Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.
Harvard Medical School, Boston, Massachusetts.
J Hosp Med. 2021 Jan;16(1):15-22. doi: 10.12788/jhm.3513.
Transitions from hospital to the ambulatory setting are high risk for patients in terms of adverse events, poor clinical outcomes, and readmission.
To develop, implement, and refine a multifaceted care transitions intervention and evaluate its effects on postdischarge adverse events.
DESIGN, SETTING, AND PARTICIPANTS: Two-arm, single-blind (blinded outcomes assessor), stepped-wedge, cluster-randomized clinical trial. Participants were 1,679 adult patients who belonged to one of 17 primary care practices and were admitted to a medical or surgical service at either of two participating hospitals within a pioneer accountable care organization (ACO).
Multicomponent intervention in the 30 days following hospitalization, including inpatient pharmacist-led medication reconciliation, coordination of care between an inpatient "discharge advocate" and a primary care "responsible outpatient clinician," postdischarge phone calls, and postdischarge primary care visit.
The primary outcome was rate of postdischarge adverse events, as assessed by a 30-day postdischarge phone call and medical record review and adjudicated by two blinded physician reviewers. Secondary outcomes included preventable adverse events, new or worsening symptoms after discharge, and 30-day nonelective hospital readmission.
Among patients included in the study, 692 were assigned to usual care and 987 to the intervention. Patients in the intervention arm had a 45% relative reduction in postdischarge adverse events (18 vs 23 events per 100 patients; adjusted incidence rate ratio, 0.55; 95% CI, 0.35-0.84). Significant reductions were also seen in preventable adverse events and in new or worsening symptoms, but there was no difference in readmission rates.
A multifaceted intervention was associated with a significant reduction in postdischarge adverse events but no difference in 30-day readmission rates.
对于患者而言，从医院过渡到门诊环境存在较高风险，会导致不良事件、临床结局不佳和再入院。
制定、实施和完善多方面的医疗过渡干预措施，并评估其对出院后不良事件的影响。
设计、地点和参与者：两臂、单盲（盲法结局评估者）、阶梯式、群组随机临床试验。参与者为 1679 名成年患者，他们属于 17 个初级保健实践之一，在参与的两个医院之一的医疗或外科服务中住院，并属于一个先驱责任医疗组织（ACO）。
住院后 30 天内的多组分干预，包括住院药剂师主导的药物重整、住院“出院倡导者”和初级保健“负责门诊临床医生”之间的护理协调、出院后电话随访和出院后初级保健就诊。
主要结局是通过出院后 30 天的电话随访和病历回顾评估的出院后不良事件发生率，并由两名盲法医师评审进行裁决。次要结局包括可预防的不良事件、出院后新的或恶化的症状和 30 天内非选择性医院再入院。
在纳入研究的患者中，692 例被分配至常规护理组，987 例被分配至干预组。干预组患者出院后不良事件的相对减少率为 45%（每 100 例患者中发生 18 例与 23 例事件；调整后发病率比，0.55；95%CI，0.35-0.84）。在可预防的不良事件和新的或恶化的症状方面也有显著降低，但再入院率没有差异。
多方面的干预措施与出院后不良事件的显著减少相关，但与 30 天再入院率无差异。
