Skip to main content

Pragmatic Clinical Trial to Improve Patient Experience Among Adults During Transitions from Hospital to Home: the PArTNER study

Abstract

Introduction

Minority-serving hospitals (MSHs) need evidence-based strategies tailored to the populations they serve to improve patient-centered outcomes after hospitalization.

Methods

We conducted a pragmatic randomized clinical trial (RCT) from October 2014 to January 2017 at a MSH comparing the effectiveness of a stakeholder-supported Navigator intervention vs. Usual care on post-hospital patient experience, outcomes, and healthcare utilization. Community health workers and peer coaches delivered the intervention which included (1) in-hospital visits to assess barriers to health/healthcare and to develop a personalized Discharge Patient Education Tool (DPET); (2) a home visit to review the DPET; and (3) telephone-based peer coaching. The co-primary outcomes were between-group comparisons of 30-day changes in Patient-Reported Outcomes Measurement Information System (PROMIS) measures of anxiety and informational support (minimum important difference is 2 to 5 units change); a p-value <0.025 was considered significant using intention-to-treat analysis. Secondary outcomes included death, ED visits, or readmissions and measures of emotional, social, and physical health at 30 and 60 days.

Results

We enrolled 1029 adults hospitalized with heart failure (28%), pneumonia (22%), MI (10%), COPD (11%), or sickle cell disease (29%). Over 80% were non-Hispanic Black. Overall, there were no significant between-group differences in the 30-day change in anxiety (adjusted difference: −1.6, 97.5% CI −3.3 to 0.1, p=0.03), informational support (adjusted difference: −0.01, 97.5% CI −2.0 to 1.9, p=0.99), or any secondary outcomes. Exploratory analyses suggested the Navigator intervention improved anxiety among participants with COPD, a primary care provider, a hospitalization in the past 12 months, or higher baseline anxiety; among participants without health insurance, the intervention improved informational support (all p-values <0.05).

Conclusions

In this pragmatic RCT at a MSH, the Navigator intervention did not improve post-hospital anxiety, informational support, or other outcomes compared to Usual care. Benefits observed in participant subgroups should be confirmed in future studies.

Trial Registration

Clinicaltrials.gov identifier: NCT02114515

This is a preview of subscription content, access via your institution.

Figure 1
Figure 2

References

  1. Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011 Feb 16;305(7):675-81.

    CAS  Article  Google Scholar 

  2. Betancourt JR, Tan-McGrory A, Kenst KS. Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries. Prepared by the Disparities Solutions Center, Mongan Institute for Health Policy at Massachusetts General Hospital. Baltimore, MD: Centers for Medicare & Medicaid Services Office of Minority Health; September 2015.

  3. Elixhauser A, Steiner C. Readmissions to U.S. Hospitals by Diagnosis, 2010: Statistical Brief #153. 2013 Apr. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb. Available from: https://www.ncbi.nlm.nih.gov/books/NBK154385/ (accessed May 5, 2021).

  4. Centers for Medicare and Medicaid Services. Hospital Readmissions Reduction Program (HRRP). Available from: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html (accessed March 18, 2021).

  5. Figueroa JF, Joynt KE, Zhou X, Orav EJ, Jha AK. Safety-net Hospitals Face More Barriers Yet Use Fewer Strategies to Reduce Readmissions. Med Care. 2017 Mar;55(3):229-235.

    Article  Google Scholar 

  6. Goldman LE, Sarkar U, Kessell E, Guzman D, Schneidermann M, Pierluissi E, Walter B, Vittinghoff E, Critchfield J, Kushel M. Support from hospital to home for elders: a randomized trial. Ann Intern Med. 2014 Oct 7;161(7):472-81.

    Article  Google Scholar 

  7. Berendsen AJ, de Jong GM, Meyboom-de Jong B, Dekker JH, Schuling J. Transition of care: experiences and preferences of patients across the primary/secondary interface - a qualitative study. BMC Health Serv Res. 2009 Apr 7;9:62.

    Article  Google Scholar 

  8. Prieto-Centurion V, Markos MA, Ramey NI, Gussin HA, Nyenhuis SM, Joo MJ, Prasad B, Bracken N, Didomenico R, Godwin PO, Jaffe HA, Kalhan R, Pickard AS, Pittendrigh BR, Schatz B, Sullivan JL, Thomashow BM, Williams MV, Krishnan JA. Interventions to reduce rehospitalizations after chronic obstructive pulmonary disease exacerbations. A systematic review. Ann Am Thorac Soc. 2014 Mar;11(3):417-24.

    Article  Google Scholar 

  9. Ursan ID, Krishnan JA, Pickard AS, Calhoun E, DiDomenico R, Prieto-Centurion V, Sullivan JB, Valentino L, Williams MV, Joo M. Engaging Patients and Caregivers to Design Transitional Care Management Services at a Minority Serving Institution. J Health Care Poor Underserved. 2016;27(1):352-365.

    Article  Google Scholar 

  10. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013 Jan 3;3(1):e001570.

    Article  Google Scholar 

  11. Figueroa JF, Zheng J, Orav EJ, Jha AK. Across US Hospitals, Black Patients Report Comparable Or Better Experiences Than White Patients. Health Aff (Millwood). 2016 Aug 1;35(8):1391-8.

    Article  Google Scholar 

  12. 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 Jul;30(7):907-15.

    Article  Google Scholar 

  13. Kangovi S, Mitra N, Grande D, White ML, McCollum S, Sellman J, Shannon RP, Long JA. Patient-centered community health worker intervention to improve posthospital outcomes: a randomized clinical trial. JAMA Intern Med. 2014 Apr;174(4):535-43.

    Article  Google Scholar 

  14. Viswanathan M, Kraschnewski J, Nishikawa B, Morgan LC, Thieda P, Honeycutt A, Lohr KN, Jonas D; RTI International-University of North Carolina Evidence-based Practice Center. Outcomes of community health worker interventions. Evid Rep Technol Assess (Full Rep). 2009 Jun;(181):1-144, A1-2, B1-14, passim.

  15. Prieto-Centurion V, Basu S, Bracken N, Calhoun E, Dickens C, DiDomenico RJ, Gallardo R, Gordeuk V, Gutierrez-Kapheim M, Hsu LL, Illendula S, Joo M, Kazmi U, Mutso A, Pickard AS, Pittendrigh B, Sullivan JL, Williams M, Krishnan JA. Design of the patient navigator to Reduce Readmissions (PArTNER) study: A pragmatic clinical effectiveness trial. Contemp Clin Trials Commun. 2019 Jul 19;15:100420.

    Article  Google Scholar 

  16. Carson SS, Goss CH, Patel SR, Anzueto A, Au DH, Elborn S, Gerald JK, Gerald LB, Kahn JM, Malhotra A, Mularski RA, Riekert KA, Rubenfeld GD, Weaver TE, Krishnan JA; American Thoracic Society Comparative Effectiveness Research Working Group. An official American Thoracic Society research statement: comparative effectiveness research in pulmonary, critical care, and sleep medicine. Am J Respir Crit Care Med. 2013 Nov 15;188(10):1253-61.

    Article  Google Scholar 

  17. American Academy of Family Physicians. Transitional Care Management. Available from: https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/transitional-care-management.html (accessed August 9, 2021).

  18. Health Measures: Transforming How Health Is Measured. Patient Reported Outcomes Measurement Information System (PROMIS). Available from: http://www.healthmeasures.net/explore-measurement-systems/promis#2 (accessed March 18, 2021).

  19. Cella D, Riley W, Stone A, Rothrock N, Reeve B, Yount S, Amtmann D, Bode R, Buysse D, Choi S, Cook K, Devellis R, DeWalt D, Fries JF, Gershon R, Hahn EA, Lai JS, Pilkonis P, Revicki D, Rose M, Weinfurt K, Hays R; PROMIS Cooperative Group. The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005-2008. J Clin Epidemiol. 2010 Nov;63(11):1179-94.

    Article  Google Scholar 

  20. Amtmann D, Cook KF, Jensen MP, Chen WH, Choi S, Revicki D, Cella D, Rothrock N, Keefe F, Callahan L, Lai JS. Development of a PROMIS item bank to measure pain interference. Pain. 2010 Jul;150(1):173-182.

    Article  Google Scholar 

  21. Health Measures. Meaningful Change for PROMIS®. Available from: https://www.healthmeasures.net/score-and-interpret/interpret-scores/promis/meaningful-change (accessed March 18, 2021).

  22. Norman GR, Sloan JA, Wyrwich KW. The truly remarkable universality of half a standard deviation: confirmation through another look. Expert Rev Pharmacoecon Outcomes Res. 2004 Oct;4(5):581-5.

    Article  Google Scholar 

  23. Harrington D, D'Agostino RB Sr, Gatsonis C, et al. New Guidelines for Statistical Reporting in the Journal. N Engl J Med. 2019;381(3):285-286.

    Article  Google Scholar 

  24. Finkelstein A, Zhou A, Taubman S, Doyle J. Health Care Hotspotting - A Randomized, Controlled Trial. N Engl J Med. 2020 Jan 9;382(2):152-162.

    Article  Google Scholar 

  25. Altfeld SJ, Shier GE, Rooney M, Johnson TJ, Golden RL, Karavolos K, Avery E, Nandi V, Perry AJ. Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial. Gerontologist. 2013 Jun;53(3):430-40.

    Article  Google Scholar 

  26. Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999 Feb 17;281(7):613-20.

    CAS  Article  Google Scholar 

  27. Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, Forsythe SR, O'Donnell JK, Paasche-Orlow MK, Manasseh C, Martin S, Culpepper L. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009 Feb 3;150(3):178-87.

    Article  Google Scholar 

  28. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006 Sep 25;166(17):1822-8.

    Article  Google Scholar 

  29. Galbraith AA, Meyers DJ, Ross-Degnan D, Burns ME, Vialle-Valentin CE, Larochelle MR, Touw S, Zhang F, Rosenthal M, Balaban RB. Long-Term Impact of a Postdischarge Community Health Worker Intervention on Health Care Costs in a Safety-Net System. Health Serv Res. 2017 Dec;52(6):2061-2078.

    Article  Google Scholar 

  30. Garbutt JM, Yan Y, Highstein G, Strunk RC. A cluster-randomized trial shows telephone peer coaching for parents reduces children's asthma morbidity. J Allergy Clin Immunol. 2015 May;135(5):1163-70.e1-2.

  31. Liss DT, Ackermann RT, Cooper A, Finch EA, Hurt C, Lancki N, Rogers A, Sheth A, Teter C, Schaeffer C. Effects of a Transitional Care Practice for a Vulnerable Population: a Pragmatic, Randomized Comparative Effectiveness Trial. J Gen Intern Med. 2019 Sep;34(9):1758-1765.

    Article  Google Scholar 

  32. McWilliams A, Roberge J, Anderson WE, Moore CG, Rossman W, Murphy S, McCall S, Brown R, Carpenter S, Rissmiller S, Furney S. Aiming to Improve Readmissions Through InteGrated Hospital Transitions (AIRTIGHT): a Pragmatic Randomized Controlled Trial. J Gen Intern Med. 2019 Jan;34(1):58-64.

    Article  Google Scholar 

  33. Gesell SB, Prvu Bettger J, Lawrence RH, Li J, Hoffman J, Lutz BJ, Grudzen C, Johnson AM, Krishnan JA, Hsu LL, Zwart D, Williams MV, Schnipper JL. Implementation of Complex Interventions: Lessons Learned From the Patient-Centered Outcomes Research Institute Transitional Care Portfolio. Med Care. 2021 Aug 1;59(Suppl 4):S344-S354.

    Article  Google Scholar 

  34. Esmail LC, Barasky R, Mittman BS, Hickam DH. Improving Comparative Effectiveness Research of Complex Health Interventions: Standards from the Patient-Centered Outcomes Research Institute (PCORI). J Gen Intern Med. 2020;35(Suppl 2):875-881.

    Article  Google Scholar 

Download references

Acknowledgements

We acknowledge the helpful oversight by our program officer, Carly Parry, PhD, MSW, MA. We also express our appreciation for the patients who elected to participate in the study, as well as their caregivers, clinicians and staff at UI Health, PArTNER research team, members of the PArTNER Data and Safety Monitoring Board (DSMB), members of the PArTNER External Advisory Committee, and the University of Illinois Institutional Review Board.

Funding

We received funding from the Patient-Centered Outcomes Research Institute (contract # IH 12-11-4365).

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Stephanie L. LaBedz MD.

Ethics declarations

Conflict of Interest

Dr. Krishnan reports contract funding from the Patient-Centered Outcomes Research Institute during the conduct of the study. Dr. Williams reports contract funding from the Patient-Centered Outcomes Research Institute (PCORI) during the conduct of the study; grants from NHLBI, contract funding from CMS, other contract funding from PCORI, consulting from OptumHealth Care Solutions, LLC, personal fees from Northwestern University, personal fees from Society of Hospital Medicine, personal fees from Oakstone Publishing CME, personal fees from Alabama Hospital Association, and personal fees from Academic Medical Centers outside the submitted work. Dr. DiDomenico reports advisory board participation for Abiomed and grants from CSL Behring outside the submitted work. Drs. LaBedz, Prieto-Centurion, Mutso, Basu, Joo, Pickard, Pittendrigh, Ms. Bracken, and Mr. Illendula have no conflicts of interest to disclose.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

ESM 1

(DOCX 645 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

LaBedz, S.L., Prieto-Centurion, V., Mutso, A. et al. Pragmatic Clinical Trial to Improve Patient Experience Among Adults During Transitions from Hospital to Home: the PArTNER study. J GEN INTERN MED (2022). https://doi.org/10.1007/s11606-022-07461-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11606-022-07461-0