Abstract 20028: Improved Outcomes with IT-enabled Care Management Following Coronary Revascularization

Objective: Hospitals are increasingly responsible for the longitudinal care of patients discharged from their institution. We report preliminary results from an IT-enabled care management program for patients following coronary revascularization at a large regional medical center. Methods: The program consisted of patient education, telephonic management, and integration with community providers. The intensity of the intervention was tailored to patient risk of subsequent utilization. We used hierarchical logistic regression to compare severity-adjusted all-cause non-elective 30-day readmissions to our institution for all patients discharged in the first year (April 2013 - April 2014) with the baseline period (January 2010 - March 2013). We used mixed effects models to compare patient responses to the Care Transitions Measure-3 (CTM-3), a CMS-endorsed measure of transition quality, and the Seattle Angina Questionnaire-7 (SAQ-7) following discharge, both of which were collected as part of routine care management. Results: We enrolled 1,542 revascularized patients in the first year, including 1,188 with PCI and 354 with CABG. The overall rate of readmission for PCI was 7.5% in the baseline period and 8.0% in the intervention period. After adjusting for patient factors, the adjusted rate of readmission was 8.9% and 6.8% (adjusted RR 0.77 [0.76 - 0.78]). The unadjusted rates for CABG were 12.6 and 12.9; with adjusted rates of 13.3 and 10.8 in the baseline and intervention period, respectively (adjusted RR 0.81 [0.8 - 0.83]). The CTM-3 score improved from 67.4±13.3 to 78.8±16.8 for PCI and from 72.7±12.7 to 75±20.7 for CABG during the intervention period (p < 0.001 for both). The SAQ domains all improved significantly during the course of the program, with improvements in Quality of Life Scale from 64±27 to 92±14 for PCI and 60±34 to 92±14 (p<0.001). Conclusions: A care management program was associated with improved process and outcome measures, including significant improvements in patient-reported outcomes, when compared to historical controls. Interdisciplinary care management programs can play a significant role in improving care, including in non-integrated healthcare environments.