Does Increased Access to Primary Care Reduce Hospital Readmissions?
Morris Weinberger, Ph.D., Eugene Z. Oddone, M.D., M.H.Sc., William G. Henderson, Ph.D., for The Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission
Background For chronically ill patients, readmission to thehospital can be frequent and costly. We studied the effect ofan intervention designed to increase access to primary careafter discharge from the hospital, with the goals of reducingreadmissions and emergency department visits and increasingpatients' quality of life and satisfaction with care.
Methods In a multicenter randomized, controlled trial at nineVeterans Affairs Medical Centers, we randomly assigned 1396veterans hospitalized with diabetes, chronic obstructive pulmonarydisease, or congestive heart failure to receive either usualcare or an intensive primary care intervention. The interventioninvolved 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 congestiveheart failure (504 patients) had disease in New York Heart Associationclass III or IV; 30 percent of those with diabetes (751 patients)had end-organ damage; and a quarter of those with chronic obstructivepulmonary disease (583 patients) required home oxygen treatmentor oral corticosteroids. The patients had extremely poor quality-of-lifescores. Although they received more intensive primary care thanthe controls, the patients in the intervention group had significantlyhigher 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 withtheir care (P<0.001), but there was no difference betweenthe study groups in quality-of-life scores, which remained verylow (P = 0.53).
Conclusions For veterans discharged from Veterans Affairs hospitals,the primary care intervention we studied increased rather thandecreased the rate of rehospitalization, although patients inthe intervention group were more satisfied with their care.
Despite strategies such as prospective payment and requiredapproval for hospitalization before admission, costs of inpatientcare in 1993 accounted for $327 billion, or 42 percent of nationalspending for medical care.1 Readmissions account for up to halfof all hospitalizations and 60 percent of hospital costs.2,3,4,5Besides the expense, readmissions may reflect poor-quality care.6,7,8,9
There is pressure both to reduce inpatient services and to deliverhigh-quality care. One efficient strategy would be to identifypatients who are at increased risk for hospital readmissionand to provide them with intensive primary care.8,10 Becauseof their multiple coexisting medical illnesses, poor functionalstatus, and low socioeconomic status,11,12,13,14 veterans dischargedfrom the General Medicine Service of Veterans Affairs MedicalCenters are one such group.6,15
We conducted a multicenter randomized, controlled trial of aprogram designed to increase access to primary care for suchveterans. Our primary hypothesis was that this program wouldreduce the patients' rates of readmission and days of hospitalizationduring the six months after discharge. We also examined theeffects of the program on the time to the first readmission,the proportion of patients readmitted, and the number of emergencydepartment visits, and on health-related quality of life andsatisfaction with care.
Methods
Study Sites
This multicenter randomized, controlled trial was conductedat nine Veterans Affairs Medical Centers (see Appendix) chosenfor diversity of location and academic affiliation; the siteswere not selected on the basis of their readmission rates. Beforethe investigation began, all the study personnel met to reviewand standardize the study protocol. The study was approved andreviewed annually by the human rights committee of the HinesVeterans Affairs Cooperative Studies Program Coordinating Center.The Research and Human Subjects Committee of each participatingVeterans Affairs Medical Center also approved the study.
Criteria for Eligibility
Patients hospitalized in the General Medicine Service were potentiallyeligible if they had a diagnosis of diabetes mellitus, chronicobstructive pulmonary disease, or congestive heart failure thatwas documented in the medical record at or before the time ofthe index admission (and that was not necessarily the reasonfor that admission). We selected these three diseases becausethey are prevalent among veterans, because patients with thesediseases are commonly readmitted, and because hospital readmissionsto treat these diseases might be reduced if primary care physiciansprovided intervention to outpatients.
Patients were excluded if they were already receiving continuouscare at a primary care clinic (for example, in general medicineor geriatrics); if they were receiving dialysis, chemotherapy,or radiation therapy; if they resided in, or planned to be dischargedto, a nursing home; if they were admitted only to undergo aprocedure; if they were participating in another active study;if they were hospitalized to rule out cancer or to receive terminalcare; if they did not speak English; if they had a score of5 or less on the Mental Status Questionnaire16 and had no caregiver; if they refused to give informed consent; or if theyhad no access to a telephone.
Study Design
Research assistants at each site screened all patients admittedto the General Medicine Service. Potentially eligible patientswere referred to the study nurse, who determined their eligibility,obtained informed consent, and collected base-line data. Thepatients were then randomly assigned to receive either customarypost-discharge care or the primary care intervention. They werestratified within each study site according to entitlement status(a variable derived from the patient's service-connection status,which can affect access to outpatient care) and index disease(diabetes, congestive heart failure, chronic obstructive pulmonarydisease, or more than one of these). The patients' group assignmentswere made by telephoning the statistical coordinating center.
All the patients were followed for six months. The researchassistant, who was unaware of the patients' group assignments,telephoned the patients 30 and 180 days after randomizationto assess their quality of life, satisfaction with care, anduse of health care services outside the Veterans Affairs MedicalCenters.
Intervention Group
At each site, the intervention was delivered by a team consistingof one licensed registered nurse and one primary care physician.The study nurses were experienced in patient care (mean lengthof experience, 5.8 years; range, 2 to 10); four had prior clinicalexperience with the Department of Veterans Affairs. There were96 attending physicians, 6 fellows in general medicine, and12 house staff. The attending physicians were predominantlyboard-certified in internal medicine (70 physicians) or familypractice (3 physicians); they had completed medical school amean of 12.7 years earlier and had a mean of 4.8 years of VeteransAffairs experience.
The intervention (the details of which are specified in Table 1)had both an inpatient component, which began immediatelyafter randomization, and an outpatient component, which beganat discharge. When patients assigned to the intervention groupwere readmitted to the hospital, the inpatient protocol wasrepeated.
Table 1. Components of the Primary Care Intervention and Mean Ratings of Compliance.
Control Group
We neither required nor prohibited any post-discharge care forthe patients in the control group. Their care after dischargecould be provided by community physicians or at Veterans Affairsclinics, as arranged by the physicians treating them as inpatients.The control patients did not have access to the primary carenurse and received no supplemental education or assessment ofneeds beyond what was customarily offered at each site.
Primary and Secondary Outcomes
For outcomes involving the use of Veterans Affairs health services,data were abstracted from the Patient Treatment File (a nationaladministrative data base containing information on all VeteransAffairs hospitalizations) and computer systems at local hospitals(to obtain data on outpatient visits) for 180 days after randomization.The use of non–Veterans Affairs health services was estimatedon the basis of reports by the patients. With the patients'permission, we asked non–Veterans Affairs providers identifiedby the patients to send records of the use of their servicesduring the study period. Only use of services that could beverified by the provider was counted. We computed the totalnumber of days of rehospitalization and rates of readmissionper patient, the time to the first readmission, the proportionof patients who were readmitted, the number of emergency departmentvisits, and the number of outpatient visits during the 180-daystudy period.
Quality of life was measured on the "short form" of a questionnaire(the SF-36) that contains 36 items and has been well validated17,18,19,20,21and widely used among veterans.12,13,14 Eight scores (physicalfunctioning, physical role functioning, emotional role functioning,social functioning, bodily pain, mental health, vitality, andgeneral perceptions of health) are calculated from the responses,ranging from 0 (for poorest) to 100 (for best); differencesof 3 to 5 points are considered important.18,21 To measure patients'satisfaction with their care, we used the following 11 scalesfrom the Patient Satisfaction Questionnaire22 that are relevantto veterans: satisfaction with emergency care, convenience ofcare, access to care, continuity of care, competence, risks(i.e., those at which doctors place their patients), qualityof doctor's facilities, expenses, explanations of care, degreeof consideration shown, and overall satisfaction. Each scaleis scored from 1 (for least satisfied) to 5 (for most satisfied).
Other Variables
Because prior hospitalization is a predictor of future use,we used the Patient Treatment File to extract data on hospitaluse for all study patients during the 180 days before randomization.According to a validated measure of coexisting conditions,23we classified the patients as being at low, medium, or highrisk for readmission at base line. The severity of each of thethree diseases being studied was estimated by a review of thepatient's chart at base line.
Each readmission to a Veterans Affairs Medical Center duringthe 180-day study period was classified in two ways by a panelof physicians comprising all the principal investigators ateach site. First, preventability was assessed on the basis ofpatient-related, clinical, or systemwide factors that couldhave averted the readmission24 (rating forms are available onrequest). Each readmission was also classified as elective ornonelective. Elective readmissions were those occurring fornonurgent, scheduled procedures (for example, cataract surgery,cardiac catheterization, bronchoscopy, hernia repair, and colonoscopicexamination). All other readmissions were considered nonelective.25
Intensity of Primary Care
For each patient in the intervention group, each component ofthe intervention (Table 1) was rated according to whether ithad been carried out according to the protocol. Scores for compliancewere aggregated for all components to calculate both overalland site-specific scores. Other indicators of the intensityof primary care delivery included the number of days from thepatient's discharge after the index hospitalization to the firstvisit to the primary care clinic, the number of visits to thatclinic, and the number and duration of telephone calls betweenpatients and primary care nurses during the study period.
Statistical Analysis
Assuming a two-sided significance level of 0.05 and 85 percentpower, we calculated that 700 patients would be needed in eachgroup in order to detect 28 percent reductions in both primaryoutcomes (readmission rates and days of rehospitalization).
The success of randomization was determined by comparing thebase-line characteristics of the intervention group with thoseof the control group by the chi-square test (for categoricalvariables), Student's t-test (for continuous variables), andthe Wilcoxon rank-sum test (for non-normally distributed variables).
Patients continued in the study for 180 days unless they diedor withdrew. For those who did not remain in the study for theentire 180 days, the data collected between randomization andthe date of censoring were used in all the analyses (that is,we conducted an intention-to-treat analysis). Our main analysesused Wilcoxon rank-sum tests (of readmission rates, days ofrehospitalization, emergency department visits, and outpatientvisits), chi-square tests (of the proportion of patients readmitted),and Kaplan–Meier estimates of survival and log-rank tests(of the time to readmission). Because the measures of qualityof life and patients' satisfaction were multidimensional, westudied them by multivariate analysis of variance. Finally,we performed an analysis of covariance for our primary and secondaryoutcomes. The covariates included the stratification variablesand the number of hospital days during the 180 days before randomization.
Results
Study Patients
From November 1992 through July 1994, 10,129 patients were screened;3209 met all eligibility criteria, and 1396 of them (43.5 percent)were randomized (range per site, 116 to 202 patients). The mostcommon reasons for the nonenrollment of eligible patients werethe patient's decision not to participate (971 patients) anddischarge from the hospital before randomization (446 patients).Patients who declined to participate typically did so becausethey had an established relationship with a specialist or anon–Veterans Affairs physician and did not wish to riskrandom assignment to the care of a new physician.
The demographic and clinical characteristics of the patientsare shown in Table 2. The patients had a substantial burdenof illness at base line: half of those with congestive heartfailure had disease in New York Heart Association class IIIor IV; one third of the diabetic patients had objective evidenceof end-organ damage; and one quarter of the patients with chronicobstructive pulmonary disease required oxygen treatment at home,oral corticosteroids, or both. Moreover, two thirds of the studypatients had risk scores that placed them at medium or highrisk for readmission. There were no statistically significantdifferences between the study groups, although there was a trendtoward more hospital days during the 180 days before randomizationin the intervention group (4.6 days, vs. 3.9 days in the controlgroup; P = 0.09).
Table 2. Base-Line Characteristics of the Patients According to Study Group.
The patients' extensive burden of illness was also evident fromtheir extremely poor base-line scores for quality of life (Table 3).The patients were moderately satisfied with most aspectsof their care, giving it an average score of approximately 3on the 5-point scales for satisfaction (Table 3). There wereno base-line differences between the study groups in qualityof life or satisfaction with care. During the study period,106 patients died (59 in the intervention group and 47 in thecontrol group), and 16 withdrew their consent to be studied(11 and 5, respectively). There were no significant differencesbetween the study groups in the follow-up status of the patients(P = 0.13).
Table 3. Base-Line Scores on Questionnaires Measuring Quality of Life and Satisfaction with Care, According to Study Group.
Intensity of Primary Care
Table 1 shows data on the patients' compliance with the interventionprotocol. The mean composite score for compliance was 89 percent(range among sites, 83 to 93 percent). The median time fromdischarge after the index hospitalization to the first visitto a general medicine clinic was significantly shorter in theintervention group (7 vs. 13 days, P<0.001). The patientsin the intervention group were more likely than the controlsto visit at least one general medicine clinic during the studyperiod (93 percent vs. 77 percent, P<0.001). Over the six-monthstudy period, the patients in the intervention group also made68 percent more visits to general medicine clinics (mean, 3.7vs. 2.2; P<0.001) and 5 percent fewer visits to subspecialtyclinics (2.1 vs. 2.2, P =0.010) than did the control patients.Otherwise, use of outpatient services, including visits to theemergency department (1.9 vs. 1.7, P = 0.12), was similar inthe two groups. In addition to providing care during visits,primary care nurses talked with the patients in the interventiongroup by telephone a mean of 7.5 times during the study period(range, 4.0 to 13.4 calls), for an average of 5.7 minutes percall. Use of outpatient services outside Veterans Affairs MedicalCenters was infrequent in both groups (intervention group, 7percent; controls, 9 percent; P = 0.55).
Hospital Use
Although the patients in the intervention group had contactwith the primary care team, the effect of the intervention onhospital use was contrary to that predicted by our hypothesis(Table 4). The intervention group had a higher monthly readmissionrate than the control group (0.19 vs. 0.14 readmission, P =0.005) and more days of rehospitalization (10.2 vs. 8.8, P =0.041). Approximately 5 percent of the use of inpatient servicesby both study groups occurred in non–Veterans Affairshospitals. We also found trends suggesting that a higher proportionof the patients in the intervention group were readmitted (49percent vs. 44 percent, P = 0.06), and were readmitted sooner(P = 0.07), than was the case in the control group. Finally,more patients in the intervention group (P = 0.052) had multiplereadmissions during the study period (Figure 1).
Figure 1. Effect of Intervention on the Number ofReadmissions.
P = 0.052 for the comparison between the study groups, by the chi-square test.
Although the study lacked adequate power to permit us to conductsubgroup analyses according to disease category, greater hospitaluse was observed in the intervention group in all three diseasestrata. There were no significant differences between groupswith regard to either nonelective (80 percent vs. 77 percent,P = 0.22) or preventable (35 percent vs. 37 percent, P = 0.57)readmissions. After we adjusted for the stratification variablesand the number of days spent in the hospital during the sixmonths before randomization, the difference between the groupsin monthly readmission rates remained significant (0.21 vs.0.15, P<0.001), although the difference in the number ofdays of rehospitalization did not (10.5 vs. 9.2, P = 0.23).
Quality of Life and Satisfaction with Care
Follow-up interviews were completed with 87 percent and 83 percentof the patients available for interview at one and six months,respectively. In both groups, patients' scores on the SF-36questionnaire were low at base line and remained so throughoutthe study period, with no significant differences between groupsat one month (P = 0.99) or six months (P = 0.53).
The patients in the intervention group were significantly moresatisfied (P<0.001) with their care than the controls atone month (data not shown), and this difference persisted atsix months (Figure 2). Although the group differences were consistenton most of the 11 scales of the Patient Satisfaction Questionnairethat we used, the differences were greatest with regard to thepatients' perceptions of the continuity of their care (33 percent)and "nonfinancial access to medical care" (i.e., barriers otherthan financial ones) (16 percent).
Figure 2. Effect of Intervention on Patients' Satisfaction with Their Care.
Bars show the difference between the six-month scores and the base-line scores. P<0.001 for the comparison between groups by multivariate analysis of variance at both one and six months. Asterisks indicate dimensions for which the difference in the mean change (on a five-point scale) between the study groups was statistically significant (P<0.001). Subscales for which no bar is shown (e.g., Risks) had a mean change of zero.
Discussion
We examined the effect of an intervention designed to enhanceprimary care for medically vulnerable patients who were dischargedfrom the General Medicine Service at nine Veterans Affairs MedicalCenters. The intervention was designed to improve their accessto primary care providers, the coordination of outpatient services,and the provision of comprehensive and continuous care.26 Althoughthe intensity of primary care was successfully increased, patientsreceiving this intervention used the hospital significantlymore during the six-month study period. At only one of the ninesites were readmissions reduced, and that site was at or belowthe median level of compliance with the intervention protocol,the frequency of primary care visits per patient, and the extentof telephone contact between patients and nurses. The primarycare intervention did not affect the quality of life of thepatients who received it, but they were substantially more satisfiedthan the controls with their care.
What may account for these findings? First, the premise thatcomprehensive primary care may reduce the use of inpatient servicesby vulnerable patients may be wrong, at least in the short term.The patients in this study had major complications of theirchronic diseases and poor quality of life. They were also athigher risk for readmission than vulnerable patients dischargedfrom a municipal teaching hospital.27,28 The primary care offeredto these seriously ill patients may have led to the detectionand treatment of previously undetected medical problems. Second,greater access to primary care providers could have improvedcommunication and, in turn, increased readmissions. Having achannel to voice their complaints can lead to more readmissionsamong severely ill patients. With a longer period of follow-up,the patients and primary care teams may become more accustomedto each other, and perhaps readmissions would be diminishedover time. Finally, the patients in the intervention group mayhave been sicker than the controls at base line. There was atrend toward more use of inpatient services in this group thanamong the controls during the six months before enrollment,but even when we adjusted for this prior use there was stilla significant difference in readmission rates, although thedifference in the number of days of rehospitalization was nolonger significant.
Did the intervention harm patients? The patients receiving itwere readmitted more frequently and spent more time in the hospitalthan those receiving usual care, but there is no evidence thatthe patients receiving the intervention experienced decreasedquality of life. Furthermore, at one and six months they weresubstantially more satisfied with their care.
How do our findings compare with those of earlier randomizedtrials of interventions designed to reduce hospital readmissions?Facilitating linkages between inpatient and outpatient careat an urban teaching hospital reduced both the use of servicesafter discharge27 and the costs of health care28 among the patientsat highest risk for readmission. However, providing access toa case manager at discharge from a Veterans Affairs MedicalCenter and thereafter had no effect on readmissions.29 Intensivedischarge planning may reduce hospital readmissions in the shortterm, but not in the long term.7,30 A single-site study of amultidisciplinary intervention directed by an experienced cardiovascularnurse reduced the use of inpatient services by high-risk elderlypatients with congestive heart failure during the 90 days afterdischarge.31 This success may be attributed to the use of anintensive, disease-specific protocol that included individualizeddietary assessment and instruction, analysis of medicationsby a geriatric cardiologist, and home visits after discharge.
This study has several limitations. First, it was conductedlargely among disadvantaged men receiving care at Veterans AffairsMedical Centers. The generalizability of our findings may alsobe affected by the presence of systematic differences betweenthe study patients and the eligible patients who did not enroll.However, the 971 eligible patients who declined to participatein the study did not differ from the study patients during thesix months after screening with regard to rates of readmissionto Veterans Affairs Medical Centers, the number of days of rehospitalization,or the proportion of patients readmitted (data not shown). Second,all the patients were screened while they were hospitalized.Intensive primary care interventions designed for outpatientswho were not identified in the hospital might have produceddifferent results. Third, we cannot assess the incremental valueof specialty care among patients receiving primary care. Forsuch patients, the mix of generalist and specialist care maybe as important as the coordination of care by a primary careteam. Finally, the intervention may have improved the qualityof care despite the increased rate of readmission.
Our findings show that tremendous resources were needed to sustainthe health of this vulnerable group of veterans. If these findingsalso apply to other groups of medically and socioeconomicallydisadvantaged patients (for example, the Medicaid population),health care administrators may be reluctant to provide careunless a high capitation rate is established. In addition, thepatients in the intervention group were significantly more satisfiedwith their care than the controls. This difference in satisfactionexceeds that previously shown to result in patients' changingtheir health care providers.32,33,34 Such information is criticalfor the design of health care systems, given that patients basetheir decisions about where they will obtain their care largelyon subjective ratings of their own experiences. Finally, andperhaps most important, this study highlights the need to evaluateassumptions about changes in health care systems rigorously,across the entire spectrum of patients and diseases. We needa better understanding of how to optimize the care of vulnerablepatients, so that the use of services is reduced and the qualityof care enhanced.
Supported by the Health Services Research and Development Service,Department of Veterans Affairs, through Veterans Affairs CooperativeStudy in Health Services No. 8 and the Career Development Program.
* Other contributing authors were Anita Giobbie-Hurder (HinesVAMC, Hines, Ill.), Maria Horner (Durham VAMC, Durham, N.C.),Francis Goldstein (William Jennings Bryan Dorn VAMC, Columbia,S.C.), Paulette Ginier (Fresno VAMC, Fresno, Calif.), CharlesMengel (Dwight D. Eisenhower VAMC, Leavenworth, Kans.), JamesHuey (Cincinnati VAMC, Cincinnati), David A. Asch (PhiladelphiaVAMC, Philadelphia), Neil Farber (Philadelphia VAMC), LawrenceLoo (Jerry Pettis Memorial VAMC, Loma Linda, Calif.), EdwardMack (Brooklyn VAMC, Brooklyn, N.Y.), David M. Smith (RichardL. Roudebush VAMC, Indianapolis), Denise M. Hynes (Hines VAMC),and John R. Feussner (Durham VAMC). Additional participatinginstitutions and investigators are listed in the Appendix.
Source Information
From the Richard L. Roudebush Veterans Affairs Medical Center (VAMC), Indianapolis (M.W.); the Center for Health Services Research in Primary Care, Durham VAMC, Durham, N.C. (E.Z.O.); and the Center for Cooperative Studies in Health Services, Hines VAMC, Hines, Ill. (W.G.H.).
Address reprint requests to Dr. Weinberger at Health Services Research and Development (11H), Richard L. Roudebush VAMC, 1481 W. Tenth St., Indianapolis, IN 46202.
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Appendix
The following additional persons and institutions participatedin this investigation: Chairperson's Office — P. Landsmanand M. Monger (Durham, N.C.). Hines Center for Cooperative Studiesin Health Services — D. Cavello and R. Lott (Hines, Ill.).Participating Veterans Affairs Medical Centers — E. Anteolaand R. Varano (Brooklyn, N.Y.); V. Hedger and J. Schultz (Cincinnati);G. Allen and J. Calkins (Columbia, S.C.); A. Ward and M. Foy(Durham, N.C.); P. Hensley and K. Cox (Fresno, Calif.); G. Redmon(Indianapolis); L. Carrel and M. Cook (Leavenworth, Kans.);E. Wise and N. Gordon (Loma Linda, Calif.); and A. Cooney andJ. Havey (Philadelphia). Executive Com-mittee — C. Ashton,T. Adams, J. Demakis, and J. Gibbs. Data Moni-toring Board —T. Meyer (chairperson), M. Foulkes, M. Hlatky, and K. Nichol.Human Rights Committee (Hines, Ill.) — T. Bering, T. Burris,A. Cole, E. Collins, M. D'Arcy, M. Emanuele, Z. Flournoy-Gill,S. Sanders, T. Schmid, A. Henrick, S. Braithwaite, W. Knopp,W. Juneau, and R. Hahn. Veterans Affairs Central Office —D. Deykin and J. Gold (Boston); and J. Gough, S. Meehan, C.Smith, and C. Welch (Washington, D.C.).
A Trial of Increased Access to Primary Care
Henley D. E., Starfield B., Parrino T. A., Snider G. L., Colucci W. S., Sawin C. T., Magill M. K., Babitz M., Silver M. P., Rich M. W., Corey G. A., Burack J. H., Portnoi V. A., Adams W. L., Weinberger M., Oddone E. Z., Henderson W. G., Welch H. G.
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335:895-898, Sep 19, 1996.
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