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Research ArticleOriginal Research

Timeliness of Outpatient Follow-up: An Evidence-Based Approach for Planning After Hospital Discharge

Carlos Jackson, Mohammad Shahsahebi, Tiffany Wedlake and C. Annette DuBard
The Annals of Family Medicine March 2015, 13 (2) 115-122; DOI: https://doi.org/10.1370/afm.1753
Carlos Jackson
1Community Care of North Carolina, Raleigh, North Carolina
PhD
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Mohammad Shahsahebi
2Duke Family Medicine, Duke University Medical Center, Durham, North Carolina
MD, MBA
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Tiffany Wedlake
1Community Care of North Carolina, Raleigh, North Carolina
MD, MPH
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C. Annette DuBard
1Community Care of North Carolina, Raleigh, North Carolina
MD, MPH
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  • For correspondence: adubard@n3cn.org
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    Figure 1

    Time to readmission for patients who did vs did not receive outpatient follow-up within 7 days of discharge: lower risk strata.

    Note: Rates vary according to the patient’s underlying clinical risk. Each stratum represents patients in clinical risk groups based on 3M Health Information System’s Clinical Risk Groups and accompanying baseline risk of a 30-day readmission.

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    Figure 2

    Time to readmission for patients who did vs did not receive outpatient follow-up within 7 days of discharge: higher risk strata.

    Note: Rates vary according to the patient’s underlying clinical risk. Each stratum represents patients in clinical risk groups based on 3M Health Information System’s Clinical Risk Groups and accompanying baseline risk of a 30-day readmission.

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    Figure 3

    Relationship between receipt of outpatient follow-up and risk of readmission.

    Incremental risk of a 30-day readmission associated with patients who have not yet received follow-up within 3, 7, 14, 21, and 30 days after discharge, and how that relationship varies according to the patient’s underlying clinical risk. Each of the 7 strata represents patients in clinical risk groups based on 3M Health Information System’s Clinical Risk Groups and accompanying baseline risk of a 30-day readmission.

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    Table 1

    Characteristics of Study Sample by Risk Strata

    Risk Strata (Readmission Risk)aNo. of Unique PatientsAge, y Mean (SD)Race No. (% White)Sex No. (% Female)
    No chronic conditions (<10%)13,21212.2 (15.1)6,592 (50.1)6,892 (52.2)
    Single chronic conditions (<10%)8,17617.3 (16.6)3,598 (44.0)4,103 (50.2)
    Multiple chronic conditions (<10%)9,70536.2 (18.7)5,058 (52.1)5,937 (61.2)
    Multiple chronic conditions (10%–19%)7,11438.2 (18.6)3,672 (51.6)4,211 (59.2)
    Multiple chronic conditions (20%–29%)4,13539.2 (19.2)2,157 (46.9)2,227 (53.9)
    Multiple chronic conditions (30%–39%)1,57040.5 (19.6)736 (37.9)885 (56.4)
    Multiple chronic conditions (≥40%)56146.2 (16.6)225 (40.1)342 (61.0)
    Total44,47326.5 (21.1)22,038 (49.6)24,597 (55.3)
    • ↵a Risk of readmission within 30 days.

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    Table 2

    30-Day Readmission Rates by Clinical Risk Strata and Outpatient Follow-up Status

    Risk Strata: Follow-up Within Indicated DaysReadmission, Receiving Follow-up %Readmission, Not Receiving Follow-up %Difference %P Value
    No chronic conditions (<10% readmission risk), n = 14,767a
     3 d4.75.91.2.004
     7 d5.16.00.9.006
     14 d4.96.41.5<.001
     21 d4.77.02.3<.001
     30 d4.57.53.0<.001
    Single chronic condition (<10% readmission risk), n= 10,027a
     3 d6.06.40.4.511
     7 d6.06.60.6.183
     14 d5.86.91.1.014
     21 d5.47.52.1<.001
     30 d5.18.43.3<.001
    Multiple chronic conditions (<10% readmission risk), n = 12,777a
     3 d308.9−0.3.720
     7 d8.99.00.1.522
     14 d7.610.22.6<.001
     21 d6.811.74.9<.001
     30 d6.213.87.6<.001
    Multiple chronic conditions (10%–19% readmission risk), n = 11,894a
     3 d14.915.40.5.387
     7 d14.415.81.4.004
     14 d12.518.35.8<.001
     21 d11.620.99.3<.001
     30 d10.724.714.0<.001
    Multiple chronic conditions (20%–29% readmission risk), n = 9,018a
     3 d21.524.73.2.011
     7 d20.126.36.2<.001
     14 d18.530.512.0<.001
     21 d17.334.817.5<.001
     30 d16.040.624.6<.001
    Multiple chronic conditions (30%–39% readmission risk), n = 4,552a
     3 d30.132.72.6.129
     7 d27.934.56.6<.001
     14 d25.040.515.5<.001
     21 d24.145.020.9<.001
     30 d22.651.228.6<.001
    Multiple chronic conditions (≥40% readmission risk), n = 2,050a
     3 d40.643.02.4.144
     7 d37.445.17.7<.001
     14 d32.751.819.1<.001
     21 d30.658.327.7<.001
     30 d28.964.335.5<.001
    • ↵a Number of index discharges.

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    Timeliness of Outpatient Follow-up: An Evidence-Based Approach for Planning After Hospital Discharge

    C. Annette DuBard , and colleagues

    Background Timely outpatient follow-up is considered key to reducing hospital readmissions. This study looks at the optimal timing of hospital follow-up for patients of varying complexity.

    What This Study Found Although most patients do not meaningfully benefit from early outpatient follow-up, high risk patients do. Among patients with up to one chronic or acute condition, readmissions are uncommon, and the timing of outpatient follow-up for up to 30 days has little effect. Among patients with multiple chronic conditions, however, follow-up within 7 days is associated with meaningful reductions in risk of readmission.

    Implications

    • While healthier patients and those with greater social support or self-management skills may be better equipped to make and attend an earlier follow-up appointment, it can potentially delay care for those with more complex needs.
    • The authors suggest that transitional care resources can best be used to ensure that highest risk patients receive follow-up within 7 days.
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The Annals of Family Medicine: 13 (2)
The Annals of Family Medicine: 13 (2)
Vol. 13, Issue 2
March/April 2015
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Timeliness of Outpatient Follow-up: An Evidence-Based Approach for Planning After Hospital Discharge
Carlos Jackson, Mohammad Shahsahebi, Tiffany Wedlake, C. Annette DuBard
The Annals of Family Medicine Mar 2015, 13 (2) 115-122; DOI: 10.1370/afm.1753

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Timeliness of Outpatient Follow-up: An Evidence-Based Approach for Planning After Hospital Discharge
Carlos Jackson, Mohammad Shahsahebi, Tiffany Wedlake, C. Annette DuBard
The Annals of Family Medicine Mar 2015, 13 (2) 115-122; DOI: 10.1370/afm.1753
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Subjects

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