Early Follow-up Can Reduce Readmission Rates

Heart failure patients who had early follow-up (within seven days of discharge) with general medicine or cardiology providers had a lower risk of being readmitted to the hospital within 30 days, according to a study from Kaiser Permanente published in the journal Medical Care.

“We found that follow-up within the first seven days post-discharge—mostly done through in-person clinic visits—was independently associated with a 19% lower chance of readmission, whereas initial follow-up after seven days was not significantly associated with readmission,” says lead researcher Keane K. Lee, MD, MS, a cardiologist and research scientist with Kaiser Permanente. “Perhaps as important, we also observed that telephone visits, mostly done by non-physician providers, within seven days after hospital discharge were associated with a non-statistically significant trend toward lower 30-day readmission rates, even after carefully accounting for potential differences between patients.

“This finding that telephone visits could reduce readmissions has never been reported and has potentially important implications. Contact by telephone with non-physicians may be more convenient for patients and family members and be more practical and cost-effective when implemented on a large scale.”

Dr. Lee suggests hospitalists have a role in creating a system to reliably arrange this follow-up.

“Hospitalists serve as a key part of the process to help patients transition successfully from the hospital back home,” Dr. Lee says.


  1. Lee KK, Yang J, Hernandez AF, Steimle AE, Go S. Post-discharge follow-up characteristics associated with 30-day readmission after heart failure hospitalization. Med Care. 2016;54(4):365-372.

Comment on this Article

Your email address will not be published. Required fields are marked *