Effectiveness of a financial incentive to physicians for timely follow-up after hospital discharge: a population-based time series analysis

BACKGROUND

Timely follow-up after hospital discharge may decrease readmission to hospital. Financial incentives to improve follow-up have been introduced in the United States and Canada, but it is unknown whether they are effective. Our objective was to evaluate the impact of an incentive program on timely physician follow-up after hospital discharge.

METHODS

We conducted an interventional time series analysis of all medical and surgical patients who were discharged home from hospital between Apr. 1, 2002, and Jan. 30, 2015, in Ontario, Canada. The intervention was a supplemental billing code for physician follow-up within 14 days of discharge from hospital, introduced in 2006. The primary outcome was an outpatient visit within 14 days of discharge. Secondary outcomes were 7-day follow-up and a composite of emergency department visits, nonelective hospital readmission and death within 14 days.

RESULTS

We included 8 008 934 patient discharge records. The incentive code was claimed in 31% of eligible visits by 51% of eligible physicians, and cost $17.5 million over the study period. There was no change in the average monthly rate of outcomes in the year before the incentive was introduced compared with the year following introduction: 14-day follow-up (66.5% v. 67.0%, overall p = 0.5), 7-day follow-up (44.9% v. 44.9%, overall p = 0.5) and composite outcome (16.7% v. 16.9%, overall p = 0.2).

INTERPRETATION

Despite uptake by physicians, a financial incentive did not alter follow-up after hospital discharge. This lack of effect may be explained by features of the incentive or by extra-physician barriers to follow-up. These barriers should be considered by policymakers before introducing similar initiatives.

Did the suicide barrier work after all? Revisiting the Bloor Viaduct natural experiment and its impact on suicide rates in Toronto

OBJECTIVE

This research aims to determine the long-term impact of the Bloor Street Viaduct suicide barrier on rates of suicide in Toronto and whether media reporting had any impact on suicide rates.

DESIGN

Natural experiment.

SETTING

City of Toronto, Canada; records at the chief coroner's office of Ontario 1993-2003 (11 years before the barrier) and 2004-2014 (11 years after the barrier).

PARTICIPANTS

5403 people who died by suicide in the city of Toronto.

MAIN OUTCOME MEASURE

Changes in yearly rates of suicide by jumping at Bloor Street Viaduct, other bridges including nearest comparison bridge and walking distance bridges, and buildings, and by other means.

RESULTS

Suicide rates at the Bloor Street Viaduct declined from 9.0 deaths/year before the barrier to 0.1 deaths/year after the barrier (incidence rate ratio (IRR) 0.005, 95% CI 0.0005 to 0.19, p=0.002). Suicide deaths from bridges in Toronto also declined significantly (IRR 0.53, 95% CI 0.40 to 0.71, p<0.0001). Media reports about suicide at the Bloor Street Viaduct were associated with an increase in suicide-by-jumping from bridges the following year.

CONCLUSIONS

The current study demonstrates that, over the long term, suicide-by-jumping declined in Toronto after the barrier with no associated increase in suicide by other means. That is, the barrier appears to have had its intended impact at preventing suicide despite a short-term rise in deaths at other bridges that was at least partially influenced by a media effect. Research examining barriers at other locations should interpret short-term results with caution.

On the Framing of Multiple Prospects

We investigated decisions involving multiple independent uncertain prospects. At the extremes, a decision maker may either consider each prospect as a separate event (segregation) or evaluate the overall distribution of outcomes (aggregation). Contrary to choice by segregation, people sometimes reject a single gamble but accept a repeated play. On the other hand, people tend to choose by segregation when a particular gamble is singled out from a larger ensemble. Similarly, physicians make different choices when they evaluate problems on a case-by-case basis than when they consider the broader picture. Peoples' tendency to segregate multiple prospects represents a significant violation of the standard theory of rational choice.

Failure of fertility therapy and subsequent adverse cardiovascular events

BACKGROUND

Infertility may indicate an underlying predisposition toward premature cardiovascular disease, yet little is known about potential long-term cardiovascular events following fertility therapy. We investigated whether failure of fertility therapy is associated with subsequent adverse cardiovascular events.

METHODS

We performed a population-based cohort analysis of women who received gonadotropin-based fertility therapy between Apr. 1, 1993, and Mar. 31, 2011, distinguishing those who subsequently gave birth and those who did not. Using multivariable Poisson regression models, we estimated the relative rate ratio of adverse cardiovascular events associated with fertility therapy failure, accounting for age, year, baseline risk factors, health care history and number of fertility cycles. The primary outcome was subsequent treatment for nonfatal coronary ischemia, stroke, transient ischemic attack, heart failure or thromboembolism.

RESULTS

Of 28 442 women who received fertility therapy, 9349 (32.9%) subsequently gave birth and 19 093 (67.1%) did not. The median number of fertility treatments was 3 (interquartile range 1-5). We identified 2686 cardiovascular events over a median 8.4 years of follow-up. The annual rate of cardiovascular events was 19% higher among women who did not give birth after fertility therapy than among those who did (1.08 v. 0.91 per 100 patient-years, p < 0.001), equivalent to a 21% relative increase in the annual rate (95% confidence interval 13%-30%). We observed no association between event rates and number of treatment cycles.

INTERPRETATION

Fertility therapy failure was associated with an increased risk of long-term adverse cardiovascular events. These women merit surveillance for subsequent cardiovascular events.

Clinical Action against Drunk Driving

In advance of a safety campaign on 17 March 2017, Donald Redelmeier and Allan Detsky call on physicians and clinical colleagues to reduce the chances that patients will drive drunk.

Life-threatening motor vehicle crashes in bright sunlight

Bright sunlight may create visual illusions that lead to driver error, including fallible distance judgment from aerial perspective. We tested whether the risk of a life-threatening motor vehicle crash was increased when driving in bright sunlight.This longitudinal, case-only, paired-comparison analysis evaluated patients hospitalized because of a motor vehicle crash between January 1, 1995 and December 31, 2014. The relative risk of a crash associated with bright sunlight was estimated by evaluating the prevailing weather at the time and place of the crash compared with the weather at the same hour and location on control days a week earlier and a week later.The majority of patients (n = 6962) were injured during daylight hours and bright sunlight was the most common weather condition at the time and place of the crash. The risk of a life-threatening crash was 16% higher during bright sunlight than normal weather (95% confidence interval: 9-24, P < 0.001). The increased risk was accentuated in the early afternoon, disappeared at night, extended to patients with different characteristics, involved crashes with diverse features, not apparent with cloudy weather, and contributed to about 5000 additional patient-days in hospital. The increased risk extended to patients with high crash severity as indicated by ambulance involvement, surgical procedures, length of hospital stay, intensive care unit admission, and patient mortality. The increased risk was not easily attributed to differences in alcohol consumption, driving distances, or anomalies of adverse weather.Bright sunlight is associated with an increased risk of a life-threatening motor vehicle crash. An awareness of this risk might inform driver education, trauma staffing, and safety warnings to prevent a life-threatening motor vehicle crash.

LEVEL OF EVIDENCE

Epidemiologic Study, level III.

The association between handheld phone bans and the prevalence of handheld phone conversations among young drivers in the United States

PURPOSE

Fourteen US states and the District of Columbia have banned handheld phone use for all drivers. We examined whether such legislation was associated with reduced handheld phone conversations among drivers aged younger than 25 years.

METHODS

Data from the 2008 to 2013 National Occupant Protection Use Survey were merged with states' legislation. The outcome was roadside-observed handheld phone conversation at stop signs or lights. Logistic regression was used.

RESULTS

A total of 32,784 young drivers were observed. Relative to drivers who were observed in states without a universal handheld phone ban, the adjusted odds ratio of phone conversation was 0.42 (95% confidence interval, 0.33-0.53) for drivers who were observed in states with bans. The relative reduction in phone conversation was 46% (23%, 61%) for laws that were effective less than 1 year, 55% (32%, 70%) for 1-2 years, 63% (51%, 72%) for 2 years or more, relative to no laws.

CONCLUSIONS

Universal handheld phone bans may be effective at reducing handheld phone use among young drivers.

Off-Road Vehicle Crash Risk during the Six Months after a Birthday

Background

Off-road vehicles are popular and thrilling for youth outside urban settings, yet sometimes result in a serious crash that requires emergency medical care. The relation between birthdays and the subsequent risk of an off-road vehicle crash is unknown.

Methods

We conducted a population-based before-and-after longitudinal analysis of youth who received emergency medical care in Ontario, Canada, due to an off-road vehicle crash between April 1, 2002, and March 31, 2014. We identified youth injured in an off-road vehicle crash through population-based health-care databases of individuals treated for medical emergencies. We included youth aged 19 years or younger, distinguishing juniors (age ≤ 15 years) from juveniles (age ≥ 16 years).

Results

A total 32,777 youths accounted for 35,202 emergencies due to off-road vehicle crashes within six months of their nearest birthday. Comparing the six months following a birthday to the six months prior to a birthday, crashes increased by about 2.7 events per 1000 juniors (18.3 vs 21.0, p < 0.0001). The difference equaled a 15% increase in relative risk (95% confidence interval 12 to 18). The increase extended for months following a birthday, was not observed for traffic crashes due to on-road vehicles, and was partially explained by a lack of helmet wearing. As expected, off-road crash risks did not change significantly following a birthday among juveniles (19.2 vs 19.8, p = 0.61).

Conclusions

Off-road vehicle crashes leading to emergency medical care increase following a birthday in youth below age 16 years. An awareness of this association might inform public health messages, gift-giving practices, age-related parental permissions, and prevention by primary care physicians.

Physician Warnings in Psychiatry and the Risk of Road Trauma: An Exposure Crossover Study

OBJECTIVE

To determine if physician warnings to psychiatric patients alter the subsequent frequency of a motor vehicle crash. A secondary objective was to determine if physician warnings change the subsequent frequency of psychiatric hospitalization.

METHODS

Exposure crossover design of 23,145 psychiatric patients diagnosed with ICD-9 schizophrenia (code 295), mood disorder (296), personality disorder (301), or substance use disorder (303, 304) and warned by their physician about driving safety between April 1, 2006, and March 31, 2011. Each patient was followed for 4 years before the warning and 1 year after the warning. Patients living outside the region or lacking a valid health card number were excluded.

RESULTS

Patients' motor vehicle crash frequency decreased from 11.78 to 8.17 events per 1,000 patients per year after a physician warning, which corresponded to a relative risk of 0.69 (95% CI, 0.59-0.81; P < .001). Psychiatric hospitalization frequency increased from 147 to 289 events per 1,000 patients per year corresponding to a relative risk of 1.97 (95% CI, 1.91-2.03; P < .001).

CONCLUSIONS

Physician warnings are associated with a subsequent decreased frequency of motor vehicle crashes and increased frequency of psychiatric hospitalization. This result suggests that physician warnings are an effective intervention for reducing road trauma but need to be weighed against potential adverse psychiatric health.

Motor vehicle crashes during pregnancy and cerebral palsy during infancy: a longitudinal cohort analysis

OBJECTIVES

To assess the incidence of cerebral palsy among children born to mothers who had their pregnancy complicated by a motor vehicle crash.

DESIGN

Retrospective longitudinal cohort analysis of children born from 1 April 2002 to 31 March 2012 in Ontario, Canada.

PARTICIPANTS

Cases defined as pregnancies complicated by a motor vehicle crash and controls as remaining pregnancies with no crash.

MAIN OUTCOME

Subsequent diagnosis of cerebral palsy by age 3 years.

RESULTS

A total of 1 325 660 newborns were analysed, of whom 7933 were involved in a motor vehicle crash during pregnancy. A total of 2328 were subsequently diagnosed with cerebral palsy, equal to an absolute risk of 1.8 per 1000 newborns. For the entire cohort, motor vehicle crashes correlated with a 29% increased risk of subsequent cerebral palsy that was not statistically significant (95% CI -16 to +110, p=0.274). The increased risk was only significant for those with preterm birth who showed an 89% increased risk of subsequent cerebral palsy associated with a motor vehicle crash (95% CI +7 to +266, p=0.037). No significant increase was apparent for those with a term delivery (95% CI -62 to +79, p=0.510). A propensity score-matched analysis of preterm births (n=4384) yielded a 138% increased relative risk of cerebral palsy associated with a motor vehicle crash (95% CI +27 to +349, p=0.007), equal to an absolute increase of about 10.9 additional cases per 1000 newborns (18.2 vs 7.3, p=0.010).

CONCLUSIONS

Motor vehicle crashes during pregnancy may be associated with an increased risk of cerebral palsy among the subgroup of cases with preterm birth. The increase highlights a specific role for traffic safety advice in prenatal care.

Driver's obesity and road crash risks in the United States

OBJECTIVE

We assessed obesity trends in U.S. drivers involved in fatal crashes since 1999 and distinguished whether crash risk factors were different between obese and nonobese drivers.

METHODS

We included only drivers of passenger cars involved in fatal traffic crashes between January 1, 1999, and December 31, 2012. Obesity was classified according to the World Health Organization guidelines and profiled between 1999 and 2012 using the adjusted prevalence ratio (aPR) from log-binomial regression models. Differences in crash risks (e.g., driver's fatality, drunk driving, seat belt nonuse) between obese and nonobese drivers were estimated as adjusted odds ratios (aORs) using logistic regression models.

RESULTS

A total of 753,024 U.S. drivers were involved in fatal crashes, for which obesity information was available for 534,887. About 56% (n = 299,078) were driving passenger cars. The prevalence of class I obesity increased from 10% in 1999 to 14% in 2012 (aPR = 1.50, 95% confidence interval [CI], 1.42-1.58), class II obesity from 3 to 5% (aPR = 2.22, 95% CI, 2.05-3.01), and class III obesity from 1 to 2% (aPR = 2.65; 95% CI, 2.27-3.10). Compared to nonobese controls, obese drivers had significantly higher risks for fatality (1.10 ≤ aOR ≤ 1.47), seat belt nonuse (1.00 ≤ aOR ≤ 1.21), need for extrication (1.01 ≤ aOR ≤ 1.23), and ambulance transport time ≥30 min (1.01 ≤ aOR ≤ 1.28). Compared to nonobese controls, obese drivers were less likely to drink drive (0.41 ≤ aOR ≤ 0.72) or speed >65 mph (0.78 ≤ aOR ≤ 0.93).

CONCLUSION

The rising national prevalence of obesity extends to U.S. drivers involved in fatal crashes and indicates the need to improve seat belt use, vehicle design, and postcrash care for this vulnerable population.

Self-harm Emergencies After Bariatric Surgery: A Population-Based Cohort Study

IMPORTANCE

Self-harm behaviors, including suicidal ideation and past suicide attempts, are frequent in bariatric surgery candidates. It is unclear, however, whether these behaviors are mitigated or aggravated by surgery.

OBJECTIVE

To compare the risk of self-harm behaviors before and after bariatric surgery.

DESIGN, SETTING, AND PARTICIPANTS

In this population-based, self-matched, longitudinal cohort analysis, we studied 8815 adults from Ontario, Canada, who underwent bariatric surgery between April 1, 2006, and March 31, 2011. Follow-up for each patient was 3 years prior to surgery and 3 years after surgery.

MAIN OUTCOMES AND MEASURES

Self-harm emergencies 3 years before and after surgery.

RESULTS

The cohort included 8815 patients of whom 7176 (81.4%) were women, 7063 (80.1%) were 35 years or older, and 8681 (98.5%) were treated with gastric bypass. A total of 111 patients had 158 self-harm emergencies during follow-up. Overall, self-harm emergencies significantly increased after surgery (3.63 per 1000 patient-years) compared with before surgery (2.33 per 1000 patient-years), equaling a rate ratio (RR) of 1.54 (95% CI, 1.03-2.30; P = .007). Self-harm emergencies after surgery were higher than before surgery among patients older than 35 years (RR, 1.76; 95% CI, 1.05-2.94; P = .03), those with a low-income status (RR, 2.09; 95% CI, 1.20-3.65; P = .01), and those living in rural areas (RR, 6.49; 95% CI, 1.42-29.63; P = .02). The most common self-harm mechanism was an intentional overdose (115 [72.8%]). A total of 147 events (93.0%) occurred in patients diagnosed as having a mental health disorder during the 5 years before the surgery.

CONCLUSIONS AND RELEVANCE

In this study, the risk of self-harm emergencies increased after bariatric surgery, underscoring the need for screening for suicide risk during follow-up.

Concussions and Repercussions

In their Perspective, Donald A. Redelmeier and Sheharyar Raza discuss the significance of Seena Fazel and colleagues' longitudinal study of traumatic brain injury (TBI)-associated outcomes.

Hospital Readmissions Following Physician Call System Change: A Comparison of Concentrated and Distributed Schedules

BACKGROUND

Physician call schedules are a critical element for medical practice and hospital efficiency. We compared readmission rates prior to and after a change in physician call system at Sunnybrook Health Sciences Centre.

METHODS

We studied patients discharged over a decade (2004 through 2013) and identified whether or not each patient was readmitted within the subsequent 28 days. We excluded patients discharged for a surgical, obstetrical, or psychiatric diagnosis. We used time-to-event analysis and time-series analysis to compare rates of readmission prior to and after the physician call system change (January 1, 2009).

RESULTS

A total of 89,697 patients were discharged, of whom 10,001 (11%) were subsequently readmitted and 4280 died. The risk of readmission was increased by about 26% following physician call system change (9.7% vs 12.2%, P <.001). Time-series analysis confirmed a 26% increase in the readmission rate after call system change (95% confidence interval, 22%-31%; P <.001). The increase in readmission rate after call system change persisted across patients with diverse ages, estimated readmission risks, and medical diagnoses. The net effect was equal to 7240 additional patient days in the hospital following call system change. A modest increase was observed at a nearby acute care hospital that did not change physician call system, and no increase in risk of death was observed with increased hospital readmissions.

CONCLUSION

We suggest that changes in physician call systems sometimes increase subsequent hospital readmission rates. Further reductions in readmissions may instead require additional resources or ingenuity.

Moving to a Highly Walkable Neighborhood and Incidence of Hypertension: A Propensity-Score Matched Cohort Study

BACKGROUND

The impact of moving to a neighborhood more conducive to utilitarian walking on the risk of incident hypertension is uncertain.

OBJECTIVE

Our study aimed to examine the effect of moving to a highly walkable neighborhood on the risk of incident hypertension.

METHODS

A population-based propensity-score matched cohort study design was used based on the Ontario population from the Canadian Community Health Survey (2001-2010). Participants were adults ≥ 20 years of age who moved from a low-walkability neighborhood (defined as any neighborhood with a Walk Score < 90) to either a high- (Walk Score ≥ 90) or another low-walkability neighborhood. The incidence of hypertension was assessed by linking the cohort to administrative health databases using a validated algorithm. Propensity-score matched Cox proportional hazard models were used. Annual health examination was used as a control event.

RESULTS

Among the 1,057 propensity-score matched pairs there was a significantly lower risk of incident hypertension in the low to high vs. the low to low-walkability groups [hazard ratio = 0.46; 95% CI, 0.26, 0.81, p < 0.01]. The crude hypertension incidence rates were 18.0 per 1,000 person-years (95% CI: 11.6, 24.8) among the low- to low-walkability movers compared with 8.6 per 1,000 person-years (95% CI: 5.3, 12.7) among the low- to high-walkability movers (p < 0.001). There were no significant differences in the hazard of annual health examination between the two mover groups.

CONCLUSIONS

Moving to a highly walkable neighborhood was associated with a significantly lower risk of incident hypertension. Future research should assess whether specific attributes of walkable neighborhoods (e.g., amenities, density, land-use mix) may be driving this relationship.

CITATION

Chiu M, Rezai MR, Maclagan LC, Austin PC, Shah BR, Redelmeier DA, Tu JV. 2016. Moving to a highly walkable neighborhood and incidence of hypertension: a propensity-score matched cohort study. Environ Health Perspect 124:754-760; http://dx.doi.org/10.1289/ehp.1510425.

Traffic Crash Risks in Morbidly Obese Drivers Before and After Weight Loss Surgery

Morbidly obese drivers have a higher risk of road crashes because of associated conditions such as obstructive sleep apnea. We assessed whether weight loss surgery has an impact on subsequent road crash risks in morbidly obese drivers. Our longitudinal self-matched cohort analyses suggest that road crash risks are three times higher in morbidly obese drivers than the population norm. Yet, weight loss surgery yields no significant reductions in crash risks. We found similar results in patients not previously diagnosed with sleep disorders, suggesting the need to clarify the relationship of obesity with road crash risk.