A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.

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.

Depression is a risk factor for rehospitalization in medical inpatients.

BACKGROUND: Rehospitalization occurs in approximately 20% of medical inpatients within 90 days of discharge. Rehospitalization accounts for considerable morbidity, mortality, and costs. Identification of risk factors could lead to interventions to reduce rehospitalization. The objective of the study was to determine if physical and mental health, substance abuse, and social support are risk factors for rehospitalization. METHOD: This was a prospective cohort study in an innercity population conducted from September 2002 to September 2004. Participants included 144 adult inpatients with at least 1 hospital admission in the past 6 months. Measurements included age, length of stay, number of admissions in the past year, and medical comorbidity as well as measures of depression, alcohol and drug abuse, social support, and health-related quality of life. The outcome studied was the rehospitalization status of participants within 90 days of the index hospitalization. RESULTS: The mean age of the subjects was 54.8 years; 48% were black and 78% spoke English as a primary language. Subjects were admitted a mean of 2.5 times in the year before the index admission. Sixty-four patients (44%) were subsequently rehospitalized within 90 days after the index admission. In bivariate analysis, rehospitalized patients had more prior admissions (median of 3.0 vs. 2.0 admissions, p = .002), greater medical comorbidity (mean Charlson Comorbidity Index score of 2.6 vs. 2.0, p = .04), and poorer physical functional status (mean SF-12 physical component score of 31.5 vs. 36.2, p = .03). A logistic regression model, including prior admissions in the last year, comorbidity, physical functional status, and depression, showed that depression tripled the odds of rehospitalization (odds ratio = 3.3, 95% CI = 1.2 to 9.3). This model had fair accuracy in identifying patients at greatest risk for rehospitalization (c statistic = 0.72). CONCLUSIONS: Hospitalized patients with a history of prior hospitalization within 6 months who screen positive for depression are 3 times more likely to be rehospitalized within 90 days in this relatively high-risk population. Screening during hospitalization for depressive symptoms may identify those at risk for rehospitalization.