More primary care reduces hospital readmissions, right?

From Weinberger, Oddone, and Henderson (NEJM, 1996):

BACKGROUND: For chronically ill patients, readmission to the hospital can be frequent and costly. We studied the effect of an intervention designed to increase access to primary care after discharge from the hospital, with the goals of reducing readmissions and emergency department visits and increasing patients’ quality of life and satisfaction with care.

METHODS: In a multicenter randomized, controlled trial at nine Veterans Affairs Medical Centers, we randomly assigned 1396 veterans hospitalized with diabetes, chronic obstructive pulmonary disease, or congestive heart failure to receive either usual care or an intensive primary care intervention. The intervention involved close follow-up by a nurse and a primary care physician, beginning before discharge and continuing for the next six months.

RESULTS: The patients were severely ill. Half of those with congestive heart failure (504 patients) had disease in New York Heart Association class III or IV; 30 percent of those with diabetes (751 patients) had end-organ damage; and a quarter of those with chronic obstructive pulmonary disease (583 patients) required home oxygen treatment or oral corticosteroids. The patients had extremely poor quality-of-life scores. Although they received more intensive primary care than the controls, the patients in the intervention group had significantly higher rates of readmission (0.19 vs 0.14 per month, P = 0.005) and more days of rehospitalization (10.2 vs 8.8, P = 0.041). The patients in the intervention group were more satisfied with their care (P < 0.001), but there was no difference between the study groups in quality-of-life scores, which remained very low (P = 0.53).

CONCLUSIONS: For veterans discharged from Veterans Affairs hospitals, the primary care intervention we studied increased rather than decreased the rate of rehospitalization, although patients in the intervention group were more satisfied with their care.

Oops! Also,

The primary care offered to these seriously ill patients may have led to the detection and treatment of previously undetected medical problems. Second, greater access to primary care providers could have improved communication and, in turn, increased readmissions. Having a channel to voice their complaints can lead to more readmissions among severely ill patients. […] Finally, the patients in the intervention group may have been sicker than the controls at base line. There was a trend toward more use of inpatient services in this group than among the controls during the six months before enrollment, but even when we adjusted for this prior use there was still a significant difference in readmission rates, although the difference in the number of days of rehospitalization was no longer significant.

Limitation: This study was based on data that is now 20 years old.


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