Impact of telephone follow-up and 24/7 hotline on 30-day readmission rates following aortic valve replacement -A randomized controlled trial

Early postoperative telehealth visit protocol implementation reduces emergency department utilization following benign foregut procedures

INTRODUCTION

Emergency department (ED) visits and readmissions following benign foregut surgery (BFS) represent a burden on patients and the health care system. The objective of this study was to identify differences in ED visits and readmissions before and after implementation of an early postoperative telehealth visit protocol for BFS. We hypothesized that utilization of telehealth visits would be associated with reduced post-operative ED and hospital utilization.

METHODS

An early postoperative telehealth protocol was initiated in 2020 at an academic medical center to provide a video conference within the first postoperative week. Consecutive elective BFS including fundoplication, Linx, paraesophageal hernia repair, and Heller myotomy performed between 2018 and 2022 were included. Outcomes included ED visits and 30-day readmission. Bivariate analyses were performed using Chi-squared testing for categorical variables. The association between telehealth visits and outcomes were evaluated using multivariable logistic regression.

RESULTS

616 patients underwent BFS during the study period. 310 (50.3%) were performed prior to the implementation of telehealth visits and 306 (49.7%) were after. 241 patients in the telehealth visit group (78.8%) completed their telehealth visit. A total of 34 patients (5.5%) had ED visits without readmission while 38 patients (6.2%) were readmitted within the first 30 days. The most common cause of ED visits and readmissions included pain (n = 18, 25%) and nausea/vomiting (n = 12, 16%). There was a significant reduction in ED visits without admission following telehealth visit implementation (7.4% vs 3.6%; OR 2.20, 95% CI 1.04-4.65, p = 0.04). There was no difference in readmission rates (6.1% versus 6.5%; OR 0.89, 95% CI 0.46-1.73, p = 0.73). The telehealth cohort had significantly lower ED visits for pain (31% vs 16.7%, p = 0.04) and nausea/vomiting (23.8% vs 6.7%, p = 0.02).

DISCUSSION

Early telehealth follow-up was associated with a significant decrease in ED visits following BFS. The majority of this was attributable to a reduction in ED visits for pain, nausea, and vomiting. These results provide a possible avenue for improving quality and cost-effectiveness within this patient population.

Transitional Care Interventions From Hospital to Community to Reduce Health Care Use and Improve Patient Outcomes: A Systematic Review and Network Meta-Analysis

Importance

Discharge from the hospital to the community has been associated with serious patient risks and excess service costs.

Objective

To evaluate the comparative effectiveness associated with transitional care interventions with different complexity levels at improving health care utilization and patient outcomes in the transition from the hospital to the community.

Data Sources

CENTRAL, Embase, MEDLINE, and PsycINFO were searched from inception until August 2022.

Study Selection

Randomized clinical trials evaluating transitional care interventions from hospitals to the community were identified.

Data Extraction and Synthesis

At least 2 reviewers were involved in all data screening and extraction. Random-effects network meta-analyses and meta-regressions were applied. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed.

Main Outcomes and Measures

The primary outcomes were readmission at 30, 90, and 180 days after discharge. Secondary outcomes included emergency department visits, mortality, quality of life, patient satisfaction, medication adherence, length of stay, primary care and outpatient visits, and intervention uptake.

Results

Overall, 126 trials with 97 408 participants were included, 86 (68%) of which were of low risk of bias. Low-complexity interventions were associated with the most efficacy for reducing hospital readmissions at 30 days (odds ratio [OR], 0.78; 95% CI, 0.66 to 0.92) and 180 days (OR, 0.45; 95% CI, 0.30 to 0.66) and emergency department visits (OR, 0.68; 95% CI, 0.48 to 0.96). Medium-complexity interventions were associated with the most efficacy at reducing hospital readmissions at 90 days (OR, 0.64; 95% CI, 0.45 to 0.92), reducing adverse events (OR, 0.42; 95% CI, 0.24 to 0.75), and improving medication adherence (standardized mean difference [SMD], 0.49; 95% CI, 0.30 to 0.67) but were associated with less efficacy than low-complexity interventions for reducing readmissions at 30 and 180 days. High-complexity interventions were most effective for reducing length of hospital stay (SMD, -0.20; 95% CI, -0.38 to -0.03) and increasing patient satisfaction (SMD, 0.52; 95% CI, 0.22 to 0.82) but were least effective for reducing readmissions at all time periods. None of the interventions were associated with improved uptake, quality of life (general, mental, or physical), or primary care and outpatient visits.

Conclusions and Relevance

These findings suggest that low- and medium-complexity transitional care interventions were associated with reducing health care utilization for patients transitioning from hospitals to the community. Comprehensive and consistent outcome measures are needed to capture the patient benefits of transitional care interventions.

The Effect of a Healthcare Services Hotline on Quality of Life and Hospital Readmissions for Patients with Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a common debilitating disease marked by frequent exacerbations and hospitalizations, economic burden, and reduced quality of life. This study aimed to determine the effect of a healthcare hotline on quality of life and hospital readmissions within 30 days of discharge for patients with COPD. Sixty patients with COPD who needed home healthcare services were recruited for this quasi-experimental study. A direct hotline was provided to patients and their caregivers in the intervention group to answer their questions about the disease. Data were collected using a demographics checklist, and St. George Respiratory Questionnaire. The number of hospitalizations and mean length of hospital stay in the intervention group within 30 days was significantly lower than the control group (p < 0.05). As for quality of life, only the mean score of symptoms was significantly different between the intervention and control groups (p < 0.05). The results showed the positive effect of a healthcare hotline on reducing readmission rates within 30 days of discharge and its low effect on quality of life of COPD patients.

A Mobile Phone App Improves Patient-Physician Communication and Reduces Emergency Department Visits After Colorectal Surgery

BACKGROUND

Emergency visits after colorectal surgery are common and require significant health care resources. However, many visits may be avoidable with alternative access to care. Mobile health technologies can facilitate patient access to health care providers.

OBJECTIVE

We hypothesized that a mobile app for postdischarge monitoring with patient-provider communication ability would reduce emergency visits after elective abdominopelvic colorectal surgery.

DESIGN

This is a prospective cohort study with a regression analysis after coarsened exact matching.

SETTING

The study was conducted at a single colorectal referral center from May 2019 to September 2020.

PATIENTS

A total of 114 patients were recruited to the intervention and were matched to a retrospective cohort of 608 patients from the 24 months before the study. All patients were managed according to an enhanced recovery pathway.

INTERVENTIONS

A mobile phone app comprised of patient education material, daily questionnaires assessing postdischarge recovery, and patient-provider chat function was used.

MAIN OUTCOME MEASURES

The primary outcomes included potentially preventable 30-day emergency visits defined according to a validated algorithm. Secondary outcomes included length of stay, complications, total emergency department visits, readmissions, and app usability.

RESULTS

Coarsened-exact matching resulted in a matched sample of 94 prospective intervention patients and 256 retrospective control patients. The prospective group was associated with fewer preventable emergency department visits (incidence rate ratio 0.34; p = 0.043) and shorter length of stay (-1.62 days; p = 0.011). There were no differences in 30-day complications, total number of emergency visits, or readmissions. Patient-reported usability of the mobile app was high, with 88% of patients reporting that the app improved their ability to communicate with their surgeon.

LIMITATIONS

We did not account for patient activation or perform a cost-analysis.

CONCLUSION

Use of a mobile app was associated with fewer potentially preventable emergency visits and shorter length of stay after major elective colorectal surgery, which may be due to enhanced postdischarge monitoring and patient-provider communication. See Video Abstract at http://links.lww.com/DCR/B878 .

APLICACIN DE TELFONO MVIL MEJORA LA COMUNICACIN ENTRE MDICO Y PACIENTE Y REDUCE LAS VISITAS AL DEPARTAMENTO DE EMERGENCIAS DESPUS DE CIRUGA COLORECTAL

ANTECEDENTES:Las visitas de emergencia después de la cirugía colorrectal son frecuentes y requieren importantes recursos sanitarios. Sin embargo, muchas visitas pueden evitarse con un acceso alternativo a la atención. Las tecnologías de salud móviles pueden facilitar el acceso de los pacientes a los proveedores de atención médica.OBJETIVO:Se planteó la hipótesis de que una aplicación móvil para el seguimiento posterior al alta con capacidad de comunicación entre el paciente y el médico reduciría las visitas de emergencia después de cirugía colorrectal abdominopélvica electiva.DISEÑO:Este es un estudio de cohorte prospectivo con un análisis de regresión después de un emparejamiento exacto aproximado.ENTORNO CLINICO:El estudio se llevó a cabo en un solo centro de referencia colorrectal entre 05/2019 y 09/2020.PACIENTES:Se reclutó un total de 114 pacientes para la intervención y se emparejaron con una cohorte retrospectiva de 608 pacientes de los 24 meses anteriores al estudio. Todos los pacientes fueron tratados con protocolo de enhanced recovery .INTERVENCIONES:Se utilizó una aplicación para teléfono móvil compuesta de material educativo para el paciente, cuestionarios diarios que evalúan la recuperación posterior al alta y una función de chat entre el paciente y el médico.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios incluyeron visitas a la emergencia en 30 días potencialmente prevenibles, definidas según un algoritmo validado. Los resultados secundarios incluyeron la duración de la estancia, complicaciones, total de visitas al departamento de emergencias, reingresos y la usabilidad de la aplicación.RESULTADOS:El emparejamiento aproximado-exacto resultó en una muestra emparejada de 94 APP + y 256 APP-. APP + se asoció con menos visitas evitables al servicio de urgencias (IRR 0,34, p = 0,043) y una estancia más corta (-1,62 días, p = 0,011). No hubo diferencias en las complicaciones a los 30 días, número total de visitas de emergencia y reingresos. La usabilidad de la aplicación móvil informada por los pacientes fue alta, y el 88% de los pacientes informaron que la aplicación mejoró su capacidad para comunicarse con su cirujano.LIMITACIONES:No contabilizamos la activación del paciente ni realizamos un análisis de costos.CONCLUSIÓNES:El uso de una aplicación móvil se asoció con menos visitas a la emergencia potencialmente prevenibles y una estadía más corta después de una gran cirugía colorrectal electiva, lo que puede deberse a una mejor monitorización posterior al alta y a la comunicación entre el paciente y el médico. Consulte Video Resumen en http://links.lww.com/DCR/B878 . (Traducción-Dr. Francisco M. Abarca-Rendon ).

Long-term effects of cardiac rehabilitation after heart valve surgery - results from the randomised CopenHeartVR trial

Aims. The CopenHeart_VR trial found positive effects of cardiac rehabilitation (CR) on physical capacity at 4 months. The long-term effects of CR following valve surgery remains unclear, especially regarding readmission and mortality. Using data from he CopenHeart_VR Trial we investigated long-term effects on physical capacity, mental and physical health and effect on mortality and readmission rates as prespecified in the original protocol. Methods. A total of 147 participants were included after heart valve surgery and randomly allocated 1:1 to 12-weeks exercise-based CR including a psycho-educational programme (intervention group) or control. Physical capacity was assessed as peak oxygen uptake (VO₂ peak) measured by cardiopulmonary exercise testing, mental and physical health by Short Form-36 questionnaire, Hospital Anxiety and Depression Scale, and HeartQol. Mortality and readmission were obtained from hospital records and registers. Groups were compared using mixed regression model analysis and log rank test. Results. No differences in VO₂ peak at 12 months or in self-assessed mental and physical health at 24 months (68% vs 75%, p = .120) was found. However, our data demonstrated reduction in readmissions in the intervention group at intermediate time points; after 3, 6 (43% vs 59%, p = .03), and 12 (53% vs 67%, p = .04) months, respectively, but no significant effect at 24 months. Conclusions. Exercise-based CR after heart valve surgery reduces combined readmissions and mortality up to 12 months despite lack of improvement in exercise capacity, physical and mental health long-term. Exercise-based CR can ensure short-term benefits in terms of physical capacity, and lower readmission within a year, but more research is needed to sustain these effects over a longer time period. These considerations should be included in the management of patients after heart valve surgery.

Effects of eHealth Interventions on Quality of Life and Psychological Outcomes in Cardiac Surgery Patients: Systematic Review and Meta-analysis

BACKGROUND

Patients undergoing heart surgery may experience a range of physiological changes, and the postoperative recovery time is long. Patients and their families often have concerns about quality of life (QoL) after discharge. eHealth interventions may improve patient participation, ensure positive and effective health management, improve the quality of at-home care and the patient's quality of life, and reduce rates of depression.

OBJECTIVE

The purpose of this study was to evaluate the effects of eHealth interventions on the physiology, psychology, and compliance of adult patients after cardiac surgery to provide a theoretical basis for clinical practice.

METHODS

We conducted systematic searches of the following 4 electronic databases: PubMed, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials. Mean (SD) values were used to calculate the pooled effect sizes for all consecutive data, including QoL, anxiety, and depression. Where the same results were obtained using different instruments, we chose the standardized mean difference with a 95% CI to represent the combined effect size; otherwise, the mean difference (MD) with a 95% CI was used. Odds ratios were used to calculate the combined effect size for all dichotomous data. The Cohen Q test for chi-square distribution and an inconsistency index (I2) were used to test for heterogeneity among the studies. We chose a fixed-effects model to estimate the effect size if there was no significant heterogeneity in the data (I2≤50%); otherwise, a random-effects model was used. The quality of the included studies was assessed using the Cochrane risk-of-bias tool for randomized trials (RoB 2).

RESULTS

The search identified 3632 papers, of which 19 met the inclusion criteria. In terms of physical outcomes, the score of the control group was lower than that of the intervention group (MD 0.15, 95% CI 0.03-0.27, I2=0%, P=.02). There was no significant difference in the mental outcomes between the intervention and control groups (MD 0.10, 95% CI -0.03 to 0.24, I2=46.4%, P=.14). The control group's score was lower than that of the intervention group for the depression outcomes (MD -0.53, 95% CI -0.89 to -0.17, I2=57.1%, P=.004). Compliance outcomes improved in most intervention groups. The results of the sensitivity analysis were robust. Nearly half of the included studies (9/19, 47%) had a moderate to high risk of bias. The quality of the evidence was medium to low.

CONCLUSIONS

eHealth improved the physical component of quality of life and depression after cardiac surgery; however, there was no statistical difference in the mental component of quality of life. The effectiveness of eHealth on patient compliance has been debated. Further high-quality studies on digital health are required.

TRIAL REGISTRATION

PROSPERO CRD42022327305; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=327305.

Optimizing Discharge After Shorter Hospitalizations: Lessons Learned Through After-Hours Calls with Thoracic Surgical Patients

OBJECTIVE

Minimally invasive procedures coupled with enhanced recovery pathways enable faster postoperative recovery and shorter hospitalizations. However, patients may experience unexpected concerns after return home, prompting after-hours calls. We aimed to characterize concerns prompting after-hours calls to improve discharge strategies.

METHODS

A single-institution, retrospective review was conducted of thoracic surgical patients from 11/4/2019 to 6/14/2020. Records were reviewed and elements of patient demographics, surgical procedures, postoperative courses, reasons for calls, and outcome of calls were collected. We compared characteristics of patients who made after-hours calls to those who did not, and performed multivariable analysis to identify characteristics associated with making an after-hours call.

RESULTS

During the study period, 379 patients underwent thoracic surgical procedures, among whom 88 (23.2%) initiated after-hours calls. Of these, 62 (70%) addressed patient symptoms, while 26 (30%) addressed patient questions including drain management, medications, and hospital policy questions. Patients making after-hours calls more frequently had undergone complex operations (26.1% vs 8.2%, P = 0.001), and were less likely to have received a standardized, clinician-initiated post-discharge telephone follow-up (29.5% vs 54.3%, P < 0.001). Complex operations increased likelihood of after-hours calls (OR: 3.33, 95% CI: 1.69-6.57, P < 0.001), while receipt of clinician-initiated telephone follow-up decreased likelihood of after-hours calls (OR: 0.38, 95% CI: 0.22-0.64, P < 0.001). There were no differences in emergency visits between the 2 groups (11% vs 8%, P = 0.370).

CONCLUSIONS

Despite efforts to optimize patient symptoms and knowledge prior to discharge, a substantial number of patients still have concerns after discharge. Many after-hours calls are related to knowledge gaps that may be addressed with improved predischarge education. Moreover, clinician-initiated telephone follow-up shows benefit in reducing after-hours calls.

Do postoperative telemedicine interventions with a communication feature reduce emergency department visits and readmissions?-a systematic review and meta-analysis

INTRODUCTION

Emergency department (ED) visits and readmissions after surgery are common and represent a significant cost-burden on the healthcare system. A notable portion of these unplanned visits are the result of expected complications or normal recovery after surgery, suggesting that improved coordination and communication in the outpatient setting could potentially prevent these. Telemedicine can improve patient-physician communication and as such may have a role in limiting unplanned emergency department visits and readmissions in postoperative patients.

METHODS

Major electronic databases were searched for randomized controlled trials and cohort studies in surgical patients examining the effect of postoperative telemedicine interventions with a communication feature on 30-day readmissions and emergency department visits as compared to current standard postoperative follow-up. All surgical subspecialties were included. Two independent reviewers assessed eligibility, extracted data, and evaluated risk of bias using standardized tools. Our primary outcomes of interest were 30-day ED visits and readmissions. Our secondary outcomes were patient satisfaction with the intervention.

RESULTS

29 studies were included in the final analysis. Fourteen studies were RCTs, and the remaining fifteen were cohort studies. Eighteen studies reported 30-day ED visit as an outcome. There was no overall reduction in 30-day ED visit in the telemedicine group (RR: 0.89, 95%CI: 0.70-1.12). Twenty-two studies reported 30-day readmission as an outcome. The overall pooled estimate did not show a difference in this outcome (RR: 0.90, 95%CI: 0.74-1.09). Fifteen studies reported a metric of patient satisfaction regarding utilization of the telemedicine intervention. All studies demonstrated high levels of satisfaction (> 80%) with the telemedicine intervention.

DISCUSSION

This review fails to demonstrate a clear reduction ED visits and readmissions to support use of a telemedicine intervention across the board. This may be in part explained by significant heterogeneity in the proportions of potentially preventable visits in each surgical specialty. As such, targeting interventions to specific surgical settings may prove most useful.

Facilitators of and barriers to reducing thirty-day readmissions and improving patient-reported outcomes after surgical aortic valve replacement: a process evaluation of the AVRre trial

BACKGROUND

The Aortic Valve Replacement Readmission (AVRre) randomized control trial tested whether a telephone intervention would reduce hospital readmissions following surgical aortic valve replacement (SAVR). The telephone support provided 30 days of continuous phone-support (hotline) and two scheduled phone-calls from the hospital after discharge. The intervention had no effect on reducing 30-day all-cause readmission rate (30-DACR) but did reduce participants' anxiety compared to a control group receiving usual care. Depression and participant-reported health state were unaffected by the intervention. To better understand these outcomes, we conducted a process evaluation of the AVRre trial to gain insight into the (1) the dose and fidelity of the intervention, (2) mechanism of impacts, and (3) contextual factors that may have influenced the outcomes.

METHODS

The process evaluation was informed by the Medical Research Council framework, a widely used set of guidelines for evaluating complex interventions. A mix of quantitative (questionnaire and journal records) and qualitative data (field notes, memos, registration forms, questionnaire) was prospectively collected, and retrospective interviews were conducted. We performed descriptive analyses of the quantitative data. Content analyses, assisted by NVivo, were performed to evaluate qualitative data.

RESULTS

The nurses who were serving the 24/7 hotline intervention desired to receive more preparation before intervention implementation. SAVR patient participants were highly satisfied with the telephone intervention (58%), felt safe (86%), and trusted having the option of calling in for support (91%). The support for the telephone hotline staff was perceived as a facilitator of the intervention implementation. Content analyses revealed themes: "gap in the care continuum," "need for individualized care," and "need for easy access to health information" after SAVR. Differences in local hospital discharge management practices influenced the 30-DACR incidence.

CONCLUSIONS

The prospective follow-up of the hotline service during the trial facilitated implementation of the intervention, contributing to high participant satisfaction and likely reduced their anxiety after SAVR. Perceived less-than-optimal preparations for the hotline could be a barrier to AVRre trial implementation. Integrating user experiences into a mixed-methods evaluation of clinical trials is important for broadening understanding of trial outcomes, the mechanism of impact, and contextual factors that influence clinical trials.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02522663. Registered on 11 August 2015.