Follow-up appointments not linked with improved readmission rate

Improved discharge processes, such as arranging hospital follow-up appointments, did not approve readmission rate or survival in general medicine patients, according to study data.

Minnesota-based researchers analyzed hospital dismissal instructions for general medicine patients dismissed in 2006 from Mayo Clinic hospitals in Rochester, Minn., (n=4,989) and noted whether appointment details for follow-up were documented. They developed survival analysis and propensity score-adjusted proportional hazards regression models to investigate the relationship between follow-up appointment arrangements and hospital readmission, ED visits and mortality at 30 and 180 days after discharge.

Of the dismissal summaries, 3,037 (60.9%) contained instructions for a follow-up appointment. No difference was found between those with a documented follow-up appointment vs. those without 30 days after dismissal. However, within 180 days of dismissal, those with a documented follow-up appointment were more likely to have a hospital readmission or an ED visit (HR=1.10; 95% CI, 1.01-1.20).

“Despite our original hypothesis that specific instructions regarding a hospital follow-up appointment would be associated with fewer hospital readmissions, we found that having documented specific follow-up instructions at dismissal was actually associated with a slightly higher likelihood of having either an emergency department visit or hospital readmission 180 days after dismissal,” the researchers concluded. “Before health care payers such as CMS reduce hospital payment for readmissions that are thought to be avoidable, a clearer understanding of the factors that may reduce hospital readmission is needed. Efforts to ensure follow-up for all patients after dismissal may not be beneficial or cost-effective.” – by Brian Ellis

Grafft C. Arch Intern Med. 2010;170:955-960.

This is especially interesting in that the findings contradict conventional "wisdom" that having a follow-up appointment and scheduled continuing outpatient medical care can avoid or delay repeat hospitalization. There are major weaknesses in this study, and the findings may not be applicable outside the Mayo Rochester setting. Rehospitalization was only tracked within the Mayo system. Patients in Mayo may be local, but they also return to their homes around the country and indeed around the world and may have been rehospitalized there, but not counted. The Mayo referral and local populations may not represent the general population — they are likely of higher socioeconomic status and more likely to keep appointments regardless of hospital discharge instructions. Clearly, economically disadvantaged inner city and rural patients are less likely to have access to continuing medical care and might benefit from more intense prospective scheduling of outpatient appointments following hospital discharge than the average Mayo patient.

– Samuel L. Wann, MD

Cardiology Today Section Editor

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