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BACKGROUND: A small number of patients are disproportionally readmitted to hospitals. The Complex High Admission Management Program (CHAMP) was established as a multidisciplinary program to improve continuity of care and reduce readmissions for frequently hospitalized patients.
OBJECTIVE: To compare hospital utilization metrics among patients enrolled in CHAMP and usual care.
DESIGN: Pragmatic randomized controlled trial.
PARTICIPANTS: Inclusion criteria were as follows: 3 or more, 30-day inpatient readmissions in the previous year; or 2 inpatient readmissions plus either a referral or 3 observation admissions in previous 6 months.
INTERVENTIONS: Patients randomized to CHAMP were managed by an interdisciplinary team including social work, physicians, and pharmacists. The CHAMP team used comprehensive care planning and inpatient, outpatient, and community visits to address both medical and social needs. Control patients were randomized to usual care and contacted 18 months after initial identification if still eligible.
MAIN MEASURES: Primary outcome was number of 30-day inpatient readmissions 180 days following enrollment. Secondary outcomes were number of hospital admissions, total hospital days, emergency department visits, and outpatient clinic visits 180 days after enrollment.
KEY RESULTS: There were 75 patients enrolled in CHAMP, 76 in control. Groups were similar in demographic characteristics and baseline readmissions. At 180 days following enrollment, CHAMP patients had more inpatient 30-day readmissions [CHAMP incidence rate 1.3 (95% CI 0.9-1.8) vs. control 0.8 (95% CI 0.5-1.1), p=0.04], though both groups had fewer readmissions compared to 180 days prior to enrollment. We found no differences in secondary outcomes.
CONCLUSIONS: Frequently hospitalized patients experienced reductions in utilization over time. Though most outcomes showed no difference, CHAMP was associated with higher readmissions compared to a control group, possibly due to consolidation of care at a single hospital. Future research should seek to identify subsets of patients with persistently high utilization for whom tailored interventions may be beneficial.
TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03097640; https://clinicaltrials.gov/ct2/show/NCT03097640.
|Family Medicine (FM)/General Practice (GP)|
|General Internal Medicine-Primary Care(US)|
"Frequently hospitalized patients experienced reductions in utilization over time". OF COURSE -- they die or get lost. "Though most outcomes showed no difference, CHAMP was associated with higher readmissions compared to a control group". That doesn't make sense to me possibly due to consolidation of care at a single hospital. "June 13, 2019; enrollment was stopped on this date due to a slowing of eligible patients and a turnover in the program’s social work staff". This was a very significant change! CAUTION -- the centralized approach has a risk of becoming fascist.
A pragmatic study with a control group, but the intervention did not result in fewer readmissions when compared with a control group with usual care. The mortality between the two groups was not significantly different and the intervention may be difficult to scale. The methods to predict future hospital utilization must be based on comorbidities and social needs, so it would help identify the populations at early risk of hospital use.
In some sense, these are not surprising results. Certain conditions cannot be managed or managed safely in outpatient settings. Close attention to medical and social problems leads to identification of those conditions and increased hospitalization.
More trials are necessary.