26 June 2014

Follow-up keeps high-risk patients out of hospital

A new study indicates that following up with a primary care doctor after a hospital stay for a serious condition, is known to reduce the risk of a patient being readmitted.

People who visit their primary care doctors shortly after high-risk surgeries are less likely to end up back in hospital during the next month, according to a new study.

Visiting a primary care doctor was particularly beneficial for the high-risk patients who experienced complications during their time in the hospital for surgery, though it made little difference for people without complications.

The findings could help determine which surgery patients most benefit from follow-up primary care, and spare those who don't the expense and inconvenience of added doctor visits, the authors say.

Several different teams
The better outcomes for some patients may reflect primary care doctors focusing on medical conditions or complications that surgeons may not notice during their follow-up appointments, said Dr. Benjamin Brooke, the study's lead author from the University of Utah School of Medicine in Salt Lake City.

"I think it's just a fact that we have several different teams managing these patients and that coordination of care is important," Brooke said.

He and his colleagues write in JAMA Surgery that following up with a primary care doctor after a hospital stay for serious conditions, such as heart failure and pneumonia, is known to reduce the risk of a patient being readmitted.
Read: Readmission to different hospital ups death rate

The role of a primary care visit after a surgery is debated, however. Some doctors believe the visits are unnecessary, for example, because complications soon after surgery are likely related to the procedure and best addressed by the surgical team.

The visits also add costs and difficulties for patients who may not be mobile after a surgery.

To see whether primary care doctor visits after high-risk surgeries make a difference in the likelihood that a patient will have to be readmitted to the hospital, the researchers compared high-risk surgery patients who went to their doctors shortly after their procedure to those who didn't.

They used data from Medicare, the US government-run health insurance programme for the elderly and disabled, collected between 2003 and 2010 on patients undergoing surgery to repair thoracic aortic aneurysms.

The procedure requires opening the chest to replace a weakened area of the aorta, the main vessel that supplies blood to the body.

Of 12,679 people who had surgery to repair a thoracic aortic aneurysm during the study period, about 21 percent ended up being admitted the hospital within a month of their surgery.

Initial complications
About 20 percent of patients who went to see their primary care doctors within a month of surgery were among those readmitted, compared to 28 percent of the people who didn't go to their doctors for follow-up visits.

The difference appeared to be isolated to those who experienced complications during their initial hospital stays. About 20 percent of those people ended up back in the hospital after going to see their primary care doctors, compared to 35 percent of those who did not go for follow-up visits.

There was not a significant difference among patients who didn't have complications during their first hospital stays.
Read: Shorter hospital stays may hinder heart failure patients

And in a separate comparison of people who had low-risk surgeries to repair a hernia, there were no differences in readmission rates between those who saw a primary care doctor and those who didn't, regardless of complications.

"What our study found is patients who were relatively low risk may not benefit as much, compared to those who were high risk," Brooke said.

Brooke and his colleagues note in their report that hospital readmissions are expensive to the healthcare system. With 6.9 million major cardiac surgeries performed in the US each year, for example, the scheduling and cost of follow-up visits for every one of those patients is a strain on the system.

Eyes and ears
Dr Douglas Johnston, a thoracic and cardiovascular surgeon at the Cleveland Clinic in Ohio, told Reuters Health that follow-up visits with primary care doctors are important – especially for people who traveled long distances for their surgery.

"I think it's very important that the primary care provider is the eyes and ears of any post operative decline and monitor any patient as they improve," said Johnston, who was not involved in the new study.

At his hospital, Johnston said, they send copies of the medical records to patients' primary care doctors and cardiologists, but many people do not have a primary care doctor.

"We encourage the patient to get one and keep them in the loop," he said.

In the current study, Brooke and his colleagues found that about 76 percent of people who underwent the high-risk thoracic surgery had a follow-up visit with their primary care doctor.

"I think it shows that we're making progress and people are realizing that patients do have to have primary care follow-up," Brooke said. "We just have to make sure that other 25 percent is not lost to follow up."

Source: JAMA Surgery, online June 25, 2014.

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