• Jeffrey L Schnipper, Lipika Samal, Nyryan Nolido, Catherine Yoon, Anuj K Dalal, Cherlie Magny-Normilus, Asaf Bitton, Ryan Thompson, Stephanie Labonville, and Gwen Crevensten.
• Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.
• J Hosp Med. 2021 Jan 1; 16 (1): 15-22.

BackgroundTransitions from hospital to the ambulatory setting are high risk for patients in terms of adverse events, poor clinical outcomes, and readmission.ObjectivesTo develop, implement, and refine a multifaceted care transitions intervention and evaluate its effects on postdischarge adverse events.Design, Setting, And ParticipantsTwo-arm, single-blind (blinded outcomes assessor), stepped-wedge, cluster-randomized clinical trial. Participants were 1,679 adult patients who belonged to one of 17 primary care practices and were admitted to a medical or surgical service at either of two participating hospitals within a pioneer accountable care organization (ACO).InterventionsMulticomponent intervention in the 30 days following hospitalization, including inpatient pharmacist-led medication reconciliation, coordination of care between an inpatient "discharge advocate" and a primary care "responsible outpatient clinician," postdischarge phone calls, and postdischarge primary care visit.Main Outcomes And MeasuresThe primary outcome was rate of postdischarge adverse events, as assessed by a 30-day postdischarge phone call and medical record review and adjudicated by two blinded physician reviewers. Secondary outcomes included preventable adverse events, new or worsening symptoms after discharge, and 30-day nonelective hospital readmission.ResultsAmong patients included in the study, 692 were assigned to usual care and 987 to the intervention. Patients in the intervention arm had a 45% relative reduction in postdischarge adverse events (18 vs 23 events per 100 patients; adjusted incidence rate ratio, 0.55; 95% CI, 0.35-0.84). Significant reductions were also seen in preventable adverse events and in new or worsening symptoms, but there was no difference in readmission rates.ConclusionA multifaceted intervention was associated with a significant reduction in postdischarge adverse events but no difference in 30-day readmission rates.

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