The Effects of a Multifaceted Intervention to Improve Care Transitions Within an Accountable Care Organization: Results of a Stepped-Wedge Cluster-Randomized Trial
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BACKGROUND: Transitions from hospital to the ambulatory setting are high risk for patients in terms of adverse events, poor clinical outcomes, and readmission.
OBJECTIVES: To develop, implement, and refine a multifaceted care transitions intervention and evaluate its effects on postdischarge adverse events.
DESIGN, SETTING, AND PARTICIPANTS: Two-arm, single-blind (blinded outcomes assessor), stepped-wedge, cluster-randomized clinical trial. Participants were 1,679 adult patients who belonged to one of 17 primary care practices and were admitted to a medical or surgical service at either of two participating hospitals within a pioneer accountable care organization (ACO).
INTERVENTIONS: Multicomponent intervention in the 30 days following hospitalization, including: inpatient pharmacist-led medication reconciliation, coordination of care between an inpatient “discharge advocate” and a primary care “responsible outpatient clinician,” postdischarge phone calls, and postdischarge primary care visit.
MAIN OUTCOMES AND MEASURES: The primary outcome was rate of postdischarge adverse events, as assessed by a 30-day postdischarge phone call and medical record review and adjudicated by two blinded physician reviewers. Secondary outcomes included preventable adverse events, new or worsening symptoms after discharge, and 30-day nonelective hospital readmission.
RESULTS: Among patients included in the study, 692 were assigned to usual care and 987 to the intervention. Patients in the intervention arm had a 45% relative reduction in postdischarge adverse events (18 vs 23 events per 100 patients; adjusted incidence rate ratio, 0.55; 95% CI, 0.35-0.84). Significant reductions were also seen in preventable adverse events and in new or worsening symptoms, but there was no difference in readmission rates.
CONCLUSION: A multifaceted intervention was associated with a significant reduction in postdischarge adverse events but no difference in 30-day readmission rates.
© 2021 Society of Hospital Medicine
CONCLUSION
In conclusion, in this real-world clinical trial, we designed, implemented, and iteratively refined a multifaceted intervention to improve care transitions within a hospital-based academic ACO. Evolution of the intervention components was the result of stakeholder input, experience with the intervention, and ACO resource constraints. The intervention reduced postdischarge adverse events. However, across the ACO network, intervention fidelity was low, and this may have contributed to the lack of effect on readmission rates. ACOs that implement interventions without hiring new personnel or protecting the time of existing personnel to conduct transitional tasks are likely to face the same challenges of low fidelity.
Acknowledgments
The authors would like to acknowledge the many people who worked on designing, implementing, and evaluating this intervention, including but not limited to: Natasha Isaac, Hilary Heyison, Jacqueline Minahan, Molly O’Reilly, Michelle Potter, Nailah Khoory, Maureen Fagan, David Bates, Laura Carr, Joseph Frolkis, Eric Weil, Jacqueline Somerville, Stephanie Ahmed, Marcy Bergeron, Jessica Smith, and Jane Millett. We would also like to thank the members of our Patient-Family Advisory Council: Maureen Fagan, Karen Spikes, Margie Hodges, Win Hodges, Aureldon Henderson, Dena Salzberg, and Kay Bander.
