Transitional care for the highest risk patients: findings of a randomised control study

Abstract

BackgroundInterventions to prevent readmissions of patients at highest risk have not been rigorously evaluated. We conducted a randomised controlled trial to determine if a post-discharge transitional care programme can reduce readmissions of such patients in Singapore.MethodsWe randomised 840 patients with two or more unscheduled readmissions in the prior 90 days and Length of stay, Acuity of admission, Comorbidity of patient, Emergency department utilisation score ≥10 to the intervention programme (n = 419) or control (n = 421). Patients allocated to the intervention group received post-discharge surveillance by a multidisciplinary integrated care team and early review in the clinic. The primary outcome was the proportion of patients with at least one unscheduled readmission within 30 days after discharge.ResultsWe found no statistically significant reduction in readmissions or emergency department visits in patients on the intervention group compared to usual care. However, patients in the intervention group reported greater patient satisfaction (p < 0.001).ConclusionAny beneficial effect of interventions initiated after discharge is small for high-risk patients with multiple comorbidity and complex care needs. Future transitional care interventions should focus on providing the entire cycle of care for such patients starting from time of admission to final transition to the primary care setting.Trial RegistrationClinicaltrials.gov, no NCT02325752

Applying the Integrated Practice Unit Concept to a Modified Virtual Ward Model of Care for Patients at Highest Risk of Readmission: A Randomized Controlled Trial

“…The age, Charlson comorbidity score and mean LACE score in our study were most similar to the study population enrolled in Dhalla’s virtual ward intervention in Canada [10] and Lee’s transitional care intervention for patients at highest risk of readmission [11]. On the basis of the markedly different outcomes between the studies, it is reasonable to conclude that multicomponent, complex interventions starting before hospital discharge and extending across the care cycle are required to reduce readmissions substantially in high risk patients.…”

“…Our trial was not registered prospectively due to a genuine administrative error by our administrator (Clinicaltrials.gov, no NCT02351648) and it was never our intention to publish only if we had positive findings. We had also published our earlier trial which did not have a significant result [11]. We noticed the error late and immediately registered our trial upon discovery of our error.…”

“…In our example, we modified the virtual ward model to include a pre-discharge hospital phase after our earlier trial [11] that followed the original virtual ward model failed to show improvements in hospital utilization. The IPU concept was originally developed to improve care for specific diseases.…”

“…Patients with a score of ≥ 10 were found to have a five times higher risk of 30-day readmission in Singapore [22]. When a LACE score ≥ 10 was combined with one or admissions in the previous 90 days, patients had a 30% risk of an unplanned 30-day readmission [11]. Eligible case finding and risk stratification using the LACE index and prior admissions in the previous 90 days is performed electronically by the hospital’s enterprise analytics platform eHIntS (Electronic Health Intelligence System) on a daily basis.…”

“…Despite the attractiveness of the concept, a formal evaluation commissioned by the Department of Health in 2013 for the participating sites found no evidence of reduction in unplanned readmissions when compared to matched controls [9]. Similarly, two large randomized clinical trials conducted independently in Canada and Singapore on a post-discharge virtual ward model were unable to reduce readmissions or death for high risk patients [10, 11]. …”