Journal Article
ReCAP: Reducing Unplanned Medical Oncology Readmissions by Improving Outpatient Care Transitions: A Process Improvement Project at the Cleveland Clinic
Montero, AJ; Stevenson, J; Guthrie, AE; Best, C; Goodman, LM; Shrotriya, S; Azzouqa, AG; Parala, A; Lagman, R; Bolwell, BJ; Kalaycio, ME; Khorana, AA; Montero, AJ; Stevenson, J; Guthrie, AE; Best, C; Goodman, LM; Shrotriya, S; Azzouqa, AG; Parala, A; Lagman, R; Bolwell, BJ; Kalaycio, ME; Khorana, AA
QUESTION ASKED: Can improving outpatient care transitions, through implementation of 48-hour nurse callbacks and 5-day follow up appointments, reduce unplanned oncology hospital readmissions in nonsurgical oncology patients?
SUMMARY ANSWER: We found that a modest reduction in 30-day unplanned oncology readmissions was achieved through systematically improving outpatient care transitions at the Cleveland Clinic. (Fig 2A) METHODS: A quality improvement project designed to improve outpatient care transitions was initiated which included: (1) provider education, (2) nursing phone calls within 48 hours postdischarge, and (3) follow up appointments with the primary medical oncologist within 5 business days postdischarge. Nursing callback included symptom management, education, medication review/compliance, and follow up appointment reminders. The number of patients discharged home with nurse callbacks and follow up appointments was measured on a monthly basis during the intervention as our primary process metrics. Monthly any-cause unplanned 30-day readmission rates were tracked during the intervention.
MAIN RESULTS OR WHAT WE FOUND: Relative to the baseline period, unplanned readmission rates during the intervention period were 4.5% lower, declining from 27.4% to 22.9% (P < .01, relative risk reduction 18%). Moreover, our intervention also reduced the monthly variation previously noted in unplanned readmissions of medical oncology patients.
BIAS, CONFOUNDING FACTORS, DRAWBACKS: Although we found that improving care transitions did in fact modestly reduce monthly readmission rates, this approach alone will be unlikely to have a major impact on most unplanned readmissions of non-surgical cancer patients. There are many factors that can vary from month to month in a large inpatient general oncology service and have a big impact on readmission rates. For example, readmission rates can vary considerably by cancer type, willingness of patients with aggressive and incurable cancers-as well as their families and primary oncologists-to forego more aggressive therapy and accept hospice care, social support, and socioeconomic status. Many of these are not easily influenced by having good outpatient continuity after discharge.
REAL-LIFE IMPLICATIONS: Improving outpatient care transitions for cancer patients that are discharged home is part and parcel of patient-centered care, independent of its impact on hospital readmissions.jop;JOP.2015.007880v1/F02F1F02FIG 2A.Unplanned 30-day readmissions and admissions over time from January 1, 2012 to March 31, 2015. (A) Control chart of monthly unplanned 30-day readmission rates, before and after implementation of the care transitions project.