Early follow-up post-discharge may cut readmissions for patients with complex conditions

Early physician follow-up with a comprehensive transitional care strategy and effective chronic disease management after discharge was associated with reduced 90-day readmissions among patients with COPD and other complex conditions.

“This population-based retrospective cohort study found that early follow-up with a [primary care] physician or relevant specialist was associated with fewer readmissions for patients with [congestive heart failure] or COPD, fewer COPD-related readmissions for patients with COPD and lower mortality for patients with [congestive heart failure], all within 90 days of discharge, but that there was no demonstrable benefit at 30 days or for patients with [acute myocardial infarction],” Farah E. Saxena, MPH, researcher at the Canadian Partnership Against Cancer in Toronto, and colleagues wrote in JAMA Network Open.

The study included 450,746 adults with a first admission for acute myocardial infarction (MI), congestive heart failure (HF) or COPD from 2005 to 2019 in Ontario, Canada. Researchers analyzed outcomes of patients who had a follow-up visit with a primary care physician or relevant specialist within 7 days of discharge.

The primary outcomes were 30- and 90-day hospital readmissions, cardiac readmissions for patients with cardiac conditions and COPD-related readmissions for those with COPD. Secondary outcomes were 30- and 90-day mortality.

There were 198,854 patients admitted for acute MI (median age, 66 years; 32.35% women), 133,058 for congestive HF (median age, 78 years; 47.03% women) and 118,834 for COPD (median age, 73 years; 49.8% women).

Early follow-up visits were recorded for 45.85% of patients with acute MI, 42.46% of patients with congestive HF and 33.79% of patients with COPD.

Compared with patients without early follow-up, those who saw a physician soon after discharge had higher rates of collaborative care and visits to a specialist within 30 days for all medically complex conditions:

• among patients with acute MI, the rate of collaborative care was 32.08% for those with early follow-up vs. 14.58% without early follow-up and the rate of visits to a specialist within 30 days was 36.38% for those with early follow-up vs. 23.82% without early follow-up;
• among patients with congestive HF, the rate of collaborative care was 37.85% vs. 14.85% and the rate of visits to a specialist within 30 days was 45.67% vs. 26.84%; and
• among patients with COPD, the rate of collaborative care was 19.25% vs. 7.15% and the rate of visits to a specialist within 30 days was 23.46% vs. 13.42%.

In addition, patients with early follow-up had lower 90-day hospital readmission rates, at 28.21% among patients with congestive HF (adjusted HR = 0.98; 95% CI, 0.96-0.99) and 21.87% among patients with COPD (aHR = 0.95; 95% CI, 0.93-0.98) compared with 30.2% and 23%, respectively, for those without early follow-up.

Patients with COPD who received early follow-up had lower 90-day COPD-related hospital readmission rates compared with patients without early follow-up (10% vs. 10.74%; aHR = 0.93; 95% CI, 0.89-0.98). The same was observed for patients with congestive HF who received early follow-up (7.16% vs. 8.2%; aHR = 0.93; 95% CI, 0.9-0.97).

However, the researchers reported no significant benefits at 30 days in any patients or for patients with acute MI overall.

“These findings may have implications for performance measurement and practice improvement. Early post-discharge physician visits may be important to maximize the reduction in adverse events associated with treatment for patients with medically complex conditions,” the researchers wrote. “However, these visits need to be part of a comprehensive transitional care strategy coupled with ongoing effective chronic disease management encompassing care coordination among multiple sectors of the health care system and providing comprehensive, patient-centered care that addresses coexisting illness.”