The Effects of a Multifaceted Intervention to Improve Care Transitions Within an Accountable Care Organization: Results of a Stepped-Wedge Cluster-Randomized Trial.

Abstract

BACKGROUND\nTransitions from hospital to the ambulatory setting are high risk for patients in terms of adverse events, poor clinical outcomes, and readmission.\n\n\nOBJECTIVES\nTo develop, implement, and refine a multifaceted care transitions intervention and evaluate its effects on postdischarge adverse events.\n\n\nDESIGN, SETTING, AND PARTICIPANTS\nTwo-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).\n\n\nINTERVENTIONS\nMulticomponent 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.\n\n\nMAIN OUTCOMES AND MEASURES\nThe 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.\n\n\nRESULTS\nAmong 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.\n\n\nCONCLUSION\nA multifaceted intervention was associated with a significant reduction in postdischarge adverse events but no difference in 30-day readmission rates.