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

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

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.

Study Overview

• Status: Recruiting
• Conditions: Patient Readmission
• Intervention / Treatment: Other: Policy intervention

• Study Type: Observational
• Enrollment (Anticipated): 300000

Contacts and Locations

• Study Contact: Name: John A Staples, MD; Phone Number: 604-682-2344; Email: john.a.staples@gmail.com
• Study Contact Backup: Name: Jason M Sutherland, PhD; Phone Number: 604-822-6812; Email: jsutherland@chspr.ubc.ca

Study Locations

• Canada
  • British Columbia
    • Vancouver, British Columbia, Canada, V6T 1Z3
      • Recruiting
      • Population Data BC
      • Contact: Tim Choi

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

Our study population will be representative of medical and surgical hospital admissions in BC.

The Interrupted time series (ITS) cohort will be comprised of hospital separations eligible for submission of fee code G78717. We will include all urgent admissions to BC hospitals with discharge dates between 1 Jan 2002 and 30 June 2017 that had a length of stay (LOS) of >4 days and are associated with a specialist Most Responsible Physician (MRP).

The regression analysis cohort study will be identical to the ITS cohort but will be restricted to index hospitalization discharge dates between 1 Jun 2012 and 31 Jul 2017 (ie. the post-G78717 period).

The unit of analysis is the index hospital admission (ie. the initial hospital admission of interest). Individual patients can contribute multiple hospital admissions to the cohort over time (although only hospital admissions occurring >30 days after a prior discharge are eligible as index hospital admissions).

Description

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]

Study Plan

How is the study designed?

What is the study measuring?

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

Collaborators and Investigators

• Sponsor: University of British Columbia

Publications and helpful links

General Publications

• Staples JA, Liu G, Brubacher JR, Karimuddin A, Sutherland JM. Physician Financial Incentives to Reduce Unplanned Hospital Readmissions: an Interrupted Time Series Analysis. J Gen Intern Med. 2021 Nov;36(11):3431-3440. doi: 10.1007/s11606-021-06803-8. Epub 2021 May 4.

Study record dates

Study Major Dates

• Study Start (Actual): July 1, 2018
• Primary Completion (Actual): September 1, 2018
• Study Completion (Anticipated): December 1, 2023

Study Registration Dates

• First Submitted: August 18, 2017
• First Submitted That Met QC Criteria: August 18, 2017
• First Posted (Actual): August 22, 2017

Study Record Updates

• Last Update Posted (Actual): May 10, 2023
• Last Update Submitted That Met QC Criteria: May 8, 2023
• Last Verified: May 1, 2023

More Information

Terms related to this study

• Other Study ID Numbers: H17-01039

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Data stewards are legally prohibited from sharing IPD.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No