Abstract 098: The Prevalence of Racial and Socioeconomic Disparities in an Outpatient Transitional Care Clinic

2017 ◽  
Vol 10 (suppl_3) ◽  
Author(s):  
Khadijah Hussain ◽  
Colin McMahon ◽  
Rachel Krallman ◽  
Daniel Montgomery ◽  
Thane Feldeisen ◽  
...  
Keyword(s):  
Transitional Care ◽  
Poverty Line ◽  
Low Ses ◽  
Readmission Rates ◽  
Care Clinic ◽  
Coronary Syndrome ◽  
Improved Outcomes ◽  
Caucasian Patients ◽  
Ed Visits ◽  
Discharge Gap

Background: Bridging the Discharge Gap Effectively (BRIDGE) is a cardiac transitional care clinic. BRIDGE has demonstrated improved patient outcomes for some populations. This study sought to determine if differences in outcomes (readmissions, ED visits, death) exist for Caucasian and non-Caucasian patients based on BRIDGE attendance and socioeconomic status (SES). Methods: Data on patients referred to BRIDGE from 2008-2014 were analyzed. Patients were split into two cohorts (Caucasian and non-Caucasian) and outcomes for each were independently compared by BRIDGE attendance and SES. Non-low SES was defined as income > $48,600 (200% poverty line for a family of 4) and low SES was income ≤ $48,600. Demographics and outcomes were compared between groups. Results: Of 2964 patients, 15.1% were non-Caucasian (n=448). Caucasians were significantly older than non-Caucasians (66.16±14.29 v 59.14±14.75, p<0.001), and were more likely to have primary diagnoses of acute coronary syndrome (28.2% v 23.5%, p=0.039) or atrial fibrillation (16.8% v 9.3%, p<0.001). Among Caucasian patients, BRIDGE attenders had significantly lower 30-day readmission rates (8.6% v 11.3%, p=0.038) and fewer ED visits within 6 months (1.80±1.3 v 2.10±2.0, p=0.049). Non-Caucasians, however, were more likely to have an ED visit within 6 months (40.9% v 33.7%, p=0.012; data not shown). Non-Caucasians of low SES were more likely to be readmitted within 6 months (40.5% v 29.5%, p=0.029) and less likely to attend BRIDGE (64.9% v 76.4%, p=0.016) than non-low SES non-Caucasians. There were no significant differences between non-low and low SES Caucasian patients. Among BRIDGE attenders, 6-month mortality rates were significantly lower for both groups (Caucasian: 5.2% v 10.8%, p<0.001; non -Caucasian: 4.3% v 10.7%, p=0.013). Conclusions: BRIDGE attendance was associated with improved outcomes in Caucasians that were not seen in non-Caucasians, with the exception of reduced mortality. Also, SES appears to impact non-Caucasians more than Caucasians, with low SES non-Caucasians having higher readmission rates and lower BRIDGE attendance than non-low SES non-Caucasians. Differences seen may be biased due to unevenly distributed groups (i.e. age and diagnosis). Efforts to target these vulnerable populations are warranted to reduce disparities.

Abstract 357: Effect of an Early Nurse Practitioner Based Transitional Care Program on Atrial Fibrillation Readmissions

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Redah Z Mahmood ◽  
Sherry M Bumpus ◽  
Daniel G Montgomery ◽  
Eva Kline-Rogers ◽  
James B Froehlich ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Nurse Practitioner ◽  
Transitional Care ◽  
Tertiary Care ◽  
Care Program ◽  
Discharge Diagnosis ◽  
Chart Audit ◽  
Care Clinic ◽  
Coronary Syndrome ◽  
Ed Visits

Background: BRIDGE is a nurse practitioner (NP) based transitional care program for cardiac patients(pts) discharged from a large tertiary care health system. Attendance at the BRIDGE clinic has been shown to reduce early readmission and ED visits for acute coronary syndrome (ACS) pts. Little is known about causes of readmission for atrial fibrillation (AF) pts and whether an NP based program affects overall readmissions. Methods: Retrospective data on 1188 pts was abstracted from 2008 to 2010 for pts referred to BRIDGE. Early (30 day) readmission of pts with discharge diagnosis of AF underwent qualitative chart audit by a trained MD abstractor. When examining if BRIDGE affected readmissions, we excluded pts with ED visits/readmits prior to BRIDGE. Results: Median time to BRIDGE was 16 days. Of 1010 with complete data, 148 (15%) had a discharge diagnosis of AF; 110/148 (74%) AF pts attended BRIDGE. Thirty day readmission (30DR) for AF was 23% (34/148); 17/34 (57%) were sent to the ED by a MD or nurse. Attending BRIDGE had no effect on outcomes at all time points (table 1); 17 patients were readmitted before BRIDGE. Readmission at 6 months for AF was 41% for those who attended BRIDGE, 29% for those who did not (p=0.190). Table 2 details reasons for all 30DR in AF pts. Chart review demonstrated that all 30DR were appropriate, 83% (25/30) of non-elective readmissions were unavoidable, and of 5 potentially avoidable readmissions, 2 were due to patient non-compliance. Conclusions: 30-day readmission rates are high for pts recently discharged with a diagnosis of AF and most are unavoidable. A NP based transitional care clinic successful in reducing 30 day readmissions for ACS pts did not prevent either early or late readmissions in AF pts.

Abstract 256: Readmission Avoidability in Acute Coronary Syndrome Patients

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Maria Souphis ◽  
Rachel Sylvester ◽  
Alison Wiles ◽  
Meghana Subramanian ◽  
William Froehlich ◽  
...  
Keyword(s):  
Transitional Care ◽  
Drug Effects ◽  
Care Program ◽  
Readmission Rates ◽  
Coronary Syndrome ◽  
History Of ◽  
Definition Of ◽  
Avoidable Readmission ◽  
Cancer Complications ◽  
Avoidable Readmissions

Background: Readmissions for ACS are common, costly, and potentially preventable. According to Medicare 13.4% of AMI admissions were followed by a rehospitalization within 15 days. A 2007 MedPAC report declared 76% of 30-day readmissions preventable. These rates are used as quality indicators despite lack of consensus on the definition of avoidable and unavoidable readmissions. We sought to define these terms and to analyze the effect of these definitions on 30-day outcomes. Methods: BRIDGE (Bridging the Discharge Gap Effectively) is an NP-led transitional care program for cardiac patients within 14 days of discharge. Retrospective data were abstracted on ACS patients readmitted before their appointments between 2008-2010. All readmissions were characterized as avoidable or unavoidable. Definitions were developed from the literature and in concert with senior cardiologists. Avoidable readmission was defined as being the result of a patient or provider issue that if managed may have prevented the admission. Unavoidable readmissions were defined as a patient in need of acute care. Avoidability status was further divided as related or unrelated to the index diagnosis. Results: Of 1188 BRIDGE referrals 304 (25.6%) experienced ACS events. In comparison to the total ACS population, patients readmitted before their BRIDGE clinic appointment (BC) (n=21, 6.9%) tended to be older, female, and were less likely to have a history of a cath or AMI (Table 1). In this study, 81% (n=17) of early readmissions were deemed unavoidable and most (n=14, 66.7%) were attributed to non-ACS issues or disease progression. These unavoidable readmissions included patients with cancer complications, chest pain, or other non-related diagnoses. Only 19% (n=4) of the readmissions were declared avoidable as a result of patient lack of adherence or provider issues such as adverse drug effects. Conclusion: The majority of early (before BC) readmissions following an index hospitalization for ACS patients referred to BRIDGE were unavoidable and unrelated to ACS. A clear discrepancy is seen between the 76% preventable readmissions in the MedPAC report and the 19% preventable readmissions in this study. Distinctions between unavoidable and avoidable readmissions should inform the utility of 30-day readmission rates as quality metrics.

Abstract 097: Effects of BRIDGE Attendance on the Outcomes of Diabetic Patients

2017 ◽  
Vol 10 (suppl_3) ◽  
Author(s):  
Caitlin Fette ◽  
Rachel Krallman ◽  
Colin McMahon ◽  
Daniel Montgomery ◽  
Jennifer Wang ◽  
...  
Keyword(s):  
Transitional Care ◽  
Care Program ◽  
Primary Diagnosis ◽  
Lower Mortality ◽  
Diabetic Patients ◽  
Post Discharge ◽  
Readmission Rates ◽  
Coronary Syndrome ◽  
Increased Risk ◽  
Discharge Outcomes

Background: Prior studies have shown that patients with diabetes mellitus (DM) have increased risk for developing cardiovascular disease. BRIdging the Discharge Gap Effectively (BRIDGE) is a nurse practitioner-delivered cardiac transitional care program for patients who have been recently discharged following a cardiac event. Previous research has shown BRIDGE to be effective in improving patient outcomes. This study sought to describe differences in outcomes 1) of heart failure (HF), acute coronary syndrome (ACS), and atrial fibrillation (AF) patients with and without concomitant DM, and 2) between diabetic patients who did and did not attend BRIDGE. Methods: Retrospective data were abstracted for HF, ACS, and AF patients from 2008-2014. Patients were divided into cohorts based on presence or absence of DM and BRIDGE attendance versus non-attendance. Outcomes (readmissions, ED visits, death) within each primary diagnosis (HF, ACS, AF) were compared between DM and non-DM patients and between those who attended BRIDGE versus those who did not for all DM patients. Results: Of 2197 patients referred to BRIDGE, 723 (32.9%) had concomitant DM. DM patients had similar outcomes to non-DM patients for most post-discharge outcomes; however, DM ACS patients had higher readmission (42.2% v 29.6%, p<0.001) and death (10.5% v. 4.5%, p=0.001) rates within 6 months, and DM AF patients had higher readmission rates within 6 months (52.1% v 37.9%, p=0.006). HF patients with DM who attended BRIDGE had lower mortality rates within 6 months of discharge than those who did not (10.3% vs. 22.1%, p=0.014). No other significant differences in outcomes were seen between BRIDGE attendees and non-attendees. Conclusions: Though not significant, patients with DM had worse post-discharge outcomes than those without DM for all primary diagnoses. In the subset of DM patients, the 30-day readmission rate for ACS patients who attended BRIDGE was half of those who did not attend. Conversely, 30-day readmission rates for HF patients were greater if they attended. This may in part explain the significantly lower mortality rate among BRIDGE attenders with HF, where patients who needed readmission were identified during their BRIDGE appointment. Due to the high prevalence of DM, efforts to tailor transitional care for this population are needed.

Abstract 304: Characteristics of Acute Coronary Syndrome Patients Referred to the Bridge Transitional Care Clinic By Time to Readmission

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
George Cholack ◽  
Joshua Garfein ◽  
Rachel H Krallman ◽  
Delaney Feldeisen ◽  
Daniel G Montgomery ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Transitional Care ◽  
Discharge Planning ◽  
Post Discharge ◽  
Care Clinic ◽  
Icu Admission ◽  
Coronary Syndrome ◽  
Female Sex ◽  
Increased Risk ◽  
Early Readmission

Introduction: Prompt follow-up post-discharge is recommended by many readmission reduction initiatives. Identifying predictors of early readmission may inform discharge planning. We compared characteristics of acute coronary syndrome (ACS) patients (pts) based on time to readmission to determine factors associated with early readmission. Methods: Pts referred to the BRIDGE transitional care clinic following index admission for ACS from 2008-2017 were eligible. Demographics and inpatient clinical characteristics were compared between pts readmitted early (0-7 days post-discharge) versus late (8-30 days post-discharge). Multivariable logistic regression models were created to identify independent predictors of early readmission. Results: Of 1220 ACS pts, 198 were readmitted within 30 days; 70 (35.4%) were readmitted early, and 10.0% of these were readmitted for ACS. Early readmissions were more likely to be female, have an ED visit prior to readmission, and have an index ICU admission. Female sex [OR: 2.26, 95% CI: 1.23, 4.16] and ICU admission [OR: 2.20, 95% CI: 1.14, 4.24] were both independent predictors of early readmission. Conclusion: Female sex and ICU admission during index were associated with roughly twice the odds of early readmission. Non-white pts were also more often readmitted early (p=0.05), suggesting potential care disparities in this population. Future studies to identify pts at increased risk of early readmission and efforts to reduce disparities are warranted.

The Role of Ultrasound-Guided Therapeutic Paracentesis in an Outpatient Transitional Care Program: A Case Series

2018 ◽  
Vol 35 (9) ◽  
pp. 1256-1260 ◽  
Author(s):  
Jeffrey Wang ◽  
Shahida Khan ◽  
Paige Wyer ◽  
Jessica Vanderwilp ◽  
Justin Reynolds ◽  
...  
Keyword(s):  
Transitional Care ◽  
Effective Means ◽  
Case Series ◽  
Care Program ◽  
Cost Effective ◽  
Refractory Ascites ◽  
Ultrasound Guided ◽  
Care Clinic ◽  
Wide Range ◽  
Ed Visits

Background: Patients with ascites suffer from distressing symptoms and are at high risk for readmission after hospitalization. Timely paracentesis is an important palliative tool in managing this vulnerable population. At our institution, we have developed a multidisciplinary transitional care program for patients discharged from the hospital with a wide range of complex conditions including refractory ascites. Methods: We present a case series of 10 patients with symptomatic ascites who were enrolled in our transitional care program and treated with ultrasound-guided therapeutic paracentesis in our clinic. Patient medical records were retrospectively reviewed to collect procedure details, outcomes, and follow-up data on emergency department (ED) visits and readmissions. Cost data were obtained from the hospital financial system. Results: Over the span of 9 months (September 2016 to July 2017), 22 total therapeutic paracenteses were performed on 10 unique patients in the transitional care clinic. Median age of the patient cohort was 52.5 years (range: 27-71 years). All patients reported immediate relief of ascites-related discomfort following the procedure. We did not observe any major adverse effects due to the in-clinic procedure. Nine of the 10 patients did not have any ED visits or readmissions within 30 days of discharge. The cost of performing ultrasound-guided paracentesis in the transitional care clinic was US$546.77 compared to US$978.32 when performed in the hospital. Conclusion: Our experience suggests that outpatient paracentesis may be a safe, feasible, and cost-effective means of providing symptom management for patients with ascites during their transition from hospital to home.

Abstract 095: Lessons Learned from the BRIDGE Registry: Major Findings From 8 Years of BRIDGE

2017 ◽  
Vol 10 (suppl_3) ◽  
Author(s):  
Morgan Bradford ◽  
Rachel Krallman ◽  
Colin McMahon ◽  
Daniel Montgomery ◽  
Eva Kline-Rogers ◽  
...  
Keyword(s):  
Transitional Care ◽  
The United States ◽  
Lessons Learned ◽  
Unplanned Readmission ◽  
Post Discharge ◽  
Care Clinic ◽  
Coronary Syndrome ◽  
Patient Reported ◽  
Comorbidity Scores

Background: Readmissions after cardiac hospitalizations are frequent and costly in the United States. Delays in follow-up and lack of adherence to guidelines may contribute to high unplanned readmission rates. Bridging the Discharge Gap Effectively (BRIDGE) is a nurse practitioner (NP) led, transitional care clinic for cardiac patients, aimed at reducing readmissions. Data on patients referred to BRIDGE has been collected since 2009; herein we report a summary of significant findings from these data. Methods: A qualitative review of results and conclusions from all published abstracts, oral presentations, and papers from the BRIDGE registry (June 2008-August 2015) was conducted. Content analysis was used to synthesize findings across studies. Results: Data from 3982 patients referred to BRIDGE have been collected. Seven themes were identified in the analysis of BRIDGE publications. During BRIDGE, NPs focused on medical history, symptoms, medication management (in 24.8% of visits), patient education, and referrals. In addition to addressing provider priorities, addressing patient concerns (daily living and clinical questions, feelings and fears) was highly salient, resulting in a high level of patient-NP connectedness as evidenced by high patient-reported scores on the Consultation and Relational Empathy scale (mean 43.5 ± 2.8; possible range 0, 50) and the Patient-Doctor Relationship Questionnaire (mean 43.05 ± 3.1; possible range 5, 45). Readmissions within 30 days were consistently lower for acute coronary syndrome (ACS) patients who attended BRIDGE compared to those who did not (6.4% v. 13.1%; p<0.01); similar results were not seen in heart failure (HF) (15.4% v. 15.7%; p=0.944) or atrial fibrillation (AF) (8.5% v. 5.2%; p=0.343) patients. A spike in HF readmissions was seen between 8-14 days post-discharge, suggesting the need for a sooner appointment. However, follow-up within 7 days of discharge did not show reduced readmissions in HF patients. AF readmissions were also difficult to avoid; in a subset of AF patients readmitted within 30 days, 51.1% (n=23) were readmitted for non-AF diagnoses. High risk patients (i.e. those with an adverse event before BRIDGE) were older, had higher Charlson comorbidity scores, and were more likely to have depression. However, marriage was associated with fewer readmissions. Conclusions: Data from the BRIDGE registry have shown that clinic attendance reduced ACS readmissions; has characterized older, depressed patients with higher Charlson comorbidity scores as being those most likely to be readmitted; and has identified areas for improvement in transitional care (e.g. AF and HF) where readmissions are difficult to avoid. Continuous quality improvement and real-time monitoring of patient outcomes have translated this research into more prompt transitional care, illustrating the importance of registry-based research.

Abstract 259: The Effects of Depression on BRIDGE Patients

2016 ◽  
Vol 9 (suppl_2) ◽  
Author(s):  
Jacob Carolan ◽  
Rachel Sylvester ◽  
Nathaniel Costin ◽  
Colin McMahon ◽  
Morgan Bradford ◽  
...  
Keyword(s):  
Hospital Discharge ◽  
Nurse Practitioner ◽  
Transitional Care ◽  
Care Program ◽  
Retrospective Data ◽  
Readmission Rates ◽  
History Of ◽  
Discharge Gap ◽  
History Of Depression

Background: Depression creates additional barriers to receiving transitional care. Bridging the Discharge Gap Effectively (BRIDGE) is a nurse practitioner-delivered cardiac transitional care program. We sought to determine if, 1) there was a difference in readmission rates of BRIDGE patients with depression (PWD) and those without depression (PWOD), and 2) if BRIDGE attendance lowered 30-day readmission rates in PWD. Methods: Retrospective data was abstracted for all patients referred to BRIDGE (June ’08 - Dec ’14). Readmission rates of PWD and PWOD were compared in both BRIDGE attenders and non-attenders. Results: Of 2446 patients, 577 (23.6%) had a history of depression. PWD were significantly younger (62.82 ± 14.04 v 66.17 ± 14.88, p<0.001), more likely to be female (55.6% v 39.1%, p<0.001), and less likely to attend their BRIDGE appointment (67.1% v 72.1%, p=0.010) than PWOD. Among BRIDGE attendees, PWD had significantly higher 60, 90, and 180 day readmission rates than PWOD (Table 1). Although 30 day readmissions were lower in PWD who attended BRIDGE, compared to PWD who did not attend BRIDGE, these results were not significant (10.5% v 12.6%, p=0.505), and this trend was not seen in 60, 90, and 180 day readmission rates. Conclusions: PWD are less likely to attend BRIDGE appointments and more likely to be readmitted. These results suggest that special attention needs to be given to PWD upon hospital discharge to ensure that proper transitional care is received and readmissions are avoided.

Abstract 313: Investigation of Substance Use in the Bridge Population

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Rossteen Abbasi ◽  
Rachel H Krallman ◽  
Delaney Feldeisen ◽  
Daniel G Montgomery ◽  
Eva M Kline-Rogers ◽  
...  
Keyword(s):  
Substance Use ◽  
Transitional Care ◽  
Substance Users ◽  
Care Clinic ◽  
Illicit Substance ◽  
Comorbidity Scores ◽  
History Of ◽  
Ed Visits ◽  
Alcohol Users ◽  
The Impact

Background: Alcohol and drug dependence has been linked to increased readmissions and ED visits in some populations. This study investigated the impact of different substance use (SU) on outcomes (ED visit, readmission, death) among hospitalized cardiac patients (pts). Methods: Data on all pts referred to the BRIDGE cardiac transitional care clinic from 2008-2017 were collected. Chart review was conducted on a random selection of pts with a history of SU (n=152) to determine the type of substance used: alcohol, tobacco, illicit substances (i.e. cocaine, narcotics, marijuana) (study conducted prior to Michigan’s legalization of marijuana), or multiple substances. Demographics and outcomes at 30 and 180 days were compared between SU groups. Results: Of 3536 pts, 305 (8.6%) had a history of SU. Compared to those without SU, SU pts were younger (57.3±13.2 v 66.7±14.5 years, p<0.001), male (72.8% v 62.1%, p<0.001), single (62.5% v 38.0%, p<0.001), non-white (21.9% v 15.6%, p=0.005), less likely to attend their BRIDGE appointment (35.7% v 28.3%, p=0.012), had lower Charlson comorbidity scores (CCS) (3.7 v 4.9, p<0.001), and were more likely to visit the ED within 180 days of discharge (44.4% v 38.1%, p=0.033). Of 152 randomly selected SU pts, 57 (37.5%) used alcohol, 20 (13.2%) tobacco, 28 (18.4%) illicit, and 47 (30.9%) multiple substances. Illicit substance users were more likely to be from low SES communities. Despite older age and higher CCS than the other SU groups, alcohol users had fewer 180 day ED visits (p=0.007) and 180 day readmissions (p=0.024) than illicit substance users, as well as fewer 180 day readmissions (p=0.044) than multiple substance users. Conclusion: Compared to the national average (US Department of Health and Human Services), pts referred to BRIDGE appear more likely to have a history of SU (6.4% v 8.6%). Despite being younger and having lower comorbid burden, SU pts in this population had worse outcomes, as seen in prior studies. Additionally, they were less likely to attend a transitional care appointment, putting them at greater risk. Alcohol users, while older and sicker, had the best outcomes among SU pts; illicit substance users had the worst. Further research to identify the causes of these ED visits and readmissions, as well as targeted strategies to improve outcomes in this population are warranted.

Abstract 309: Outcomes of Depressed Patients With and Without Antidepressant Prescription

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Ashley Francis ◽  
Rachel H Krallman ◽  
Delaney Feldeisen ◽  
Daniel G Montgomery ◽  
Eva M Kline-Rogers ◽  
...  
Keyword(s):  
Transitional Care ◽  
Additional Treatment ◽  
Cardiac Patients ◽  
Treatment Modalities ◽  
Post Discharge ◽  
Care Clinic ◽  
Antidepressant Prescription ◽  
Increased Risk ◽  
Antidepressant Use ◽  
Ed Visits

Background: Many studies have shown a relationship between depression and an increased risk of rehospitalization, suggesting assessment and management, potentially including antidepressants, should remain an important part of inpatient treatment. However, studies analyzing the outcomes associated with antidepressant use among cardiac patients have shown mixed results. This study aims to describe the long-term outcomes (ED visits, readmissions, and death) of a cohort of cardiac patients with concomitant depression treated with antidepressants. Methods: A total of 151 patients with a medical history of depression were randomly selected between 2008-2017 from a cardiac transitional care clinic registry. A retrospective chart review was conducted to determine the frequency of antidepressant prescription at discharge following a cardiac hospital admission. Demographics and outcomes were compared between those prescribed and those not prescribed antidepressants at discharge. Results: Of 4,298 patients, 1,067 (24.8%) had a diagnosis of depression recorded in their medical record. Of the 151 randomly selected depression patients, 106 (70.2%) were on at least one antidepressant at discharge. Significantly more females were prescribed antidepressants at discharge than males (78.0% v. 58.3%, p=0.010). No significant differences were seen in race, socioeconomic status, or outcomes at 30, 60, 90, or 180 days post-discharge between those prescribed and those not prescribed antidepressants at discharge. However, when compared to patients without depression (n=3,231), those on at least one antidepressant had significantly more 30-day ED visits (25.5% vs 17%, p=0.026), 180-day ED visits (52.9% vs 38.1%, p=0.002), and 180-day readmissions (55.8% vs 40.1%, p=0.001). Conclusions: Patients with depression had worse outcomes than those without depression, despite the majority (70.2%) being treated with antidepressants. These results suggest efforts should be made post-discharge to closely monitor patients with depression, even if they are prescribed antidepressants, and additional treatment modalities should be researched.

Abstract 339: Insights into Readmission Rates of Atrial Fibrillation Patients

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Thomas Vasko ◽  
Rachel Sylvester ◽  
William Froehlich ◽  
Meghana Subramanian ◽  
Alison Wiles ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Transitional Care ◽  
Care Program ◽  
Post Discharge ◽  
Readmission Rates ◽  
Bridge Program ◽  
Coronary Syndrome ◽  
Significant Difference ◽  
Care Models

Purpose and Background: Bridging the Discharge Gap Effectively (BRIDGE) is an NP-driven transitional care program for cardiovascular patients. It has demonstrated lower rates of readmission for patients with acute coronary syndrome who participated, but a similar benefit was not seen for atrial fibrillation (AF) patients. We sought to assess differences between AF patients who participated in the BRIDGE program and those who did not. Methods: Retrospective review of all patients referred to BRIDGE with a primary discharge diagnosis of AF was conducted (n=148). An equal number of BRIDGE attendees was randomly matched to non-attendees (n=36). Univariate techniques were used to compare groups. Results: Of 148 AF patients referred to BRIDGE, 84 (56.8%) attended BRIDGE, 36 (24.3%) saw cardiologists or PCPs for their first post-discharge follow-up, and 28 (18.9%) saw other providers or had unknown follow up. There was no significant difference in median time to follow up (12.5 days for attendees vs 9.0 days for non-attendees, p=0.503). Of the 72 patients reviewed, 17 (23.6%) were readmitted within 30 days (Table 1). Non-attendees were more likely (85.7% vs 40% p=0.134) to be readmitted with AF/related diagnoses as compared to attendees. More than half of 30-day readmissions for BRIDGE attendees were unrelated to AF (n=6, 60.0%). There was a trend toward greater incidence of comorbid CAD, HTN, CHF, or vascular disease among BRIDGE attendees, compared to non-attendees. Conclusion: Readmission patterns vary in AF patients; comorbid conditions play a role in early 30-day readmissions for AF patients despite adequate transitional care. NP-driven transitional care models, compared to traditional follow-up with a physician provider, may help identify additional issues related to comorbidities, leading to readmission. A larger sample is needed to better understand this dichotomy and to determine what measures can be taken to enhance the BRIDGE program for AF patients.

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