Does a Complex Care Discharge Planning Initiative Reduce Unplanned Hospital Readmissions? (G78717-Readmits)

Study Overview
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Brief Summary
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Unplanned hospital readmissions are associated with increases in morbidity, mortality, cost and patient dissatisfaction,. Policymakers continue to seek effective policy solutions to avoid readmissions in order to improve quality of care and reduce unnecessary expenditures,. One attempt to reduce readmissions was implemented on June 1 2012, when the Specialist Services Committee of British Columbia (a partnership of Doctors of BC and the Ministry of Health) introduced the new G78717 fee code for physicians. The objective of the fee code was to create a financial incentive for physicians to provide a point-of-care supplemental discharge summary to patients and their primary care providers prior to discharge from hospital. Initially, only urgent hospital admissions were eligible for this incentive payment but on Nov 1 2015 the incentive was extended to include elective admissions as well. The other eligibility criteria remained unchanged. The effectiveness and cost-effectiveness of the fee code intervention is unknown. This study will address important questions relevant to this policy intervention using rigorous methods and empirical data. This study will employ two methods for measuring changes in readmission risk. First, we will use interrupted (multivariate) time series to measure whether there was a temporal change in provincial readmission risk associated with the implementation of the new fee code. We will complement the above analyses with a stronger design, comparing hospitalizations for which the fee code was charged (intervention group) with a cohort of clinically similar hospitalizations for which the fee code was not charged (control group). For this approach, multivariate logistic regression will be the primary statistical method. Using this analytic strategy, 30-day readmission risk between the intervention and control group will be measured over time, adjusted for patient-, provider-, and hospitalization-level covariates.

Official Title
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Does a Complex Care Discharge Planning Initiative Reduce Unplanned Hospital Readmissions?

Conditions
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Patient Readmission

Intervention / Treatment
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* Other: Policy intervention


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: The study population will be comprised of all hospital discharges in British Columbia between 1 Jan 2002 and 30 June 2017. Exclusion Criteria: We will exclude separations with the following International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA) codes as the Most Responsible Diagnosis: Codes O00 - O99 [Pregnancy, childbirth and the puerperium] Codes P00 - P96 [Certain conditions originating in the perinatal period]

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Intervention/Treatment |
| --- |
|Other: Policy intervention|Incentive payment for physicians|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Unplanned hospital readmission within 30 days | Unplanned hospital readmission within 30 days | 30 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Unplanned (urgent) hospital readmission within 1 year of index hospital discharge | Unplanned (urgent) hospital readmission within 1 year of index hospital discharge | 1 year | 
| Primary care visits within 30 days and 1 year of index hospital discharge | Primary care visits within 30 days and 1 year of index hospital discharge | 30 days and 1 year | 
| Emergency department visit | Emergency department visit within 30 days and 1 year of index hospital discharge | 30 days and 1 year | 
| Death | Death within 30 days and 1 year of index hospital discharge | 30 days and 1 year | 
| Use of transitional or stepdown care | Use of transitional or stepdown care (eg. rehabilitation, extended care, intermediate /personal care) after discharge from acute care but prior to return home | 30 days and 1 year | 
| Improvements in appropriate population-level post-discharge prescription prevalence of an indicated medication | Using health services records, we will identify a sub-cohort of patients with an index admission for acute coronary syndrome, heart failure, or chronic ischemic heart disease. Within this subcohort, we will determine the proportion of patients who filled at least one prescription for beta-blockers within 60 days of index hospital discharge date. | 60 days | 
| Improvements in appropriate population-level post-discharge prescription prevalence of a contraindicated medication | Using health services records, we will identify a sub-cohort of older adults (aged >/=65 years at date of index hospital discharge date). Within this subcohort, we will determine the proportion of patients who filled at least one prescription for a potentially inappropriate medication within 60 days of index hospital discharge date. Our list of potentially inappropriate medications has been adapted from those listed in the American Geriatrics Society 2015 Updated Beers Criteria. | 60 days |