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Trial of a Disease Management Program to Reduce Hospital Readmissions of the Chronically Critically Ill^*

^* From the School of Nursing (Drs. Daly, Douglas, and Kelley) and from the School of Medicine (Drs. O’Toole and Montenegro), Case Western Reserve University, Cleveland, OH.

Correspondence to: Barbara J. Daly, PhD, RN, School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106-4904; e-mail: bjd4{at}case.edu

Background: Patients requiring prolonged periods of intensive care and mechanical ventilation are termed chronically critically ill. They are prone to continued morbidity and mortality after hospital discharge and are at high risk for hospital readmission. Disease management (DM) programs have been shown to be effective in improving both coordination and efficiency of care after hospital discharge for populations with single-disease diagnoses, but have not been tested with patients with multiple-disease diagnoses, such as the chronically critically ill.

Study objectives: To test the effect of a DM program on hospital readmission patterns of chronically critically ill patients during the first 2 months after hospital discharge and to estimate the cost-effectiveness of the DM program.

Design: Randomized, controlled trial.

Setting: Academic medical center, extended care facilities, and participant homes.

Participants: Three hundred thirty-four consenting adults from one academic medical center who underwent > 3 days of mechanical ventilation and survived to hospital discharge.

Intervention: Two hundred thirty-one patients in the experimental group received care coordination, family support, teaching, and monitoring of therapies from a team of advanced-practice nurses, a geriatrician, and a pulmonologist for 2 months post-hospital discharge.

Measurements: Rehospitalization rate, time-to-first rehospitalization, duration of rehospitalization, mortality during rehospitalization, and associated costs.

Results: Patients who received DM services had significantly fewer mean days of rehospitalization (11.4; 95% confidence interval [CI], 9.3 to 12.6) compared with the control group (16.7 days; 95% CI, 12.5 to 21.0; p = 0.03). There were no other significant differences between experimental and control groups, although all measures of rehospitalization risk for the experimental group were in a positive direction. Total cost savings associated with the intervention were approximately $481,811 for the 93 subjects who were readmitted to the hospital.

Conclusions: Chronic critical illness may have a natural trajectory of continued morbidity following hospital discharge that is not affected by the provision of additional care coordination services. Nevertheless, given the high cost of rehospitalization and the additional burden it imposes on patients and families, interventions that can reduce the duration of rehospitalization are cost-effective and merit continued testing.

Key Words: chronically critically ill • disease management • long-term ventilation