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Impact of early primary care follow-up after discharge on hospital readmissions

  • Damien BricardEmail author
  • Zeynep Or
Original Paper

Abstract

Reducing repeated hospitalizations of patients with chronic conditions is a policy objective for improving system efficiency. We test the hypothesis that the risk of readmission is associated with the timing and intensity of primary care follow-up after discharge, focusing on patients hospitalized for heart failure in France. We propose a discrete-time model which takes into account that primary care treatments have a lagged and cumulative effect on readmission risk, and an instrumental variable approach, exploiting geographical differences in availability of generalists. We show that the early consultations with a GP after discharge can reduce the 28-day readmission risk by almost 50%, and that patients with higher ambulatory care utilization have smaller odds of readmission. Furthermore, geographical disparities in primary care affect indirectly the readmission risk. These results suggest that interventions which strengthen communication between hospitals and generalists are elemental for reducing readmissions and for developing effective strategies at the hospital level, it is also necessary to consider primary care resources that are available to patients.

Keywords

Readmissions Primary care Hospital Instrumental variable Discrete-time model 

JEL Classification

C22 I12 L24 

Notes

Acknowledgements

We would like to thank Brigitte Dormont, Anne Penneau, Denis Raynaud, Thérèse Stukel, and Marianne Tenand for their helpful comments and suggestions on a previous version of this paper which allowed improving substantially the content. We are also grateful to Nelly Le Guen who helped to construct the database used in the analysis and Nicola Sirven for his helpful remarks on the estimation strategy. Any remaining errors and omissions are our own.

Funding

This research did not receive any specific Grant from funding agencies in the public, commercial, or not-for-profit sectors.

Compliance with ethical standards

Conflict of interest

The authors declare no competing financial interest.

References

  1. 1.
    Kristensen, S.R., Bech, M., Quentin, W.: A roadmap for comparing readmission policies with application to Denmark, England, Germany and the United States. Health Policy. 119, 264–273 (2015)CrossRefGoogle Scholar
  2. 2.
    Desai, A.S., Stevenson, L.W.: Rehospitalization for heart failure. Circulation. 126, 501–506 (2012)CrossRefGoogle Scholar
  3. 3.
    Pracht, E.E., Bass, E.: Exploring the link between ambulatory care and avoidable hospitalizations at the Veteran Health Administration. J. Healthc. Qual. 33, 47–56 (2011)CrossRefGoogle Scholar
  4. 4.
    Weinberger, M., Oddone, E.Z., Henderson, W.G.: Does increased access to primary care reduce hospital readmissions?. N. Engl. J. Med. 334, 1441–1447 (1996)CrossRefGoogle Scholar
  5. 5.
    Cohen, J.W.: Medicaid policy and the substitution of hospital outpatient care for physician care. Health Serv. Res. 24, 33 (1989)PubMedPubMedCentralGoogle Scholar
  6. 6.
    Fortney, J.C., Steffick, D.E., Burgess, J.F., Maciejewski, M.L., Petersen, L.A.: Are primary care services a substitute or complement for specialty and inpatient services? Health Serv. Res. 40, 1422–1442 (2005)CrossRefGoogle Scholar
  7. 7.
    HAS: Haute Autorité de Santé. Guide du parcours de soins, Insuffisance cardiaque, février 2012. HAS, Saint-Denis La Plaine (2012)Google Scholar
  8. 8.
    HAS: Haute Autorité de Santé. Mode d’emploi du plan personnalité de santé (PPS) pour les personnes à risque de perte d’autonomie (PAERPA), Mars 2014. HAS, Saint-Denis La Plaine (2015)Google Scholar
  9. 9.
  10. 10.
    Members, A.F., McMurray, J.J., Adamopoulos, S., Anker, S.D., Auricchio, A., Böhm, M., Dickstein, K., Falk, V., Filippatos, G., Fonseca, C.: ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur. Heart J. 33, 1787–1847 (2012)CrossRefGoogle Scholar
  11. 11.
    Gabet, A., Juillière, Y., Lamarche-Vadel, A., Vernay, M., Olié, V.: National trends in rate of patients hospitalized for heart failure and heart failure mortality in France, 2000–2012. Eur. J. Heart Fail. 17, 583–590 (2015)CrossRefGoogle Scholar
  12. 12.
    Allison, P.D.: Discrete-time methods for the analysis of event histories. Sociol. Methodol. 13, 61–98 (1982)CrossRefGoogle Scholar
  13. 13.
    Jenkins, S.P.: Easy estimation methods for discrete-time duration models. Oxf. Bull. Econ. Stat. 57, 129–136 (1995)CrossRefGoogle Scholar
  14. 14.
    Newhouse, J.P., McClellan, M.: Econometrics in outcomes research: the use of instrumental variables. Annu. Rev. Public Health. 19, 17–34 (1998)CrossRefGoogle Scholar
  15. 15.
    National Quality Forum (NQF).: National voluntary consensus standards for hospital care 2007: performance measures. A Consensus Report. National Quality Forum, Washington, DC (2008)Google Scholar
  16. 16.
    Axon, R.N., Williams, M.V.: Hospital readmission as an accountability measure. Jama. 305, 504–505 (2011)CrossRefGoogle Scholar
  17. 17.
    Laudicella, M., Donni, P.L., Smith, P.C.: Hospital readmission rates: signal of failure or success? J. Health Econ. 32, 909–921 (2013)CrossRefGoogle Scholar
  18. 18.
    Papanicolas, I., McGuire, A.: Using a Vector Autoregression Framework to Measure the Quality of English NHS Hospitals (2011)Google Scholar
  19. 19.
  20. 20.
    Bradley, E.H., Curry, L., Horwitz, L.I., Sipsma, H., Wang, Y., Walsh, M.N., Goldmann, D., White, N., Piña, I.L., Krumholz, H.M.: Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ. Cardiovasc. Qual. Outcomes. 6, 444–450 (2013)CrossRefGoogle Scholar
  21. 21.
    Heidenreich, P.A., Hernandez, A.F., Yancy, C.W., Liang, L., Peterson, E.D., Fonarow, G.C.: Get with the guidelines program participation, process of care, and outcome for Medicare patients hospitalized with heart failure. Circ. Cardiovasc. Qual. Outcomes. 5, 37–43 (2012)CrossRefGoogle Scholar
  22. 22.
    Coyte, P.C., Young, W., Croxford, R.: Costs and outcomes associated with alternative discharge strategies following joint replacement surgery: analysis of an observational study using a propensity score. J. Health Econ. 19, 907–929 (2000)CrossRefGoogle Scholar
  23. 23.
    Ho, V., Hamilton, B.H.: Hospital mergers and acquisitions: does market consolidation harm patients? J. Health Econ. 19, 767–791 (2000)CrossRefGoogle Scholar
  24. 24.
    Leppin, A.L., Gionfriddo, M.R., Kessler, M., Brito, J.P., Mair, F.S., Gallacher, K., Wang, Z., Erwin, P.J., Sylvester, T., Boehmer, K.: Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern. Med. 174, 1095–1107 (2014)CrossRefGoogle Scholar
  25. 25.
    Hansen, L.O., Young, R.S., Hinami, K., Leung, A., Williams, M.V.: Interventions to reduce 30-day rehospitalization: a systematic review. Ann. Intern. Med. 155, 520–528 (2011)CrossRefGoogle Scholar
  26. 26.
    Vest, J.R., Gamm, L.D., Oxford, B.A., Gonzalez, M.I., Slawson, K.M.: Determinants of preventable readmissions in the United States: a systematic review. Implement. Sci. 5, 88 (2010)CrossRefGoogle Scholar
  27. 27.
    Avaldi, V.M., Lenzi, J., Castaldini, I., Urbinati, S., Di Pasquale, G., Morini, M., Protonotari, A., Maggioni, A.P., Fantini, M.P.: Hospital readmissions of patients with heart failure: the impact of hospital and primary care organizational factors in Northern Italy. PLoS One. 10, e0127796 (2015)CrossRefGoogle Scholar
  28. 28.
    Joynt, K.E., Jha, A.K.: Who has higher readmission rates for heart failure, and why?. Circ. Cardiovasc. Qual. Outcomes. 4, 53–59 (2011)CrossRefGoogle Scholar
  29. 29.
    Krumholz, H.M., Parent, E.M., Tu, N., Vaccarino, V., Wang, Y., Radford, M.J., Hennen, J.: Readmission after hospitalization for congestive heart failure among Medicare beneficiaries. Arch. Intern. Med. 157, 99–104 (1997)CrossRefGoogle Scholar
  30. 30.
    Peikes, D., Chen, A., Schore, J., Brown, R.: Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. Jama. 301, 603–618 (2009)CrossRefGoogle Scholar
  31. 31.
    Holland, R., Battersby, J., Harvey, I., Lenaghan, E., Smith, J., Hay, L.: Systematic review of multidisciplinary interventions in heart failure. Heart. 91, 899–906 (2005)CrossRefGoogle Scholar
  32. 32.
    McAlister, F.A., Stewart, S., Ferrua, S., McMurray, J.J.: Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J. Am. Coll. Cardiol. 44, 810–819 (2004)PubMedGoogle Scholar
  33. 33.
    Phillips, C.O., Wright, S.M., Kern, D.E., Singa, R.M., Shepperd, S., Rubin, H.R.: Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. Jama. 291, 1358–1367 (2004)CrossRefGoogle Scholar
  34. 34.
    Lorch, S.A., Baiocchi, M., Silber, J.H., Even-Shoshan, O., Escobar, G.J., Small, D.S.: The role of outpatient facilities in explaining variations in risk-adjusted readmission rates between hospitals. Health Serv. Res. 45, 24–41 (2010)CrossRefGoogle Scholar
  35. 35.
    Murtaugh, C.M., Deb, P., Zhu, C., Peng, T.R., Barrón, Y., Shah, S., Moore, S.M., Bowles, K.H., Kalman, J., Feldman, P.H.: Reducing readmissions among heart failure patients discharged to home health care: effectiveness of early and intensive nursing services and early physician follow-up. Health Serv. Res. 52, 1445–1472 (2017)CrossRefGoogle Scholar
  36. 36.
    Rogers, J., Perlic, M., Madigan, E.A.: The effect of frontloading visits on patient outcomes. Home Healthc. Now. 25, 103–109 (2007)CrossRefGoogle Scholar
  37. 37.
    Feltner, C., Jones, C.D., Cené, C.W., Zheng, Z.-J., Sueta, C.A., Coker-Schwimmer, E.J., Arvanitis, M., Lohr, K.N., Middleton, J.C., Jonas, D.E.: Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann. Intern. Med. 160, 774–784 (2014)CrossRefGoogle Scholar
  38. 38.
    Hernandez, A.F., Greiner, M.A., Fonarow, G.C., Hammill, B.G., Heidenreich, P.A., Yancy, C.W., Peterson, E.D., Curtis, L.H.: Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. Jama. 303, 1716–1722 (2010)CrossRefGoogle Scholar
  39. 39.
    McAlister, F.A., Youngson, E., Bakal, J.A., Kaul, P., Ezekowitz, J., van Walraven, C.: Impact of physician continuity on death or urgent readmission after discharge among patients with heart failure. Can. Med. Assoc. J. 185, E681–E689 (2013)CrossRefGoogle Scholar
  40. 40.
    Ezekowitz, J.A., Van Walraven, C., McAlister, F.A., Armstrong, P.W., Kaul, P.: Impact of specialist follow-up in outpatients with congestive heart failure. Can. Med. Assoc. J. 172, 189–194 (2005)CrossRefGoogle Scholar
  41. 41.
    Barlet, M., Coldefy, M., Collin, C., Lucas-Gabrielli, V.: (2012), Local potential accessibility: a new measure of accessibility to private general practitioners, Issues in Health Economics, no. 175, 2012/04. Irdes, ParisGoogle Scholar
  42. 42.
    Chandra, A., Staiger, D.O.: Productivity spillovers in health care: evidence from the treatment of heart attacks. J. Polit. Econ. 115, 103–140 (2007)CrossRefGoogle Scholar
  43. 43.
    Cutler, D.M.: The lifetime costs and benefits of medical technology. J. Health Econ. 26, 1081–1100 (2007)CrossRefGoogle Scholar
  44. 44.
    McClellan, M., McNeil, B.J., Newhouse, J.P.: Does more intensive treatment of acute myocardial infarction in the elderly reduce mortality?: analysis using instrumental variables. Jama. 272, 859–866 (1994)CrossRefGoogle Scholar
  45. 45.
    Cawley, J., Markowitz, S., Tauras, J.: Lighting up and slimming down: the effects of body weight and cigarette prices on adolescent smoking initiation. J. Health Econ. 23, 293–311 (2004)CrossRefGoogle Scholar
  46. 46.
    Jones, A.M., Rice, N., Roberts, J.: Sick of work or too sick to work? Evidence on self-reported health shocks and early retirement from the BHPS. Econ. Model. 27, 866–880 (2010)CrossRefGoogle Scholar
  47. 47.
    Terza, J.V., Basu, A., Rathouz, P.J.: Two-stage residual inclusion estimation: addressing endogeneity in health econometric modeling. J. Health Econ. 27(3), 531–543 (2008)CrossRefGoogle Scholar
  48. 48.
    Basu, A., Coe, N.B., Chapman, C.G.: 2SLS versus 2SRI: appropriate methods for rare outcomes and/or rare exposures. Health Econ. 27(6), 937–955 (2018)CrossRefGoogle Scholar
  49. 49.
    Luo, W., Qi, Y.: An enhanced two-step floating catchment area (E2SFCA) method for measuring spatial accessibility to primary care physicians. Health Place. 15, 1100–1107 (2009)CrossRefGoogle Scholar
  50. 50.
    McGrail, M.R., Humphreys, J.S.: A new index of access to primary care services in rural areas. Aust. N. Z. J. Public Health 33, 418–423 (2009)CrossRefGoogle Scholar
  51. 51.
    Lucas-Gabrielli, V., Nestrigue, C.: Analyse de Sensibilité de l’Accessibilité Potentielle Localisée (APL). Irdes Doc. Trav (2016)Google Scholar
  52. 52.
    Charlson, M.E., Pompei, P., Ales, K.L., MacKenzie, C.R.: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J. Chronic Dis. 40, 373–383 (1987)CrossRefGoogle Scholar
  53. 53.
    Quan, H., Sundararajan, V., Halfon, P., Fong, A., Burnand, B., Luthi, J.-C., Saunders, L.D., Beck, C.A., Feasby, T.E., Ghali, W.A.: Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med. Care. 1130–1139 (2005)Google Scholar
  54. 54.
    Or, Z., Penneau, A.: Analyse des déterminants territoriaux du recours aux urgences non suivi d’une hospitalisation. Irdes, Paris (2017)Google Scholar
  55. 55.
    Dourgnon, P., Naiditch, M.: The preferred doctor scheme: a political reading of a French experiment of gate-keeping. Health Policy. 94, 129–134 (2010)CrossRefGoogle Scholar
  56. 56.
    Desai, A.S., Stevenson, L.W.: Rehospitalization for heart failure: predict or prevent?. Circulation 126, 501–506 (2012)CrossRefGoogle Scholar
  57. 57.
    Lee, D.S., Stukel, T.A., Austin, P.C., Alter, D.A., Schull, M.J., You, J.J., Chong, A., Henry, D., Tu, J.V.: Improved outcomes with early collaborative care of ambulatory heart failure patients discharged from the emergency departmentclinical perspective. Circulation. 122, 1806–1814 (2010)CrossRefGoogle Scholar
  58. 58.
    Vallejo-Torres, L., Morris, S.: Primary care supply and quality of care in England. Eur. J. Health Econ. 19, 499–519 (2018)CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Institut de Recherche et de Documentation en Economie de la Santé (IRDES)ParisFrance

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