About 1 in 5 Medicare fee-for-service patients discharged from the hospital is rehospitalized within 30 days In this systematic review of 43 studies evaluating interventions to reduce readmission 

Interventions to Reduce 30-Day Rehospitalization: A Systematic Review

Glucose control and vascular complications in veterans with type 2 diabetes

Importance Reducing early ( Objective To synthesize the evidence of the efficacy of interventions to reduce early hospital readmissions and identify intervention features—including their impact on treatment burden and on patients’ capacity to enact postdischarge self-care—that might explain their varying effects. Data Sources We searched PubMed, Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, and Scopus (1990 until April 1, 2013), contacted experts, and reviewed bibliographies. Study Selection Randomized trials that assessed the effect of interventions on all-cause or unplanned readmissions within 30 days of discharge in adult patients hospitalized for a medical or surgical cause for more than 24 hours and discharged to home. Data Extraction and Synthesis Reviewer pairs extracted trial characteristics and used an activity-based coding strategy to characterize the interventions; fidelity was confirmed with authors. Blinded to trial outcomes, reviewers noted the extent to which interventions placed additional work on patients after discharge or supported their capacity for self-care in accordance with the cumulative complexity model. Main Outcomes and Measures Relative risk of all-cause or unplanned readmission with or without out-of-hospital deaths at 30 days postdischarge. Results In 42 trials, the tested interventions prevented early readmissions (pooled random-effects relative risk, 0.82 [95% CI, 0.73-0.91]; P I 2  = 31%), a finding that was consistent across patient subgroups. Trials published before 2002 reported interventions that were 1.6 times more effective than those tested later (interaction P  = .01). In exploratory subgroup analyses, interventions with many components (interaction P  = .001), involving more individuals in care delivery (interaction P  = .05), and supporting patient capacity for self-care (interaction P  = .04) were 1.4, 1.3, and 1.3 times more effective than other interventions, respectively. A post hoc regression model showed incremental value in providing comprehensive, postdischarge support to patients and caregivers. Conclusions and Relevance Tested interventions are effective at reducing readmissions, but more effective interventions are complex and support patient capacity for self-care. Interventions tested more recently are less effective.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/1868538/ioi140038.pdf

Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials.

Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial

Background Medication discrepancies at care transitions are common and lead to patient harm. Medication reconciliation is a strategy to reduce this risk. Objectives To summarize available evidence on medication reconciliation interventions in the hospital setting and to identify the most effective practices. Data Sources MEDLINE (1966 through February 2012) and a manual search of article bibliographies. Study Selection Twenty-six controlled studies. Data Extraction Data were extracted on study design, setting, participants, inclusion/exclusion criteria, intervention components, timing, comparison group, outcome measures, and results. Data Synthesis Studies were grouped by type of medication reconciliation intervention—pharmacist related, information technology (IT), or other—and were assigned quality ratings using US Preventive Services Task Force criteria. Results Fifteen of 26 studies reported pharmacist-related interventions, 6 evaluated IT interventions, and 5 studied other interventions. Six studies were classified as good quality. The comparison group for all the studies was usual care; no studies compared different types of interventions. Studies consistently demonstrated a reduction in medication discrepancies (17 of 17 studies), potential adverse drug events (5 of 6 studies), and adverse drug events (2 of 2 studies) but showed an inconsistent reduction in postdischarge health care utilization (improvement in 2 of 8 studies). Key aspects of successful interventions included intensive pharmacy staff involvement and targeting the intervention to a high-risk patient population. Conclusions Rigorously designed studies comparing different inpatient medication reconciliation practices and their effects on clinical outcomes are scarce. Available evidence supports medication reconciliation interventions that heavily use pharmacy staff and focus on patients at high risk for adverse events. Higher-quality studies are needed to determine the most effective approaches to inpatient medication reconciliation.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/1203516/iiq120035_1057_1069.pdf

Hospital-based medication reconciliation practices: a systematic review

RATIONALE:
Care coordination has shown inconsistent results as a mechanism to reduce hospital readmission and postdischarge emergency department (ED) visit rates.

OBJECTIVE:
To assess the impact of a supplemental care bundle targeting high-risk elderly inpatients implemented by hospital-based staff compared to usual care on a composite outcome of hospital readmission and/or ED visitation at 30 and 60 days following discharge.

PATIENTS/METHODS:
Randomized controlled pilot study in 41 medical inpatients predisposed to unplanned readmission or postdischarge ED visitation, conducted at Baylor University Medical Center. The intervention group care bundle consisted of medication counseling/reconciliation by a clinical pharmacist (CP), condition specific education/enhanced discharge planning by a care coordinator (CC), and phone follow-up.

RESULTS:
Groups had similar baseline characteristics. Intervention group readmission/ED visit rates were reduced at 30 days compared to the control group (10.0% versus 38.1%, P = 0.04), but not at 60 days (30.0% versus 42.9%, P = 0.52). For those patients who had a readmission/postdischarge ED visit, the time interval to this event was longer in the intervention group compared to usual care (36.2 versus 15.7 days, P = 0.05). Study power was insufficient to reliably compare the effects of the intervention on lengths of index hospital stay between groups.

CONCLUSIONS:
A targeted care bundle delivered to high-risk elderly inpatients decreased unplanned acute health care utilization up to 30 days following discharge. Dissipation of this effect by 60 days postdischarge defines reasonable expectations for analogous hospital-based educational interventions. Further research is needed regarding the impacts of similar care bundles in larger populations across a variety of inpatient settings. Journal of Hospital Medicine 2009;4:211–218. © 2009 Society of Hospital Medicine.

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Reduction of 30‐day postdischarge hospital readmission or emergency department (ED) visit rates in high‐risk elderly medical patients through delivery of a targeted care bundle

Background
Diabetes is a leading cause of death and disability, and its prevalence is increasing. When diet fails, patients with type 2 diabetes mellitus (T2DM) are prescribed oral hypoglycemics for glycemic control. Few studies have explored initial use or change from initial oral hypoglycemic therapy in the primary care setting. We aimed to describe the utilization of initial oral hypoglycemics among newly diagnosed patients with diabetes from 1998–2009 and changes from initial to subsequent therapy among patients prescribed older oral hypoglycemic agents using electronic health records.

Methods
This observational cohort study used electronic health records from newly diagnosed patients with T2DM between 1 January 1998 and 31 March 2009 at two large health systems in the USA. Oral hypoglycemics included older (biguanide, sulfonylurea, and thiazolidinedione) and newer agents (incretin mimetic agents, alpha-glucosidase inhibitors, and D-phenylalanine derivatives). Multinomial regression models were fit to evaluate initial older oral hypoglycemic medication. We used incidence density sampling and conditional logistic regression models to evaluate predictors of regimen change.

Results
Most patients were treated from the biguanide class of oral hypoglycemics (67%), but there were differences in initial prescribing by age and race. HbA1c (Odds Ratio for HbA1c 7.0–8.9 vs < 7.0, 5.87 [95% Confidence Interval: 3.62–9.52]; Odds Ratio for HbA1c ≥ 9 vs < 7.0, 20.25 [95% Confidence Interval: 8.32–49.29] and Black people (Odds Ratio, 0.29 [95% Confidence Interval: 0.14, 0.60]) versus White people were associated with regimen change in the adjusted analysis.

Conclusions
Clinical and demographic characteristics influence choice and duration of initial oral hypoglycemic treatment as well as regimen changes. Copyright © 2012 John Wiley & Sons, Ltd.

Initial and subsequent therapy for newly diagnosed type 2 diabetes patients treated in primary care using data from a vendor-based electronic health record

Results of genetic analysis of 11 341 participants enrolled in the My Life, Our Future hemophilia genotyping initiative in the United States

Hemophilia A is characterized by unpredictable spontaneous bleeds and chronic comorbidities. However, limited data exists at the national level into detailed management patterns related to patient clinical characteristics, representative real‐world dosing and treatment frequency, and costs. To assess and characterize the US severe hemophilia A (SHA) population, including subgroups of patients, in terms of clinical and demographic characteristics, healthcare resource utilization received at hemophilia treatment centers (HTCs), and projected annual costs of treatment utilizing data from the ATHNdataset of the American Thrombosis and Hemostasis Network (ATHN). Adult male people with SHA (PwSHA) (FVIII < 1%) were identified in the ATHNdataset between January 2013 and September 2019. This retrospective cohort study described patients’ demographic and clinical characteristics, clinical history, as well as the HTC‐related health resource utilization (HRU), treatment utilization, and projected annual treatment costs of US PwSHA received over the most recent year. Results are reported for the overall population and for three mutually exclusive subpopulations of patients: PwSHA with a history of and/or current inhibitors, PwSHA without a history of inhibitors but with (or a history of) one or more transfusion‐transmitted infections (hepatitis B virus [HBV], hepatitis C virus [HCV], or human immunodeficiency virus [HIV]), and PwSHA without a history of inhibitors or of transfusion‐transmitted infections (HBV, HCV, or HIV). Of the overall PwSHA cohort (N = 3677), there was a high prevalence of HCV (24.1%) and HIV (13.7%), while the prevalence of HBV (4.9%) was lower. Note that 20.5% of PwSHA overall currently or ever had FVIII inhibitors. On average, PwSHA had 2.8 total HTC visits per year, including 0.9 comprehensive care visits, 1.1 telephone contact visits, 0.5 office visits, and 0.1 surgeries or other procedures. However, 23.3% of PwSHA were not seen at an HTC, and 33.8% of PwSHA did not have a comprehensive care visit during their most recent year of data. HTC‐related HRU was similar between the overall cohort and across the patient subpopulations, although PwSHA and inhibitors had more frequent HTC visits (a mean of 3.6 visits annually vs. 2.5–2.8 in the other groups). Using reported treatment frequency and dosing, estimated mean annual hemophilia treatment costs varied by treatment and across the three subpopulations: extended half‐life factor product ($893,609–934,301 by subpopulation), standard half‐life factor product ($798,700–930,812), plasma‐derived factor product ($613,220–801,061), and non‐factor product treatment ($765,289—833,240). This study summarized recent sociodemographic and clinical characteristics, HTC‐related HRU, and HA treatments and projected costs among adult PwSHA, including among key subpopulations of PwSHA. PwSHA experience substantial clinical and resource burden on a chronic basis, despite the care coordination efforts of ATHN‐affiliated HTCs. These findings motivate further exploration of the drivers of resource utilization, observed differences across subpopulations and other disparities, and ongoing monitoring of clinical and treatment burden in the face of an evolving care landscape.

https://onlinelibrary.wiley.com/doi/pdfdirect/10.1002/jha2.412

Dunlei Cheng

Papers

Reduction of 30‐day postdischarge hospital readmission or emergency department (ED) visit rates in high‐risk elderly medical patients through delivery of a targeted care bundle

Initial and subsequent therapy for newly diagnosed type 2 diabetes patients treated in primary care using data from a vendor-based electronic health record

Results of genetic analysis of 11 341 participants enrolled in the My Life, Our Future hemophilia genotyping initiative in the United States

Resource utilization and treatment costs of patients with severe hemophilia A: Real‐world data from the ATHNdataset