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• Filed under: Departments, Key Clinical Question, Clinical

• Keywords: medication errors, discharge, patient outcomes, follow up, transition of care

Do post-discharge telephone calls to patients reduce the rate of complications?

From: The Hospitalist, August 2008

by Kelley Moulds, MD, and Kenneth Epstein, MD, MBA

Case

A 75-year-old male with history of diabetes and heart disease is discharged from the hospital after treatment for pneumonia. He has eight medications on his discharge list and is given two new prescriptions at discharge. He has a primary care provider but will not be able to see her until three weeks after discharge. Will a follow-up call decrease potential complications?

Overview

Medication errors are prevalent, especially during the transition period from discharge to follow-up with primary care physicians. There are more than 700,000 emergency department (ED) visits each year for adverse drug events with nearly 120,000 of these episodes resulting in hospitalization.1

The likelihood of an adverse drug event increases in patients using more than five medications and when there is a lack of understanding of how and why they are taking certain medications, scenarios common on hospital discharge.2 Studies evaluating effective means to reduce medication errors during transitions out of the hospital offer few solutions. One effective method, however, appears to be follow-up telephone calls.

Telephone calls have been looked at in multiple studies and usually are performed in the studies by nurses, nurse practitioners, or pharmacists and occur within days of discharge from the hospital. These calls offer a mechanism to provide answers to questions about their medical condition or medications.

Review of the Data

There is a wide range of studies evaluating the benefit of a post-discharge telephone call. Unfortunately, most of the data are of low methodological quality with low patient numbers and high risk of bias.3

Much of the data are divided into subgroups of patients, including ED patients, cardiac patients, surgical patients, medicine patients, and other small groups. The end points also vary and examine areas such as patient satisfaction, reduction in medication errors, and effect on readmissions or repeat ED visits. The bulk of studies used a standardized script. These calls lasted only minutes, which could make it user-friendly, especially for a busy hospitalist’s schedule. Unfortunately, the effect of these interventions is mixed.

With ED patients, phone calls have been shown to be an effective means of communication between patients and physicians. In a study of 297 patients, the authors were only able to reach half the patients but still were able to identify medical problems needing referral or further intervention in 37% of the patients contacted.4 Another two studies revealed similar results with approximately 40% of the contacted patients requiring further clarification on their discharge instructions.5,6

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Importantly, 95% of these patients felt the call was beneficial. Thus, more than one-third of patients discharged from an ED are likely to have problems and a follow-up telephone call offers an opportunity to intervene on these potential problems. Another ED study evaluated patients older than 75 and found a nurse liaison could effectively assess the complexity of a patient’s questions and appropriately advise them over the phone or triage them to the correct care provider for further care.7

Post-discharge follow-up telephone calls also can benefit patients discharged from the hospital. A recent paper reported that approximately 12% of patients develop new or worsening symptoms within a few days post-discharge and adverse drug events can occur in between 23% to 49% of people during this transition period.8-10

Another study evaluating resource use in heart failure patients found follow-up telephone calls significantly decreased the average number of hospital days over six months time and readmission rate at six months in the call group, as well as increased patient satisfaction.11

A randomized placebo-controlled trial evaluating follow-up calls from pharmacists to discharged medical patients found the call group patients were more satisfied with their post-discharge care. Additionally, there were less ED visits within 30 days of discharge in the call group compared to placebo or standard care.12

On the other hand, several studies have questioned the utility of follow-up telephone calls for improving transitions of care. A Stanford University group divided medical and surgical patients into three groups with one receiving routine follow-up calls, another requiring a patient-initiated call and a final group without any intervention and found there was no difference between these groups in regards to patient satisfaction or 30-day readmission rates.13

An outpatient trial completed at a South Dakota Veterans Affairs clinic also determined telephone calls had little effect on decreasing resources or hospital admissions.14

Although this study did not include inpatients, it demonstrates the fact that follow-up telephone calls may not be as helpful as shown in other trials and that more thorough and well-designed trials are needed to more definitively answer this question.

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Back to the Case

The hospitalist makes a call to the patient to follow-up after he is discharged, and he says he is glad she called. He had questions about one of his medications that was discontinued while he was hospitalized and wants to know if he should restart it. He also says he is having low-grade fevers again and is not sure if he should come back in for evaluation.

The hospitalist is able to answer his questions about his medication list and instructs him to restart the metformin they had stopped while he was an inpatient. The hospitalist also is able to better explain what symptoms to be aware of and when the patient should come in for re-evaluation. The patient appreciates the five-minute call, and the hospitalist is glad she cleared up the patient’s confusion regarding his medications before a serious error or unnecessary readmission to the hospital occurred. TH

Dr. Moulds is a third-year internal medicine resident at the University of Colorado Denver. Dr. Epstein is director of medical affairs and clinical research at IPC-The Hospitalist Company.

References

1. www.cdc.gov.
2. Epstein K, Juarez E, Loya K, Gorman MJ, Singer A. Frequency of new or worsening symptoms in the post-hospitalization period. J Hosp Med. 2007 Mar;2(2):58-68.
3. Mistiaen P, Poot E. Telephone follow-up, initiated by a hospital-based health professional, for post-discharge problems in patients discharged from hospital to home. Cochrane Database Syst Rev. 2006, Issue 4. Art. No.: CD004510. DOI:10.1002/14651858.CD004510.pub3.
4. Shesser R, Smith M, Adams S, Walls R, Paxton M. The effectiveness of an organized follow-up system. Ann Emerg Med. 1986 Aug;15(8):911-915.
5. Jones J, Clark W, Bradford J, Dougherty J. Efficacy of a telephone follow-up system in the emergency department. J Emerg Med. 1988 May-June;6(3):249-254.
6. Jones JS, Young MS, LaFleur RA, Brown MD. Effectiveness of an organized follow-up system for elder patients released from the emergency department. Acad Emerg Med. 1997 Dec;4(12):1147-1152.
7. Poncia HD, Ryan J, Carver M. Next day telephone follow up of the elderly: a needs assessment and critical incident monitoring tool for the accident and emergency department. J Accid Emerg Med. 2000 Sep;17(5):337-340.
8. Kripalani S, Price M, Vigil V, Epstein K. Frequency and predictors of prescription-related issues after hospital discharge. J Hosp Med. 2008 Jan/Feb;3(1):12-19.
9. Forster A, Murff H, Peterson J, Gandhi T, Bates D. Adverse drug events occurring following hospital discharge. J Gen Intern Med. 2005;20:317-323.
10. Forster A, Murff H, Peterson J, Gandhi T, Bates D. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-167.
11. Riegel B, Carlson B, Kopp Z, LePetri B, Glaser D, Unger A. Effect of a standardized nurse case-management telephone intervention on resource use in patients with chronic heart failure. Arch Intern Med. 2002 Mar 25;162(6):705-712.
12. Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. Am J Med. 2001 Dec 21;111(9B):26S-30S.
13. Bostrom J, Caldwell J, McGuire K, Everson D. Telephone follow-up after discharge from the hospital: does it make a difference? Appl Nurs Res. 1996 May;9(2):47-52.
14. Welch HG, Johnson DJ, Edson R. Telephone care as an adjunct to routine medical follow-up. A negative randomized trial. Eff Clin Pract. 2000 May-June;3(3):123-130.
15. Coleman E, Smith J, Raha D, Min S. Posthospital medication discrepancies. Arch Intern Med. 2005;165:1842-1847.