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Requests for reprints should be addressed to J. Benjamin Crocker, MD, Ambulatory Practice of the Future, Division of Primary Care, Department of Medicine, Massachusetts General Hospital, 101 Merrimac Street, 10th Floor, Suite 1000, Boston, MA 02114
Ambulatory Practice of the Future, Division of Primary Care, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
Program in Hospital Medicine, Division of Primary Care and General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
Postdischarge telephone follow-up plays an integral part in transitional care efforts in many regions. We systematically reviewed the literature to evaluate the evidence regarding the impact of primary care–based telephone follow-up on postdischarge emergency department visits and hospital readmissions.
Methods
We performed an electronic database search for relevant telephone follow-up studies originating in adult primary care settings.
Results
Only 3 studies (N=1765) met entry criteria for this review. None of the studies demonstrated evidence of reduced admissions or emergency department visits from primary care–based telephone follow-ups. All 3 studies reported improved primary care office contact as a result of telephone follow-up intervention.
Conclusions
Despite the growing use of primary care-based telephone follow-up in the postdischarge period, there are no high-quality studies demonstrating its benefit. However, its positive impact on patient engagement holds potentially meaningful implications. In light of recent national health care legislation, the primary care field is ripe for high-quality studies to evaluate the effectiveness of telephone follow-up for patients in the postdischarge period. Particular areas of research focus are discussed.
Recent economic and political pressures, including passage of the Affordable Health Care for America Act, have thrust the concerns about identifying opportunities for affordable and high-quality health care to the forefront of public debate, and have accelerated the exploration of methods to improve the quality and cost-effectiveness of healthcare.
The potential opportunities for significant cost-savings and quality improvement have intensified research in the field of transitional care, defined as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different levels or locations of care.”
Although primary care-based postdischarge telephone follow-up is increasingly used, there is a paltry body of literature on the subject.
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The current limited evidence demonstrates no effectiveness of this tool on hospital readmission or emergency department visits.
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However, its positive impact on patient engagement through office contacts raises meaningful implications.
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Recent national healthcare legislation will demand involvement of primary care-based teams in the development of successful transitional care strategies.
Because of the growing trend of primary care practitioners working within a single clinic environment, larger numbers of caretakers from different settings are now commonly involved in coordinating the transitional care of patients.
Because most hospitals receive payments for inpatient care based on diagnosis-related groups, there are strong financial incentives to control costs and length of stay by aggressively discharging patients “quicker and sicker.”
Complex treatment plans present a significant challenge for patients and families to manage alone and are often left unresolved at the time of discharge.
Such a scenario provides little time to organize and implement these plans and imparts significant risks of preventable complications and hospital readmissions, with enormous associated health care costs. Once considered a problem largely attributed to “patient nonadherence,” unnecessary postdischarge readmissions are now seen as breakdowns in a largely unstructured and nonstandardized discharge process that has been described as “random events connected to highly variable actions with only a remote possibility of meeting implied expectations.”
As a result, postdischarge readmissions within 30 days of hospitalization are increasingly regarded as a marker of inpatient quality of care and a significant contributor to increasing health care costs.
Closing the Quality Gap: a Critical Analysis of Quality Improvement Strategies. Volume 7. Agency for Healthcare Research and Quality,
Rockville, MD2007
One commonly used strategy in the outpatient setting to maintain continuity with patients across transitions is the telephone call. An active postdischarge telephone follow-up intervention may help patients troubleshoot problems they face after discharge.
of 33 studies involving 5110 patients examining the effect of telephone follow-up after patient discharge from the hospital determined that no firm or statistically significant conclusions could be drawn regarding the effectiveness of telephone follow-up intervention, the studies evaluated in this review only looked at telephone follow-up intervention performed by hospital-based, not primary care office–based, personnel. Therefore, we performed a systematic review of the literature to investigate the strength of telephone follow-up as an effective primary care–based intervention in improving quality outcomes for the postdischarge period.
Materials and Methods
We performed an electronic search of Ovid Medline, Ovid Nursing Database, PsychINFO, EBM Reviews, and EMBASE from the beginning of indexing (1948 for Ovid Databases, 1967 for PsychINFO, 1974 for EMBASE) to December 7, 2011, for studies that reported the effect of primary care–based telephone follow-up on postdischarge outcomes.
Search Strategy
The search was performed using the following combination of exploded Medical Subject Heading terms and text words: [“primary care” or “primary health care” or “primary care physician” or “family medicine” or “patient centered medical home” or “medical home”] and [“telephone” or “phone” or “phone call” or “telephone call” or “telephone follow up” or “telephone followup”] and [“post discharge” or “postdischarge” or “patient discharge” or “discharge”] and [“outcome” or “outcomes” or “readmission” or “re-admission” or “rehospitalization” or “re-hospitalization”].
Study Selection
By using predefined inclusion and exclusion criteria, 2 investigators (JBC and JTC) independently reviewed the electronic search results to identify potentially relevant articles. The search was limited to adult human subjects. Abstracts were reviewed for relevance with the following criteria: inclusion of original articles with case-control, cohort, or randomized controlled study design; exclusion of studies with interventions that were not primarily telephone based or primary care office based, or were not performed by a member of a primary care team. Citations that did not have available text (eg, meeting abstracts with no published full text article) were excluded. Duplicate citations were removed.
Disagreements were resolved by consensus. Full text of relevant articles was reviewed. If relevance could not be determined from the full citation, the full text of the article was retrieved and reviewed. References of selected articles were reviewed for other potentially relevant articles. Content experts in the area of transitional care research were contacted to identify relevant unpublished research.
Data Extraction and Synthesis
Two reviewers (JBC and JTC) independently extracted data on patient and study characteristics and outcomes using tabular techniques. Bias was assessed at the study level.
Results
Search Results
After limiting the search to the stipulated criteria, 166 citations remained (Figure). Fifty-five duplicate citations were removed, leaving 111 citations. After review for further eligibility, 61 articles did not include telephone follow-up as a primary intervention. Thirty articles included telephone follow-up, but not as an independent or primary intervention or as a primary care–based intervention. Despite a priori selection of studies involving adult populations, 8 pediatric articles were excluded. Ten review articles and noncontrolled studies were excluded.
FigureFlow diagram of study selection. TFU=telephone follow-up.
Two articles met the primary search criteria. One additional eligible article was identified via manual review of references in the 2 originally identified studies. No additional articles were identified via solicited recommendations from published authors in the field.
Study Characteristics
Table summarizes the study design, sample size, target population, setting, nature of telephone follow-up intervention used, duration of study follow-up, outcome measures, and intervention effect of the 3 eligible studies. The studies
involved a combined total of 1765 patients discharged from general medicine inpatient units at academic teaching hospitals. Two trials were carried out at single academic community hospital sites,
Study sample sizes ranged from 96 to 1001 patients, and study follow-up ranged from 6 to 12 months. All 3 studies enlisted primary care nurses or primary care nurse case managers to perform the intervention and were supervised by primary care physicians.
TablePostdischarge Telephone Follow-up in Primary Care Study Characteristics
evaluated 1001 patients discharged from a university-affiliated general medicine unit to determine whether intensive postdischarge care reduced nonelective readmissions and increased postdischarge ambulatory contacts. The primary care nurse placed telephone calls to the intervention group to review care needs, reconcile medications, assist in scheduling outpatient appointments and rescheduling missed appointments, and assess barriers to keeping appointments. Outcome measures included nonelective readmissions and office contacts and visits.
conducted a randomized controlled trial to assess the efficacy of case managers to control hospital use among 668 patients who were discharged from a university-affiliated Veterans Affairs medical center. The case manager contacted patients in the intervention group to review previously identified unmet needs, discuss early warning signs and medications, review scheduled appointments and determine barriers to keeping them, and solicit new problems or needs. Outcome measures included nonelective admissions, emergency department visits, and outpatient primary care contacts.
randomized 96 eligible general medical service patients in 2 urban community hospitals in an effort to evaluate a low-cost telephone follow-up intervention to promptly reconnect patients to their medical home after discharge. The intervention group received a telephone call from a nurse in the patient's medical home. Medication reconciliation, discharge diagnosis, aftercare instructions, symptoms solicitation, and follow-up appointment/test coordination were provided. Outcome measures included absence of follow-up within 21 days of discharge, readmission within 31 days of discharge, emergency department admission within 31 days, and failure by the primary care provider to complete the workup recommended by the hospital team.
Risk of Bias
Sequence Generation and Allocation Concealment
Although all 3 studies were randomized controlled trials, none of them described the randomization process in detail or reported adequate concealment of allocation. Baseline data for the experimental and control groups were detailed. Fitzgerald et al
did not report gender distribution in the intervention or control group.
Blinding of Caregivers, Patients, and Outcome Assessors
The healthcare personnel who performed the telephone follow-up intervention were not blinded to the control and intervention groups. Each study used unique discharge planning and office follow-up methods in addition to the telephone follow-up intervention, which may have confounded the effect of the telephone follow-up.
Follow-up and Intention-to-Treat Analysis
None of the studies reported dropout rates. Two of the studies
reported a statistically significant improvement in office follow-up rate within 21 days of discharge with the telephone follow-up intervention.
Implications of Key Findings
Prior studies evaluating hospital-based telephone follow-up as a component of transitional care have demonstrated reduced postdischarge emergency department visit and hospital readmission rates, cost, and improved quality of life and continuity of care
Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial.
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.
Our systematic review analyzed the effect of published primary care–based telephone follow-up studies on postdischarge outcomes. It was somewhat surprising that fewer published trials have examined this intervention in the ambulatory setting compared with the hospital setting. None of the eligible studies in our review demonstrated reduced readmissions or emergency department use in the postdischarge period.
The lack of significant findings may be partially explained by 3 issues associated with the quality of design in the eligible studies. First, all 3 trials may not have been powered to detect a meaningful effect of primary care–based telephone follow-up on readmission and emergency department visit rates. None of the studies reported power calculations to determine an appropriate sample size.
Second, the core components of an ideal telephone follow-up intervention have not been standardized in the literature. Although Balaban et al
did not. This makes comparison of telephone follow-up script content impossible in this systematic review. Establishing what constitutes a meaningful telephone follow-up intervention would allow for more effectively designed studies. Pertinent components of the scripted telephone follow-up call might include an evaluation of clinical symptoms related to the hospitalization; focused patient education; assessments of medication use, reconciliation, adherence, and complications; and appointment and test scheduling, including follow-up with the primary care provide. Clearly, the most evidence-based component of these elements is assessing medication-related issues,
These trials have established that adverse drug events are common during the postdischarge transition period and lead to unnecessary readmissions. Another component of the telephone follow-up script might include the patient's self-assessment of his/her health status,
such as the Care Transitions Measure, which has been validated among recently discharged patients as helping to predict readmission or emergency department visits.
Third, an overarching assumption of telephone follow-up is that those at higher risk of adverse postdischarge outcomes (readmissions, emergency department visits) should benefit more than those at lower risk. Therefore, understanding the risk profile of patients who benefit most from telephone follow-up may help transitional care teams better allocate resources to the highest risk group for this intervention. It is difficult to compare the effect of telephone follow-up on adverse outcomes among the 3 studies because groups within each study may not have held similar risk profiles for readmission. Only 1 study in our review attempted to formally address this issue. By using a previously published model for stratifying patients for risk of readmission,
claimed that the incidence of all office contacts and scheduled appointments, as well as nonelective readmissions, was positively associated with risk level, and that the largest differences between intervention and control groups were observed in the highest risk level.
A variety of models identifying patients at high risk for readmission have been developed,
Predicting non-elective hospital readmissions: a multi-site study Department of Veterans Affairs Cooperative Study Group on Primary Care and Readmissions.
but a standardized method would enable improved patient selection for better-designed studies and comparison among those studies. This seems especially relevant to the current state of postdischarge care because the Affordable Care Act mandates that hospitals with high risk-standardized readmission rates be subjected to a Medicare reimbursement penalty beginning in 2013.
Although the major outcomes of readmissions and emergency department visits were not significantly affected, the finding of increased primary care contact due to postdischarge telephone follow-up intervention in all 3 eligible studies is noteworthy. Because a large proportion of postdischarge problems relate to informational needs of patients,
early postdischarge contact may provide opportunities to address communication or continuity gaps. Data are limited and controversial, however, as to whether patients who actually attend their follow-up visits soon after discharge have a lower readmission rate.
Nonetheless, the finding of improved postdischarge clinical contact raises important questions: Can telephone follow-up independently drive meaningful postdischarge outcomes? If telephone follow-up enables more primary care clinic visits, what components specific to the postdischarge clinic visit should be emphasized to reduce undesired postdischarge outcomes? If primary care contact is increased largely in the form of prescription refill requests, should primary care–based pharmacists, as part of the potential make-up of the modern patient centered medical home,
play a more central role in future evaluation? These distinctions are important, because future primary care research will need to focus on those aspects of postdischarge transitional care that are most likely to influence meaningful clinical outcomes.
A few outstanding issues bear consideration for future studies examining the role of telephone follow-up. The current national promotion and endorsement of the “patient centered medical home” model of care
is expected to facilitate a more comprehensive level of primary care, including postdischarge care. Understanding, then, the general level of primary care provider awareness and prevailing attitudes about postdischarge transitional care issues could inform how interventions, such as telephone follow-up, should be developed and implemented. Determining who among the primary care team (eg, nurse, physician, medical assistant, health coach, case manager, or pharmacist) is most effective in administering the postdischarge telephone follow-up could hold significant workflow and financial implications for its implementation. Likewise, because care for the hospitalized patient has become increasingly reliant on the interdependence of both inpatient and outpatient teams to provide transitional care, understanding which components of those teams can most effectively implement postdischarge telephone follow-up could be critical to developing cost-effective and applicable models of postdischarge care. Growing attention to these issues is highlighted in the first collaborative consensus policy statement on transitions of care between the inpatient and outpatient settings published in 2009.
Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine.
Last, in light of federal Health Information Technology for Economic and Clinical Health/American Recovery and Reinvestment Act legislation mandating increasingly meaningful use of health information technology,
Health Information Technology for Economic and Clinical Health/American Recovery and Reinvestment Act. HR 1, 111th Congress, 1st Session, Title XIII, Section 13001. February 17, 2009.
updated technology and software development that accompany evolving standards of communication, such as computer and mobile web-based video platforms, will be essential in future studies of postdischarge transitional care interventions.
Study Limitations
Our systematic review was limited by a number of factors. Although our search was fairly comprehensive, it may have overlooked relevant studies held in other databases not used for this review. Excluding citations without available text may have prevented us from including otherwise meaningful studies. We did not contact everyone who might be considered an expert in the field of transitional care and were unable to reach some on our intended list, so we could have missed the opportunity to learn of other relevant studies for inclusion. Publication bias (nonpublication of research findings) might explain why so few articles met inclusion criteria for this review. We thought a formal evaluation with a funnel plot was unlikely to yield significant information given the small number of studies identified by the inclusion criteria.
Conclusions
Hospitalization often creates discontinuity of care, which can lead to adverse events, including increased hospital readmission and unnecessary resource use. Although there may be a perceived role for primary care-based telephone follow-up, our review found an alarming paucity of published trials addressing this intervention and no demonstrable effectiveness in reducing posthospitalization readmissions or emergency department visits, but it did show improved ability to engage patients in follow-up with their primary care providers. High-quality studies are still needed to evaluate the effect of a primary care-based telephone follow-up intervention. Considering the high costs of adverse postdischarge events, even a small reduction in emergency department visits or hospital readmission rates through use of this relatively low-cost tool could yield considerable savings and improve postdischarge health quality. With the advent of the medical home, primary care teams are poised to contribute to the study and development of effective transitional care strategies for patients in the postdischarge period.
Acknowledgment
Dr J. Benjamin Crocker thanks the Richard Winickoff Primary Care Fellowship at Massachusetts General Hospital.
References
Patient Protection and Affordable Care Act, HR 3590, 111th Congress, 2nd Session, January 5, 2010.
Closing the Quality Gap: a Critical Analysis of Quality Improvement Strategies. Volume 7. Agency for Healthcare Research and Quality,
Rockville, MD2007 (Care Coordination. AHRQ Publication No. 04(07)-0051-7)
Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial.
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.
Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine.
Health Information Technology for Economic and Clinical Health/American Recovery and Reinvestment Act. HR 1, 111th Congress, 1st Session, Title XIII, Section 13001. February 17, 2009.
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