Trial Outcomes & Findings for Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization (NCT NCT02689076)

Last Updated: 2023-07-27

Results Overview

Percentage of patients with VA and non-VA hospital admission or readmission 90 days after non-VA hospital or ED discharge (or, if the patient is not discharged home, 90 days after discharge home from a rehabilitation facility)

Recruitment status

COMPLETED

Study phase

Target enrollment

796 participants

Primary outcome timeframe

90 days

Results posted on

2023-07-27

Participant Flow

Participant milestones

Participant milestones
Measure	HIE Notification Plus Care Coordination VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) plus post-hospital geriatric care transitions intervention HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange Care transitions intervention: Post-hospital geriatrics care transitions coordinator provides home visit and telephone support for 30 days after hospital discharge	HIE Notification Alone VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) followed by usual post-hospital care HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange	Usual Care (No HIE Notification and No Care Coordination) Absence of VA provider notification of non-VA hospitalization via HIE plus Absence of post-hospital geriatric care transitions intervention \[Usual Care\]
Overall Study STARTED	268	337	191
Overall Study COMPLETED	87	115	191
Overall Study NOT COMPLETED	181	222	0

Reasons for withdrawal

Reasons for withdrawal
Measure	HIE Notification Plus Care Coordination VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) plus post-hospital geriatric care transitions intervention HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange Care transitions intervention: Post-hospital geriatrics care transitions coordinator provides home visit and telephone support for 30 days after hospital discharge	HIE Notification Alone VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) followed by usual post-hospital care HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange
Overall Study Did not have a non-VA encounter during study period (includes death before a non-VA encounter)	172	213
Overall Study Discharged from non-VA facility to long-term care facility for an indefinite period	3	1
Overall Study Did not have an HIE match	2	0
Overall Study Death during non-VA encounter	2	5
Overall Study Provider declined to participate after participant assignment	1	1
Overall Study Participant no longer active in VA system	1	0
Overall Study Enrolled in GRACE or hospice during non-VA encounter	0	2

Baseline Characteristics

Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization

Baseline characteristics by cohort

Baseline characteristics by cohort
Measure	HIE Notification Plus Care Coordination n=87 Participants VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) plus post-hospital geriatric care transitions intervention HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange Care transitions intervention: Post-hospital geriatrics care transitions coordinator provides home visit and telephone support for 30 days after hospital discharge	HIE Notification Alone n=115 Participants VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) followed by usual post-hospital care HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange	Usual Care (No HIE Notification and No Care Coordination) n=191 Participants Absence of VA provider notification of non-VA hospitalization via HIE plus Absence of post-hospital geriatric care transitions intervention \[Usual Care\]	Total n=393 Participants Total of all reporting groups
Age, Continuous	77.7 Years STANDARD_DEVIATION 8.5 • n=5 Participants	76.3 Years STANDARD_DEVIATION 7.4 • n=7 Participants	72.5 Years STANDARD_DEVIATION 7.1 • n=5 Participants	74.8 Years STANDARD_DEVIATION 7.8 • n=4 Participants
Sex: Female, Male Female	1 Participants n=5 Participants	2 Participants n=7 Participants	5 Participants n=5 Participants	8 Participants n=4 Participants
Sex: Female, Male Male	86 Participants n=5 Participants	113 Participants n=7 Participants	186 Participants n=5 Participants	385 Participants n=4 Participants
Ethnicity (NIH/OMB) Hispanic or Latino	12 Participants n=5 Participants	14 Participants n=7 Participants	27 Participants n=5 Participants	53 Participants n=4 Participants
Ethnicity (NIH/OMB) Not Hispanic or Latino	75 Participants n=5 Participants	98 Participants n=7 Participants	164 Participants n=5 Participants	337 Participants n=4 Participants
Ethnicity (NIH/OMB) Unknown or Not Reported	0 Participants n=5 Participants	3 Participants n=7 Participants	0 Participants n=5 Participants	3 Participants n=4 Participants
Race (NIH/OMB) American Indian or Alaska Native	0 Participants n=5 Participants	1 Participants n=7 Participants	0 Participants n=5 Participants	1 Participants n=4 Participants
Race (NIH/OMB) Asian	1 Participants n=5 Participants	0 Participants n=7 Participants	0 Participants n=5 Participants	1 Participants n=4 Participants
Race (NIH/OMB) Native Hawaiian or Other Pacific Islander	0 Participants n=5 Participants	1 Participants n=7 Participants	1 Participants n=5 Participants	2 Participants n=4 Participants
Race (NIH/OMB) Black or African American	15 Participants n=5 Participants	28 Participants n=7 Participants	64 Participants n=5 Participants	107 Participants n=4 Participants
Race (NIH/OMB) White	69 Participants n=5 Participants	79 Participants n=7 Participants	110 Participants n=5 Participants	258 Participants n=4 Participants
Race (NIH/OMB) More than one race	0 Participants n=5 Participants	1 Participants n=7 Participants	0 Participants n=5 Participants	1 Participants n=4 Participants
Race (NIH/OMB) Unknown or Not Reported	2 Participants n=5 Participants	5 Participants n=7 Participants	16 Participants n=5 Participants	23 Participants n=4 Participants
Region of Enrollment United States	87 Participants n=5 Participants	115 Participants n=7 Participants	191 Participants n=5 Participants	393 Participants n=4 Participants
VA Hospital Utilization in Year Prior to Enrollment	9 Participants n=5 Participants	16 Participants n=7 Participants	33 Participants n=5 Participants	58 Participants n=4 Participants

PRIMARY outcome

Timeframe: 90 days

Outcome measures

Outcome measures
Measure	HIE Notification Plus Care Coordination n=87 Participants VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) plus post-hospital geriatric care transitions intervention HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange Care transitions intervention: Post-hospital geriatrics care transitions coordinator provides home visit and telephone support for 30 days after hospital discharge	HIE Notification Alone n=115 Participants VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) followed by usual post-hospital care HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange	Usual Care (No HIE Notification and No Care Coordination) n=191 Participants Absence of VA provider notification of non-VA hospitalization via HIE plus Absence of post-hospital geriatric care transitions intervention \[Usual Care\]
Number of Participants With Hospital Readmission	23 Participants	21 Participants	35 Participants

SECONDARY outcome

Timeframe: 30 days

VA follow-up visit with a VA provider (physician or nurse practitioner) within 30 days of non-VA hospital discharge or ED visit.

Outcome measures

Outcome measures
Measure	HIE Notification Plus Care Coordination n=87 Participants VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) plus post-hospital geriatric care transitions intervention HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange Care transitions intervention: Post-hospital geriatrics care transitions coordinator provides home visit and telephone support for 30 days after hospital discharge	HIE Notification Alone n=115 Participants VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) followed by usual post-hospital care HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange	Usual Care (No HIE Notification and No Care Coordination) n=191 Participants Absence of VA provider notification of non-VA hospitalization via HIE plus Absence of post-hospital geriatric care transitions intervention \[Usual Care\]
Number of Participants With Scheduled Follow-up	35 Participants	37 Participants	39 Participants

SECONDARY outcome

Timeframe: 30 days

Population: Participants were included in the analysis who had a 30-day interview and answered the required questions. No participants in the Usual Care group are included in the analysis because they did not have a 30-day interview.

The number of discrepancies in medications classified as high risk for hospitalized older adults, including opioid analgesics, insulin, non-steroidal anti-inflammatory drugs, digoxin, antipsychotics, sedatives/hypnotics, and anticoagulants based on medical record review and patient or caregiver interview 30 days after non-VA hospital discharge.

Outcome measures

Outcome measures
Measure	HIE Notification Plus Care Coordination n=52 Participants VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) plus post-hospital geriatric care transitions intervention HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange Care transitions intervention: Post-hospital geriatrics care transitions coordinator provides home visit and telephone support for 30 days after hospital discharge	HIE Notification Alone n=72 Participants VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) followed by usual post-hospital care HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange	Usual Care (No HIE Notification and No Care Coordination) Absence of VA provider notification of non-VA hospitalization via HIE plus Absence of post-hospital geriatric care transitions intervention \[Usual Care\]
Number of High-risk Medication Discrepancies	63 count of medication discrepancies	81 count of medication discrepancies	—

SECONDARY outcome

Timeframe: 30 days

A measure of condition self-knowledge and transitional care quality from the patient's perspective is ascertained by patient or caregiver interview 30 days after non-VA hospital discharge. The investigators will use an adapted 3-item version which includes items such as: "After I left the hospital, I had all the information I needed to be able to take care of myself" with the response options strongly agree, agree, disagree, strongly disagree, and don't know. The investigators chose to use the 3-item rather than a 15-item version as the shorter instrument demonstrates excellent correlation with the longer version but with lower respondent burden. Unabbreviated scale title is "3-Item Care Transitions Measure" and minimum value is 1 and maximum value is 12. Higher scores mean a better transition/outcome.

Outcome measures

Outcome measures
Measure	HIE Notification Plus Care Coordination n=54 Participants VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) plus post-hospital geriatric care transitions intervention HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange Care transitions intervention: Post-hospital geriatrics care transitions coordinator provides home visit and telephone support for 30 days after hospital discharge	HIE Notification Alone n=73 Participants VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) followed by usual post-hospital care HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange	Usual Care (No HIE Notification and No Care Coordination) Absence of VA provider notification of non-VA hospitalization via HIE plus Absence of post-hospital geriatric care transitions intervention \[Usual Care\]
Care Transitions Measure Score	3.0 score on a scale Interval 3.0 to 3.7	3.0 score on a scale Interval 3.0 to 3.7	—

Adverse Events

HIE Notification Plus Care Coordination

Serious events: 23 serious events

Other events: 31 other events

Deaths: 20 deaths

HIE Notification Alone

Serious events: 21 serious events

Other events: 43 other events

Deaths: 31 deaths

Usual Care (No HIE Notification and No Care Coordination)

Serious events: 35 serious events

Other events: 0 other events

Deaths: 26 deaths

Serious adverse events

Serious adverse events
Measure	HIE Notification Plus Care Coordination n=55 participants at risk；n=87 participants at risk VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) plus post-hospital geriatric care transitions intervention HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange Care transitions intervention: Post-hospital geriatrics care transitions coordinator provides home visit and telephone support for 30 days after hospital discharge	HIE Notification Alone n=75 participants at risk；n=115 participants at risk VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) followed by usual post-hospital care HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange	Usual Care (No HIE Notification and No Care Coordination) n=191 participants at risk Absence of VA provider notification of non-VA hospitalization via HIE plus Absence of post-hospital geriatric care transitions intervention \[Usual Care\]
Surgical and medical procedures Hospital Readmission [Time frame 90 days]	26.4% 23/87 • 90 days Participants were assessed for death regardless of whether or not they completed the study, whereas participants were assessed for Serious and Other (Not Including Serious) Adverse Events only if they completed the study. In addition, high-risk medication discrepancy was not assessed in the Usual Care group.	18.3% 21/115 • 90 days Participants were assessed for death regardless of whether or not they completed the study, whereas participants were assessed for Serious and Other (Not Including Serious) Adverse Events only if they completed the study. In addition, high-risk medication discrepancy was not assessed in the Usual Care group.	18.3% 35/191 • 90 days Participants were assessed for death regardless of whether or not they completed the study, whereas participants were assessed for Serious and Other (Not Including Serious) Adverse Events only if they completed the study. In addition, high-risk medication discrepancy was not assessed in the Usual Care group.

Other adverse events

Other adverse events
Measure	HIE Notification Plus Care Coordination n=55 participants at risk；n=87 participants at risk VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) plus post-hospital geriatric care transitions intervention HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange Care transitions intervention: Post-hospital geriatrics care transitions coordinator provides home visit and telephone support for 30 days after hospital discharge	HIE Notification Alone n=75 participants at risk；n=115 participants at risk VA provider notification of non-VA hospitalization via electronic health information exchange (HIE) followed by usual post-hospital care HIE Notification: VA provider notification of non-VA hospitalization or ED visit via electronic health information exchange	Usual Care (No HIE Notification and No Care Coordination) n=191 participants at risk Absence of VA provider notification of non-VA hospitalization via HIE plus Absence of post-hospital geriatric care transitions intervention \[Usual Care\]
Surgical and medical procedures Any high-risk medication discrepancy	56.4% 31/55 • 90 days Participants were assessed for death regardless of whether or not they completed the study, whereas participants were assessed for Serious and Other (Not Including Serious) Adverse Events only if they completed the study. In addition, high-risk medication discrepancy was not assessed in the Usual Care group.	57.3% 43/75 • 90 days Participants were assessed for death regardless of whether or not they completed the study, whereas participants were assessed for Serious and Other (Not Including Serious) Adverse Events only if they completed the study. In addition, high-risk medication discrepancy was not assessed in the Usual Care group.	— 0/0 • 90 days Participants were assessed for death regardless of whether or not they completed the study, whereas participants were assessed for Serious and Other (Not Including Serious) Adverse Events only if they completed the study. In addition, high-risk medication discrepancy was not assessed in the Usual Care group.

Additional Information

Kimberly M. Judon

James J. Peters VA Medical Center

Phone: 718-584-9000

Email: [email protected]

Results disclosure agreements

Principal investigator is a sponsor employee
Publication restrictions are in place