Our findings are consistent with the literature review conducted by Scott et al,27 which found that multicomponent interventions are more successful at reducing readmissions than single-component interventions. In our Group 1 clinics, we implemented 8 of the 12 predischarge, postdischarge, and bridging interventions identified by Hansen et al28 (medication reconciliation, discharge planning, scheduling of a follow-up appointment before discharge, follow-up telephone calls, timely communication with ambulatory providers, timely ambulatory provider follow-up, physician continuity across the inpatient and outpatient setting, and patient-centered discharge instructions).
Study strengths and weaknesses. The strengths of this study include means and quality of data capture for hospital readmission rates in the study setting. Limitations include the small sample sizes, which did not allow us to conduct a multivariable adjusted analysis that would have taken into account patient characteristics, seasons, and temporal correlations. These covariates might drive study findings in a way that results in us drawing inaccurate conclusions—the analysis we conducted (unadjusted) assumed that the events that occurred in each month were unrelated to what might have occurred in the prior month or subsequent month.
Patients in the 2 study groups did exhibit differences that could have contributed to our findings. For example, the average length of stay for Group 2 patients was longer by just over 1 day compared with that in Group 1. This may suggest Group 2 patients were sicker, and thus may have needed to be readmitted within 30 days of their discharge. We cannot know for certain that patients in Group 1 were less ill, as this would require a more discriminating study design. As with many studies, additional questions arise, but these serve to further a line of research that is vitally important.
Another factor that could have affected our findings is that Group 1 patient readmission rates started off higher than the Group 2 patients, so there is a chance that regression to the mean rather than changes in clinical care could have contributed to some of the decrease in Group 1 readmission rates. There are potential subject-level, provider-level, and clinic-level factors that could have been used to adjust for potential confounding. Future studies could address these factors. Longer study follow-up would provide an even better picture of the difference between the groups.
A multicomponent intervention works. Creating a culture of continuity is an important aspect of PCMH. Not all primary care clinics or PCMHs may have built-in relationships for inpatient care of their patients. We would argue that outpatient adoption of the enhanced “reaching in” and a multicomponent intervention would have a significant positive impact on patient care and improve the transition from in- to outpatient care, and likely reduce readmissions.
CORRESPONDENCE
Brett White, MD, 4411 SW Vermont St, Portland, OR 97219; brettwhitemd@gmail.com
The authors gratefully acknowledge the clinic and inpatient physicians and staffs as well as the Research Program in the Department of Family Medicine, Oregon Health & Science University.