• Andrew McWilliams, Jason Roberge, William E Anderson, Charity G Moore, Whitney Rossman, Stephanie Murphy, Stephannie McCall, Ryan Brown, Shannon Carpenter, Scott Rissmiller, and Scott Furney.
• Carolinas Health Care System, Charlotte, NC, USA. andrew.mcwilliams@carolinashealthcare.org.
• J Gen Intern Med. 2019 Jan 1; 34 (1): 58-64.

BackgroundDespite years of intense focus, inpatient and observation readmission rates remain high and largely unchanged. Hospitals have little, robust evidence to guide the selection of interventions effective at reducing 30-day readmissions in real-world settings.ObjectiveTo evaluate if implementation of recent recommendations for hospital transition programs is effective at reducing 30-day readmissions in a population discharged to home and at high-risk for readmission.DesignA non-blinded, pragmatic randomized controlled trial ( Clinicaltrials.gov : NCT02763202) conducted at two hospitals in Charlotte, North Carolina.PatientsA total of 1876 adult patients, under the care of a hospitalist, and at high risk for readmissions.InterventionRandom allocation to a Transition Services (TS) program (n = 935) that bridges inpatient, outpatient, and home settings, providing patients virtual and in-person access to a dedicated multidisciplinary team for 30-days, or usual care (n = 941).Main MeasureThirty-day, unplanned, inpatient, or observation readmission rate.Key ResultsThe 30-day readmission rate was 15.2% in the TS group and 16.3% in the usual care group (RR 0.93; 95% [CI, 0.76 to 1.15]; P = 0.52). There were no significant differences in readmissions at 60 and 90 days or in 30-day Emergency Department visit rates. Patients, who were referred to TS and readmitted, had less Intensive Care Unit admissions 15.5% vs. 26.8% (RR 0.74; 95% [CI, 0.59 to 0.93]; P = 0.02).ConclusionsAn intervention inclusive of contemporary recommendations does not reduce a high-risk population's 30-day readmission rate. The high crossover to usual care (74.8%) reflects the challenge of non-participation that is ubiquitous in the real-world implementation of population health interventions.Trial RegistryClinicalTrials.gov ; registration ID number: NCT02763202, URL: https://clinicaltrials.gov/ct2/show/NCT02763202.

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