Physician Follow-Up Visits After Acute Care Hospitalization for Elderly Medicare Beneficiaries Discharged to Noninstitutional Settings
ABSTRACT The purpose of this study was to assess the effect of posthospital physician follow-up on readmissions in older adults. Physician follow-up visits after discharge have been promoted as a way to improve outcomes and reduce readmissions, but the evidence base for this recommendation is limited. A retrospective analysis of data from the Medicare Current Beneficiary Survey (MCBS) was conducted for 2001 to 2003. Data were extracted on elderly Medicare beneficiaries with an index hospitalization in 2002, and physician follow-up visits and readmissions within 90 days of discharge were identified. Analysis was conducted with multivariable logistic regression modeling to assess the independent effect on 90-day readmission of any physician follow-up, timing of physician follow-up, and follow-up with only primary care physicians. A generalized linear model was used to assess the effect of physician follow-up on total health expenditures. The analytical sample included 326 beneficiaries; 79% had a physician follow-up visit within 90 days, and 28% were readmitted within 90 days. In multivariable modeling, physician follow-up was negatively associated with 90-day readmissions (odds ratio=0.23, 95% confidence interval=0.13-0.43). Follow-up visits were protective against readmissions regardless of timing of visit and when restricted to those by primary care physicians. Having a follow-up visit was associated with approximately $10,000 lower annual health expenditures. In conclusion, physician follow-up protects against readmission after adjusting for important covariates and is associated with significantly lower expenditures. Future efforts should ensure that patients have adequate physician follow-up.
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ABSTRACT: Survivors of severe acute kidney injury remain at high risk of death well after apparent recovery from the initial insult. Here we determine whether early nephrology follow-up after a hospitalization complicated by severe acute kidney injury associates with patient survival. This consisted of a cohort study of all hospitalized adults in Ontario from 1996 to 2008 with acute kidney injury who received temporary inpatient dialysis and survived for 90 days following discharge independent from dialysis. Propensity scores were used to match individuals with early nephrology follow-up, defined as a visit with a nephrologist within 90 days of discharge, to those without. The outcome was time to all-cause mortality of 3877 patients who met the eligibility criteria within a maximum follow-up of 2 years. A total of 1583 patients had early nephrology follow-up of whom 1184 were successfully matched 1:1 to those not receiving early follow-up. The incidence of all-cause mortality was lower in those patients with early nephrology follow-up compared with those without (8.4 compared with 10.6 per 100-patient years, hazard ratio 0.76 (95% CI: 0.62-0.93)). Thus, early nephrology follow-up after hospitalization with acute kidney injury and temporary dialysis was associated with improved survival. This finding requires definitive testing in a randomized controlled trial.Kidney International advance online publication, 16 January 2013; doi:10.1038/ki.2012.451.Kidney International 01/2013; 83(5). DOI:10.1038/ki.2012.451 · 8.56 Impact Factor
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ABSTRACT: Hospital readmission rates within 30 days following acute myocardial infarction (AMI) are a national performance metric. Prior data suggest that early physician follow-up after heart failure hospitalizations can reduce readmissions; whether these results can be extended to AMI is unclear. We analyzed data from the CRUSADE Registry linked with Medicare claims from 2003-2006 for 25,872 non-ST-segment elevation myocardial infarction (NSTEMI) patients ≥65 years old discharged home from 228 hospitals with >25 patients and full revascularization capabilities. After adjusting for patient, treatment, and hospital characteristics, we examined the relationship between hospital-level physician follow-up within 7 days of discharge and 30-day all-cause readmission using logistic regression. The median hospital-level percentage of patients receiving early physician follow-up was 23.3% (IQR 17.1%-29.1%). Among 24,165 patients with Medicare fee-for-service eligibility 30 days after discharge, 18.5% of patients were readmitted within 30 days of index hospitalization. Unadjusted and adjusted rates of 30-day readmission did not differ among quartiles of hospital-level early physician follow-up. Similarly, each 5% increase in hospital early follow-up was associated with an insignificant change in risk for readmission (adjusted OR 0.99; 95% CI 0.97, 1.02; p=0.60). Sensitivity analyses extended these null findings to 30-day cardiovascular readmissions, high-risk subgroups, and early cardiology follow-up. While rates of early physician follow-up after AMI varied among U.S. hospitals, hospitals with higher early follow-up rates did not have lower 30-day readmission rates. Targeting strategies other than early physician follow-up may be necessary to reduce readmission rates in this population.Circulation 08/2013; 128(11). DOI:10.1161/CIRCULATIONAHA.113.004569 · 14.43 Impact Factor
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ABSTRACT: Background: The association between early outpatient follow-up and 30-day readmission has not been evaluated in any surgical population. Our study characterizes the relationship between outpatient follow-up and early readmissions among surgical patients. Methods: We queried the medical record at a large, tertiary care institution (July 2008-December 2012) to determine rates of 30-day outpatient follow-up and readmission for general or vascular operative procedures. Results: The majority of discharges for general (84% of 7,552) and vascular (75% of 2,362) surgery had a follow-up visit before readmission or within 30 days of discharge. General surgery patients who were not readmitted had high rates of follow-up (88%) and received follow-up at approximately 2 weeks postdischarge (median, 11 days after discharge). In contrast, readmitted general surgery patients received first follow-up at 1 week (median, 8 days); 49% had follow-up. Vascular surgery patients showed a similar trend. More than one half of patients readmitted after follow-up were readmitted within 24 hours of their most recent outpatient visit. Conclusion: Current routine follow-up does not occur early enough to detect adverse events and prevent readmission. Early outpatient care may prevent readmission in some patients, but often serves as a conduit for readmission among patients already experiencing complications.Surgery 10/2014; 156(4):949-58. DOI:10.1016/j.surg.2014.06.041 · 3.38 Impact Factor