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Boockvar, K. S., Koufacos, N. S., May, J., Schwartzkopf, A. L., Guerrero, V. M., Judon, K. M., Schubert, C. C., Franzosa, E., & Dixon, B. E. (2022). Effect of Health Information Exchange Plus a Care Transitions Intervention on Post-Hospital Outcomes Among VA Primary Care Patients: a Randomized Clinical Trial. Journal of General Internal Medicine, 37(16), 4054–4061. https://doi.org/10.1007/s11606-022-07397-5

Justification/Rationale for Study

The study compared the efficacy of a health information exchange (HIE) notification followed by a post-hospital care transitions intervention (CTI) to HIE notification alone among veterans aged 65 and older who received primary care at VA facilities and had non-VA hospital admissions or emergency department visits. Given the difficulties of care transitions and the dangers associated with fragmented care, particularly among older patients, evaluating the impact of treatments on post-hospital outcomes is critical for enhancing the quality of care across health systems.

Gap in Practice

Despite the potential benefits of care transition interventions and HIE in improving post-hospital outcomes, no research has been conducted to assess the combined effect of HIE notification and CTI on veterans getting care from VA and non-VA facilities. This knowledge gap prevents the development of effective measures to reduce adverse outcomes and improve care continuity for veterans migrating between hospital settings.

Purpose of the Study

(Include list of independent variables [IVs] and dependent variables [DVs])

The study sought to compare the results of veterans who received HIE notification followed by a care transitions intervention (CTI) versus those who got HIE notification alone following non-VA acute care contacts. The primary objective was 90-day hospital admission or readmission, with secondary outcomes including emergency department visits, prompt VA primary care team follow-up, patients' understanding of their condition(s) and medication(s), and prescription discrepancies. The study focused on older veterans getting care in VA and non-VA institutions to evaluate the impact of interventions in improving post-hospital outcomes and care continuity.

Theoretical or Conceptual Framework

The study was directed by the care transitions intervention paradigm, focusing on addressing the risks associated with hospital release and enhancing continuity of care for older patients, particularly veterans getting care from both VA and non-VA institutions. The interventions were based on the Coleman model, focusing on patient activation and self-management of care, such as medication management, condition education, patient-centered record-keeping, appointment management, and provider communication. Health information exchange (HIE) permitted real-time notification of non-VA acute care interactions, allowing appropriate interventions to assist care transitions and prevent adverse outcomes.

Study Design and Sampling Procedures

A cluster-randomized controlled trial was conducted on 605 veterans aged 65 or older who received primary care at two VA facilities and had non-VA hospital admissions or emergency department visits between 2016 and 2019. The study involved 202 veterans who experienced at least one index non-VA acute care encounter, with each site receiving approval from the local Institutional Review Board and patients providing written informed consent.

Data Collection Procedures

The study followed all veterans for non-VA acute care encounters, including hospital admissions or ED visits. Non-VA facilities sent real-time electronic Health Level 7 (HL7) admission-discharge-transfer (ADT) messages to the regional Health Information Exchange (HIE) network for veterans with acute care encounters. Study coordinators subscribed to the HIE network messages, created notes within the VA Computerized Patient Record System, and routed them to the veteran's VA primary care provider.

Data Analyses Used

The study analyzed 90-day hospital admission or readmission using multilevel generalized linear mixed regression. Secondary outcomes included ED visits, VA primary care team phone contacts, follow-up visits, patients' understanding of condition and medication, and high-risk medication discrepancies. Analyses considered clustering within primary care teams and repeated observations of participants using linear mixed regression and negative binomial regression.

Description of Significant Results

· The study demonstrated no significant difference in 90-day hospital admission or readmission rates between the HIE-plus-CTI and HIE-alone groups (25.8% and 20.2%, respectively).

· There were also no significant changes in secondary outcomes such as emergency department visits, VA primary care team contacts, VA follow-up visits, patients' understanding of their condition(s) and prescription(s), and high-risk medication discrepancies.

· The significant findings remained unchanged after sensitivity and subgroup analysis, showing robust results.

Discussion of Findings, including Limitations of the Study

The study found that adding a care transition intervention to health information exchange (HIE) notification did not improve post-hospital outcomes for veterans compared to HIE notification alone. Despite potential benefits, the study did not find evidence of its effectiveness in reducing hospital readmissions or improving other secondary outcomes. Limitations include lack of blinding, possible selection bias, and generalizability to other populations beyond VA primary care patients. Further research is needed to identify effective care transition interventions across health systems.