Heather M Gilmartin1,2, Theodore Warsavage1, Anne Hines1, Chelsea Leonard1, Lynette Kelley1, Ashlea Wills1, David Gaskin1, Lexus Ujano-De Motta1, Brigid Connelly1, Mary E Plomondon3, Fan Yang4, Peter Kaboli5,6, Robert E Burke7,8, Christine D Jones1,9. 1. Research Department, Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VHA Eastern Colorado Healthcare System, Aurora, Colorado, USA. 2. Department of Health Systems, Management and Policy, School of Public Health, University of Colorado, Aurora, Colorado, USA. 3. Clinical Assessment Reporting and Tracking Program, Office of Quality and Patient Safety, Veterans' Health Administration, Washington, District of Columbia, USA. 4. Department of Biostatistics and Informatics, School of Public Health, University of Colorado, Aurora, Colorado, USA. 5. Research Department, Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health, and Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City VA Healthcare System, Iowa City, Iowa, USA. 6. Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA. 7. Research Department, Center for Health Equity Research and Promotion, Corporal Crescenz Veterans Health Administration Medical Center, Philadelphia, Pennsylvania, USA. 8. Hospital Medicine Section - Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA. 9. Division of Hospital Medicine, Department of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA.
Abstract
BACKGROUND: Veterans are often transferred from rural areas to urban VA Medical Centers for care. The transition from hospital to home is vulnerable to postdischarge adverse events. OBJECTIVE: To evaluate the effectiveness of the rural Transitions Nurse Program (TNP). DESIGN, SETTING, AND PARTICIPANTS: National hybrid-effectiveness-implementation study, within site propensity-matched cohort in 11 urban VA hospitals. 3001 Veterans were enrolled in TNP from April 2017 to September 2019, and 6002 matched controls. INTERVENTION AND OUTCOMES: The intervention was led by a transitions nurse who assessed discharge readiness, provided postdischarge communication with primary care providers (PCPs), and called the Veteran within 72 h of discharge home to assess needs, and encourage follow-up appointment attendance. Controls received usual care. The primary outcomes were PCP visits within 14 days of discharge and all-cause 30-day readmissions. Secondary outcomes were 30-day emergency department (ED) visits and 30-day mortality. Patients were matched by length of stay, prior hospitalizations and PCP visits, urban/rural status, and 32 Elixhauser comorbidities. RESULTS: The 3001 Veterans enrolled in TNP were more likely to see their PCP within 14 days of discharge than 6002 matched controls (odds ratio = 2.24, 95% confidence interval [CI] = 2.05-2.45). TNP enrollment was not associated with reduced 30-day ED visits or readmissions but was associated with reduced 30-day mortality (hazard ratio = 0.33, 95% CI = 0.21-0.53). PCP and ED visits did not have a significant mediating effect on outcomes. The observational design, potential selection bias, and unmeasurable confounders limit causal inference. CONCLUSIONS: TNP was associated with increased postdischarge follow-up and a mortality reduction. Further investigation to understand the reduction in mortality is needed. Published 2022. This article is a U.S. Government work and is in the public domain in the USA.
BACKGROUND: Veterans are often transferred from rural areas to urban VA Medical Centers for care. The transition from hospital to home is vulnerable to postdischarge adverse events. OBJECTIVE: To evaluate the effectiveness of the rural Transitions Nurse Program (TNP). DESIGN, SETTING, AND PARTICIPANTS: National hybrid-effectiveness-implementation study, within site propensity-matched cohort in 11 urban VA hospitals. 3001 Veterans were enrolled in TNP from April 2017 to September 2019, and 6002 matched controls. INTERVENTION AND OUTCOMES: The intervention was led by a transitions nurse who assessed discharge readiness, provided postdischarge communication with primary care providers (PCPs), and called the Veteran within 72 h of discharge home to assess needs, and encourage follow-up appointment attendance. Controls received usual care. The primary outcomes were PCP visits within 14 days of discharge and all-cause 30-day readmissions. Secondary outcomes were 30-day emergency department (ED) visits and 30-day mortality. Patients were matched by length of stay, prior hospitalizations and PCP visits, urban/rural status, and 32 Elixhauser comorbidities. RESULTS: The 3001 Veterans enrolled in TNP were more likely to see their PCP within 14 days of discharge than 6002 matched controls (odds ratio = 2.24, 95% confidence interval [CI] = 2.05-2.45). TNP enrollment was not associated with reduced 30-day ED visits or readmissions but was associated with reduced 30-day mortality (hazard ratio = 0.33, 95% CI = 0.21-0.53). PCP and ED visits did not have a significant mediating effect on outcomes. The observational design, potential selection bias, and unmeasurable confounders limit causal inference. CONCLUSIONS: TNP was associated with increased postdischarge follow-up and a mortality reduction. Further investigation to understand the reduction in mortality is needed. Published 2022. This article is a U.S. Government work and is in the public domain in the USA.
Authors: Piper H Williams; Heather M Gilmartin; Chelsea Leonard; Michaela S McCarthy; Lynette Kelley; Gary K Grunwald; Christine D Jones; Melanie D Whittington Journal: J Gen Intern Med Date: 2022-08-30 Impact factor: 6.473