Association between post-hospital clinic and telephone follow-up provider visits with 30-day readmission risk in an integrated health system.

BACKGROUND: Follow-up visits with clinic providers after hospital discharge may not be feasible for some patients due to functional limitations, transportation challenges, need for physical distancing, or fear of exposure especially during the current COVID-19 pandemic. METHODS: The aim of the study was to determine the effects of post-hospital clinic (POSH) and telephone (TPOSH) follow-up provider visits versus no visit on 30-day readmission. We used a retrospective cohort design based on data from 1/1/2017 to 12/31/2019 on adult patients (n = 213,513) discharged home from 15 Kaiser Permanente Southern California hospitals. Completion of POSH or TPOSH provider visits within 7 days of discharge was the exposure and all-cause 30-day inpatient and observation stay readmission was the primary outcome. We used matching weights to balance the groups and Fine-Gray subdistribution hazard model to assess for readmission risk. RESULTS: Unweighted all-cause 30-day readmission rate was highest for patients who completed a TPOSH (17.3%) followed by no visit (14.2%), non-POSH (evaluation and management visits that were not focused on the hospitalization: 13.6%) and POSH (12.6%) visits. The matching weighted models showed that the effects of POSH and TPOSH visits varied across patient subgroups. For high risk (LACE 11+) medicine patients, both POSH (HR: 0.77, 95% CI: 0.71, 0.85, P < .001) and TPOSH (HR: 0.91, 95% CI: 0.83, 0.99, P = .03) were associated with 23 and 9% lower risk of 30-day readmission, respectively, compared to no visit. For medium to low risk medicine patients (LACE< 11) and all surgical patients regardless of LACE score or age, there were no significant associations for either visit type with risk of 30-day readmission. CONCLUSIONS: Post-hospital telephone follow-up provider visits had only modest effects on 30-day readmission in high-risk medicine patients compared to clinic visits. It remains to be determined if greater use and comfort with virtual visits by providers and patients as a result of the pandemic might improve the effectiveness of these encounters.

Temporal trends in heart failure mortality in an integrated healthcare delivery system, California, and the US, 2001-2017.

BACKGROUND: In recent years, decreases in mortality rates attributable to cardiovascular diseases have slowed but mortality attributable to heart failure (HF) has increased. METHODS: Between 2001-2017, trends in age-adjusted mortality with HF as an underlying cause for Kaiser Permanente Southern California (KPSC) members were derived through linkage with state death files and compared with trends among California residents and the US. Average annual percent change (AAPC) and 95% confidence intervals (CI) were calculated using Joinpoint regression. Analyses were repeated examining HF as a contributing cause of death. RESULTS: In KPSC, the age-adjusted HF mortality rates were comparable to California but lower than the US, increasing from 23.9 per 100,000 person-years (PY) in 2001 to 44.7 per 100,000 PY in 2017, representing an AAPC of 1.3% (95% CI 0.0%, 2.6%). HF mortality also increased in California from 33.9 to 46.5 per 100,000 PY (AAPC 1.5%, 95% CI 0.3%, 2.7%), while remaining unchanged in the US at 57.9 per 100,000 PY in 2001 and 2017 (AAPC 0.0%, 95% CI - 0.5%, 0.5%). Trends among KPSC members ≥ 65 years old were similar to the overall population, while trends among members 45-64 years old were flat between 2001-2017. Small changes in mortality with HF as a contributing cause were observed in KPSC members between 2001 and 2017, which differed from California and the US. CONCLUSION: Lower rates of HF mortality were observed in KPSC compared to the US. Given the aging of the US population and increasing prevalence of HF, it will be important to examine individual and care-related factors driving susceptibility to HF mortality.

Impact of Inpatient Palliative Care on Quality of End-of-Life Care and Downstream Acute and Postacute Care Utilization.

BACKGROUND: Additional evidence is needed regarding the impact of inpatient palliative care (IPC) on the quality of end-of-life care and downstream utilization. AIM: Examine the effects of IPC on quality of end-of-life care and acute and postacute care use in a large integrated system. DESIGN: Retrospective cohort design. SETTING/PARTICIPANTS: Adult decedents from January 1, 2012, to December 31, 2014, who had at least one hospitalization at 11 Kaiser Permanente Southern California medical centers in the 12 months before death and not hospitalized for a trauma-related condition or receiving home-based PC or hospice were included in the cohort. MATERIALS AND METHODS: Inverse probability of treatment weighting of propensity scores was used to compare outcomes between patients exposed to IPC (n = 3742) and controls (n = 12,755) who never received IPC before death. RESULTS: Patients who received IPC were more likely to enroll in home-based PC or hospice (69% vs. 43%) and were less likely to die in a hospital (15% vs. 29%) or intensive care (2% vs. 9%) compared with controls (all, p < 0.001). IPC exposure was associated with higher risk for rehospitalization (HR: 1.18, 95% CI 1.11-1.25) and more frequent emergency department visits (RR: 1.16, 95% CI 1.07-1.26) with no increase in postacute care use compared with controls. Stratified analyses showed that IPC effects on acute care utilization were dependent on code status. CONCLUSION: IPC exposure was associated with higher enrollment in home-based PC/hospice and more deaths at home. The increased acute care utilization by the IPC group may reflect persistent confounding by indication.

Completion of an Outpatient Visit After Skilled Nursing Facility Discharge and Readmission Risk.

OBJECTIVES: Examine the association between completion of an outpatient visit with a physician or advanced practice provider (PCP) within 7 days of discharge from a short skilled nursing facility (SNF) stay and 30-day readmission and determine if functional status at discharge moderates visit effectiveness. DESIGN: Retrospective cohort study. SETTING: Large integrated health care system. PARTICIPANTS: Adults 65 years and older, discharged home from a short SNF stay (n = 4073). INTERVENTION: None. MEASUREMENTS: Exposure is completion of an outpatient visit with a PCP within 7 days of discharge from an SNF. Primary outcome is readmission within 30 days of SNF discharge. Covariates included gender, risk score for readmission or early death, medical or surgical hospitalization, SNF facility, SNF length of stay, SNF stay in the previous 12 months, discharge to home or home health, and discharge functional independence measures (FIM). RESULTS: A total of 476 (11.6%) patients were readmitted within 30 days of SNF discharge. Patients who completed an outpatient visit with a PCP within 7 days of SNF discharge had a 23% higher risk of being readmitted compared to patients who did not complete any visit (hazard ratio [HR] 1.23, 95% confidence interval [CI] 1.01-1.50). Patients who had FIM scores ≥80 and completed a visit had an increased readmission risk (HR 1.37, 95% CI 1.04-1.79); the increased risk was not seen for those with worse functional impairment, FIM <80 (HR 1.11, 95% CI 0.85-1.46). CONCLUSION: The finding of increased risk of readmission post SNF discharge with completion of an outpatient visit likely reflects inadequate adjustment for selection bias in this observational study, which strongly argues for the need to design prospective studies to test transitional care services post SNF discharge.

Three-year weight outcomes from a bariatric surgery registry in a large integrated healthcare system.

BACKGROUND: A registry was created for patients having procedures for weight loss from 2004 to the present time at a large integrated healthcare system. The objective of this study was to compare findings to the literature and national quality monitoring databases and present 3-year weight loss outcomes. METHODS: Patients are passively enrolled in the registry with the following characteristics: a bariatric procedure for weight loss after January 1, 2004 and actively enrolled in the health plan at the time of surgery. RESULTS: Compared to national surgical quality databases, the registry (n = 20,296) has a similar proportion of Roux-en-Y gastric bypass (RYGB; 58%), more vertical sleeve gastrectomy (SG; 40%), fewer banding (2%) procedures, more Hispanic patients (35%), and higher rates of 1 year follow-up (78%). RYGB patients lost more weight at every time point up to 3 years after surgery compared with SG patients (P<.001). Non-Hispanic white RYGB patients had a higher percent excess weight loss than non-Hispanic black (P<.001) and Hispanic (P<.001) RYGB patients. There were no differences between SG racial/ethnic groups in percent excess weight loss throughout the 3-year follow-up period. CONCLUSION: We are one of the first groups to publish comparison weight outcomes for RYGB and SG in a diverse patient population, showing that the responses to RYGB and not SG vary by race/ethnicity.

Complex case conferences associated with reduced hospital admissions for high-risk patients with multiple comorbidities.

OBJECTIVES: Reducing avoidable hospital readmissions presents an opportunity to improve health care quality and reduce avoidable costs. We studied the effect person-focused care may have on reducing avoidable admissions to the hospital. METHODS: Among patients with heart failure discharged from the hospital, we evaluated the effect on 30-day readmissions of transitions-in-care interventions: home health visits, follow-up phone calls, and physician office visits. We also used a standardized diagnostic tool to interview readmitted patients to identify social reasons that may have contributed to the readmission. Finally, we used the learnings from both interventions to develop a new intervention: a single complex disease case conference that included the entire health care team. We measured hospital admissions for 21 patients during the 6 months before and after their complex case conferences. RESULTS: Observed-over-expected hospital readmission rates were lowest for patients receiving a postdischarge visit with a home health nurse and a follow-up visit with their physician (0.54), compared with solely a physician visit (0.81), home health visit (1.2), or phone call (1.55). Various social issues may contribute to hospital readmissions, including caregiver knowledge, ability to care for oneself at home, and issues related to medications (adherence, ability to pay, and knowledge about potential side effects). Substantially fewer hospital admissions occurred after complex case conferences. CONCLUSIONS: Complex case conferences with disease-focused and person-focused interventions may be associated with reduced hospital admissions for patients with heart failure and multiple comorbidities.

The readmission reduction program of Kaiser Permanente Southern California-knowledge transfer and performance improvement.

In 2011, Kaiser Permanente Northwest Region (KPNW) won the Lawrence Patient Safety Award for its innovative work in reducing hospital readmission rates. In 2012, Kaiser Permanente Southern California (KPSC) won the Transfer Projects Lawrence Safety Award for the successful implementation of the KPNW Region's "transitional care" bundle to a Region that was almost 8 times the size of KPNW. The KPSC Transition in Care Program consists of 6 KPNW bundle elements and 2 additional bundle elements added by the KPSC team. The 6 KPNW bundle elements were risk stratification, standardized discharge summary, medication reconciliation, a postdischarge phone call, timely follow-up with a primary care physician, and a special transition phone number on discharge instructions. The 2 additional bundle elements added by KPSC were palliative care consult if indicated and a complex-case conference. KPSC has implemented most of the KPNW and KPSC bundle elements during the first quarter of 2012 for our Medicare risk population at all of our 13 medical centers. Each year, KPSC discharges approximately 40,000 Medicare risk patients. After implementation of bundle elements, KPSC Medicare risk all-cause 30-day Healthcare Effectiveness Data and Information Set readmissions observed-over-expected ratio and readmission rates from December 2010 to November 2012 decreased from approximately 1.0 to 0.80 and 12.8% to 11%, respectively.