Presentations

Abstract

Introduction: Following hospitalization, patients without insurance carry an increased risk of adverse health outcomes. Social determinants of health and health-systems issues are contributing factors, and hospital readmissions are a reliable indicator of poor health outcomes following hospitalization. Government programs, such as the Medicare Hospital Readmission Reduction Program, have incentivized the development of programs that prevent hospital readmissions. There are many different interventions that healthcare delivery systems have implemented to mitigate hospital readmissions, and previous studies have shown inverse relationships between early outpatient follow-up visits and readmissions. The aim of this study was to explore the benefit of an intervention incentive for patients who lack insurance, to reduce hospital readmissions and emergency department visits, and to identify factors that affect attendance at a hospital discharge clinic follow-up appointment for this vulnerable patient population.

Methods: This was a cross sectional study that utilized deidentified data of adult patients hospitalized at a 525-bed tertiary care teaching hospital in Norfolk, Virginia between January 2016 and June 2018. These patients were scheduled for a hospital discharge appointment with an ambulatory care clinic (ACC) restricted primarily to patients without insurance within 90 days of a hospitalization. Data was extracted from the electronic medical record (EMR) system of Sentara Healthcare. The initial data set included 3149 observations, with each observation representing a patient hospital discharge clinic visit at the ACC. The final number of participants included in analysis was 1741. The primary outcome evaluated was attendance at initial hospital discharge outpatient visit, while the secondary outcomes were readmission and emergency department visit(s) within 90 days of discharge. The data set included the following covariates: age, race, ethnicity, length of hospital admission, cost of hospitalization, discharge to follow-up time interval, month in which the follow-up visit was scheduled, and the hospital encounter information for 90 days after discharge (visit to ED, frequency of ED visits, rehospitalization, frequency of rehospitalizations). To assess for associations between attendance at first follow-up visit and each categorical variable, chi-square tests were used. Mann Whitney U tests were conducted to assess associations between each continuous variable and attendance at first follow-up visit.

Results: Variables that were significantly associated with attendance at the first follow-up visit were age, race, length of hospital stay, and discharge to appointment date time interval. Age was positively associated with attending the first hospital discharge clinic visit (OR: 1.009; CI [1.002 - 1.017]; p=0.012]). The odds of attending the first follow up visit was about 30% less among patients reported in the EMR as White compared with patients reported in the EMR as Black (OR: 0.68; CI [0.55 - 0.85], p=0.001). Length of hospital stay demonstrated a positive correlation with the likelihood of attendance at the first hospital discharge clinic visit (χ²(df) = [insert chi-sq value], p=0.036). Finally, the discharge to follow-up time interval was associated with attending the first hospital discharge clinic visit (OR: 0.981; CI [0.974 - 0.987]; p <0.001). Those who attended their scheduled outpatient follow-up visit had lower odds of being re-hospitalized in 90 days after discharge compared to those who did not attend their hospital discharge clinic visit (OR: 0.76; CI [0.59 - 0.96]; p =0.022).

Conclusion: These results suggest that patients who lack insurance who have a prompt follow-up appointment scheduled after hospital discharge are more likely to attend their appointment. Importantly, results also suggest that patients without insurance who attend the initial follow up visit after hospitalization are less likely to be readmitted to the hospital within 90 days of discharge. Hospital systems that design clear short-interval follow-up plans for their patients without insurance after discharge from the hospital can reduce barriers to care and help patients access appropriate follow-up, leading to decreased hospital admissions, more efficient resource utilization, and ultimately better patient outcomes. To accomplish short-interval follow-up, hospital systems and their community counterparts should ensure that there is adequate appointment availability, something that requires effective staffing, scheduling technology, and patient education at discharge. Further research is needed to identify factors that impact attendance at hospital follow-up appointments.