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Early Follow-up With Patients after Hospitalization for Heart Failure Reduces Readmission Rates

March 16, 2016

Older man sitting in exam room talking to physician, the physician has his hand on the man's shoulder. They are smiling.

OAKLAND, Calif. — Heart failure patients who had early follow-up with general medicine or cardiology providers within seven days of being discharged from the hospital had a lower chance of being readmitted to the hospital within 30 days, according to a study from Kaiser Permanente published today in the journal Medical Care.

Heart failure is the leading cause of hospitalization among adults 65 years and older and more than 1 million patients are hospitalized due to heart failure each year. In addition, among Medicare patients hospitalized for heart failure, more than 20 percent are readmitted within 30 days. Although improving the efficiency and effectiveness of care after hospitalization has been a major focus, there is a little evidence from large-scale studies in clinical practice regarding the impact of particular interventions in improving patient outcomes.

“Our study showed that the timing of follow-up after hospitalization for heart failure is an important factor. Early follow-up within seven days, even with a telephone call, was associated with lower risk of readmission, whereas follow-up after seven days was not associated with this benefit,” said lead author Keane K. Lee, MD, MS, a cardiologist and research scientist with Kaiser Permanente in Northern California.

The study population consisted of 11,985 adults who were hospitalized for heart failure between 2006 and 2013, and who were discharged to home without hospice care. There were 1,587 cases of patients being readmitted to the hospital within the first 30 days after discharge who were then carefully matched with 7,935 patients who were not readmitted based on having the same follow-up time as the corresponding case.

Early follow-up within one week was independently associated with 19 percent lower odds of readmission, while follow-up after one week was not associated with lower readmission risk. Approximately 70 percent of the patients had either a clinic visit or a telephone call within 30 days of hospital discharge, with about 50 percent having contact within the first seven days. The majority — 84 percent — of the follow-up contacts were clinic visits, while the other 16 percent were telephone calls. While all clinic visits were with physicians, it is important to note that 45 percent of the telephone calls were made by non-physician providers who were trained to follow an outpatient heart-failure treatment protocol.

“These data suggest that health systems can implement different methods of systematic, early patient contact to improve transitional care and, ultimately, clinical outcomes,” Dr. Lee noted. “Once the patient is back home, a phone call within a few days with either a physician or non-physician care team member may be more practical to implement by many health care delivery systems compared with clinic visits for all patients.”

Another enabling factor, according to senior author Alan S. Go, MD, chief of Cardiovascular and Metabolic Conditions at the Kaiser Permanente Northern California Division of Research, is the integration of care among providers — internal medicine, family medicine and cardiology — made possible by the organization’s coordinated approach to health care combined with its comprehensive electronic medical record system across inpatient and outpatient settings.

“Heart failure poses a substantial health and economic burden nationally and is expected to grow significantly in the next several decades,” Dr. Go said. “Our results imply that clinicians may be able to leverage the increasing integration occurring in health care to improve the effectiveness of transitional care and reduce hospital readmissions in high-risk populations.”

This study was funded by grants from the Kaiser Permanente Northern California Community Benefit Fund and the National Heart, Lung and Blood Institute of the National Institutes of Health, U.S. Department of Health and Human Services.

About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes, and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 500-plus staff is working on more than 400 epidemiological and health services research projects. For more information, visit or follow us @KPDOR.

About Kaiser Permanente
Kaiser Permanente is committed to helping shape the future of health care. We are recognized as one of America’s leading health care providers and not-for-profit health plans. Founded in 1945, Kaiser Permanente has a mission to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. We currently serve more than 10 million members in eight states and the District of Columbia. Care for members and patients is focused on their total health and guided by their personal physicians, specialists and team of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the-art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health. For more information, go to: