A Reengineered Hospital Discharge Program to Decrease Rehospitalization

A Randomized Trial

  1. Brian W. Jack, MD;
  2. Veerappa K. Chetty, PhD;
  3. David Anthony, MD, MSc;
  4. Jeffrey L. Greenwald, MD;
  5. Gail M. Sanchez, PharmD, BCPS;
  6. Anna E. Johnson, RN;
  7. Shaula R. Forsythe, MA, MPH;
  8. Julie K. O'Donnell, MPH;
  9. Michael K. Paasche-Orlow, MD, MA, MPH;
  10. Christopher Manasseh, MD;
  11. Stephen Martin, MD, MEd; and
  12. Larry Culpepper, MD, MPH
  1. From Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, and Brown University Alpert Medical School, Pawtucket, Rhode Island.

    Abstract

    Background: Emergency department visits and rehospitalization are common after hospital discharge.

    Objective: To test the effects of an intervention designed to minimize hospital utilization after discharge.

    Design: Randomized trial using block randomization of 6 and 8. Randomly arranged index cards were placed in opaque envelopes labeled consecutively with study numbers, and participants were assigned a study group by revealing the index card.

    Setting: General medical service at an urban, academic, safety-net hospital.

    Patients: 749 English-speaking hospitalized adults (mean age, 49.9 years).

    Intervention: A nurse discharge advocate worked with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education with an individualized instruction booklet that was sent to their primary care provider. A clinical pharmacist called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications. Participants and providers were not blinded to treatment assignment.

    Measurements: Primary outcomes were emergency department visits and hospitalizations within 30 days of discharge. Secondary outcomes were self-reported preparedness for discharge and frequency of primary care providers' follow-up within 30 days of discharge. Research staff doing follow-up were blinded to study group assignment.

    Results: Participants in the intervention group (n = 370) had a lower rate of hospital utilization than those receiving usual care (n = 368) (0.314 vs. 0.451 visit per person per month; incidence rate ratio, 0.695 [95% CI, 0.515 to 0.937]; P = 0.009). The intervention was most effective among participants with hospital utilization in the 6 months before index admission (P = 0.014). Adverse events were not assessed; these data were collected but are still being analyzed.

    Limitation: This was a single-center study in which not all potentially eligible patients could be enrolled, and outcome assessment sometimes relied on participant report.

    Conclusion: A package of discharge services reduced hospital utilization within 30 days of discharge.

    Funding: Agency for Healthcare Research and Quality and National Heart, Lung, and Blood Institute, National Institutes of Health.

    Article and Author Information

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    • ClinicalTrials.gov registration number: NCT00252057.

    Responses to this article

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