A Randomized Trial Exploring the Effect of a Telephone Call Follow-up on Care Plan Compliance Among Older Adults Discharged Home From the Emergency Department

Authors

  • Kevin Biese MD,

    Corresponding author
    1. Department of Emergency Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
    2. Division of Geriatric Medicine, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
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  • Michael LaMantia MD,

    1. Division of Geriatric Medicine, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
    2. Indiana University Center for Aging Research Regenstrief Institute, Inc., Indianapolis, IN
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  • Frances Shofer PhD,

    1. Department of Emergency Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
    2. Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
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  • Brenda McCall RN,

    1. UNC Health Care, Chapel Hill, NC
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  • Ellen Roberts PhD, MPH,

    1. Division of Geriatric Medicine, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
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  • Sally C. Stearns PhD,

    1. Department of Health Policy and Management, The Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
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  • Stephanie Principe,

    1. Davidson College, Davidson, NC
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  • John S. Kizer MD,

    1. Division of Geriatric Medicine, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
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  • Charles B. Cairns MD,

    1. Department of Emergency Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
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  • Jan Busby-Whitehead MD

    1. Division of Geriatric Medicine, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
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  • Presented at the Society for Academic Emergency Medicine Annual Meeting, Boston, MA, June 2011; and the American Geriatrics Society Annual Scientific Meeting, Washington, DC, May 2011.
  • Funded by the Duke Endowment and the Community Connection for Seniors.
  • The authors have no relevant financial information or potential conflicts of interest to disclose.

Abstract

Objectives

Older patients discharged from the emergency department (ED) have difficulty comprehending discharge plans and are at high risk of adverse outcomes. The authors investigated whether a postdischarge telephone call–mediated intervention by a nurse would improve discharge care plan adherence, specifically by expediting post–ED visit physician follow-up appointments and/or compliance with medication changes. The second objectives were to determine if this telephone call intervention would reduce return ED visits and/or hospitalizations within 35 days of the index ED visit and to determine potential cost savings of this intervention.

Methods

This was a 10-week randomized, controlled trial among patients aged 65 and older discharged to home from an academic ED. At 1 to 3 days after each patient's index ED visit, a trained nurse called intervention group patients to review discharge instructions and assist with discharge plan compliance; placebo call group patients received a patient satisfaction survey call, while the control group patients were not called. Data collection calls occurred at 5 to 8 days and 30 to 35 days after the index ED visits for all three groups. Chi-square or Fisher's exact tests were performed for categorical data and the Kruskal-Wallis test examined group differences in time to follow-up.

Results

A total of 120 patients completed the study. Patients were 60% female and 72% white, with a mean age of 75 years (standard deviation [SD] ± 7.58 years). Intervention patients were more likely to follow up with medical providers within 5 days of their ED visits than either the placebo or the control group patients (54, 20, and 37%, respectively; p = 0.04). All groups performed well in medication acquisition and comprehension of medication indications and dosage. There were no differences in return visits to the ED or hospital within 35 days of the index ED visit for intervention patients, compared to placebo or control group patients (22, 33, and 27%, respectively; p = 0.41). An economic analysis showed an estimated 70% chance that this intervention would reduce total costs.

Conclusions

Telephone call follow-up of older patients discharged from the ED resulted in expedited follow-up for patients with their primary care physicians. Further study is warranted to determine if these results translate into improved patient outcomes, decreased return ED visits or hospital admissions, and cost savings resulting from this intervention.

Resumen

Objetivos

Los pacientes mayores dados de alta desde el servicio de urgencias (SU) tienen la dificultad para comprender los planes de alta y poseen alto riesgo de resultados adversos. Se investigó si una intervención mediante una llamada telefónica por un enfermero tras el alta mejoraría la adherencia al plan de cuidados al alta, específicamente para las citas de seguimiento al médico tras la visita al SU y/o el cumplimiento con los cambios de medicación. Los objetivos secundarios fueron determinar si esta intervención telefónica reduciría las revisitas al SU y/o los reingresos hospitalarios en los primeros 35 días desde la visita índice al SU, y determinar el ahorro potencial de costes de esta intervención.

Metodología

Ensayo clínico aleatorizado de 10 semanas de duración en pacientes de 65 años o más dados de alta a su domicilio desde un SU universitario. Entre el día 1 y 3 de la visita índice al SU, un enfermero con formación realizó una llamada telefónica a los pacientes del grupo de intervención para revisar las instrucciones al alta y ayudar con el cumplimiento del plan al alta; los pacientes del grupo de llamadas placebo recibieron una encuesta telefónica de satisfacción; mientras que los pacientes del grupo control no recibieron la llamada telefónica. La recogida de datos de las llamadas telefónicas tuvo lugar entre los días 5 a 8 y 30 a 35 tras la visita índice al SU para los tres grupos. Se realizaron test de ji-cuadrado y test exacto de Fisher para las variables cualitativas y el test de Kruskal Wallis para analizar las diferencias entre los grupos en el tiempo de seguimiento.

Resultados

Ciento veinte pacientes completaron el estudio. Los pacientes fueron en un 60% mujeres y en un 72% blancos, con una edad media de 75 años (DE 7.58 años). Los pacientes del grupo de intervención tuvieron mayor probabilidad de seguimiento con un médico en los 5 primeros días de la visita al SU que los pacientes de los grupos de control y placebo (54%, 20% y 37% respectivamente, p = 0,04). Todos los grupos realizaron bien la adquisición de la medicación y la comprensión de las indicaciones y dosis de la medicación. Hubo una diferencia numérica pero no a nivel estadístico de las revisitas al SU o el reingreso hospitalario en los primeros 35 días de la visita al SU índice para los pacientes de los grupos de intervención, comparado con los pacientes del grupo control y placebo (22%, 33%, y 27% respectivamente, p = 0,41). Un análisis de costes mostró una oportunidad estimada de reducir los costes totales con esta intervención en un 70%.

Conclusiones

El seguimiento telefónico de los pacientes mayores dados de alta desde el SU resultó en una mayor solicitud de seguimiento de los pacientes a los médicos de atención primaria. Se requieren futuros estudios para determinar si estos resultados se traducen en la mejoría de los resultados del paciente, y confirman una disminución de la revisita al SU o los reingresos hospitalarios y una reducción de costes con esta intervención.

Ancillary