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Associations between post-discharge medical consultations and 30-day unplanned hospital readmission: A prospective observational cohort study

  • Author Footnotes
    1 These authors contributed equally to this work.
    Gregor John
    Correspondence
    Corresponding author at: Department of Internal Medicine, Neuchâtel Hospital Network, Rue de la Maladière 45, Neuchâtel CH-2000, Switzerland.
    Footnotes
    1 These authors contributed equally to this work.
    Affiliations
    Department of Internal Medicine, Neuchâtel Hospital Network, Rue de la Maladière 45, Neuchâtel CH-2000, Switzerland

    Department of Internal Medicine, Geneva University Hospitals (HUG), Gabrielle-Perret-Gentil 4, Geneva CH-1205, Switzerland

    University of Geneva, Rue Michel-Servet 1, Geneva CH-1211, Switzerland
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  • Author Footnotes
    1 These authors contributed equally to this work.
    Loïc Payrard
    Footnotes
    1 These authors contributed equally to this work.
    Affiliations
    Department of Medicine, Neuchâtel Hospital Network, Rue de la Maladière 45, Neuchâtel CH-2000, Switzerland
    Search for articles by this author
  • Jacques Donzé
    Affiliations
    Department of Medicine, Neuchâtel Hospital Network, Neuchâtel, Switzerland

    Department of Medicine, University of Lausanne, Switzerland, Division of Internal Medicine, Bern University Hospital, Bern, Switzerland

    Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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  • Author Footnotes
    1 These authors contributed equally to this work.
Open AccessPublished:January 13, 2022DOI:https://doi.org/10.1016/j.ejim.2022.01.013

      Highlights

      • Hospital readmission after discharge from internal medicine unit is frequent.
      • Post-discharge care are important to mitigate the readmission risk.
      • General practitioner (GP) consultation decrease hospital readmission.
      • GP consultation is associated with less emergency room visits.
      • Specialist consultation may be associated with more hospital readmission.

      Abstract

      Background

      The period following hospital discharge is one of significant vulnerability. Little is known about the relationship between post-discharge healthcare use and the risk of readmission.

      Objectives

      To explore associations between medical consultations and other healthcare use parameters and the risk of 30-day unplanned hospital readmission.

      Methods

      Between July 2017 and March 2018, we monitored all adult internal medicine patients for 30 days after their discharge from four mid-sized hospitals. Using follow-up telephone calls, we assessed their post-discharge healthcare use: consultations with general practitioners (GPs) and specialist physicians, emergency room (ER) visits, and home visits by nurses. The binary outcome was defined as any unplanned hospital readmission within 30 days of discharge, and this was analyzed using logistic regression.

      Results

      Of 934 patients discharged, 111 (12%) experienced at least one unplanned hospital readmission within 30 days. Attending at least one GP consultation decreased the odds of readmission by half (adjusted OR: 0.5; 95%CI: 0.3–0.7), whereas attending at least one specialist consultation doubled those odds (aOR: 2.0; 95%CI: 1.2–3.3). GP consultations also reduced the odds of the combined risk of an ER visit or unplanned hospital readmission (aOR: 0.5; 95%CI: 0.3–0.7). ER visits were also associated with a higher readmission risk after adjusting for confounding factors (aOR: 10.0; 95%CI: 6.0–16.8).

      Conclusion

      GP consultations were associated with fewer ER visits and unplanned hospital readmissions.

      Keywords

      1. Introduction

      Early readmission after hospital discharge is frequent, partly preventable, and puts a heavy burden on healthcare systems [
      • Jencks S.F.
      • Williams M.V.
      • Coleman E.A.
      Rehospitalizations among patients in the medicare fee-for-service program.
      ,
      • van Walraven C.
      • Bennett C.
      • Jennings A.
      • Austin P.C.
      • Forster A.J.
      Proportion of hospital readmissions deemed avoidable: a systematic review.
      ]. Many risk factors—like adverse drug events [
      • Dalleur O.
      • Beeler P.E.
      • Schnipper J.L.
      • Donzé J.
      30-day potentially avoidable readmissions due to adverse drug events.
      ], physician workload [
      • Mueller S.K.
      • Donzé J.
      • Schnipper J.L.
      Intern workload and discontinuity of care on 30-day readmission.
      ], patients’ comorbidities [
      • Donzé J.
      • Aujesky D.
      • Williams D.
      • Schnipper J.L.
      Potentially avoidable 30-day hospital readmissions in medical patients: derivation and validation of a prediction model.
      ]—and the internationally validated HOSPITAL score for 30-day potentially avoidable readmission [
      • Donzé J.D.
      • Williams M.V.
      • Robinson E.J.
      • Zimlichman E.
      • Aujesky D.
      • Vasilevskis E.E.
      • et al.
      International validity of the hospital score to predict 30-day potentially avoidable hospital readmissions.
      ] can be assessed directly during the hospital stay. However, physiological stresses experienced during hospitalization extend beyond discharge, resulting in a period of increased vulnerability [
      • Krumholz H.M.
      Post-hospital syndrome-an acquired, transient condition of generalized risk.
      ]. Thus, formal and informal post-discharge support and healthcare can play valuable roles in mitigating the risks of hospital readmission [
      • Rennke S.
      • Nguyen O.K.
      • Shoeb M.H.
      • Magan Y.
      • Wachter R.M.
      • Ranji S.R.
      Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review.
      ].
      General practitioners (GPs) are essential actors in healthcare transitions from hospital to ambulatory care. Misky et al. found an almost 90% reduction in 30-day readmissions for the same medical condition as the index hospitalization, after a timely follow-up consultation with a GP [
      • Misky G.J.
      • Wald H.L.
      • Coleman E.A.
      Post-hospitalization transitions: examining the effects of timing of primary care provider follow-up.
      ]. In a retrospective observational study, Jackson et al. found a significant reduction in readmissions among high-risk patients who consulted with a physician within seven days of discharge [
      • Jackson C.
      • Shahsahebi M.
      • Wedlake T.
      • DuBard C.A.
      Timeliness of outpatient follow-up: an evidence-based approach for planning after hospital discharge.
      ]. However, in prospective studies, the relationship between consultations with a GP and readmission rates has been inconsistent, with Field et al. finding no effects for consultations with a GP within seven days of hospital discharge [
      • Field T.S.
      • Ogarek J.
      • Garber L.
      • Reed G.
      • Gurwitz J.H.
      Association of early post-discharge follow-up by a primary care physician and 30-day rehospitalization among older adults.
      ]. Besides, a randomized trial involving intensive primary care interventions (close follow-up by a nurse and a GP) among patients suffering from diabetes, chronic obstructive pulmonary disease, or heart failure, showed even an increase in the number of 6-month readmissions compared to usual care [
      • Weinberger M.
      • Oddone E.Z.
      • Henderson W.G.
      Does increased access to primary care reduce hospital readmissions? Veterans affairs cooperative study group on primary care and hospital readmission.
      ]. Therefore, the relationship between post-discharge healthcare use and unplanned readmission after hospital discharge in medical patients remains unclear.
      We aimed to evaluate the relationships between medical consultations after hospital discharge—dichotomized between GP and specialist consultations—and 30-day unplanned readmission risk. We also aimed to evaluate associations between other healthcare use (home visits by nurses, home support, and emergency room visits) and the 30-day unplanned readmission risk.

      2. Methods

      This study is part of phase 1 of the TARGET-READ study (Transition cAre intervention targeted to high-risk patiEnts To Reduce rEADmission; clinicaltrials.org NCT03496896). Patients were enrolled during a hospital stay, and their healthcare use and unplanned readmissions were monitored for 30 days.

      2.1 Settings and participants

      Between July 2017 and March 2018, all the adult patients admitted to general internal medicine units for 24 h or more and then discharged alive from four secondary and tertiary hospitals in Switzerland (Neuchâtel, Liestal, Bienne, and Fribourg) were consecutively included in the study. Patients previously enrolled in the study, admitted electively, living outside Switzerland, without a telephone, not speaking a national language, or unwilling or unable to give written informed consent were excluded. Each participating center's ethics committee approved the study protocol.
      Everyone living in Switzerland have at least a standard health insurance that cover for all main healthcare services, including access to outpatient treatment by GP or specialists, emergency treatment and hospitalization. Patients are free to choose their own GP and may consult specialists without a referral from their GP. However, some patients may choose a cheaper insurance policy plan with the obligation to see first their GP before to be referred to a specialist.
      In Switzerland, GP have no role in the care of hospitalized patients, which is assumed by physicians working solely at the hospital.

      2.2 Outcomes and measurements

      The primary outcome was 30-day unplanned hospital readmission. Secondary outcomes were the time to the first hospital readmission, cumulative hospital length of stay (LOS), and the number of emergency room (ER) visits.
      Trained study nurses collected patients’ characteristics, demographic data, diagnoses at index hospitalization, discharge destination, and calculated their HOSPITAL score, which includes: hemoglobin level at discharge, discharge from an oncology unit or an active cancer diagnosis, sodium level at discharge, procedure during the index hospitalization, index admission type (urgent or emergent), number of hospital admissions during the previous year, and LOS ≥ 8 days [
      • Donzé J.D.
      • Williams M.V.
      • Robinson E.J.
      • Zimlichman E.
      • Aujesky D.
      • Vasilevskis E.E.
      • et al.
      International validity of the hospital score to predict 30-day potentially avoidable hospital readmissions.
      ].
      Information on health care use (home visits by nurses, home support, number of medical consultations or ER visits) and unplanned hospital readmissions were collected using three planned, follow-up telephone calls at 2–4 days, 13–15 days, and 30 days after discharge and hospital chart screening. Death was recorded using registers of death, calls to GPs, and calls to next of kin. To limit information bias, study nurses used a standardized form to collect information from patients or, when needed, next of kin or GPs. When patients were readmitted to hospital, they and their medical professional (specialist or GP) were asked for their subjective feelings about whether the admission had been avoidable.

      2.3 Statistics

      The primary analysis—unplanned hospital readmissions associated with medical consultation—was made using logistic regression analysis. We repeated this separately for GPs and specialist physicians and for the combined outcome of ER visits and hospital readmissions.
      The unadjusted impact of GP or specialist consultations on the time to a first hospital readmission was calculated using Kaplan–Meier survival analysis and an unweighted, two-sided, log-rank test to compare groups. The proportional hazards assumption was verified using Schoenfeld residuals and a visual inspection of the log-minus-log plots. The associations between medical consultations and cumulative LOS on readmission were tested using a linear regression model adjusted for confounding factors and in which LOS was log-transformed to correct for skewed data.
      Patients with missing information on post-discharge medical information (3.5%) were excluded from the main analysis. The data was missing at random.
      Associations between other healthcare use and 30-day readmission were analyzed using logistic regression analyses. All analyses were adjusted for age (continuous), HOSPITAL score (continuous), being of Swiss nationality (binary), and numbers of comorbidities (continuous).
      Group characteristics were compared using the chi-squared test or Fisher's exact test, where appropriate, for categorical variables. The Mann–Whitney test was used for continuous variables, as these were not normally distributed. The significance level was set at 5%, and all analyses were performed using STATA statistical software, version 15.0 (StataCorp LP, College Station, TX, USA).

      3. Results

      Of 3239 patients screened, 934 were finally included in the study (Fig. 1). Within 30 days of discharge, 22 (2%) had died and 111 (12%) had experienced at least one unplanned hospital readmission. Participants’ baseline characteristics are shown in Table 1.
      Table 1Characteristics of the entire patient population and their post-discharge medical consultations. Values are numbers (percentages) unless otherwise stated.
      Total(N = 934)30-day post-discharge medical consultations*
      No consultations (n = 168)≥ 1 GP consultation(n = 569)≥ 1 specialist consultation(n = 164)p-value
      General
      Age (years), median (IQR 25%–75%)71 (58–80)75 (62–82.5)71 (59–80)66 (54–75)< 0.001
      Male

      Female
      509 (56%)

      392 (44%)
      96 (57%)

      72 (43%)
      315 (55%)

      255 (45%)
      98 (60%)

      65 (40%)
      0.53
      Swiss nationality

      Other nationality
      783 (87%)

      118 (13%)
      155 (92%)

      13 (8%)
      494 (87%)

      76 (13%)
      134 (82%)

      29 (17%)
      0.022†
      Place of living

      Home

      Sheltered accommodation

      Nursing Home Other or unknown


      882 (94)

      11 (1.2)

      35 (3.7)

      6 (1%)


      158 (94%)

      2 (1%)

      8 (5%)

      0 (0%)


      541 (95%)

      7 (1%)

      20 (4%)

      2 (0%)


      152 (93%)

      2 (1%)

      5 (3%)

      4 (2%)
      0.21†
      Work

      Active

      Unemployment

      Receiving social or invalidity benefits

      Retired

      Other or unknown


      206 (23%)

      16 (2%)

      55 (6%)

      602 (67%)

      22 (2%)


      31 (18%)

      2 (1%)

      8 (5%)

      122 (73%)

      5 (3%)


      123 (23%)

      10 (2%)

      31 (5%)

      386 (68%)

      13 (2%)


      45 (28%)

      4 (2%)

      16 (10%)

      94 (58%)

      4 (2%)
      0.15†
      Health insurance

      None

      Standard

      Standard +

      Semi-private

      Private


      1 (0%)

      421 (47%)

      256 (28%)

      160 (18%)

      62 (7%)


      1 (1%)

      81 (48%)

      44 (26%)

      26 (16%)

      15 (9%)


      0

      259 (45%)

      164 (29%)

      111 (19%)

      36 (6%)


      0

      81 (50%)

      48 (29%)

      23 (14%)

      11 (7%)
      0.30†
      Comorbidities
      Number of comorbidities, median (IQR 25%–75%)1 (0–3)1 (0–3)1 (0–3)1 (0–2)0.60
      Chronic heart failure131 (15%)20 (12%)95 (17%)16 (10%)0.05
      Ischemic heart disease241 (27%)46 (28%)157 (28%)38 (23%)0.53
      Atrial fibrillation162 (18%)27 (16%)114 (20%)21 (13%)0.09
      PAD83 (9%)16 (10%)59 (10%)8 (5%)0.09
      Diabetes205 (23%)37 (22%)137 (24%)31 (19%)0.48
      Dementia28 (3%)4 (2%)23 (4%)1 (1%)0.09†
      COPD92 (10%)19 (11%)63 (11%)10 (6%)0.15
      Active cancer132 (15%)28 (17%)51 (9%)53 (32%)< 0.001
      Chronic renal disease189 (21%)33 (20%)126 (22%)30 (18%)0.49
      Cirrhosis29 (3%)4 (2%)22 (4%)3 (2%)0.50†
      Substance abuse94 (10%)12 (7%)62 (11%)20 (12%)0.29
      Psychiatric disease92 (10%)20 (12%)56 (10%)16 (10%)0.72
      Hospitalization index
      LOS hospitalization index, median (IQR 25%–75%)6 (4–9)6 (4–10)6 (4–9)6 (4–8)0.99
      Place of discharge

      Home

      Nursing home


      862 (96%)

      39 (4%)


      156 (93%)

      12 (7%)


      547 (96%)

      23 (4%)


      159 (98%)

      4 (2%)


      0.12†
      Left against medical advice15 (2%)5 (3%)10 (2%)00.07
      HOSPITAL score, median (IQR 25%–75%)3 (2–5)3 (2–5)3 (2–4)4 (2–6)< 0.001
      COPD: chronic obstructive pulmonary disease; IQR: interquartile range; LOS: length of stay; PAD: peripheral arterial disease.
      * 33 participants had missing data (at random) regarding their post-discharge consultation. Therefore, the sum of the columns is 901 and not 934; † Fischer's exact test (instead of chi-squared test).

      3.1 Primary care professionals and hospital readmission

      During the 30-day post-discharge period, 569 (61%) and 164 (18%) patients consulted their GP or specialist, respectively, whereas 168 (18%) consulted neither (Table 2). Patients who consulted a physician within 30 days of discharge were younger, less frequently Swiss nationals, had higher rates of heart failure or active oncological disease, and had HOSPITAL scores significantly statistically different from those of patients who did not consult one (Table 1).
      Table 2Association between healthcare use and hospitalization index score and risk of 30-day unplanned hospital readmission.
      Unplanned 30-day hospital readmission
      Yes (n = 111)No(n = 813)ORAdjusted* OR
      Medical professional
      Patient had no medical professional1121.7 (0.2–12.9)1.1 (0.1–8.9)
      Medical consultation (any)786550.7 (0.4–1.2)0.7 (0.4–1.1)
      GP consultations485260.4 (0.3–0.7)0.5 (0.3–0.7)
      No. of GP consultations (vs. none)

      1

      2 or more


      20

      28


      219

      303


      0.5 (0.3–0.8)

      0.5 (0.3–0.8)


      0.5 (0.3–0.9)

      0.5 (0.3–0.8)
      Specialist consultations301332.1 (1.3–3.3)2.0 (1.2–3.3)
      No. of specialist visits

      1

      2 or more


      10

      20


      42

      87


      2.2 (1.1–4.6)

      2.3 (1.3–3.9)


      2.3 (1.1–4.8)

      2.0 (1.1–3.5)
      No medical consultation vs.

      GP consultation

      Specialist consultation


      48

      30


      526

      133
      -

      0.5 (0.3–0.9)

      1.4 (0.8–2.5)
      -

      0.6 (0.3–0.9)

      1.3 (0.7–2.4)
      Nursing professional
      Home visits by a nurse371911.6 (1.1–2.5)1.1 (0.7–1.9)
      Informal support
      Living with someone vs. living alone735411.0 (0.6–1.5)1.1 (0.7–1.7)
      Homecare support
      Homecare support (any vs. none)432191.7 (1.1–2.6)1.4 (0.9–2.3)
      Homecare support for cleaning412131.6 (1.1–2.5)1.4 (0.9–2.2)
      Homecare support for buying groceries16761.6 (0.9–2.9)1.3 (0.7–2.5)
      Homecare support for eating13691.4 (0.8–2.6)1.1 (0.5–2.0)
      No. of homecare support initiatives

      1

      2

      3


      24

      11

      8


      130

      39

      50


      1.6 (1.0–2.6)

      2.5 (1.2–5.0)

      1.4 (0.7–3.0)


      1.4 (0.8–2.4)

      2.1 (1.0–4.4)

      1.1 (0.5–2.5)
      Emergency room (ER) visits
      ER visits (yes vs. no)414310.5 (6.4–17.2)10.0 (6.0–16.8)
      No. of ER visits (vs. none)

      1

      2

      3 or more


      34

      5

      2


      37

      5

      1


      10.1 (5.9–17.1)

      10.8 (3.1–38.9)

      21.7 (2.0–245.6)


      9.7 (5.6–16.7)

      12.0 (3.1–45.5)

      14.1 (1.2–164.7)
      ER: emergency room; GP: general practitioner; No.: number; OR: odds ratio.
      * adjusted for HOSPITAL score, age, number of comorbidities, and Swiss nationality.
      When primary care professionals were not dichotomized, univariate and adjusted analyses did not associate medical consultations with a greater risk of 30-day unplanned hospital readmission (Table 2). When these consultations were dichotomized between GPs and specialists, a GP consultation decreased the risk of readmission (OR 0.4, 95%CI: 0.3–0.7), whereas a specialist consultation increased it (OR 2.1, 95%CI: 1.3–3.3). These two associations persisted in adjusted analyses (Table 2).
      Time to first hospital readmission was also associated with post-discharge GP consultations (HR: 0.47, 95%CI: 0.32–0.70; adjusted HR: 0.49, 95%CI: 0.33–0.74), and specialist consultations (HR: 2.0, 95%CI: 1.32–3.12; adjusted HR: 1.88, 95%CI: 1.21–2.93) (Fig. 2).
      Fig. 2
      Fig. 2Time to 30-day hospital readmission associated with no consultation (solid line), or at least one post-discharge consultation with a GP (dash) or a specialist physician (dots). Log-rank test for survival difference p < 0.001.
      GP consultations reduced the odds of an ER visit (adjusted OR: 0.62, 95%CI: 0.39–1.00) and the combined risk of an ER visit or unplanned readmission (adjusted OR: 0.51, 95%CI: 0.35–0.74). Specialist consultations, however, were associated with an increased adjusted combined risk of an ER visit or unplanned readmission (adjusted OR: 1.69, 95%CI: 1.10–2.62) (Table 3).
      Table 3Secondary outcomes associated with primary care professional consultations.
      Without consultation(n = 168)With GP consultation(n = 569)p-valueWith specialist consultation(n = 164)p-value
      Unplanned hospital readmission24 (14%)48 (8%)< 0.00130 (18%)0.002
      Emergency room (ER) visits20 (12%)40 (7%)0.01119 (12%)0.150
      More than 1 visit to ER12 (2%)8 (1%)-4 (2%)-
      Hospital readmission or ER visit34 (20%)70 (12%)< 0.00139 (24%)< 0.001
      Cumulative hospital LOS of readmissions, median days (IQR 25%–75%)8 (4.5–15)6 (2–10)0.11*6 (4–9)0.96*
      ER: emergency room; GP: general practitioner; IQR: interquartile range; LOS: hospital length of stay.
      * calculated using the Kruskal–Wallis test.
      There was no difference in the cumulative LOS for readmissions within 30 days between patients who had consulted their GP, those who had consulted their specialist, and those who had consulted neither (Table 3).

      3.2 Other post-discharge healthcare use and readmission risks

      Home visits by nurses, home support, and ER visits were associated with 30-day unplanned readmissions. However, only ER visits remained associated after adjustment for confounding factors (Table 2). Patients’ subjective feeling that their readmission to hospital had been avoidable was associated with a higher proportion of ER visits but not with their other uses of healthcare services (e.g., home visits by nurses) (Appendix Table A1).
      Table A1Healthcare use by patients readmitted to hospital within 30 days of discharge and according to subjective impressions of hospitalization being avoidable according to the patient and their primary care professional.
      Avoidable according to patientP-valueAvoidable according to professionalP-value
      noyesnoyes
      Any medical consultation34 (89%)4 (11%)0.35730 (88%)4 (12%)0.132
      Specialist consultation24 (89%)3 (11%)0.74217 (85%)3 (15%)0.740
      Home visits by a nurse24 (86%)4 (14%)0.97521 (81%)5 (19%)0.760
      Living with someone vs. living alone48 (69%)7 (58%)0.51841 (68%)6 (46%)0.200
      Homecare support (any vs. none)29 (41%)4 (33%)0.75526 (43%)3 (23%)0.227
      Emergency room (ER) visits24 (34%)9 (75%)0.01018 (30%)6 (45%)0.329
      ER: emergency room; GP: general practitioner.
      * median number of comorbidities = 1, ** median HOSPITAL score = 3.

      4. Discussion

      In this multicenter prospective cohort, patients discharged from internal medicine units who consulted with their GP at least once soon afterwards were half as likely to be readmitted to hospital or to visit an ER within 30 days, compared to patients who did not consult their GP. In contrast, those who consulted a specialist physician soon after hospital discharge were twice as likely to be readmitted or to visit an ER in comparison to patients who did not visit their specialist.
      To the best of our knowledge, associations between medical consultations and readmission risk have been inconsistently reported in the past. Only one randomized interventional study has shown the paradoxical increase in readmission risk following consultation [
      • Weinberger M.
      • Oddone E.Z.
      • Henderson W.G.
      Does increased access to primary care reduce hospital readmissions? Veterans affairs cooperative study group on primary care and hospital readmission.
      ], whereas other retrospective studies observed a lower risk [
      • Lin C.Y.
      • Barnato A.E.
      • Degenholtz H.B.
      Physician follow-up visits after acute care hospitalization for elderly medicare beneficiaries discharged to noninstitutional settings.
      ,
      • Chakravarthy V.
      • Ryan M.J.
      • Jaffer A.
      • Golden R.
      • McClenton R.
      • Kim J.
      • et al.
      Efficacy of a transition clinic on hospital readmissions.
      ,
      • Riverin B.D.
      • Strumpf E.C.
      • Naimi A.I.
      • Li P.
      Optimal timing of physician visits after hospital discharge to reduce readmission.
      ,
      • Marcondes F.O.
      • Punjabi P.
      • Doctoroff L.
      • Tess A.
      • O'Neill S.
      • Layton T.
      • et al.
      Does scheduling a postdischarge visit with a primary care physician increase rates of follow-up and decrease readmissions?.
      ]. The GP and specialist consultations in our study showed two opposite associations, neutralizing each other when analyzed together; thus, overall, consulting a physician was not associated with 30-day readmission risk. Variations in other studies might have come from the types of medical consultations included [
      • Lin C.Y.
      • Barnato A.E.
      • Degenholtz H.B.
      Physician follow-up visits after acute care hospitalization for elderly medicare beneficiaries discharged to noninstitutional settings.
      ,
      • Riverin B.D.
      • Strumpf E.C.
      • Naimi A.I.
      • Li P.
      Optimal timing of physician visits after hospital discharge to reduce readmission.
      ], post-discharge follow-up times [
      • Weinberger M.
      • Oddone E.Z.
      • Henderson W.G.
      Does increased access to primary care reduce hospital readmissions? Veterans affairs cooperative study group on primary care and hospital readmission.
      ], the type of readmissions considered [
      • Misky G.J.
      • Wald H.L.
      • Coleman E.A.
      Post-hospitalization transitions: examining the effects of timing of primary care provider follow-up.
      ], or patients’ individual risks [
      • Jackson C.
      • Shahsahebi M.
      • Wedlake T.
      • DuBard C.A.
      Timeliness of outpatient follow-up: an evidence-based approach for planning after hospital discharge.
      ].
      Our observed lower rate of readmissions has several possible explanations. First, patients consulting their GP are less prone to visiting ERs, which are a major stepping-stone to hospital admission. Interestingly, more readmitted patients with a ER visit within the 30 days than those without an ER visit felt that their readmission could have been avoided. Second, an early consultation with a GP could increase the potential for medication reconciliation, avoiding drug prescription errors, and identifying or treating adverse drug reactions after hospital discharge [
      • Kripalani S.
      • Jackson A.T.
      • Schnipper J.L.
      • Coleman E.A.
      Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists.
      ,
      • Abrashkin K.A.
      • Cho H.J.
      • Torgalkar S.
      • Markoff B.
      Improving transitions of care from hospital to home: what works?.
      ]. Third, the potential causative association between GP consultations and lower numbers of readmissions could, in fact, result from an inverse relationship. Readmitted patients may not have had the opportunity to consult their GP because they lacked time between the two hospitalizations. Also, readmitted patients or patients presenting at ERs could be too sick to benefit from care from their GP and may have been readmitted regardless of a consultation. To mitigate this effect, we adjusted for age, comorbidities, and HOSPITAL score (a score that has been associated with readmission and mortality risks). However, an interventional study randomly assigning patients at risk of readmission to a consultation with their GP (or not) would be required to definitively appreciate whether this observed relationship was causative or not.
      The observed opposite relationship between specialist consultations and readmissions agreed with previous reports [
      • Riverin B.D.
      • Strumpf E.C.
      • Naimi A.I.
      • Li P.
      Optimal timing of physician visits after hospital discharge to reduce readmission.
      ]. On the one hand, this inverse effect could be due to the different types of patients consulting GPs and specialists. Many end-organ failures (e.g., heart, lung, and kidney) deserving specialized care repeatedly decompensate and need frequent hospital admission [
      • Platz E.
      • Jhund P.S.
      • Claggett B.L.
      • Pfeffer M.A.
      • Swedberg K.
      • Granger C.B.
      • et al.
      Prevalence and prognostic importance of precipitating factors leading to heart failure hospitalization: recurrent hospitalizations and mortality.
      ,
      • Kong C.W.
      • Wilkinson T.M.A.
      Predicting and preventing hospital readmission for exacerbations of COPD.
      ]. Furthermore, the patients in our study consulting specialists had more oncological diseases, and oncological diseases and their treatment are known to increase admission risk [
      • Numico G.
      • Cristofano A.
      • Mozzicafreddo A.
      • Cursio O.E.
      • Franco P.
      • Courthod G.
      • et al.
      Hospital admission of cancer patients: avoidable practice or necessary care?.
      ]. On the other hand, healthcare systems oriented towards clearly separated medical specialties could lack the more general approach needed following hospital discharge (medication reconciliation, avoiding drug errors, and identifying or treating adverse drug reactions) [
      • Kripalani S.
      • Jackson A.T.
      • Schnipper J.L.
      • Coleman E.A.
      Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists.
      ,
      • Abrashkin K.A.
      • Cho H.J.
      • Torgalkar S.
      • Markoff B.
      Improving transitions of care from hospital to home: what works?.
      ]. Besides, the lack of a statistically significant difference between patients consulting specialists or not consulting a physician at all could suggest that the increased risk of readmission was mainly driven by not consulting a GP. However, this analysis was of limited statistical power.
      The findings present some limitations. First, as an observational study, associations may result from unconsidered confounding factors. Second, GPs and specialists were dichotomized and mutually exclusive in this study. Indeed, patients were asked to state which type of medical professional was most involved in their post-discharge care, but both a GP and a specialist might share this responsibility. Not considering the possibility of dual care might have favored the positive results with GPs. Nevertheless, for oncological diseases, which represented a substantial proportion of our study's patients under specialized care, patients were often treated exclusively by specialists, with GPs taking over responsibility after therapy has ended. However, within our 30-day post-discharge window, few patients attended more than one consultation with a physician, thus reducing the chances of having consulted a GP and a specialist.
      In conclusion, consultations with a GP were associated with fewer ER visits and unplanned readmissions, whereas consultations with a specialist physician were associated with a higher risk of these outcomes. Interventional studies are needed to explore the nature of this association in more detail.

      Declaration of Competing Interest

      The authors declare they have no conflict of interest

      Funding

      Jacques Donzé received funds from the Swiss National Science Foundation as part of the TARGET-READ study (PP00P3_170656).

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      Linked Article

      • Preventing re-admission: Are general practitioners the solution?
        European Journal of Internal MedicineVol. 99
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          In the United States the Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions [1]. The program supports the national goal of improving health care for Americans by linking payment to the quality of hospital care. The Centers for Medicare & Medicaid Service (CMS) includes the following six condition or procedure-specific 30-day risk-standardized unplanned readmission measures in the program: Acute Myocardial Infarction, Chronic Obstructive Pulmonary Disease, Heart Failure, Pneumonia, Coronary Artery Bypass Graft Surgery, Elective Primary Hip and/or Total Knee Arthroplasty.
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