Clinical question: Does the use of a patient navigator to guide hospitalized patients through the health care system reduce 30-day readmission rates?
Bottom line: The use of a community health worker acting as a patient navigator (PN), both during hospitalization and after discharge, to assist patients with coordination of care, follow-up appointments, provider communication, and medication compliance decreases the 30-day readmission rate in older high-risk patients, but increased admissions in younger patients, suggesting that the younger population may require different strategies to decrease their use of hospital-based care. (LOE = 1b-)
Reference: Balaban RB, Galbraith AA, Burns ME, Vialle-Valentin CE, Larochelle MR, Ross-Degnan D. A patient navigator intervention to reduce hospital readmissions among high-risk safety-net patients: a randomized controlled trial. J Gen Intern Med 2015;30(7):907-915.
Study design: Randomized controlled trial (nonblinded)
Funding source: Government
Setting: Inpatient (any location) with outpatient follow-up
Synopsis: This US study took place within a safety-net hospital system in Massachusetts that has a large underserved patient population. The authors enrolled more than 1500 hospitalized patients with at least 1 of 5 risk factors for readmission (older than 60 years, previous hospitalization within the last 6 months, length of stay of 3 days or more, or admission diagnoses of heart failure or chronic obstructive pulmonary disease). Patients in the intervention group were assigned to a hospital-based community health worker, or PN, while patients in the control group received usual care. The PN's primary responsibility was helping the patient navigate through the health care system, including assessing postdischarge needs, assisting with communication with inpatient providers and primary care physicians, confirming and rescheduling follow-up appointments, addressing barriers to taking medications, and assisting with transportation and insurance issues. These services were provided through a hospital visit and at least 3 weekly postdischarge phone calls. Patients in both groups were racially diverse and the majority carried public insurance. The patients older than 60 years were more medically complex, but younger patients had more psychiatric disorders and substance use disorders, as well as higher rates of previous hospitalizations and longer lengths of stay.
Overall, the 30-day readmission rate did not differ significantly between the control and intervention groups, but the study was underpowered given the limits to enrollment during the prespecified period. In an adjusted analysis of the 2 age subgroups, however, readmissions decreased by 4% in older intervention patients and they increased by 12% in younger intervention patients (both differences statistically significant).
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.