- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT00101868
Value of Technology to Transfer Discharge Information
Study Overview
Status
Intervention / Treatment
Detailed Description
Objectives: The study is designed to compare the benefits of discharge health information technology versus usual care in high-risk patients recently discharged from acute care hospitalization.
STUDY HYPOTHESES:
The primary efficacy endpoint is the proportion of patients readmitted at least once within 6 months after the index admission. Readmission is for any reason and includes observation status and full admission status.
Primary hypothesis: Among high-risk patients recently discharged from acute care hospitalization, there is a significant decrease in the primary efficacy endpoint for patients who receive discharge health information technology versus usual care discharge instructions.
Secondary hypothesis 1A: In the same patient population, the time to first readmission is greater for patients who receive discharge health information technology versus usual care discharge instructions.
Secondary hypothesis 1B: In the same patient population, the mean number of hospital days per patient within 6 months after index hospital discharge is lower for patients who receive discharge health information technology versus usual care discharge instructions.
Secondary hypothesis 2: In the same patient population, the mean score for effectiveness and satisfaction with discharge process is greater for patients who receive discharge health information technology versus usual care discharge instructions.
Secondary hypothesis 3: In the same patient population, the proportion of patients who report their pharmacist needed to clarify the discharge prescription is lower for patients who receive discharge health information technology versus usual care discharge instructions.
Secondary hypothesis 4: In the same patient population, the proportion of patients with at least one adverse event within 4 weeks after hospital discharge is lower for patients who receive discharge health information technology versus usual care discharge instructions.
Secondary hypothesis 5: In the same population, the mean satisfaction score with drug information will be higher for patients who receive discharge health information technology versus usual care discharge instructions.
Secondary hypothesis 6: Among primary care physicians who provide post-discharge care to high-risk patients, the mean score for discharge process effectiveness and satisfaction will be greater for patients who receive discharge health information technology versus usual care discharge instructions.
Secondary hypothesis 7: Among hospitalist physicians who discharge high-risk patients, the mean score for physicians' satisfaction with the discharge process will be greater for physicians assigned to discharge health information technology versus usual care discharge instructions.
METHODS: The trial design is a randomized cluster, single-blind (outcome assessors blind), controlled trial. The study design conforms to recent guidelines for randomized controlled trials. The test intervention is discharge application of health information technology. The control intervention is usual care (hand-written discharge instructions) described below. Each patient will remain in the study for 6 months. Enrollment in the study will last approximately 18 months. There will be no interim analysis.
Research personnel will obtain informed consent from potentially eligible inpatients. Informed consent from patients will occur during the screening visit.
Screening visit: Investigators will train research personnel to perform screening and informed consent. The screening visit may occur within 2 days of the planned discharge. After obtaining informed consent, research personnel will record items in the baseline assessment. Research personnel will ask patients about self-rated health, coronary artery disease (including angina pectoris myocardial infarction), diabetes mellitus in past year, hospitalization in past year, number of doctor visits in past year, presence of an informal caregiver able to care for the patient for several days, age, and gender. The screening questionnaire was validated. Research personnel will calculate a PRA score during the screening visit. PRA scores 0.5 and above define high-risk patients who have a 50% probability of being admitted to a hospital two or more times within 4 years. When the PRA score is applied to Medicaid beneficiaries followed for one year, 57% of patients with PRA 0.5 and above will have at least one hospital admission or 0.99 +/- 0.24 hospital admissions per person-year survived (mean +/- SE). Research personnel will offer informed consent to patients with PRA score 0.4 and above.
Research personnel will record limited information for patients who are ineligible or who refuse consent.
Baseline Assessment: The baseline assessment will occur after informed consent and before discharge. The ten-point clock test will be used as the screening instrument for orientation. Research personnel will record patient's name, address, age, stated race, gender, and discharge medication prescription. Research personnel will record patient contact information and alternate contact information in order to perform post-hospital telephone interviews required by the protocol.
Intervention allocation: The time of random treatment allocation will be after the baseline assessment and before discharge. Patients will not receive study treatment if they fail to consent or if they fail the inclusion/exclusion criteria. Treatment assignment will be in a 1:1 ratio to either discharge application of health information technology or usual care discharge instructions. The unit of randomization will be the hospitalist physician who performs the discharge process. The randomization process is designed to assure random allocation by cluster with the cluster determined by the discharging physician. Allocation concealment is not possible since all the enrolled patients who are discharged by the hospitalist physician will receive the same study intervention.
Dispense patient logbook: The purpose of the patient logbook is to promote ascertainment of study endpoints.
Patient telephone interview: discharge process effectiveness and satisfaction The purpose of the first telephone interview is to acquire data to measure secondary endpoints 2, 3, and 5. One week (5 to 9 days) after the hospital discharge date, research personnel will perform a telephone interview with the patient. Interviewers will instruct the patient to avoid mentioning the random intervention assignment. To address secondary hypothesis 2, interview questions will follow the PREPARED text. The PREPARED instrument surveys four key process domains: information exchange (community services and equipment), medication management, preparation for coping after discharge and control of discharge circumstances. The questions in PREPARED measure the patient's overall satisfaction with discharge, whether equipment and community service needs were met, and use of health services and health related costs post-discharge. The telephone interviewers will ask patients if their pharmacist had to call the doctor when attempting to fill the discharge prescriptions. The purpose of the question about pharmacists is to address secondary hypothesis 3. The telephone interviewers will ask questions from the Satisfaction with Information about Medicines Scale (SIMS). The SIMS is a 17-item survey with internal consistency and test-retest reliability. The SIMS survey instrument addresses secondary hypothesis 5.
Primary care physician questionnaire: discharge process effectiveness and satisfaction. The primary care physician questionnaire addresses secondary hypothesis 6. Within 10 to 18 days after the hospital discharge date, research personnel will contact the primary care physician to perform a survey.
Patient interview: adverse event assessment. The purpose of the second patient interview is to address secondary hypothesis 4. Approximately 4 weeks (20 to 40 days) after the index hospital discharge date, research physician personnel will perform a telephone interview with the patient. Physicians trained to assess adverse events will perform the telephone interview. Interviewers will instruct the patient to avoid mentioning the random intervention assignment. The interview tool is a modification of a validated survey instrument.
Hospitalist (discharging) physician questionnaire: The purpose of the survey is to address secondary hypothesis 7.
Patient interview: readmission assessment. The purpose of the third patient interview is to ascertain the primary endpoint, secondary endpoints (1A, 1B), and tertiary endpoints. Approximately 6 months (170 to 190 days) after the hospital discharge date, research personnel who are blinded to intervention assignment will perform a telephone interview with the patient. Interviewers will instruct the patient to avoid mentioning the random intervention assignment. Interviewers will ask the patient to consult their patient logbook while answering questions. Interviewers will record the admissions to the hospital, dates of admission, duration of hospital stay, number of outpatient physician visits, and number of emergency department visits that did not result in hospital admission.
Guess treatment assignment by blinded observers: The purpose of the guess is to measure the effectiveness of the blind.
Conditions for Early Withdrawal of Treatment: Patients may terminate study intervention at any time and return to the standard care if they withdraw their consent. If a patient withdraws from the study for any reason, then research personnel will conduct an end-of-study visit.
Sample size determination: The primary analysis is the difference in proportion of patients in the two study groups who achieve the primary efficacy endpoint of readmission within 6 months of discharge. The estimated event rate in the standard therapy group is 37%, which is the control group event rate from a systematic review of randomized controlled trials of discharge interventions. The minimum clinically relevant difference, 13%, corresponds to a standardized increment of 28.2% and is the empirical boundary for quantitative significance.
The required sample size for the primary analysis is 275 patients in the group assigned to discharge application of health information technology and 275 patients in the group assigned to control (usual care) therapy. In a previous study of discharge planning, the investigators enrolled 28% (363/1296) of potentially eligible patients. In the same study, 72% (262/363) of enrolled patients completed the 6-month assessment. Our hospitalist service discharges 297 patients per month. We estimate we will screen 5456 patients within 18.37 months. We estimate 50% of screened patients will be potentially eligible according to the Pra criteria. Among potentially eligible patients, we estimate 28% will consent to study enrollment. Therefore, the number of enrolled patients will be 5456 x 50% x 28% = 764. We estimate 72% (550/764) of enrolled patients will continue in the study until the 6-month assessment.
After 3 months of patient enrollment, we found the rate of enrollment was too low to achieve the required sample size. In 2005, we requested and received approval from Agency Healthcare Research Quality and Institutional Review Board to lower patient inclusion criterion, probability or repeat admission (PRA), from 0.50 to 0.40.
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Contacts and Locations
Study Locations
-
-
Illinois
-
Peoria, Illinois, United States, 61637
- OSF Saint Francis Medical Center
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Inpatients at OSF Saint Francis Medical Center
- Discharged by the hospitalist service or other inpatient services
- High risk for poor post-discharge outcomes defined as probability of readmission (PRA) 0.4 or above
Exclusion Criteria:
- Less than 18 years old
- Unwilling or unable to provide written consent
- Life expectancy less than 6 months
- Will receive outpatient care from a primary care physician who is the same as the discharging physician
- Do not speak English or Spanish
- Not alert and oriented when admitted
- Do not have telephone for post-discharge contact
- Do not reside in Central Illinois
- Will be discharged to a nursing home
- Previously enrolled as subjects in the trial
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Health Services Research
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Single
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: Discharge communication software
Computerized-Physician-Order-Entry software application to facilitate communication at time of hospital discharge to patients, retail pharmacists, community physicians.
Software had required fields, pick lists, standard drug doses, alerts, reminders, online reference information.
Software prompted discharging physician to enter pending tests, order tests after discharge.
Hospital physicians used software on day of discharge to generate four documents automatically: personalized letter to outpatient physician, legible prescriptions, and legible discharge order
|
Computerized physician order entry software used by discharging physician
Other Names:
|
Active Comparator: Usual care discharge process
Hospital physicians and ward nurses completed handwritten discharge forms on the day of discharge.
The forms contained blanks for discharge diagnoses, discharge medications, medication instructions, post discharge activities and restrictions, post discharge diet, post discharge diagnostic and therapeutic interventions, and appointments.
Patients received handwritten copies of the forms, one page of which also included medication instructions and prescriptions
|
Handwritten
Other Names:
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Hospital Readmission, at Least One
Time Frame: within 6 months after discharge
|
Number of participants with at least one readmission within 6 months after discharge from index hospital visit
|
within 6 months after discharge
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Patients' Perception of Discharge Process, Effectiveness, Satisfaction, Preparedness
Time Frame: 1 week after discharge
|
1 week after discharge
|
|
Patients' Perception of Discharge Process, Satisfaction
Time Frame: 1 week after discharge
|
1 week after discharge
|
|
Pharmacist Needed to Clarify the Discharge Prescription
Time Frame: 1 day after discharge
|
1 day after discharge
|
|
Pharmacist's Satisfaction With Discharge Prescription
Time Frame: 1 day after discharge
|
1 day after discharge
|
|
At Least One Adverse Event Within One Month After Discharge
Time Frame: 1 month after discharge
|
Number of participants with at least one adverse event within one month after discharge
|
1 month after discharge
|
Patient's Satisfaction With Drug Information
Time Frame: 1 week after discharge
|
1 week after discharge
|
|
Primary Care Physician's Perception, Effectiveness
Time Frame: 10 days after discharge
|
10 days after discharge
|
|
Primary Care Physician's Perception, Satisfaction
Time Frame: 10 days after discharge
|
10 days after discharge
|
|
Discharge Physician Satisfaction With Discharge Process
Time Frame: 6 months after using discharge process
|
6 months after using discharge process
|
|
Number of Outpatient Visits
Time Frame: within 6 months after discharge
|
within 6 months after discharge
|
|
Number of Emergency Department Visits
Time Frame: within 6 months after discharge
|
Number of participants with at least one emergency department visit within six months after discharge
|
within 6 months after discharge
|
Physician Time Spent to Complete the Discharge Application
Time Frame: averaged over 2 years of patient enrollment
|
averaged over 2 years of patient enrollment
|
Collaborators and Investigators
Collaborators
Investigators
- Principal Investigator: James F Graumlich, MD, University of Illinois College of Medicine
Publications and helpful links
General Publications
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- Grimmer K, Moss J. The development, validity and application of a new instrument to assess the quality of discharge planning activities from the community perspective. Int J Qual Health Care. 2001 Apr;13(2):109-16. doi: 10.1093/intqhc/13.2.109.
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- Horne R, Hankins M, Jenkins R. The Satisfaction with Information about Medicines Scale (SIMS): a new measurement tool for audit and research. Qual Health Care. 2001 Sep;10(3):135-40. doi: 10.1136/qhc.0100135...
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- Kerry SM, Bland JM. Unequal cluster sizes for trials in English and Welsh general practice: implications for sample size calculations. Stat Med. 2001 Feb 15;20(3):377-90. doi: 10.1002/1097-0258(20010215)20:33.0.co;2-n.
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- McInnes E, Mira M, Atkin N, Kennedy P, Cullen J. Can GP input into discharge planning result in better outcomes for the frail aged: results from a randomized controlled trial. Fam Pract. 1999 Jun;16(3):289-93. doi: 10.1093/fampra/16.3.289.
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- Paquette-Lamontagne N, McLean WM, Besse L, Cusson J. Evaluation of a new integrated discharge prescription form. Ann Pharmacother. 2001 Jul-Aug;35(7-8):953-8. doi: 10.1345/aph.10244.
- Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA. 2004 Mar 17;291(11):1358-67. doi: 10.1001/jama.291.11.1358. Erratum In: JAMA. 2004 Sep 1;292(9):1022.
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- Nace GS, Graumlich JF, Aldag JC. Software design to facilitate information transfer at hospital discharge. Inform Prim Care. 2006;14(2):109-19. doi: 10.14236/jhi.v14i2.621.
- Graumlich JF, Novotny NL, Aldag JC. Brief scale measuring patient preparedness for hospital discharge to home: Psychometric properties. J Hosp Med. 2008 Nov-Dec;3(6):446-54. doi: 10.1002/jhm.316.
- Graumlich JF, Grimmer-Somers K, Aldag JC. Discharge planning scale: community physicians' perspective. J Hosp Med. 2008 Nov-Dec;3(6):455-64. doi: 10.1002/jhm.371.
- Graumlich JF, Novotny NL, Stephen Nace G, Kaushal H, Ibrahim-Ali W, Theivanayagam S, William Scheibel L, Aldag JC. Patient readmissions, emergency visits, and adverse events after software-assisted discharge from hospital: cluster randomized trial. J Hosp Med. 2009 Sep;4(7):E11-9. doi: 10.1002/jhm.469.
- Graumlich JF, Novotny NL, Nace GS, Aldag JC. Patient and physician perceptions after software-assisted hospital discharge: cluster randomized trial. J Hosp Med. 2009 Jul;4(6):356-63. doi: 10.1002/jhm.565.
- Novotny NL, Anderson MA. Prediction of early readmission in medical inpatients using the Probability of Repeated Admission instrument. Nurs Res. 2008 Nov-Dec;57(6):406-15. doi: 10.1097/NNR.0b013e31818c3e06.
Study record dates
Study Major Dates
Study Start
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Estimate)
Study Record Updates
Last Update Posted (Estimate)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Keywords
Other Study ID Numbers
- 1R01HS015084-01 (U.S. AHRQ Grant/Contract)
- 1R01HS015084-02 (U.S. AHRQ Grant/Contract)
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