Monday, April 20, 2015

Does every discharged patient need close outpatient follow-up?

- Jennifer Middleton, MD, MPH

Reducing unnecessary readmissions has been of increasing interest to hospitals and health systems, but, until recently, no evidence base supported the current Medicare strategy of incentivizing outpatient follow-up within 30 days of discharge. Theoretically, this close follow-up allows the patient's outpatient physician to proactively address issues that, left unaddressed, could result in the patient being readmitted. Jackson et al in this month's Annals of Family Medicine showed that this strategy is beneficial, but only for patients with multiple chronic conditions.

The authors examined a year's worth of North Carolina Medicaid claims data to identify which patients had follow-up after hospital discharge and when after discharge they had it. They also stratified patients into risk categories for readmission in 30 days; to determine this risk, they looked at patients with similar diagnoses in the previous 5 years of claims data and identified readmission trends. They found that patients with 0 or 1 chronic medical conditions didn't benefit from close follow-up, as their baseline readmission rate was already quite low. For patients with multiple chronic medical conditions, though, close follow-up significantly reduced readmissions:
For those whose readmission risk exceeds 20%, our analysis suggests that 1 readmission may be prevented for every 5 patients who receive outpatient follow-up within 14 days. These patients are characterized by having 3 or more chronic conditions, often including advanced coronary artery disease, chronic obstructive pulmonary disease, chronic renal failure, congestive heart failure, diabetes, ischemic vascular disease, or a history of organ transplant, dialysis, or total parenteral nutrition. 
The challenge, conclude the authors, is that risk stratification for readmission is not common practice at the time of discharge.

The authors used claims data to identify regional "bounce back" trends, but validated tools like LACE might be easier for busier family physicians (Length of stay, Acute admission, Charlson comorbidity index tool, and number of Emergency Department visits in the last 6 months). The tricky part may be incorporating a tool like LACE into a busy outpatient-only family physicians' office. If the hospital discharging a patient doesn't calculate a LACE score, should the physicians' office prior to scheduling a follow-up appointment? It may be easier to just keep scheduling all discharged patients a follow-up appointment within 14 days, but how patient-centered is it to do so for the patients who may not benefit? How much responsibility for ensuring timely post-discharge follow-up should fall on the hospital, and how much on the outpatient family physician?

The question left unanswered by this study is what other benefits patients get from close follow-up besides lowered readmission rates. Are they more confident managing their medical conditions? Do those low-risk patients still find value in close follow-up? Hopefully researchers are focusing on other elements of post-hospital care besides readmissions to answer these patient-oriented questions.

In the meantime, the Family Practice Management website includes this article on using the Medicare transitional care management codes along with blog posts answering common questions about the codes and this list of additional resources.

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