Researchers at UC San Francisco have found that a nurse-led intervention program designed to reduce readmissions among ethnically and linguistically diverse older patients did not improve 30-day hospital readmission rates. Their findings suggest hospitals evaluate such programs before implementing or continuing.
Their study is in the Oct. 7 issue of Annals of Internal Medicine.
"The lack of effect in this population, which was well connected to primary care, suggests reducing readmissions is challenging," said co-lead author L. Elizabeth Goldman, MD, MCR, associate professor in the UCSF Division of General Internal Medicine at San Francisco General Hospital and Trauma Center (SFGH). "Our findings should give pause to hospitals adopting interventions shown to work in dissimilar populations and settings without evaluating their effect and should prompt consideration of alternate or additional approaches to reducing readmissions in populations with significant medical comorbidity and language diversity."
According to the study, as many as 30 percent of hospitalized elders are readmitted within 30 days, and many are preventable. Recent changes in payment models, such as the formation of accountable care organizations and the implementation of Medicare readmission penalties, have led many hospitals to initiate discharge support programs to reduce readmissions and improve elderly patients' transitions from the hospital to their home. Previous studies have shown these programs to have mixed success.
To learn if intervention programs have a beneficial impact, Goldman and her colleagues studied 700 adults age 55 and older who spoke English, Spanish or Chinese (Mandarin or Cantonese) in a publicly funded, urban Northern California hospital and were being discharged to the community. This studied population had high rates of multiple co-morbid medical conditions and low health literacy.
From July 2010 to February 2013, the usual standard of care for discharge was compared to in-hospital, one-on-one self-management education before discharge by a dedicated language-concordant registered nurse combined with a telephone follow up after discharge from a nurse practitioner.
Based on data from area hospitals, the researchers determined the number of emergency room visits and readmissions to those hospitals at 30, 90 and 180 days after initial hospital discharge. At 30 days, the readmission rate through the intervention program and usual care was approximately 15 percent, which is lower than the national average readmission rate for Medicare patients. Emergency room visits in the intervention study may have been higher than in the usual care group.
As a result, the researchers emphasize caution when adapting interventions used in other populations. Readmission penalties could disproportionately affect hospitals serving diverse populations, particularly if standard interventions do not work.
"There has been a tremendous push nationally to adopt these hospital-based transitional care programs, particularly ones that require few additional resources," said senior author Margot Kushel, MD, professor of general internal medicine. "However, in this diverse elderly population, the intervention did not have an impact on key policy relevant outcomes."
Other contributors to the Annals of Internal Medicine study from the UCSF Division of General Internal Medicine were co-lead author Urmimala Sarkar, MD, MPH, associate professor; Edgar Pierluissi, MD, professor; Jeff Critchfield, MD, professor; Michelle Schneidermann, MD, associate professor; and David Guzman, MS, statistician. Eric Vittinghoff, PhD, MPH, professor of epidemiology and biostatistics at UCSF, Eric Kessell, PhD, policy analyst at the UC Berkeley School of Public Health, and Barbara Walter, RN, MSN, nursing consultant, also contributed.
Financial support was provided by grants from The Gordon and Betty Moore Foundation, Agency for Healthcare Research and Quality, and the National Institutes of Health.
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