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- 1. 息2014 MFMER | slide-1 Preventing 30-day hospital readmissions A systematic review and meta-analysis of randomized trials Aaron Leppin, MD Knowledge and Evaluation Research Unit, Mayo Clinic Academy Health Annual Research Meeting San Diego, CA; June 8, 2014
- 2. 息2014 MFMER | slide-2 Disclosures and Funding none
- 3. 息2014 MFMER | slide-3 Background Reducing readmissions requires better understanding of causes Patient appraisal of need is key Depends on perception of resources Hospital is a source of capacity Recently discharged patients have low capacity for self-care1 1Krumholz, N Engl J Med. 2013.
- 4. 息2014 MFMER | slide-4 The Cumulative Complexity Model Shippee, J Clin Epidemiol., 2012
- 5. 息2014 MFMER | slide-5 Hypothesis When burdensome and insufficiently supported demands are placed on patients and caregivers post-discharge, it will overwhelm capacity and lead to readmission May, Montori, and Mair; BMJ. 2009.
- 6. 息2014 MFMER | slide-6 Objectives To synthesize RCT evidence of discharge interventions in reducing 30-day readmissions To explore the characteristics of these interventions that are most associated with their effectiveness
- 7. 息2014 MFMER | slide-7 Methods Data Sources and Study Selection Database search from 1990 to April 1, 2013 Reviewed bibliographies, expert contacts Eligibility Criteria Randomized trials of any discharge intervention Assessing risk of unplanned or all-cause readmission within 30-days with or without out of hospital deaths Patients admitted >24 hours for med/surg diagnosis and discharged to home
- 8. 息2014 MFMER | slide-8 Methods Data Extraction and Synthesis Extracted patient, intervention, and outcome characteristics Used activity-based coding strategy to de- bundle interventions and confirmed with authors Blinded raters evaluated net intervention descriptions to judge impact on patient workload and capacity
- 9. 息2014 MFMER | slide-9 Methods Activity-based Coding Strategy Discharge planning Case management Telephone follow-up Telemonitoring Patient education Self-management Medication intervention Home visits Follow-up scheduled Pt-centered discharge instructions Provider continuity Timely follow-up PCP communication Patient hotline Rehab intervention Streamlining Making requisite Other
- 10. 息2014 MFMER | slide-10 Methods Identifying Net Interventions CONTROLINTERVENTION Discharge planning Telephone follow-up Discharge planning Telephone follow-up Patient education NET INTERVENTION Patient education
- 11. 息2014 MFMER | slide-11 Methods Intervention Capacity/Workload Ratings IncreaseDecrease No Change
- 12. 息2014 MFMER | slide-12 Methods Data Analysis Random effects meta-analysis of relative risks of readmission in 30-days Planned, exploratory subgroup analyses of patient, intervention, and outcome characteristics Post-hoc regression model assessing value of comprehensive support in reducing 30-day readmissions
- 13. 息2014 MFMER | slide-13 Results Trial identification and Meta-analysis 47 randomized trials; 18 providing previously unpublished data 42 reported patient-level rates Pooled RR: 0.82 (95% CI 0.73 to 0.91) P<.001 I2=31% 5 reported event numbers only Pooled RR: 0.93 (95% CI 0.72 to 1.20) P=.59 I2=23%
- 14. 息2014 MFMER | slide-14 Results Subgroup analyses Intervention characteristics with significant interactions for reducing 30 day readmission rates Rated to increase patient capacity (P=.04) Delivered by two or more individuals (P=.05) Comprised five or more activities (P=.001) Study published prior to 2002 (P=.01)
- 15. 息2014 MFMER | slide-15 Results Meta-regression: Comprehensive support Variable scores from 0 to 4; 1 point each for: Rated to increase patient capacity Five or more meaningful patient interactions Two or more humans involved in delivery Five or more intervention activities Summed scores3 categories Category 1: 0 points Category 2: 1-2 points Category 3: 3-4 points
- 16. 息2014 MFMER | slide-16 Results Regression effects of comprehensive support Study Characteristic Number of Studies RR of Readmission Compared to Reference 95% Confidence Interval p value Category 1 15 1 (reference) Category 2 20 0.82 0.66 to 1.02 0.07 Category 3 7 0.63 0.43 to 0.91 0.02 Publication in 2002 or after 33 1.47 1.10 to 1.96 0.01
- 17. 息2014 MFMER | slide-17 Results Category 3 Interventions: consistent and complex strategy that emphasized the assessment and addressing of factors related to patient context and capacity for self-care (including the impact of comorbidities, functional status, caregiver capabilities, socioeconomic factors, potential for self- management, and patient and caregiver goals for care). These interventions coordinated care across the inpatient-to-outpatient transition and involved multiple patient interactions; all but 1 involved patient home visits. Leppin, JAMA Internal Medicine, 2014
- 18. 息2014 MFMER | slide-18 Strengths/Limitations Largest and most homogenous collection of randomized trial evidence Hypothesis-generating work Evidence of publication bias Workload and capacity ratings were global assessments; no validated or criterion-based scale
- 19. 息2014 MFMER | slide-19 Conclusions and Implications A comprehensive and complex strategy that fully supports patients post-discharge has shown consistent value (many report cost savings) Recent meta-analysis in heart failure is complementary; stresses value of home visits1 Many interventions currently being tested do not follow this strategy and are less effective 1Feltner, Annals of Internal Medicine, 2014
- 20. 息2014 MFMER | slide-20 Acknowledgements Michael R. Gionfriddo, PharmD Maya Kessler, MD Juan Pablo Brito, MBBS Frances S. Mair, MD Katie Gallacher, MBChB Zhen Wang, Phd Patricia J. Erwin, MLS Tanya Sylvester, BS Kasey Boehmer, BS Henry H. Ting, MD, MBA M. Hassan Murad, MD Nathan D. Shippee, PhD Victor M. Montori, MD
- 21. 息2014 MFMER | slide-21 Thank you for your attention! Leppin.Aaron@mayo.edu www.minimallydisruptivemedicine.org Leppin AL, Gionfriddo MR, Kessler M, et al. Preventing 30-Day Hospital Readmissions: A Systematic Review and Meta-analysis of Randomized Trials. JAMA Intern Med. Published online May 12, 2014. doi:10.1001/jamainternmed.2014.1608.