al. Insurance status and access to urgent ambulatory care follow‐up appointments. JAMA. 2005;294(10):1248–1254.
  17. Kerr EA, Siu AL. Follow‐up after hospital discharge: does insurance make a difference? J Health Care Poor Underserved. 1993;4(2):133–142.
  18. Burt CW, McCaig LF, Simon AE. Emergency department visits by persons recently discharged from U.S. hospitals. Natl Health Stat Report. 2008;(6):1–9.
  19. Hadley J. Insurance coverage, medical care use, and short‐term health changes following an unintentional injury or the onset of a chronic condition. JAMA. 2007;297(10):1073–1084.
  20. Baker DW, Shapiro MF, Schur CL. Health insurance and access to care for symptomatic conditions. Arch Intern Med. 2000;160(9):1269–1274.
  21. Weissman JS, Stern R, Fielding SL, et al. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med. 1991;114(4):325–331.
  22. Misky GJ, Wald H, Coleman EA. Post‐hospitalization transitions: examining the effects of timing of primary care provider follow‐up. J Hosp Med. 2010;5:392–397.
  23. Rothkopf J, Brookler K, Wadhwa S, et al. Medicaid patients seen at federally qualified health centers use hospital services less than those seen by private providers. Health Aff (Millwood). 2011;30(7):1335–1342.
  24. Robbins JM, Valdmanis VG, Webb DA. Do public health clinics reduce rehospitalizations?: the urban diabetes study. J Health Care Poor Underserved. 2008;19(2):562–573.
  25. Chan TC, Killeen JP, Castillo EM, et al. Impact of an internet‐based emergency department appointment system to access primary care at safety net community clinics. Ann Emerg Med. 2009;54(2):279–284.
  26. Shimada SL, Montez‐Rath ME, Loveland SA, et al. Racial disparities in patient safety indicator (psi) rates in the veterans health administration. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches. Vol. 1: Assessment. Rockville, MD: Agency for Healthcare Research and Quality; 2008. Available at: http://www.ncbi.nlm.nih.gov/books/NBK43651, Accessed November 1, 2013.
  27. Dudas V, Bookwalter T, Kerr KM, et al. The impact of follow‐up telephone calls to patients after hospitalization. Dis Mon. 2002;48(4):239–248.
References
  1. MacDougall DA, Feliu AL, Boccuzzi SJ, et al. Economic burden of deep‐vein thrombosis, pulmonary embolism, and post‐thrombotic syndrome. Am J Health Syst Pharm. 2006;63(20 suppl 6):S5–S15.
  2. Park B, Messina L, Dargon P, et al. Recent trends in clinical outcomes and resource utilization for pulmonary embolism in the United States: findings from the nationwide inpatient sample. Chest. 2009;136(4):983–990.
  3. Spyropoulos AC, Lin J. Direct medical costs of venous thromboembolism and subsequent hospital readmission rates: an administrative claims analysis from 30 managed care organizations. J Manag Care Pharm. 2007;13(6):475–486.
  4. Smith S, Geske J, Maguire J, Zane N, Carter R, Morgenthaler T. Early anticoagulation is associated with reduced mortality for acute pulmonary embolism. Chest. 2010;137(6):1382–1390.
  5. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999;353(9162):1386–1389.
  6. University of North Carolina Air Care website. Available at: http://www.unchealthcare.org/site/Nursing/servicelines/aircare/2009npsg. National Patient Safety Goal/NPSG.03.05.01. http://www.unchealthcare.org/site/Nursing/servicelines/aircare/. Accessed November 1, 2013.
  7. National consensus standards for the prevention and care of deep vein thrombosis (DVT) project between The Joint Commission and the National Quality Forum (NQF) 2008. Available at: http://www.jointcommission.org/venous_thromboembolism. Accessed November 1, 2013.
  8. Misky GJ, Manheim JC, Zehnder N, et al. Health Care disparities on venous thromboembolism based on insurance status in the United States. J Thromb Thrombolysis. 2011:32(4):393–398.
  9. Hyers TM, Spyropolous AC; INNOVATE Investigators. Community‐based treatment of venous thromboembolism with a low‐molecular weight heparin and warfarin. J Thromb Thrombolysis. 2007;24(3):225–232.
  10. Kidney R, Hosny G, Canning MB, et al. Implementation of a clinical pathway for emergency department out‐patient management of deep vein thrombosis. Ir Med J. 2010;103(8):246–248.
  11. Spyropoulos AC. Outpatient‐based treatment protocols in the management of venous thromboembolic disease. Am J Manag Care. 2000;6(20 suppl):S1034–S1044.
  12. Lee M, Pao D, Hsu T, et al. Cost savings and effectiveness of outpatient treatment with low molecular weight heparin of deep vein thrombosis in a community hospital. Can J Clin Pharmacol. 2004;11(1):e17–e27.
  13. Vinson DR, Berman DA. Outpatient treatment of deep venous thrombosis: a clinical care pathway managed by the emergency department. Ann Emerg Med. 2001;37(3):251–258.
  14. Tillman DJ, Charland SL, Witt DM. Effectiveness and economic impact associated with a program for outpatient management of acute deep vein thrombosis in a group model health maintenance organization. Arch Intern Med. 2000;160(19):2926–2932.
  15. Dunn AS, Schechter C, Gotlin A, et al. Outpatient treatment of deep venous thrombosis in diverse inner‐city patients. Am J Med. 2001;110(6):458–462.
  16. Asplin BR, Rhodes KV, Levy H, et al. Insurance status and access to urgent ambulatory care follow‐up appointments. JAMA. 2005;294(10):1248–1254.
  17. Kerr EA, Siu AL. Follow‐up after hospital discharge: does insurance make a difference? J Health Care Poor Underserved. 1993;4(2):133–142.
  18. Burt CW, McCaig LF, Simon AE. Emergency department visits by persons recently discharged from U.S. hospitals. Natl Health Stat Report. 2008;(6):1–9.
  19. Hadley J. Insurance coverage, medical care use, and short‐term health changes following an unintentional injury or the onset of a chronic condition. JAMA. 2007;297(10):1073–1084.
  20. Baker DW, Shapiro MF, Schur CL. Health insurance and access to care for symptomatic conditions. Arch Intern Med. 2000;160(9):1269–1274.
  21. Weissman JS, Stern R, Fielding SL, et al. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med. 1991;114(4):325–331.
  22. Misky GJ, Wald H, Coleman EA. Post‐hospitalization transitions: examining the effects of timing of primary care provider follow‐up. J Hosp Med. 2010;5:392–397.
  23. Rothkopf J, Brookler K, Wadhwa S, et al. Medicaid patients seen at federally qualified health centers use hospital services less than those seen by private providers. Health Aff (Millwood). 2011;30(7):1335–1342.
  24. Robbins JM, Valdmanis VG, Webb DA. Do public health clinics reduce rehospitalizations?: the urban diabetes study. J Health Care Poor Underserved. 2008;19(2):562–573.
  25. Chan TC, Killeen JP, Castillo EM, et al. Impact of an internet‐based emergency department appointment system to access primary care at safety net community clinics. Ann Emerg Med. 2009;54(2):279–284.
  26. Shimada SL, Montez‐Rath ME, Loveland SA, et al. Racial disparities in patient safety indicator (psi) rates in the veterans health administration. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches. Vol. 1: Assessment. Rockville, MD: Agency for Healthcare Research and Quality; 2008. Available at: http://www.ncbi.nlm.nih.gov/books/NBK43651, Accessed November 1, 2013.
  27. Dudas V, Bookwalter T, Kerr KM, et al. The impact of follow‐up telephone calls to patients after hospitalization. Dis Mon. 2002;48(4):239–248.
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Implementation of an acute venous thromboembolism clinical pathway reduces healthcare utilization and mitigates health disparities
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Gregory J. Misky, MD
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Address for correspondence and reprint requests: Gregory J. Misky, MD, Associate Professor of Medicine, University of Colorado School of Medicine, Leprino Office Building, Rm 474, 12401 E. 17th Ave., Aurora, CO 80045; Telephone: 720‐848‐4289; Fax: 720‐848‐4293; E‐mail: gregory.misky@ucdenver.edu
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Lack of Timely PCP Follow‐Up

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Post‐hospitalization transitions: Examining the effects of timing of primary care provider follow‐up
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Gregory J. Misky, MD
Heidi L. Wald, MD, MSPH
Eric A. Coleman, MD, MPH

Care transitions between the inpatient and outpatient settings are a known period of risk in a patient's care. For instance, 1 in 5 medical patients suffers an adverse event during the first several weeks after hospital discharge, with half of these requiring the use of additional healthcare resources.1 Additionally, medication and lab monitoring errors occur in up to half of all discharged patients.2 Nearly 1 in 5 hospitalized patients, admitted with 1 of 16 different conditions including asthma, diabetes, congestive heart failure and urinary tract infection is readmitted to the hospital within six months. Up to 60% of resources are used in rehospitalized patients.3, 4 In Medicare beneficiaries, the readmission rate is as high as 20% at 30 days. The same study suggests that up to half of Medicare patients readmitted within 30 days are not seen in the outpatient setting following discharge.5 Such statistics underscore the need for seamless post‐discharge care.

Studies of post‐discharge primary care provider (PCP) follow‐up highlight the gaps in current practice within the transition from the hospital to PCP follow‐up. For instance, while more than 1 in 4 discharged patients (27.6%) at one large teaching hospital had outpatient work‐ups recommended by their hospital physicians, more than a third (35.9%) of these recommendations were ultimately not completed. Furthermore, at this same center, an increased time interval between hospital discharge and PCP follow‐up decreased the likelihood that a work‐up recommended by a hospital physician was completed.6 In patients who do have a PCP, post‐hospitalization follow‐up is frequently impacted by a variety of factors, including co‐payment requirements, transportation issues, lack of health insurance, as well as scheduling a follow‐up appointment while in the hospital.710 Uninsured patients are at particular risk for failures in transitions, have poorer health outcomes and higher mortality than insured counterparts, and are nearly 3 times more likely to make an ED visit following hospital discharge.1113

In order to better understand the role of post‐discharge PCP follow‐up, we sought to identify: (1) the percentage of general medical inpatients lacking timely PCP follow‐up after discharge from the hospital, and (2) the impact of patients lacking timely PCP follow‐up on 30‐day readmission rate and hospital length of stay (LOS). For the purposes of this study, we have defined timely PCP follow up as occurring within 4 weeks of hospital discharge.

Methods

Study Setting and Population

This prospective cohort enrolled a convenience sample of patients admitted to Internal Medicine ward teams at the University of Colorado Hospital Anschutz Inpatient Pavilion between December 2007 and March 2008. Up to 2 patients were enrolled on weekdays on the morning following admission (ie, Sunday night through Thursday night admissions). Patients were screened for study entry if they were able to participate in an interview as identified by their medical team and available in their room. Of a total of 121 patients screened for study entry by a professional research assistant (PRA), 75 ultimately provided HIPAA authorization, informed consent, and completed the in‐hospital interview. The most common reasons for screened patients refusing study enrollment included being not interested (26) and too ill (10). Ten subjects were lost to follow‐up after hospital discharge, including one subject who was deceased. Therefore, 65 patients successfully completed the follow‐up phone interview and were included in the analyses. Characteristics of the 121 screened patients and the 75 study patients were similar with respect to sex, age, race, and payer mix, and representative of the demographics of the patient population at large. Case mix indices (mean) were similar among the 121 screened (1.23), 75 enrolled (1.27), and final 65 study patients (1.25).

Exclusion Criteria

Patients admitted to the medical observation unit; patients admitted at night who are ultimately reassigned to specialty services (Oncology, Cardiology, Hepatology and Acute Care for the Elderly) were excluded. Human immunodeficiency virus (HIV) patients were excluded because of routine outpatient ID follow‐up; patients <18 years of age; patients lacking a telephone; patients admitted on Friday and Saturday nights; and outside hospital transfers.

Measures

The primary study outcome was the rate of timely PCP follow‐up defined as that occurring within 4 weeks of hospital discharge. PCP was defined in this study as either a patient's known PCP (or another provider in the same clinic), or a nurse practitioner/physician assistant. Patients seen in follow‐up by a specialist related to the discharge diagnosis, eg, an Endocrinologist in a patient hospitalized for Diabetic complications; a Rheumatologist following up an SLE patient, etc., were also counted as having PCP follow‐up as defined in this study.

Additional outcomes included three measures of hospital readmission: hospital readmission for same condition; hospital readmission or other care sought (ie, ED, Urgent Care) for same condition; and hospital readmission for any condition, and index hospital LOS. The distinction between same condition and any condition was made in an attempt to delineate a potentially preventable readmission (as an example, one study patient was subsequently readmitted with a gunshot injury that clearly would not have been affected by the presence of any PCP follow‐up). Determination of same vs. any condition was made by the investigators through information obtained from patients on follow‐up phone interviews: Have you been readmitted to the University Hospital or another hospital since your discharge last month from the University Hospital? If yes: where, when, and why? The investigators determined same vs. any through comparing this information to the primary diagnosis from the index hospitalization obtained from the final discharge documentation. A condition was considered same if the readmission was for the same condition or for treatment/complications related to the index hospitalized condition.

Descriptive data collected included patient demographics, diagnoses, insurance status, presence of an identified, established PCP, time to PCP follow‐up in weeks, effects of payer source, admitting service (hospitalist vs. General Internal Medicine (GIM) attending), and nature of presenting illness (acute vs. acute on chronic condition). Categories of insurance obtained from chart review included commercial, self‐pay (uninsured), Medicare, Medicaid and Veterans.

Data Collection

A PRA screened and obtained informed consent and a Health Insurance Portability and Accountability Act (HIPAA) waiver from patients the day following admission. At that time, the PRA obtained the patients' vital information from chart review and a scripted patient interview: age, sex, PCP, categories of insurance, contact phone numbers, and admitting date and diagnoses. The in‐house interview included eight questions examining a patient's experiences of and attitudes toward PCPs. Four weeks after discharge, patients were contacted by the PRA via telephone. Scripted telephone interviews were used to determine occurrence and timing of PCP follow‐up and hospital readmission status (to any hospital) per patient self‐report. Potential barriers to PCP follow‐up were assessed. Up to 3 attempts were made to contact study subjects out to 4 weeks from the initial call (8 weeks total). If an appointment for an enrolled patient had been made, but had not yet occurred, an additional phone call was made 2 weeks later to determine whether, and when, the appointment was kept. Review of discharge summaries determined a patient's hospital LOS.

Data Analysis

Descriptive statistics were calculated for the study population. Univariate comparisons were completed for patient characteristics and study outcomes for patients with and without PCP follow‐up. We used t‐tests for continuous variables (age and LOS) and chi‐square or Fisher's exact tests when necessary for dichotomous variables (gender, uninsured vs. insured, and all hospital readmission outcomes). Comparisons according to PCP follow‐up for the categorical variables were tested with the Cochran‐Mantel‐Haenszel statistic for general association (race and insurance category) or for trends in the ordinal variable (education).

Patient characteristics and study outcomes with univariate P value < 0.1 were assessed for inclusion in the multivariate logistic regression models. Separate logistic regression models were examined with PCP follow‐up (yes/no) as the explanatory variable and the 3 hospital readmission rates as the outcomes. Final logistic regression models included the primary predictor, PCP follow‐up, along with potential predictor variables with P value < 0.05. Statistical analyses were carried out using SAS version 9.2 (SAS Institute, Cary, NC).

This protocol was approved by the Colorado Multiple Institutional Review Board (COMIRB) prior to the implemented study.

Results

Sixty‐five patients completed this study. The mean age of the study population was 55.3 years and approximately half (52.3%) of the study participants were female. Fifty‐two subjects reported having an established PCP on admission to the hospital (80%). The rate of timely PCP follow‐up overall was 49.2%. Table 1 shows the study population characteristics stratified by presence of timely PCP follow‐up. Patients lacking timely PCP follow‐up were much younger (48.4 vs. 62.4 years; P < 0.001) than those with timely PCP follow‐up; there were also non‐significant trends toward patients lacking timely PCP follow‐up being non‐white: (33.3% vs. 25%, P = 0.23) and having lower education level (72.7% with high school or lower education vs. 56.2% for those with PCP follow‐up, P = 0.15) than those with timely PCP follow‐up. Of the 32 patients having timely PCP follow‐up, 15.6% were uninsured. In comparison, among the 33 patients lacking timely PCP follow‐up after hospital discharge, over a third (36%) were uninsured (P = 0.06). Among the uninsured, a large majority (70.5%) lacked timely PCP follow‐up (P = 0.06). In contrast, only 11 of the 26 Medicare patients (42.3%) lacked timely PCP follow‐up (P = 0.13).

Patient Characteristics Stratified by Timely PCP Follow‐Up
Study DemographicsTimely PCP Follow‐Up (n = 32)No PCP Follow‐Up (n = 33)P Value

  • Abbreviations: PCP, Primary Care Physician; SD, standard deviation; VA, Veterans Administration.

  • Primary insurance of patient.

Female, n (%)17 (53.1)17 (51.5)0.90
Age, years, mean (SD)62.448.4<0.001
Race, n (%)   
Caucasian24 (75.0)23 (69.7)0.23
African American7 (21.9)5 (15.2) 
Hispanic/Latino1 (3.1)5 (15.2) 
Highest grade completed, n (%)   
Grammar school2 (6.3)3 (9.1)0.15
High school16 (50.0)21 (63.6) 
College13 (40.6)9 (27.3) 
Postgraduate1 (3.1)0 (0) 
Insurance*, n (%)   
Medicare15 (46.9)11 (33.3)0.13
Medicaid1 (3.1)3 (9.1) 
Commercial/private6 (18.8)6 (18.2) 
VA/Tri‐Care5 (15.6)1 (3.0) 
Self‐pay/uninsured5 (15.6)12 (36.4)0.06
Case mix index, median1.151.11 

Readmissions

The 30‐day readmission rates for all study subjects were 12.3% for a patient's same medical condition, 17.2% for readmission or other care sought for the same condition, and 21.5% for any condition. Table 2 contains univariate comparisons for the patient outcomes of readmission and LOS stratified by timely PCP follow‐up. Hospital readmission for the same medical condition was significantly higher in patients lacking timely PCP follow‐up compared to those with timely PCP follow‐up (21.2% vs. 3.1%, P = 0.05). The composite outcome of hospital readmission and/or other care sought (emergency department or urgent care) for a patient's same condition was also significantly higher in patients lacking timely PCP follow‐up (28.1% vs. 6.3%; P = 0.02). However, hospital readmission for any condition did not differ with absence of timely PCP follow‐up.

Outcomes Stratified by Timely PCP Follow‐Up (n = 65)
OutcomeTimely PCP Follow‐Up (n = 32)No PCP Follow‐Up (n = 33)P Value

  • Abbreviations: ED, emergency department; PCP, primary care physician; SD, standard deviation.

  • n = 32.

Length of stay (days), mean (SD)4.4 (3.7)6.3 (5.2)0.11
Hospital readmission for same condition within 30‐days of discharge, n (%)1 (3.1)7 (21.2)0.05
Hospital readmission or other care sought (ie, ED, urgent care) for same condition within 30‐days of discharge, n (%)2 (6.3)9 (28.1)*0.02
Hospital readmission for any condition within 30‐days of discharge, n (%)5 (15.6)9 (27.3)0.25

Multiple logistic regression revealed that patients lacking timely PCP follow‐up were 10 times more likely to be readmitted for the same condition within 30 days of hospital discharge (odds ratio [OR] = 9.9; P = 0.04) and nearly seven times as likely to be readmitted for the same condition or receive other care (OR = 6.8, P = 0.02) (Table 3).

Results of Logistic Regression Models for Association of Untimely PCP Follow‐Up With Hospital Readmission Outcomes
OutcomeOdds Ratio (CI)P Value

  • NOTE: Adjusted for uninsured status.

  • Abbreviation: CI, confidence interval.

Hospital readmission for same condition9.9 (1.2‐84.7)0.04
Hospital readmission or other care for same condition6.8 (1.4‐34.3)0.02
Hospital readmission for any condition2.3 (0.7‐7.9)0.17

LOS

Overall hospital LOS in all patients was 5.4 4.6 days. In patients lacking timely PCP follow‐up, there was a trend toward longer hospital LOS: 6.3 days vs. 4.4 days, P = 0.11. For all uninsured study patients (17), the mean LOS was 6.4 days vs. 5.0 days for all other insurance categories, P = 0.31.

Insurance Status

Being uninsured was associated with a patient lacking timely PCP follow‐up (P = 0.06), but was not directly associated with higher readmission or longer hospital LOS (OR = 1.0, P = 0.96). The lack of insurance was not a significant predictor of hospital readmission in the multiple logistic regression models.

Timing of PCP Follow‐Up

In evaluating timing of any PCP follow‐up after hospital discharge and clinical outcomes, most PCP follow‐up (90.6%) occurred within the first 2 weeks following hospital discharge. However, we found no statistical difference between timing of post‐discharge PCP follow‐up and hospital readmission outcomes (hospital readmission for same reason, P = 0.51; hospital readmission or other care sought for same reason, P = 0.89), or in hospital LOS (P = 0.87). Timing of PCP follow‐upwhen comparing post‐hospitalization follow‐up <1 week, 1 to 2 weeks, and 2 to 4 weekswas not predictive of readmission rates or LOS.

Established PCP

When significance of having an established PCP prior to hospital admission was evaluated, 52 patients reported having an established PCP on hospital admission (80%), half of whom were Medicare patients. Of the 13 patients with no PCP on admission, the majority (10) were self‐pay (77%, P < 0.0001). Interestingly, only 29 (55.8%) of the patients who reported a PCP on admission to the hospital saw their PCP within 4 weeks of hospital discharge. Of 13 patients without a PCP on admission, only 3 obtained 4‐week PCP follow‐up. When we examined our study outcomes for subjects stratified by the presence of an established PCP prior to hospitalization, we found univariate association with timely post‐discharge PCP follow‐up (56% of those with established PCP vs. 23% of those without, P = 0.04), but no difference in readmission rates or hospital LOS.

Severity of patient illnessmeasured using hospital data and the case mix index (CMI)of the 3 patient populations (screened, enrolled, final) was quite similar. The CMI (mean) for the 121 screened patients was 1.23. The CMI for the 75 enrolled patients was 1.27. And the CMI in the 65 final study patients was 1.25. When evaluating illness severity (CMI) of patients in relation to hospital LOS between the 2 final study populations, the CMI (median) was also similar: 1.15 for the 32 patients with timely PCP follow‐up vs. 1.11 for the 33 patients without timely PCP follow‐up.

We found no association when looking at the rate of timely PCP follow‐up based on admitting service attending, or acute vs. acute on chronic diagnosis.

Barriers to PCP follow‐up most frequently cited by study patients were: lacking a PCP (no established PCP prior to hospital, no insurance, out of town, recently changed insurance), could not get an appointment, discharged to a half‐way house, and saw another doctor (specialist unrelated to discharge diagnosis).

Discussion

A growing body of work highlights the role of multiple, varied interventions at, or following discharge, in improving outcomes during the transition from inpatient to outpatient care. Examples include care coordination by advanced nurse practitioners, follow‐up pharmacist phone calls, and involvement of a transition coach encouraging active patient involvementall are known to improve patient outcomes following a hospitalization.1418 The active involvement of a PCP is central to a number of these proven interventions to ensure effective completion of ongoing patient care. And while some previous studies suggest increased overall resource utilization when PCP follow‐up occurs after hospitalization,19 the level of fragmented care that occurs in today's hospitalized patient, as well as the fact many patients lack PCP care at all, raises questions about clinical outcomes after hospitalization related to timely PCP follow‐up. The issue of appropriateness of resources utilized has also not been adequately explored.

Within this context, this study examines the role that PCP follow‐up might play in such interventions and its' effects on patient outcomes. Notably, in this urban academic medical center, we found that timely PCP follow‐up after hospital discharge occurred in fewer than half of general medical inpatients. Lack of timely PCP follow‐up was associated with increased hospital readmission for the same condition and a trend toward a longer index hospital LOS.

While this small study cannot fully elucidate the impact of lack of timely PCP follow‐up on post‐discharge care, our findings suggest some mechanisms by which lack of timely PCP follow‐up might result in poor outcomes. For instance, patients lacking a PCP visit after discharge may not obtain needed follow‐up care in the post‐discharge period, leading to clinical deterioration and hospital readmission. Uninsured patients may be at particular risk for failed transition because they are less likely to have consistent PCP access, whether as an already established patient or one newly assigned.20, 21 Perhaps a larger study would better demonstrate statistical significance in reflecting the association between uninsured patients, lack of a PCP, and post‐discharge follow‐up deficiencies. There may, in fact, be issues related to patient attitudes and beliefs, such as subjectively feeling better or even an implicit distrust of the healthcare system among the uninsured, that exist as well. Even among patients with a PCP prior to hospitalization, PCP follow‐up after hospital discharge may be lacking due to modifiable factors such as patient attitudes and beliefs and logistical barriers in arranging follow‐up.

Patients without potential for timely PCP follow‐up might be kept in the hospital longer to ensure they are well enough medically to sufficiently meet their own follow‐up needs. Hospital LOS might be increased by providers to compensate for the lack of PCP follow‐up. Alternatively, these patients may be sicker with their index hospitalization.

It is not surprising that payer source appears to influence a patients' ability to obtain timely PCP follow‐up. It is well documented that uninsured patients have higher healthcare resource utilization.2224 Lack of access to primary care in such patients contributes to a cycle of using the most expensive sites of care. In our study, we found many of the patients lacking timely PCP follow‐up were younger, perhaps reflecting the same patient population who have higher rates of being uninsured. Conversely, older patients are more likely to have PCP access, in large part due to having Medicare benefits (although this dynamic has shown a shift in recent years). The uninsured may present sicker as a result of lacking pre‐hospital PCP access or transportation to a PCP visit.

Limitations

This study was performed at a single, academic institution limiting its' generalizability. In addition, this small cohort study, which took place over four winter months, may have implicit biases toward certain disease entities and follow‐up issues unique to study size and season. The small study size was dictated by a finite amount of available resources, potentially contributing to minor inconsistencies with some of the results. While statistical significance was still seen with many of our results, a much larger study may better enhance the study outcomes.

It also remains unclear why the effects of PCP follow‐up were evident for a patient's same condition, but not for any condition. The distinction between designations is potentially subjective and may be difficult to accurately determine. Most existing readmission studies in the literature assign readmission for any condition. A future, larger study may be able to examine whether this difference exists between same vs. any condition.

As an academic medical center, access to specialty clinics may be facilitated, thus increasing PCP follow‐up in patients who might otherwise not have it available to them. Additionally, our subjects were limited to a convenience sample of the population of the general medicine wards and may not be representative of all medical inpatients. Patients lacking a telephone were missed. We relied on patient recollection and self‐report of PCP follow‐up visits and re‐hospitalizations. While we acknowledge limitations of patient self‐report, both in communication and comprehension, we believe patients are reasonably able to report on whether or not they were readmitted to the hospital, the cause of their readmission and whether/when they had PCP follow‐up. Patient self‐report could be collected systematically and without long time lags. Finally, the research team did not have reliable access to readmission data for hospitals other than the facility in which the study was conducted.

It is possible patients readmitted early after discharge may have been counted as lacking PCP follow‐up simply because the readmission occurred so soon after discharge precluding the opportunity for PCP follow‐up to occur. The effects of patients having non‐PCP (home health nurse, pharmacist, phone advice) follow‐up after hospital discharge were not examined.

Also, LOS and readmission to a hospital may be more a reflection of disease severity than the absence of PCP follow‐up, ie, patients ultimately readmitted after hospital discharge may have been a sicker subset of patients upon index hospitalization.

In this urban academic medical center, discharged medicine patients commonly lack timely PCP follow‐up. The lack of timely PCP follow‐up after hospital discharge was associated with higher rates of readmission and a non‐significant trend toward longer hospital lengths of stay. Hospital discharge represents a period of significant risk in patient care necessitating the effective continuation of treatment plans including follow‐up of laboratory, radiology or other testing, and management by a variety of providers. PCPs may play a crucial role in care coordination during this period. Structured intervention performed at the time of discharge might increase post‐hospital PCP access and facilitate timely PCP follow‐up to ensure continuity of needed care after hospital discharge in the most vulnerable patients. Such interventions might include systems improvements, such as increasing PCP access in the post‐hospital period, to increase the likelihood that complex needs are met at a vulnerable period in patient care.

A more effective handoff between inpatient and outpatient settings may ultimately improve clinical outcomes, diminish resource utilization, and decrease overall healthcare costs.

Acknowledgements

The authors thank Traci Yamashita and Karen Mellis, Professional Research Assistants.

References
  1. Forster AJ, Murff HJ, Gandhi TK, Bates DW.The incidence and severity of adverse events affecting patients after discharge from the hospital.Ann Intern Med.2003;13:161–167.
  2. Moore C, Wisnivesky J, Williams S, McGinn T.Medical errors related to discontinuity of care from an inpatient to outpatient setting.J Gen Intern Med.200318:646–651.
  3. Zook CJ, Moore FD.The high cost users of medical care.N Engl J Med.1980;302:996–1002.
  4. Friedman B, Basu J.The rate and cost of hospital readmissions for preventable conditions.Med Care Res Rev.2004;61:225–240.
  5. Jencks S, Williams M, Coleman E.Rehospitalizations among patients in the medicare fee‐for‐service program.N Engl J Med.2009;360;14:1418–1428.
  6. Moore C, McGinn T, Halm E.Tying up loose ends. Discharging patients with unresolved medical issues.Arch Intern Med.2007;167:1305–1311.
  7. Kiefe CI, Harrison PL.Post‐hospitalization followup appointment‐keeping among the medically indigent.J Community Health.1993;18(5):271–282.
  8. Ide BA, Curry MA, Drobnies B.Factors related to the keeping of appointments by indigent clients.J Health Care Poor Underserved.1993;4(1):21–39.
  9. Wheeler K, Crawford R, McAdams D, Robinson R, Dunbar VG, Cook CB.Inpatient to outpatient transfer of diabetes care: perceptions of barriers to postdischarge followup in urban African American patients.Ethn Dis.2007;17(2):238–243.
  10. Einstadter D, Cebul RD, Franta PR.Effect of a nurse case manager on postdischarge follow‐up.J Gen Intern Med.1996v;11(11):684–688.
  11. Burt CW, McCaig LF, Simon AE.Emergency department visits by persons recently discharges from U.S. hospitals.Natl Health Stat Report.2008;(6):1–9.
  12. Bradbury RC, Golec JH, Steen PM.Comparing uninsured and privately insured hospital patients: admission severity, health outcomes and resource use.Health Serv Manage Res.2001;14(3):203–210.
  13. Hadley J, Steinberg EP, Feder J.Comparison of uninsured and privately insured hospital patients. Condition on admission, resource use, and outcome.JAMA.1991;265(3):374–379.
  14. Einstadter D, Cebul R, Franta P.Effect of a nurse case manager on postdischarge follow‐up.J Gen Intern Med.1996;11:684–688.
  15. Coleman E, Parry C, Chalmers S, Min S.The care transitions intervention: results of a randomized controlled trial.Arch Intern Med.2006;166(17):1822–1828.
  16. Rich M, Beckham V, Wittenberg C, Leven C, Freedland K, Carney R.A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure.N Engl J Med.1995;333:1190–1195.
  17. vanWalraven C, Mamdani M, Fang J, Austin P.Continuity of care and patient outcomes after hospital discharge.J Gen Intern Med.2004;19:624–631.
  18. Jack BW, Chetty VK, Anthony D, et al.A reengineered hospital discharge program to decrease rehospitalization.Ann Intern Med.2009;150:178–187.
  19. Weinberger M, Oddone EZ, Henderson WG.Does increased access to primary care reduce hospital readmissions?N Engl J Med.1996;334:1441–1447.
  20. Hoffman C, Paradise J.Health insurance and access to health care in the united states.Ann NY Acad Sci.1008;1136:149–160.
  21. Pleis J, Leithbridge‐Cejku S.2006.Summary health statistics for U.S. adults: National Health Interview Survey. 2005, NCHS/CDC/USDHHS, Vital Health Statistics, Series 10.
  22. Burt CW, McCaig LF, Simon AE.Emergency department visits by persons recently discharges from U.S. hospitals.Natl Health Stat Report.2008;(6):1–9.
  23. Hadley J, Steinberg EP, Feder J.Comparison of uninsured and privately insured hospital patients. Condition on admission, resource use, and outcome.JAMA.1991;265(3):374–379.
  24. Bradbury RC, Golec JH, Steen PM.Comparing uninsured and privately insured hospital patients: admission severity, health outcomes and resource use.Health Serv Manage Res.2001;14(3):203–210.
Article PDF
666_ftp.pdf
Issue
Journal of Hospital Medicine - 5(7)
Publications
Journal of Hospital Medicine
Page Number
392-397
Legacy Keywords
continuity of hospital care, post‐hospital PCP follow‐up, transitions of care
Sections
Original Research
Author(s)
Gregory J. Misky, MD
Heidi L. Wald, MD, MSPH
Eric A. Coleman, MD, MPH
Author(s)
Gregory J. Misky, MD
Heidi L. Wald, MD, MSPH
Eric A. Coleman, MD, MPH
Article PDF
666_ftp.pdf
Article PDF
666_ftp.pdf

Care transitions between the inpatient and outpatient settings are a known period of risk in a patient's care. For instance, 1 in 5 medical patients suffers an adverse event during the first several weeks after hospital discharge, with half of these requiring the use of additional healthcare resources.1 Additionally, medication and lab monitoring errors occur in up to half of all discharged patients.2 Nearly 1 in 5 hospitalized patients, admitted with 1 of 16 different conditions including asthma, diabetes, congestive heart failure and urinary tract infection is readmitted to the hospital within six months. Up to 60% of resources are used in rehospitalized patients.3, 4 In Medicare beneficiaries, the readmission rate is as high as 20% at 30 days. The same study suggests that up to half of Medicare patients readmitted within 30 days are not seen in the outpatient setting following discharge.5 Such statistics underscore the need for seamless post‐discharge care.

Studies of post‐discharge primary care provider (PCP) follow‐up highlight the gaps in current practice within the transition from the hospital to PCP follow‐up. For instance, while more than 1 in 4 discharged patients (27.6%) at one large teaching hospital had outpatient work‐ups recommended by their hospital physicians, more than a third (35.9%) of these recommendations were ultimately not completed. Furthermore, at this same center, an increased time interval between hospital discharge and PCP follow‐up decreased the likelihood that a work‐up recommended by a hospital physician was completed.6 In patients who do have a PCP, post‐hospitalization follow‐up is frequently impacted by a variety of factors, including co‐payment requirements, transportation issues, lack of health insurance, as well as scheduling a follow‐up appointment while in the hospital.710 Uninsured patients are at particular risk for failures in transitions, have poorer health outcomes and higher mortality than insured counterparts, and are nearly 3 times more likely to make an ED visit following hospital discharge.1113

In order to better understand the role of post‐discharge PCP follow‐up, we sought to identify: (1) the percentage of general medical inpatients lacking timely PCP follow‐up after discharge from the hospital, and (2) the impact of patients lacking timely PCP follow‐up on 30‐day readmission rate and hospital length of stay (LOS). For the purposes of this study, we have defined timely PCP follow up as occurring within 4 weeks of hospital discharge.

Methods

Study Setting and Population

This prospective cohort enrolled a convenience sample of patients admitted to Internal Medicine ward teams at the University of Colorado Hospital Anschutz Inpatient Pavilion between December 2007 and March 2008. Up to 2 patients were enrolled on weekdays on the morning following admission (ie, Sunday night through Thursday night admissions). Patients were screened for study entry if they were able to participate in an interview as identified by their medical team and available in their room. Of a total of 121 patients screened for study entry by a professional research assistant (PRA), 75 ultimately provided HIPAA authorization, informed consent, and completed the in‐hospital interview. The most common reasons for screened patients refusing study enrollment included being not interested (26) and too ill (10). Ten subjects were lost to follow‐up after hospital discharge, including one subject who was deceased. Therefore, 65 patients successfully completed the follow‐up phone interview and were included in the analyses. Characteristics of the 121 screened patients and the 75 study patients were similar with respect to sex, age, race, and payer mix, and representative of the demographics of the patient population at large. Case mix indices (mean) were similar among the 121 screened (1.23), 75 enrolled (1.27), and final 65 study patients (1.25).

Exclusion Criteria

Patients admitted to the medical observation unit; patients admitted at night who are ultimately reassigned to specialty services (Oncology, Cardiology, Hepatology and Acute Care for the Elderly) were excluded. Human immunodeficiency virus (HIV) patients were excluded because of routine outpatient ID follow‐up; patients <18 years of age; patients lacking a telephone; patients admitted on Friday and Saturday nights; and outside hospital transfers.

Measures

The primary study outcome was the rate of timely PCP follow‐up defined as that occurring within 4 weeks of hospital discharge. PCP was defined in this study as either a patient's known PCP (or another provider in the same clinic), or a nurse practitioner/physician assistant. Patients seen in follow‐up by a specialist related to the discharge diagnosis, eg, an Endocrinologist in a patient hospitalized for Diabetic complications; a Rheumatologist following up an SLE patient, etc., were also counted as having PCP follow‐up as defined in this study.

Additional outcomes included three measures of hospital readmission: hospital readmission for same condition; hospital readmission or other care sought (ie, ED, Urgent Care) for same condition; and hospital readmission for any condition, and index hospital LOS. The distinction between same condition and any condition was made in an attempt to delineate a potentially preventable readmission (as an example, one study patient was subsequently readmitted with a gunshot injury that clearly would not have been affected by the presence of any PCP follow‐up). Determination of same vs. any condition was made by the investigators through information obtained from patients on follow‐up phone interviews: Have you been readmitted to the University Hospital or another hospital since your discharge last month from the University Hospital? If yes: where, when, and why? The investigators determined same vs. any through comparing this information to the primary diagnosis from the index hospitalization obtained from the final discharge documentation. A condition was considered same if the readmission was for the same condition or for treatment/complications related to the index hospitalized condition.

Descriptive data collected included patient demographics, diagnoses, insurance status, presence of an identified, established PCP, time to PCP follow‐up in weeks, effects of payer source, admitting service (hospitalist vs. General Internal Medicine (GIM) attending), and nature of presenting illness (acute vs. acute on chronic condition). Categories of insurance obtained from chart review included commercial, self‐pay (uninsured), Medicare, Medicaid and Veterans.

Data Collection

A PRA screened and obtained informed consent and a Health Insurance Portability and Accountability Act (HIPAA) waiver from patients the day following admission. At that time, the PRA obtained the patients' vital information from chart review and a scripted patient interview: age, sex, PCP, categories of insurance, contact phone numbers, and admitting date and diagnoses. The in‐house interview included eight questions examining a patient's experiences of and attitudes toward PCPs. Four weeks after discharge, patients were contacted by the PRA via telephone. Scripted telephone interviews were used to determine occurrence and timing of PCP follow‐up and hospital readmission status (to any hospital) per patient self‐report. Potential barriers to PCP follow‐up were assessed. Up to 3 attempts were made to contact study subjects out to 4 weeks from the initial call (8 weeks total). If an appointment for an enrolled patient had been made, but had not yet occurred, an additional phone call was made 2 weeks later to determine whether, and when, the appointment was kept. Review of discharge summaries determined a patient's hospital LOS.

Data Analysis

Descriptive statistics were calculated for the study population. Univariate comparisons were completed for patient characteristics and study outcomes for patients with and without PCP follow‐up. We used t‐tests for continuous variables (age and LOS) and chi‐square or Fisher's exact tests when necessary for dichotomous variables (gender, uninsured vs. insured, and all hospital readmission outcomes). Comparisons according to PCP follow‐up for the categorical variables were tested with the Cochran‐Mantel‐Haenszel statistic for general association (race and insurance category) or for trends in the ordinal variable (education).

Patient characteristics and study outcomes with univariate P value < 0.1 were assessed for inclusion in the multivariate logistic regression models. Separate logistic regression models were examined with PCP follow‐up (yes/no) as the explanatory variable and the 3 hospital readmission rates as the outcomes. Final logistic regression models included the primary predictor, PCP follow‐up, along with potential predictor variables with P value < 0.05. Statistical analyses were carried out using SAS version 9.2 (SAS Institute, Cary, NC).

This protocol was approved by the Colorado Multiple Institutional Review Board (COMIRB) prior to the implemented study.

Results

Sixty‐five patients completed this study. The mean age of the study population was 55.3 years and approximately half (52.3%) of the study participants were female. Fifty‐two subjects reported having an established PCP on admission to the hospital (80%). The rate of timely PCP follow‐up overall was 49.2%. Table 1 shows the study population characteristics stratified by presence of timely PCP follow‐up. Patients lacking timely PCP follow‐up were much younger (48.4 vs. 62.4 years; P < 0.001) than those with timely PCP follow‐up; there were also non‐significant trends toward patients lacking timely PCP follow‐up being non‐white: (33.3% vs. 25%, P = 0.23) and having lower education level (72.7% with high school or lower education vs. 56.2% for those with PCP follow‐up, P = 0.15) than those with timely PCP follow‐up. Of the 32 patients having timely PCP follow‐up, 15.6% were uninsured. In comparison, among the 33 patients lacking timely PCP follow‐up after hospital discharge, over a third (36%) were uninsured (P = 0.06). Among the uninsured, a large majority (70.5%) lacked timely PCP follow‐up (P = 0.06). In contrast, only 11 of the 26 Medicare patients (42.3%) lacked timely PCP follow‐up (P = 0.13).

Patient Characteristics Stratified by Timely PCP Follow‐Up
Study DemographicsTimely PCP Follow‐Up (n = 32)No PCP Follow‐Up (n = 33)P Value

  • Abbreviations: PCP, Primary Care Physician; SD, standard deviation; VA, Veterans Administration.

  • Primary insurance of patient.

Female, n (%)17 (53.1)17 (51.5)0.90
Age, years, mean (SD)62.448.4<0.001
Race, n (%)   
Caucasian24 (75.0)23 (69.7)0.23
African American7 (21.9)5 (15.2) 
Hispanic/Latino1 (3.1)5 (15.2) 
Highest grade completed, n (%)   
Grammar school2 (6.3)3 (9.1)0.15
High school16 (50.0)21 (63.6) 
College13 (40.6)9 (27.3) 
Postgraduate1 (3.1)0 (0) 
Insurance*, n (%)   
Medicare15 (46.9)11 (33.3)0.13
Medicaid1 (3.1)3 (9.1) 
Commercial/private6 (18.8)6 (18.2) 
VA/Tri‐Care5 (15.6)1 (3.0) 
Self‐pay/uninsured5 (15.6)12 (36.4)0.06
Case mix index, median1.151.11 

Readmissions

The 30‐day readmission rates for all study subjects were 12.3% for a patient's same medical condition, 17.2% for readmission or other care sought for the same condition, and 21.5% for any condition. Table 2 contains univariate comparisons for the patient outcomes of readmission and LOS stratified by timely PCP follow‐up. Hospital readmission for the same medical condition was significantly higher in patients lacking timely PCP follow‐up compared to those with timely PCP follow‐up (21.2% vs. 3.1%, P = 0.05). The composite outcome of hospital readmission and/or other care sought (emergency department or urgent care) for a patient's same condition was also significantly higher in patients lacking timely PCP follow‐up (28.1% vs. 6.3%; P = 0.02). However, hospital readmission for any condition did not differ with absence of timely PCP follow‐up.

Outcomes Stratified by Timely PCP Follow‐Up (n = 65)
OutcomeTimely PCP Follow‐Up (n = 32)No PCP Follow‐Up (n = 33)P Value

  • Abbreviations: ED, emergency department; PCP, primary care physician; SD, standard deviation.

  • n = 32.

Length of stay (days), mean (SD)4.4 (3.7)6.3 (5.2)0.11
Hospital readmission for same condition within 30‐days of discharge, n (%)1 (3.1)7 (21.2)0.05
Hospital readmission or other care sought (ie, ED, urgent care) for same condition within 30‐days of discharge, n (%)2 (6.3)9 (28.1)*0.02
Hospital readmission for any condition within 30‐days of discharge, n (%)5 (15.6)9 (27.3)0.25

Multiple logistic regression revealed that patients lacking timely PCP follow‐up were 10 times more likely to be readmitted for the same condition within 30 days of hospital discharge (odds ratio [OR] = 9.9; P = 0.04) and nearly seven times as likely to be readmitted for the same condition or receive other care (OR = 6.8, P = 0.02) (Table 3).

Results of Logistic Regression Models for Association of Untimely PCP Follow‐Up With Hospital Readmission Outcomes
OutcomeOdds Ratio (CI)P Value

  • NOTE: Adjusted for uninsured status.

  • Abbreviation: CI, confidence interval.

Hospital readmission for same condition9.9 (1.2‐84.7)0.04
Hospital readmission or other care for same condition6.8 (1.4‐34.3)0.02
Hospital readmission for any condition2.3 (0.7‐7.9)0.17

LOS

Overall hospital LOS in all patients was 5.4 4.6 days. In patients lacking timely PCP follow‐up, there was a trend toward longer hospital LOS: 6.3 days vs. 4.4 days, P = 0.11. For all uninsured study patients (17), the mean LOS was 6.4 days vs. 5.0 days for all other insurance categories, P = 0.31.

Insurance Status

Being uninsured was associated with a patient lacking timely PCP follow‐up (P = 0.06), but was not directly associated with higher readmission or longer hospital LOS (OR = 1.0, P = 0.96). The lack of insurance was not a significant predictor of hospital readmission in the multiple logistic regression models.

Timing of PCP Follow‐Up

In evaluating timing of any PCP follow‐up after hospital discharge and clinical outcomes, most PCP follow‐up (90.6%) occurred within the first 2 weeks following hospital discharge. However, we found no statistical difference between timing of post‐discharge PCP follow‐up and hospital readmission outcomes (hospital readmission for same reason, P = 0.51; hospital readmission or other care sought for same reason, P = 0.89), or in hospital LOS (P = 0.87). Timing of PCP follow‐upwhen comparing post‐hospitalization follow‐up <1 week, 1 to 2 weeks, and 2 to 4 weekswas not predictive of readmission rates or LOS.

Established PCP

When significance of having an established PCP prior to hospital admission was evaluated, 52 patients reported having an established PCP on hospital admission (80%), half of whom were Medicare patients. Of the 13 patients with no PCP on admission, the majority (10) were self‐pay (77%, P < 0.0001). Interestingly, only 29 (55.8%) of the patients who reported a PCP on admission to the hospital saw their PCP within 4 weeks of hospital discharge. Of 13 patients without a PCP on admission, only 3 obtained 4‐week PCP follow‐up. When we examined our study outcomes for subjects stratified by the presence of an established PCP prior to hospitalization, we found univariate association with timely post‐discharge PCP follow‐up (56% of those with established PCP vs. 23% of those without, P = 0.04), but no difference in readmission rates or hospital LOS.

Severity of patient illnessmeasured using hospital data and the case mix index (CMI)of the 3 patient populations (screened, enrolled, final) was quite similar. The CMI (mean) for the 121 screened patients was 1.23. The CMI for the 75 enrolled patients was 1.27. And the CMI in the 65 final study patients was 1.25. When evaluating illness severity (CMI) of patients in relation to hospital LOS between the 2 final study populations, the CMI (median) was also similar: 1.15 for the 32 patients with timely PCP follow‐up vs. 1.11 for the 33 patients without timely PCP follow‐up.

We found no association when looking at the rate of timely PCP follow‐up based on admitting service attending, or acute vs. acute on chronic diagnosis.

Barriers to PCP follow‐up most frequently cited by study patients were: lacking a PCP (no established PCP prior to hospital, no insurance, out of town, recently changed insurance), could not get an appointment, discharged to a half‐way house, and saw another doctor (specialist unrelated to discharge diagnosis).

Discussion

A growing body of work highlights the role of multiple, varied interventions at, or following discharge, in improving outcomes during the transition from inpatient to outpatient care. Examples include care coordination by advanced nurse practitioners, follow‐up pharmacist phone calls, and involvement of a transition coach encouraging active patient involvementall are known to improve patient outcomes following a hospitalization.1418 The active involvement of a PCP is central to a number of these proven interventions to ensure effective completion of ongoing patient care. And while some previous studies suggest increased overall resource utilization when PCP follow‐up occurs after hospitalization,19 the level of fragmented care that occurs in today's hospitalized patient, as well as the fact many patients lack PCP care at all, raises questions about clinical outcomes after hospitalization related to timely PCP follow‐up. The issue of appropriateness of resources utilized has also not been adequately explored.

Within this context, this study examines the role that PCP follow‐up might play in such interventions and its' effects on patient outcomes. Notably, in this urban academic medical center, we found that timely PCP follow‐up after hospital discharge occurred in fewer than half of general medical inpatients. Lack of timely PCP follow‐up was associated with increased hospital readmission for the same condition and a trend toward a longer index hospital LOS.

While this small study cannot fully elucidate the impact of lack of timely PCP follow‐up on post‐discharge care, our findings suggest some mechanisms by which lack of timely PCP follow‐up might result in poor outcomes. For instance, patients lacking a PCP visit after discharge may not obtain needed follow‐up care in the post‐discharge period, leading to clinical deterioration and hospital readmission. Uninsured patients may be at particular risk for failed transition because they are less likely to have consistent PCP access, whether as an already established patient or one newly assigned.20, 21 Perhaps a larger study would better demonstrate statistical significance in reflecting the association between uninsured patients, lack of a PCP, and post‐discharge follow‐up deficiencies. There may, in fact, be issues related to patient attitudes and beliefs, such as subjectively feeling better or even an implicit distrust of the healthcare system among the uninsured, that exist as well. Even among patients with a PCP prior to hospitalization, PCP follow‐up after hospital discharge may be lacking due to modifiable factors such as patient attitudes and beliefs and logistical barriers in arranging follow‐up.

Patients without potential for timely PCP follow‐up might be kept in the hospital longer to ensure they are well enough medically to sufficiently meet their own follow‐up needs. Hospital LOS might be increased by providers to compensate for the lack of PCP follow‐up. Alternatively, these patients may be sicker with their index hospitalization.

It is not surprising that payer source appears to influence a patients' ability to obtain timely PCP follow‐up. It is well documented that uninsured patients have higher healthcare resource utilization.2224 Lack of access to primary care in such patients contributes to a cycle of using the most expensive sites of care. In our study, we found many of the patients lacking timely PCP follow‐up were younger, perhaps reflecting the same patient population who have higher rates of being uninsured. Conversely, older patients are more likely to have PCP access, in large part due to having Medicare benefits (although this dynamic has shown a shift in recent years). The uninsured may present sicker as a result of lacking pre‐hospital PCP access or transportation to a PCP visit.

Limitations

This study was performed at a single, academic institution limiting its' generalizability. In addition, this small cohort study, which took place over four winter months, may have implicit biases toward certain disease entities and follow‐up issues unique to study size and season. The small study size was dictated by a finite amount of available resources, potentially contributing to minor inconsistencies with some of the results. While statistical significance was still seen with many of our results, a much larger study may better enhance the study outcomes.

It also remains unclear why the effects of PCP follow‐up were evident for a patient's same condition, but not for any condition. The distinction between designations is potentially subjective and may be difficult to accurately determine. Most existing readmission studies in the literature assign readmission for any condition. A future, larger study may be able to examine whether this difference exists between same vs. any condition.

As an academic medical center, access to specialty clinics may be facilitated, thus increasing PCP follow‐up in patients who might otherwise not have it available to them. Additionally, our subjects were limited to a convenience sample of the population of the general medicine wards and may not be representative of all medical inpatients. Patients lacking a telephone were missed. We relied on patient recollection and self‐report of PCP follow‐up visits and re‐hospitalizations. While we acknowledge limitations of patient self‐report, both in communication and comprehension, we believe patients are reasonably able to report on whether or not they were readmitted to the hospital, the cause of their readmission and whether/when they had PCP follow‐up. Patient self‐report could be collected systematically and without long time lags. Finally, the research team did not have reliable access to readmission data for hospitals other than the facility in which the study was conducted.

It is possible patients readmitted early after discharge may have been counted as lacking PCP follow‐up simply because the readmission occurred so soon after discharge precluding the opportunity for PCP follow‐up to occur. The effects of patients having non‐PCP (home health nurse, pharmacist, phone advice) follow‐up after hospital discharge were not examined.

Also, LOS and readmission to a hospital may be more a reflection of disease severity than the absence of PCP follow‐up, ie, patients ultimately readmitted after hospital discharge may have been a sicker subset of patients upon index hospitalization.

In this urban academic medical center, discharged medicine patients commonly lack timely PCP follow‐up. The lack of timely PCP follow‐up after hospital discharge was associated with higher rates of readmission and a non‐significant trend toward longer hospital lengths of stay. Hospital discharge represents a period of significant risk in patient care necessitating the effective continuation of treatment plans including follow‐up of laboratory, radiology or other testing, and management by a variety of providers. PCPs may play a crucial role in care coordination during this period. Structured intervention performed at the time of discharge might increase post‐hospital PCP access and facilitate timely PCP follow‐up to ensure continuity of needed care after hospital discharge in the most vulnerable patients. Such interventions might include systems improvements, such as increasing PCP access in the post‐hospital period, to increase the likelihood that complex needs are met at a vulnerable period in patient care.

A more effective handoff between inpatient and outpatient settings may ultimately improve clinical outcomes, diminish resource utilization, and decrease overall healthcare costs.

Acknowledgements

The authors thank Traci Yamashita and Karen Mellis, Professional Research Assistants.

Care transitions between the inpatient and outpatient settings are a known period of risk in a patient's care. For instance, 1 in 5 medical patients suffers an adverse event during the first several weeks after hospital discharge, with half of these requiring the use of additional healthcare resources.1 Additionally, medication and lab monitoring errors occur in up to half of all discharged patients.2 Nearly 1 in 5 hospitalized patients, admitted with 1 of 16 different conditions including asthma, diabetes, congestive heart failure and urinary tract infection is readmitted to the hospital within six months. Up to 60% of resources are used in rehospitalized patients.3, 4 In Medicare beneficiaries, the readmission rate is as high as 20% at 30 days. The same study suggests that up to half of Medicare patients readmitted within 30 days are not seen in the outpatient setting following discharge.5 Such statistics underscore the need for seamless post‐discharge care.

Studies of post‐discharge primary care provider (PCP) follow‐up highlight the gaps in current practice within the transition from the hospital to PCP follow‐up. For instance, while more than 1 in 4 discharged patients (27.6%) at one large teaching hospital had outpatient work‐ups recommended by their hospital physicians, more than a third (35.9%) of these recommendations were ultimately not completed. Furthermore, at this same center, an increased time interval between hospital discharge and PCP follow‐up decreased the likelihood that a work‐up recommended by a hospital physician was completed.6 In patients who do have a PCP, post‐hospitalization follow‐up is frequently impacted by a variety of factors, including co‐payment requirements, transportation issues, lack of health insurance, as well as scheduling a follow‐up appointment while in the hospital.710 Uninsured patients are at particular risk for failures in transitions, have poorer health outcomes and higher mortality than insured counterparts, and are nearly 3 times more likely to make an ED visit following hospital discharge.1113

In order to better understand the role of post‐discharge PCP follow‐up, we sought to identify: (1) the percentage of general medical inpatients lacking timely PCP follow‐up after discharge from the hospital, and (2) the impact of patients lacking timely PCP follow‐up on 30‐day readmission rate and hospital length of stay (LOS). For the purposes of this study, we have defined timely PCP follow up as occurring within 4 weeks of hospital discharge.

Methods

Study Setting and Population

This prospective cohort enrolled a convenience sample of patients admitted to Internal Medicine ward teams at the University of Colorado Hospital Anschutz Inpatient Pavilion between December 2007 and March 2008. Up to 2 patients were enrolled on weekdays on the morning following admission (ie, Sunday night through Thursday night admissions). Patients were screened for study entry if they were able to participate in an interview as identified by their medical team and available in their room. Of a total of 121 patients screened for study entry by a professional research assistant (PRA), 75 ultimately provided HIPAA authorization, informed consent, and completed the in‐hospital interview. The most common reasons for screened patients refusing study enrollment included being not interested (26) and too ill (10). Ten subjects were lost to follow‐up after hospital discharge, including one subject who was deceased. Therefore, 65 patients successfully completed the follow‐up phone interview and were included in the analyses. Characteristics of the 121 screened patients and the 75 study patients were similar with respect to sex, age, race, and payer mix, and representative of the demographics of the patient population at large. Case mix indices (mean) were similar among the 121 screened (1.23), 75 enrolled (1.27), and final 65 study patients (1.25).

Exclusion Criteria

Patients admitted to the medical observation unit; patients admitted at night who are ultimately reassigned to specialty services (Oncology, Cardiology, Hepatology and Acute Care for the Elderly) were excluded. Human immunodeficiency virus (HIV) patients were excluded because of routine outpatient ID follow‐up; patients <18 years of age; patients lacking a telephone; patients admitted on Friday and Saturday nights; and outside hospital transfers.

Measures

The primary study outcome was the rate of timely PCP follow‐up defined as that occurring within 4 weeks of hospital discharge. PCP was defined in this study as either a patient's known PCP (or another provider in the same clinic), or a nurse practitioner/physician assistant. Patients seen in follow‐up by a specialist related to the discharge diagnosis, eg, an Endocrinologist in a patient hospitalized for Diabetic complications; a Rheumatologist following up an SLE patient, etc., were also counted as having PCP follow‐up as defined in this study.

Additional outcomes included three measures of hospital readmission: hospital readmission for same condition; hospital readmission or other care sought (ie, ED, Urgent Care) for same condition; and hospital readmission for any condition, and index hospital LOS. The distinction between same condition and any condition was made in an attempt to delineate a potentially preventable readmission (as an example, one study patient was subsequently readmitted with a gunshot injury that clearly would not have been affected by the presence of any PCP follow‐up). Determination of same vs. any condition was made by the investigators through information obtained from patients on follow‐up phone interviews: Have you been readmitted to the University Hospital or another hospital since your discharge last month from the University Hospital? If yes: where, when, and why? The investigators determined same vs. any through comparing this information to the primary diagnosis from the index hospitalization obtained from the final discharge documentation. A condition was considered same if the readmission was for the same condition or for treatment/complications related to the index hospitalized condition.

Descriptive data collected included patient demographics, diagnoses, insurance status, presence of an identified, established PCP, time to PCP follow‐up in weeks, effects of payer source, admitting service (hospitalist vs. General Internal Medicine (GIM) attending), and nature of presenting illness (acute vs. acute on chronic condition). Categories of insurance obtained from chart review included commercial, self‐pay (uninsured), Medicare, Medicaid and Veterans.

Data Collection

A PRA screened and obtained informed consent and a Health Insurance Portability and Accountability Act (HIPAA) waiver from patients the day following admission. At that time, the PRA obtained the patients' vital information from chart review and a scripted patient interview: age, sex, PCP, categories of insurance, contact phone numbers, and admitting date and diagnoses. The in‐house interview included eight questions examining a patient's experiences of and attitudes toward PCPs. Four weeks after discharge, patients were contacted by the PRA via telephone. Scripted telephone interviews were used to determine occurrence and timing of PCP follow‐up and hospital readmission status (to any hospital) per patient self‐report. Potential barriers to PCP follow‐up were assessed. Up to 3 attempts were made to contact study subjects out to 4 weeks from the initial call (8 weeks total). If an appointment for an enrolled patient had been made, but had not yet occurred, an additional phone call was made 2 weeks later to determine whether, and when, the appointment was kept. Review of discharge summaries determined a patient's hospital LOS.

Data Analysis

Descriptive statistics were calculated for the study population. Univariate comparisons were completed for patient characteristics and study outcomes for patients with and without PCP follow‐up. We used t‐tests for continuous variables (age and LOS) and chi‐square or Fisher's exact tests when necessary for dichotomous variables (gender, uninsured vs. insured, and all hospital readmission outcomes). Comparisons according to PCP follow‐up for the categorical variables were tested with the Cochran‐Mantel‐Haenszel statistic for general association (race and insurance category) or for trends in the ordinal variable (education).

Patient characteristics and study outcomes with univariate P value < 0.1 were assessed for inclusion in the multivariate logistic regression models. Separate logistic regression models were examined with PCP follow‐up (yes/no) as the explanatory variable and the 3 hospital readmission rates as the outcomes. Final logistic regression models included the primary predictor, PCP follow‐up, along with potential predictor variables with P value < 0.05. Statistical analyses were carried out using SAS version 9.2 (SAS Institute, Cary, NC).

This protocol was approved by the Colorado Multiple Institutional Review Board (COMIRB) prior to the implemented study.

Results

Sixty‐five patients completed this study. The mean age of the study population was 55.3 years and approximately half (52.3%) of the study participants were female. Fifty‐two subjects reported having an established PCP on admission to the hospital (80%). The rate of timely PCP follow‐up overall was 49.2%. Table 1 shows the study population characteristics stratified by presence of timely PCP follow‐up. Patients lacking timely PCP follow‐up were much younger (48.4 vs. 62.4 years; P < 0.001) than those with timely PCP follow‐up; there were also non‐significant trends toward patients lacking timely PCP follow‐up being non‐white: (33.3% vs. 25%, P = 0.23) and having lower education level (72.7% with high school or lower education vs. 56.2% for those with PCP follow‐up, P = 0.15) than those with timely PCP follow‐up. Of the 32 patients having timely PCP follow‐up, 15.6% were uninsured. In comparison, among the 33 patients lacking timely PCP follow‐up after hospital discharge, over a third (36%) were uninsured (P = 0.06). Among the uninsured, a large majority (70.5%) lacked timely PCP follow‐up (P = 0.06). In contrast, only 11 of the 26 Medicare patients (42.3%) lacked timely PCP follow‐up (P = 0.13).

Patient Characteristics Stratified by Timely PCP Follow‐Up
Study DemographicsTimely PCP Follow‐Up (n = 32)No PCP Follow‐Up (n = 33)P Value

  • Abbreviations: PCP, Primary Care Physician; SD, standard deviation; VA, Veterans Administration.

  • Primary insurance of patient.

Female, n (%)17 (53.1)17 (51.5)0.90
Age, years, mean (SD)62.448.4<0.001
Race, n (%)   
Caucasian24 (75.0)23 (69.7)0.23
African American7 (21.9)5 (15.2) 
Hispanic/Latino1 (3.1)5 (15.2) 
Highest grade completed, n (%)   
Grammar school2 (6.3)3 (9.1)0.15
High school16 (50.0)21 (63.6) 
College13 (40.6)9 (27.3) 
Postgraduate1 (3.1)0 (0) 
Insurance*, n (%)   
Medicare15 (46.9)11 (33.3)0.13
Medicaid1 (3.1)3 (9.1) 
Commercial/private6 (18.8)6 (18.2) 
VA/Tri‐Care5 (15.6)1 (3.0) 
Self‐pay/uninsured5 (15.6)12 (36.4)0.06
Case mix index, median1.151.11 

Readmissions

The 30‐day readmission rates for all study subjects were 12.3% for a patient's same medical condition, 17.2% for readmission or other care sought for the same condition, and 21.5% for any condition. Table 2 contains univariate comparisons for the patient outcomes of readmission and LOS stratified by timely PCP follow‐up. Hospital readmission for the same medical condition was significantly higher in patients lacking timely PCP follow‐up compared to those with timely PCP follow‐up (21.2% vs. 3.1%, P = 0.05). The composite outcome of hospital readmission and/or other care sought (emergency department or urgent care) for a patient's same condition was also significantly higher in patients lacking timely PCP follow‐up (28.1% vs. 6.3%; P = 0.02). However, hospital readmission for any condition did not differ with absence of timely PCP follow‐up.

Outcomes Stratified by Timely PCP Follow‐Up (n = 65)
OutcomeTimely PCP Follow‐Up (n = 32)No PCP Follow‐Up (n = 33)P Value

  • Abbreviations: ED, emergency department; PCP, primary care physician; SD, standard deviation.

  • n = 32.

Length of stay (days), mean (SD)4.4 (3.7)6.3 (5.2)0.11
Hospital readmission for same condition within 30‐days of discharge, n (%)1 (3.1)7 (21.2)0.05
Hospital readmission or other care sought (ie, ED, urgent care) for same condition within 30‐days of discharge, n (%)2 (6.3)9 (28.1)*0.02
Hospital readmission for any condition within 30‐days of discharge, n (%)5 (15.6)9 (27.3)0.25

Multiple logistic regression revealed that patients lacking timely PCP follow‐up were 10 times more likely to be readmitted for the same condition within 30 days of hospital discharge (odds ratio [OR] = 9.9; P = 0.04) and nearly seven times as likely to be readmitted for the same condition or receive other care (OR = 6.8, P = 0.02) (Table 3).

Results of Logistic Regression Models for Association of Untimely PCP Follow‐Up With Hospital Readmission Outcomes
OutcomeOdds Ratio (CI)P Value

  • NOTE: Adjusted for uninsured status.

  • Abbreviation: CI, confidence interval.

Hospital readmission for same condition9.9 (1.2‐84.7)0.04
Hospital readmission or other care for same condition6.8 (1.4‐34.3)0.02
Hospital readmission for any condition2.3 (0.7‐7.9)0.17

LOS

Overall hospital LOS in all patients was 5.4 4.6 days. In patients lacking timely PCP follow‐up, there was a trend toward longer hospital LOS: 6.3 days vs. 4.4 days, P = 0.11. For all uninsured study patients (17), the mean LOS was 6.4 days vs. 5.0 days for all other insurance categories, P = 0.31.

Insurance Status

Being uninsured was associated with a patient lacking timely PCP follow‐up (P = 0.06), but was not directly associated with higher readmission or longer hospital LOS (OR = 1.0, P = 0.96). The lack of insurance was not a significant predictor of hospital readmission in the multiple logistic regression models.

Timing of PCP Follow‐Up

In evaluating timing of any PCP follow‐up after hospital discharge and clinical outcomes, most PCP follow‐up (90.6%) occurred within the first 2 weeks following hospital discharge. However, we found no statistical difference between timing of post‐discharge PCP follow‐up and hospital readmission outcomes (hospital readmission for same reason, P = 0.51; hospital readmission or other care sought for same reason, P = 0.89), or in hospital LOS (P = 0.87). Timing of PCP follow‐upwhen comparing post‐hospitalization follow‐up <1 week, 1 to 2 weeks, and 2 to 4 weekswas not predictive of readmission rates or LOS.

Established PCP

When significance of having an established PCP prior to hospital admission was evaluated, 52 patients reported having an established PCP on hospital admission (80%), half of whom were Medicare patients. Of the 13 patients with no PCP on admission, the majority (10) were self‐pay (77%, P < 0.0001). Interestingly, only 29 (55.8%) of the patients who reported a PCP on admission to the hospital saw their PCP within 4 weeks of hospital discharge. Of 13 patients without a PCP on admission, only 3 obtained 4‐week PCP follow‐up. When we examined our study outcomes for subjects stratified by the presence of an established PCP prior to hospitalization, we found univariate association with timely post‐discharge PCP follow‐up (56% of those with established PCP vs. 23% of those without, P = 0.04), but no difference in readmission rates or hospital LOS.

Severity of patient illnessmeasured using hospital data and the case mix index (CMI)of the 3 patient populations (screened, enrolled, final) was quite similar. The CMI (mean) for the 121 screened patients was 1.23. The CMI for the 75 enrolled patients was 1.27. And the CMI in the 65 final study patients was 1.25. When evaluating illness severity (CMI) of patients in relation to hospital LOS between the 2 final study populations, the CMI (median) was also similar: 1.15 for the 32 patients with timely PCP follow‐up vs. 1.11 for the 33 patients without timely PCP follow‐up.

We found no association when looking at the rate of timely PCP follow‐up based on admitting service attending, or acute vs. acute on chronic diagnosis.

Barriers to PCP follow‐up most frequently cited by study patients were: lacking a PCP (no established PCP prior to hospital, no insurance, out of town, recently changed insurance), could not get an appointment, discharged to a half‐way house, and saw another doctor (specialist unrelated to discharge diagnosis).

Discussion

A growing body of work highlights the role of multiple, varied interventions at, or following discharge, in improving outcomes during the transition from inpatient to outpatient care. Examples include care coordination by advanced nurse practitioners, follow‐up pharmacist phone calls, and involvement of a transition coach encouraging active patient involvementall are known to improve patient outcomes following a hospitalization.1418 The active involvement of a PCP is central to a number of these proven interventions to ensure effective completion of ongoing patient care. And while some previous studies suggest increased overall resource utilization when PCP follow‐up occurs after hospitalization,19 the level of fragmented care that occurs in today's hospitalized patient, as well as the fact many patients lack PCP care at all, raises questions about clinical outcomes after hospitalization related to timely PCP follow‐up. The issue of appropriateness of resources utilized has also not been adequately explored.

Within this context, this study examines the role that PCP follow‐up might play in such interventions and its' effects on patient outcomes. Notably, in this urban academic medical center, we found that timely PCP follow‐up after hospital discharge occurred in fewer than half of general medical inpatients. Lack of timely PCP follow‐up was associated with increased hospital readmission for the same condition and a trend toward a longer index hospital LOS.

While this small study cannot fully elucidate the impact of lack of timely PCP follow‐up on post‐discharge care, our findings suggest some mechanisms by which lack of timely PCP follow‐up might result in poor outcomes. For instance, patients lacking a PCP visit after discharge may not obtain needed follow‐up care in the post‐discharge period, leading to clinical deterioration and hospital readmission. Uninsured patients may be at particular risk for failed transition because they are less likely to have consistent PCP access, whether as an already established patient or one newly assigned.20, 21 Perhaps a larger study would better demonstrate statistical significance in reflecting the association between uninsured patients, lack of a PCP, and post‐discharge follow‐up deficiencies. There may, in fact, be issues related to patient attitudes and beliefs, such as subjectively feeling better or even an implicit distrust of the healthcare system among the uninsured, that exist as well. Even among patients with a PCP prior to hospitalization, PCP follow‐up after hospital discharge may be lacking due to modifiable factors such as patient attitudes and beliefs and logistical barriers in arranging follow‐up.

Patients without potential for timely PCP follow‐up might be kept in the hospital longer to ensure they are well enough medically to sufficiently meet their own follow‐up needs. Hospital LOS might be increased by providers to compensate for the lack of PCP follow‐up. Alternatively, these patients may be sicker with their index hospitalization.

It is not surprising that payer source appears to influence a patients' ability to obtain timely PCP follow‐up. It is well documented that uninsured patients have higher healthcare resource utilization.2224 Lack of access to primary care in such patients contributes to a cycle of using the most expensive sites of care. In our study, we found many of the patients lacking timely PCP follow‐up were younger, perhaps reflecting the same patient population who have higher rates of being uninsured. Conversely, older patients are more likely to have PCP access, in large part due to having Medicare benefits (although this dynamic has shown a shift in recent years). The uninsured may present sicker as a result of lacking pre‐hospital PCP access or transportation to a PCP visit.

Limitations

This study was performed at a single, academic institution limiting its' generalizability. In addition, this small cohort study, which took place over four winter months, may have implicit biases toward certain disease entities and follow‐up issues unique to study size and season. The small study size was dictated by a finite amount of available resources, potentially contributing to minor inconsistencies with some of the results. While statistical significance was still seen with many of our results, a much larger study may better enhance the study outcomes.

It also remains unclear why the effects of PCP follow‐up were evident for a patient's same condition, but not for any condition. The distinction between designations is potentially subjective and may be difficult to accurately determine. Most existing readmission studies in the literature assign readmission for any condition. A future, larger study may be able to examine whether this difference exists between same vs. any condition.

As an academic medical center, access to specialty clinics may be facilitated, thus increasing PCP follow‐up in patients who might otherwise not have it available to them. Additionally, our subjects were limited to a convenience sample of the population of the general medicine wards and may not be representative of all medical inpatients. Patients lacking a telephone were missed. We relied on patient recollection and self‐report of PCP follow‐up visits and re‐hospitalizations. While we acknowledge limitations of patient self‐report, both in communication and comprehension, we believe patients are reasonably able to report on whether or not they were readmitted to the hospital, the cause of their readmission and whether/when they had PCP follow‐up. Patient self‐report could be collected systematically and without long time lags. Finally, the research team did not have reliable access to readmission data for hospitals other than the facility in which the study was conducted.

It is possible patients readmitted early after discharge may have been counted as lacking PCP follow‐up simply because the readmission occurred so soon after discharge precluding the opportunity for PCP follow‐up to occur. The effects of patients having non‐PCP (home health nurse, pharmacist, phone advice) follow‐up after hospital discharge were not examined.

Also, LOS and readmission to a hospital may be more a reflection of disease severity than the absence of PCP follow‐up, ie, patients ultimately readmitted after hospital discharge may have been a sicker subset of patients upon index hospitalization.

In this urban academic medical center, discharged medicine patients commonly lack timely PCP follow‐up. The lack of timely PCP follow‐up after hospital discharge was associated with higher rates of readmission and a non‐significant trend toward longer hospital lengths of stay. Hospital discharge represents a period of significant risk in patient care necessitating the effective continuation of treatment plans including follow‐up of laboratory, radiology or other testing, and management by a variety of providers. PCPs may play a crucial role in care coordination during this period. Structured intervention performed at the time of discharge might increase post‐hospital PCP access and facilitate timely PCP follow‐up to ensure continuity of needed care after hospital discharge in the most vulnerable patients. Such interventions might include systems improvements, such as increasing PCP access in the post‐hospital period, to increase the likelihood that complex needs are met at a vulnerable period in patient care.

A more effective handoff between inpatient and outpatient settings may ultimately improve clinical outcomes, diminish resource utilization, and decrease overall healthcare costs.

Acknowledgements

The authors thank Traci Yamashita and Karen Mellis, Professional Research Assistants.

References
  1. Forster AJ, Murff HJ, Gandhi TK, Bates DW.The incidence and severity of adverse events affecting patients after discharge from the hospital.Ann Intern Med.2003;13:161–167.
  2. Moore C, Wisnivesky J, Williams S, McGinn T.Medical errors related to discontinuity of care from an inpatient to outpatient setting.J Gen Intern Med.200318:646–651.
  3. Zook CJ, Moore FD.The high cost users of medical care.N Engl J Med.1980;302:996–1002.
  4. Friedman B, Basu J.The rate and cost of hospital readmissions for preventable conditions.Med Care Res Rev.2004;61:225–240.
  5. Jencks S, Williams M, Coleman E.Rehospitalizations among patients in the medicare fee‐for‐service program.N Engl J Med.2009;360;14:1418–1428.
  6. Moore C, McGinn T, Halm E.Tying up loose ends. Discharging patients with unresolved medical issues.Arch Intern Med.2007;167:1305–1311.
  7. Kiefe CI, Harrison PL.Post‐hospitalization followup appointment‐keeping among the medically indigent.J Community Health.1993;18(5):271–282.
  8. Ide BA, Curry MA, Drobnies B.Factors related to the keeping of appointments by indigent clients.J Health Care Poor Underserved.1993;4(1):21–39.
  9. Wheeler K, Crawford R, McAdams D, Robinson R, Dunbar VG, Cook CB.Inpatient to outpatient transfer of diabetes care: perceptions of barriers to postdischarge followup in urban African American patients.Ethn Dis.2007;17(2):238–243.
  10. Einstadter D, Cebul RD, Franta PR.Effect of a nurse case manager on postdischarge follow‐up.J Gen Intern Med.1996v;11(11):684–688.
  11. Burt CW, McCaig LF, Simon AE.Emergency department visits by persons recently discharges from U.S. hospitals.Natl Health Stat Report.2008;(6):1–9.
  12. Bradbury RC, Golec JH, Steen PM.Comparing uninsured and privately insured hospital patients: admission severity, health outcomes and resource use.Health Serv Manage Res.2001;14(3):203–210.
  13. Hadley J, Steinberg EP, Feder J.Comparison of uninsured and privately insured hospital patients. Condition on admission, resource use, and outcome.JAMA.1991;265(3):374–379.
  14. Einstadter D, Cebul R, Franta P.Effect of a nurse case manager on postdischarge follow‐up.J Gen Intern Med.1996;11:684–688.
  15. Coleman E, Parry C, Chalmers S, Min S.The care transitions intervention: results of a randomized controlled trial.Arch Intern Med.2006;166(17):1822–1828.
  16. Rich M, Beckham V, Wittenberg C, Leven C, Freedland K, Carney R.A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure.N Engl J Med.1995;333:1190–1195.
  17. vanWalraven C, Mamdani M, Fang J, Austin P.Continuity of care and patient outcomes after hospital discharge.J Gen Intern Med.2004;19:624–631.
  18. Jack BW, Chetty VK, Anthony D, et al.A reengineered hospital discharge program to decrease rehospitalization.Ann Intern Med.2009;150:178–187.
  19. Weinberger M, Oddone EZ, Henderson WG.Does increased access to primary care reduce hospital readmissions?N Engl J Med.1996;334:1441–1447.
  20. Hoffman C, Paradise J.Health insurance and access to health care in the united states.Ann NY Acad Sci.1008;1136:149–160.
  21. Pleis J, Leithbridge‐Cejku S.2006.Summary health statistics for U.S. adults: National Health Interview Survey. 2005, NCHS/CDC/USDHHS, Vital Health Statistics, Series 10.
  22. Burt CW, McCaig LF, Simon AE.Emergency department visits by persons recently discharges from U.S. hospitals.Natl Health Stat Report.2008;(6):1–9.
  23. Hadley J, Steinberg EP, Feder J.Comparison of uninsured and privately insured hospital patients. Condition on admission, resource use, and outcome.JAMA.1991;265(3):374–379.
  24. Bradbury RC, Golec JH, Steen PM.Comparing uninsured and privately insured hospital patients: admission severity, health outcomes and resource use.Health Serv Manage Res.2001;14(3):203–210.
References
  1. Forster AJ, Murff HJ, Gandhi TK, Bates DW.The incidence and severity of adverse events affecting patients after discharge from the hospital.Ann Intern Med.2003;13:161–167.
  2. Moore C, Wisnivesky J, Williams S, McGinn T.Medical errors related to discontinuity of care from an inpatient to outpatient setting.J Gen Intern Med.200318:646–651.
  3. Zook CJ, Moore FD.The high cost users of medical care.N Engl J Med.1980;302:996–1002.
  4. Friedman B, Basu J.The rate and cost of hospital readmissions for preventable conditions.Med Care Res Rev.2004;61:225–240.
  5. Jencks S, Williams M, Coleman E.Rehospitalizations among patients in the medicare fee‐for‐service program.N Engl J Med.2009;360;14:1418–1428.
  6. Moore C, McGinn T, Halm E.Tying up loose ends. Discharging patients with unresolved medical issues.Arch Intern Med.2007;167:1305–1311.
  7. Kiefe CI, Harrison PL.Post‐hospitalization followup appointment‐keeping among the medically indigent.J Community Health.1993;18(5):271–282.
  8. Ide BA, Curry MA, Drobnies B.Factors related to the keeping of appointments by indigent clients.J Health Care Poor Underserved.1993;4(1):21–39.
  9. Wheeler K, Crawford R, McAdams D, Robinson R, Dunbar VG, Cook CB.Inpatient to outpatient transfer of diabetes care: perceptions of barriers to postdischarge followup in urban African American patients.Ethn Dis.2007;17(2):238–243.
  10. Einstadter D, Cebul RD, Franta PR.Effect of a nurse case manager on postdischarge follow‐up.J Gen Intern Med.1996v;11(11):684–688.
  11. Burt CW, McCaig LF, Simon AE.Emergency department visits by persons recently discharges from U.S. hospitals.Natl Health Stat Report.2008;(6):1–9.
  12. Bradbury RC, Golec JH, Steen PM.Comparing uninsured and privately insured hospital patients: admission severity, health outcomes and resource use.Health Serv Manage Res.2001;14(3):203–210.
  13. Hadley J, Steinberg EP, Feder J.Comparison of uninsured and privately insured hospital patients. Condition on admission, resource use, and outcome.JAMA.1991;265(3):374–379.
  14. Einstadter D, Cebul R, Franta P.Effect of a nurse case manager on postdischarge follow‐up.J Gen Intern Med.1996;11:684–688.
  15. Coleman E, Parry C, Chalmers S, Min S.The care transitions intervention: results of a randomized controlled trial.Arch Intern Med.2006;166(17):1822–1828.
  16. Rich M, Beckham V, Wittenberg C, Leven C, Freedland K, Carney R.A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure.N Engl J Med.1995;333:1190–1195.
  17. vanWalraven C, Mamdani M, Fang J, Austin P.Continuity of care and patient outcomes after hospital discharge.J Gen Intern Med.2004;19:624–631.
  18. Jack BW, Chetty VK, Anthony D, et al.A reengineered hospital discharge program to decrease rehospitalization.Ann Intern Med.2009;150:178–187.
  19. Weinberger M, Oddone EZ, Henderson WG.Does increased access to primary care reduce hospital readmissions?N Engl J Med.1996;334:1441–1447.
  20. Hoffman C, Paradise J.Health insurance and access to health care in the united states.Ann NY Acad Sci.1008;1136:149–160.
  21. Pleis J, Leithbridge‐Cejku S.2006.Summary health statistics for U.S. adults: National Health Interview Survey. 2005, NCHS/CDC/USDHHS, Vital Health Statistics, Series 10.
  22. Burt CW, McCaig LF, Simon AE.Emergency department visits by persons recently discharges from U.S. hospitals.Natl Health Stat Report.2008;(6):1–9.
  23. Hadley J, Steinberg EP, Feder J.Comparison of uninsured and privately insured hospital patients. Condition on admission, resource use, and outcome.JAMA.1991;265(3):374–379.
  24. Bradbury RC, Golec JH, Steen PM.Comparing uninsured and privately insured hospital patients: admission severity, health outcomes and resource use.Health Serv Manage Res.2001;14(3):203–210.
Issue
Journal of Hospital Medicine - 5(7)
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Journal of Hospital Medicine - 5(7)
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Post‐hospitalization transitions: Examining the effects of timing of primary care provider follow‐up
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Post‐hospitalization transitions: Examining the effects of timing of primary care provider follow‐up
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continuity of hospital care, post‐hospital PCP follow‐up, transitions of care
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Gregory J. Misky, MD
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Division of General Internal Medicine, University of Colorado Denver, Leprino Building, Mail Stop F 782, 12401 E. 17th Ave., Rm. 937, Aurora, CO 80045
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