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| Name | Class |
|---|---|
| Providence St. Patrick Hospital, Missoula Montana | UNKNOWN |
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Residents of rural and frontier counties experience significant disparities in health care access and outcomes when compared to their urban counterparts. The organization of health care delivery contributes significantly to these disparities. For rural residents with multiple chronic conditions, transitioning along the continuum of care, between systems of treatment and support, and between dispersed locations present significant challenges. One critical challenge involves hospitalization for treatment because it requires travel to locations at a significant distance from home and disrupts personal and family routines. The transition back home is also problematic because discharge planning does not adequately account for limited access to care in rural areas. Indeed, discharge planning has been recently described as a "black hole;" fragmented and uncoordinated, and contributing to poor outcomes and patient dissatisfaction. The specific aim of this research is to ascertain rural patients' actual experience of the discharge planning process and to involve patients and rural providers in designing and testing a contextually appropriate rural options discharge model (ROADMAP) that improves patient outcomes and reduces re-hospitalizations.
Residents of rural counties experience significant disparities in health care access and outcomes when compared to their urban counterparts. These disparities are structural; based in our market-based medical care delivery system. For rural residents with multiple chronic conditions, transitioning along the continuum of care, between systems of treatment and support, and between dispersed locations both expose and produce disparities. The transition home from hospitalization for treatment exposes the current urban bias. Indeed, discharge planning is fragmented and uncoordinated, and contributes to poor the disparities. The specific aims of this research is to ascertain rural patients' actual experience of discharge; then to involve patients and rural providers in using those data to design a contextually appropriate rural options at discharge model of active planning (ROADMAP) that improves patient outcomes and reduces disparities. Objectives include:
Researchers will work in four counties of the Missoula Hospital Referral Region with a total population of 53,116 living on 12,342 square miles (4.3 persons per square mile). Researchers will recruit patients seeking treatment from St. Patrick Hospital. Patients and patient advocates will serve on an Innovations Design Team (IDT) to create the ROADMAP. Researchers will first interview patients (n = 40) who have been discharged to one of the rural counties. Researchers will compare their experiences to guidelines. Next, they will conduct a Design Survey (n=600) to verify goals important to patients. The IDT will use these findings to develop design requirements for ROADMAP. Finally, we will use a quasi-experimental research design to compare the patient designed rural ROADMAP to standard practice. The primary outcome measures are measures that reflect the patient's values for health-related quality of life and functional status, as well as hospital re-admissions. An independent statistician will use Hierarchical Linear Modeling to examine the complex relationships. This approach accounts for patients nested in four counties and the correlated errors inherent in within subject analysis. Health care reform sets the occasion for rapid diffusion of ROADMAP. This can provide an incremental reduction in rural disparities. Incorporating patient and provider input increases the likelihood it will fit within the emerging reimbursement model. Researchers expect that ROADMAP will reduce re-hospitalizations by as much as 30%, and improve patient recovery and return to participation in daily life.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Standard hospital discharge services | No Intervention | Patients received standard discharge planning; the baseline and return to baseline groups were combined to form a single standard discharge group | |
| Enhanced rural discharge and transition | Experimental | Enhanced rural discharge and transition involved conducting a functional needs assessment before discharge. Identified needs were shared with a Local Community Transition Coordinator (LCTC). Needs include such patient centered issues as housing, transportation, emotional support, support for completing daily chores, and assistance in securing local follow-up appointments. Once a patient returned home, the LCTC conduct a review of discharge orders to insure a patient can meet those recommendations. Then the LCTC worked with the patient to develop and implement a transition plan that linked the patient to local resources he or she can use to address needs. The LCTC also provided direct supports. This plan was implemented over the course of the first 30 days after discharge. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Enhanced rural discharge and transition | Behavioral | While in the treating hospital, patients from small towns and rural communities are engaged in package of procedures designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs and the provision of enhanced recovery supports to the patient. |
| Measure | Description | Time Frame |
|---|---|---|
| Hospital Re-admissions Analyzed by Poisson Regression | Number of admissions to any hospital reported by the patients after discharge from a regional hospital to one of four rural counties. | 3, 7 ,14, 21, 30, 60, and 90 days after discharge |
| Hospital Re-admissions Analyzed by Logistic Regression | Proportion of patients who self-report at least one hospital readmission to any hospital after discharge from a regional hospital to one of four rural counties. | 3, 7 ,14, 21, 30, 60, and 90 days after discharge |
| Emergency Department (ED) Visits Analyzed by Poisson Regression | Number of self-reported visits to the emergency department of any hospital reported by patients after discharge from a regional hospital to one of four rural counties. | 3, 7, 14, 21,30, 60, and 90 days after discharge |
| Emergency Department (D) Visits Analyzed by Logistic Regression | Proportion of patients who report at least one emergency department visit after discharge from a regional hospital to one of four rural counties. | 3, 7, 14, 21,30, 60, and 90 days after discharge |
| Primary Care Provider (PCP) Visits Analyzed by Poisson Regression | This reflects the number of visits to a patient's local primary care provider at 3, 7, 14, 21,30, 60, and 90 days after discharge. | 3, 7, 14, 21, 30, 60, and 90 days after discharge |
| Primary Care Provider (PCP) Visits Analyzed by Logistic Regression | This reflects the proportion of patients who reported at least one visit to a their local primary care provider at 3, 7, 14, 21,30, 60, and 90 days after discharge. |
| Measure | Description | Time Frame |
|---|---|---|
| Short Form (SF12) Physical Health Score | The SF12 is a twelve-item standardized questionnaire that measures overall, physical health, and mental health. Patients rate each item on an ordinal scale. Data are analyzed using a proprietary algorithm. Scores range from 0 to 100. Higher scores reflect a better health status. The analysis creates an overall health score and sub scores that reflect physical health and mental health. Both Physical and Mental Health Composite Scales combine the 12 items in such a way that they compare to a national norm of a mean score of 50.0 and a standard deviation of 10.0. |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Tom W Seekins, Ph.D. | University of Montana | Principal Investigator |
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We recruited participants from among patients admitted to Saint Patrick Hospital, a regional referral hospital, from one of four counties. All four were non-metropolitan counties and three of the counties met the criteria of being a frontier county (population of less than 6 people per square mile).
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| ID | Title | Description |
|---|---|---|
| FG000 | Standard Hospital Discharge Planning Services | Patients receive standard discharge planning services. |
| FG001 | Enhanced Discharge Planning and Rural Transition Supports | The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transition needs and the provision of recovery supports to the patient. Enhanced Transitions Planning: While in the treating hospital, patients from small towns and rural communities are engaged in a process designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs. Once home, a Local Community Transition Coordinator provides support to address needs. |
| Title | Milestones | Reasons Not Completed | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
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| ID | Title | Description |
|---|---|---|
| BG000 | Current Treatment | Patients receive that current discharge planning services and supports. |
| BG001 | Enhanced Transitions Planning | The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs and the provision of recovery supports to the patient. Enhanced Transitions Planning: While in the treating hospital, patients from small towns and rural communities are engaged in package of procedures designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs and the provision of enhanced recovery supports to the patient. |
| Units | Counts |
|---|---|
| Participants |
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| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | Mean |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Hospital Re-admissions Analyzed by Poisson Regression | Number of admissions to any hospital reported by the patients after discharge from a regional hospital to one of four rural counties. | Patients between 18 and 75 years old admitted to regional referral hospital for treatment, who enrolled in study and were discharged to one of four rural counties | Posted | Number | Hospital Readmission | 3, 7 ,14, 21, 30, 60, and 90 days after discharge |
|
Up to 90 days post discharge
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Standard Hospital Discharge Planning Services | Patients receive standard discharge planning services. |
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The overall sample was small due to the rural focus of the program. The sample size for emergency department visits and hospitalizations was low, making it difficult to detect differences.
| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Tom Seekins, Ph.D. | University of Montana | 2432654 | 406 | TOm.Seekins@UMontana.edu |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot_SAP | Yes | Yes | No | Study Protocol and Statistical Analysis Plan | Sep 13, 2017 | Sep 13, 2017 | Prot_SAP_000.pdf |
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Patients were recruited from those admitted from one of four rural counties. In the initial phase, all patients enrolled from any county were assigned to a baseline condition. After enrollment stabilized, patients from one county were enrolled in the intervention while patients from the other three counties remained in baseline. Subsequently the intervention was introduced to the other counties sequentially while others remained in baseline. A return to baseline conditions followed a period after the intervention had been introduced in all counties.
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| 3, 7, 14, 21, 30, 60, and 90 days after discharge |
| 3, 7, 14, 21, 30, 60, and 90 days after discharge |
| Short Form (SF12) Mental Health Score | The SF12 is a twelve-item standardized questionnaire that measures overall, physical health, and mental health. Patients rate each item on an ordinal scale. Data are analyzed using a proprietary algorithm. Scores range from 0 to 100. Higher scores reflect a better health status. The analysis creates an overall health score and sub scores that reflect physical health and mental health. Both Physical and Mental Health Composite Scales combine the 12 items in such a way that they compare to a national norm of a mean score of 50.0 and a standard deviation of 10.0. | 3, 7, 14, 21, 30, 60, and 90 days after discharge |
| Care Transition Measure (CTM3) | The CTM3 is a three-item standardized questionnaire to measures patients' perspectives on coordination of hospital discharge care. Patients rate whether they strongly agree, agree, disagree, or strongly disagree with three items (hospital staff too my preferences into account, I had a good idea what I was responsible for once I left the hospital, and I clearly understood the purpose for taking each of my medications). They may also rate an items as not applicable to their situation. Ratings are converted to a scale that ranges from 0 to 100. Higher scores reflect better discharge care. | 3 days after discharge |
| Rural Transition Measure (RTM14) | The RTM14 is a fourteen-item questionnaire to measures patients' perspectives on the delivery of transition services and supports after discharge from a regional hospital to a small town or rural community. Patients respond by indicating whether they strongly disagree, disagree, agree, or strongly agree with each of the 14 items. Patients may also indicate whether an item is not applicable to their situation. Ratings are converted to a scale that ranges from 0 to 100. Higher scores reflect better transition service performance. | 7, 14, 21, 30, 60, and 90 days after discharge |
| BG002 | Total | Total of all reporting groups |
| years |
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| Sex: Female, Male | Count of Participants | Participants |
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| Ethnicity (NIH/OMB) | Count of Participants | Participants |
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| Race (NIH/OMB) | Count of Participants | Participants |
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| Region of Enrollment | Participants recruited from among patients from four rural counties in St. Patrick Hospital's the catchment area, including Beaverhead, Lake, Powell, and Sanders Counties Montana. | Number | participants |
|
| Patient Activation Measure (PAM10) | Patients completed the 10-item Patient Activation Measure (PAM10) questionnaire measuring a patient's confidence in their knowledge, skills, and abilities to manage their health once they were discharged from a hospital. Patients indicated whether they strongly agreed, agreed, disagreed, or strongly disagreed with each statement. A patient could also indicate that a particular item was not applicable to their situation. Total scores ranged from 0.0 to 100.0. Higher scores indicated greater confidence in their capacity for self-management. | Mean | Full Range | units on a scale |
|
| Length of Stay, Acuity, Co-morbidity, and Emergency Department Visits (LACE+) | The LACE+ uses a proprietary algorithm to calculate the likelihood of a patient's hospital readmission based on information derived from the patient's electronic medical record. Generally, higher scores reflect higher risk. Scores range from 0 to 100. A score of 28 or less is categorized as low risk. A score of 29 to 58 is categorized as medium risk. A score of 59 or higher is categorized as high risk. | We analyzed LACE+ data for 112 patients as the electronic medical record did not establish this measure until after the study started. | Mean | Full Range | units on a scale |
|
The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs and the provision of recovery supports to the patient. Enhanced Discharge Planning & Rural Transition Support: While in the treating hospital, patients from small towns and rural communities are engaged in package of procedures designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs and the provision of enhanced recovery supports to the patient. |
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| Primary | Hospital Re-admissions Analyzed by Logistic Regression | Proportion of patients who self-report at least one hospital readmission to any hospital after discharge from a regional hospital to one of four rural counties. | Patients between 18 and 75 years old admitted to regional referral hospital for treatment, who enrolled in study and were discharged to one of four rural counties | Posted | Number | proportion of patients rehospitalized | 3, 7 ,14, 21, 30, 60, and 90 days after discharge |
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| Primary | Emergency Department (ED) Visits Analyzed by Poisson Regression | Number of self-reported visits to the emergency department of any hospital reported by patients after discharge from a regional hospital to one of four rural counties. | Patients between 18 and 75 years old admitted to regional referral hospital for treatment, who enrolled in study and were discharged to one of four rural counties | Posted | Number | Emergency Department Visits | 3, 7, 14, 21,30, 60, and 90 days after discharge |
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| Primary | Emergency Department (D) Visits Analyzed by Logistic Regression | Proportion of patients who report at least one emergency department visit after discharge from a regional hospital to one of four rural counties. | Patients between 18 and 75 years old admitted to regional referral hospital for treatment, who enrolled in study and were discharged to one of four rural counties | Posted | Number | participants with at least one ED visit | 3, 7, 14, 21,30, 60, and 90 days after discharge |
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| Primary | Primary Care Provider (PCP) Visits Analyzed by Poisson Regression | This reflects the number of visits to a patient's local primary care provider at 3, 7, 14, 21,30, 60, and 90 days after discharge. | Patients between 18 and 75 years old admitted to a regional referral hospital for treatment, who enrolled in the study and were discharged to one of four rural counties. | Posted | Number | Primary Care Provider Visits | 3, 7, 14, 21, 30, 60, and 90 days after discharge |
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| Secondary | Short Form (SF12) Physical Health Score | The SF12 is a twelve-item standardized questionnaire that measures overall, physical health, and mental health. Patients rate each item on an ordinal scale. Data are analyzed using a proprietary algorithm. Scores range from 0 to 100. Higher scores reflect a better health status. The analysis creates an overall health score and sub scores that reflect physical health and mental health. Both Physical and Mental Health Composite Scales combine the 12 items in such a way that they compare to a national norm of a mean score of 50.0 and a standard deviation of 10.0. | Patients between 18 and 75 years old admitted to regional referral hospital for treatment, who enrolled in study and were discharged to one of four rural counties | Posted | Mean | Standard Deviation | units on a scale | 3, 7, 14, 21, 30, 60, and 90 days after discharge |
|
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| Secondary | Short Form (SF12) Mental Health Score | The SF12 is a twelve-item standardized questionnaire that measures overall, physical health, and mental health. Patients rate each item on an ordinal scale. Data are analyzed using a proprietary algorithm. Scores range from 0 to 100. Higher scores reflect a better health status. The analysis creates an overall health score and sub scores that reflect physical health and mental health. Both Physical and Mental Health Composite Scales combine the 12 items in such a way that they compare to a national norm of a mean score of 50.0 and a standard deviation of 10.0. | Patients between 18 and 75 years old admitted to regional referral hospital for treatment, who enrolled in study and were discharged to one of four rural counties | Posted | Mean | Standard Deviation | units on a scale | 3, 7, 14, 21, 30, 60, and 90 days after discharge |
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| Secondary | Care Transition Measure (CTM3) | The CTM3 is a three-item standardized questionnaire to measures patients' perspectives on coordination of hospital discharge care. Patients rate whether they strongly agree, agree, disagree, or strongly disagree with three items (hospital staff too my preferences into account, I had a good idea what I was responsible for once I left the hospital, and I clearly understood the purpose for taking each of my medications). They may also rate an items as not applicable to their situation. Ratings are converted to a scale that ranges from 0 to 100. Higher scores reflect better discharge care. | Patients between 18 and 75 years old admitted to regional referral hospital for treatment, who enrolled in study and were discharged to one of four rural counties | Posted | Mean | Standard Deviation | Survey Response Scores | 3 days after discharge |
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| Secondary | Rural Transition Measure (RTM14) | The RTM14 is a fourteen-item questionnaire to measures patients' perspectives on the delivery of transition services and supports after discharge from a regional hospital to a small town or rural community. Patients respond by indicating whether they strongly disagree, disagree, agree, or strongly agree with each of the 14 items. Patients may also indicate whether an item is not applicable to their situation. Ratings are converted to a scale that ranges from 0 to 100. Higher scores reflect better transition service performance. | Patients between 18 and 75 years old admitted to regional referral hospital for treatment, who enrolled in study and were discharged to one of four rural counties | Posted | Mean | Standard Deviation | Survey Response Scores | 7, 14, 21, 30, 60, and 90 days after discharge |
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| Primary | Primary Care Provider (PCP) Visits Analyzed by Logistic Regression | This reflects the proportion of patients who reported at least one visit to a their local primary care provider at 3, 7, 14, 21,30, 60, and 90 days after discharge. | Patients between 18 and 75 years old admitted to a regional referral hospital for treatment, who enrolled in the study and were discharged to one of four rural counties. | Posted | Number | Proportion with Primary Care Visits | 3, 7, 14, 21, 30, 60, and 90 days after discharge |
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| 2 |
| 77 |
| 0 |
| 77 |
| 0 |
| 77 |
| EG001 | Enhanced Discharge Planning and Rural Transition Supports | The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transition needs and the provision of recovery supports to the patient. Enhanced Transitions Planning: While in the treating hospital, patients from small towns and rural communities are engaged in a process designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs. Once home, a Local Community Transition Coordinator provides support to address needs. | 0 | 50 | 0 | 50 | 0 | 50 |
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| Unknown or Not Reported |
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| Native Hawaiian or Other Pacific Islander |
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| Black or African American |
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| White |
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| More than one race |
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| Unknown or Not Reported |
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| 7 days after discharge |
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| 14 days after discharge |
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| 21 days after discharge |
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| 30 days after discharge |
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| 60 days after discharge |
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| 90 days after discharge |
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| H0: There is no difference in the proportion of patients with at least one ED visits by day 7 (null hypothesis); H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 7. | Regression, Logistic | 0.211 | P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 7, 110 (66 baseline and 44 intervention) patients were used in this analysis. |
| H0: There is no difference in the proportion of patients with at least one ED visits by day 14 (null hypothesis); H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 14. | Regression, Logistic | 0.424 | P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 14, 104 (61 baseline and 43 intervention) patients were used in this analysis. |
| H0: There is no difference in the proportion of patients with at least one ED visits by day 21 (null hypothesis); H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 21. | Regression, Logistic | 0.191 | P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 21, 98 (57 baseline and 41 intervention) patients were used in this analysis. |
| H0: There is no difference in the proportion of patients with at least one ED visits by day 30 (null hypothesis); H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 30. | Regression, Logistic | 0.478 | P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 30, 95 (56 baseline and 39 intervention) patients were used in this analysis. |
| H0: There is no difference in the proportion of patients with at least one ED visits by day 60 (null hypothesis); H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 60. | Regression, Logistic | 0.452 | P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 60, 87 (53 baseline and 34 intervention) patients were used in this analysis. |
| Regression, Logistic | 0.381 | P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | H0: There is no difference in the proportion of patients with at least one ED visits by day 90 (null hypothesis); H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 90. | For day 90, 83 (49 baseline and 34 intervention) patients were used in this analysis. |
| 7 days after discharge |
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| 14 days after discharge |
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| 21 days after discharge |
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| 30 days after discharge |
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| 60 days after discharge |
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| 90 days after discharge |
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| H0: There is no difference in the cumulative number of ED visits for day 7 (null hypothesis); H1: The cumulative number of ED visits for the standard discharge group is greater than that for the enhanced discharge group for day 7. | Poisson regression | 0.286 | P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 7, 113 (68 baseline and 45 intervention) patients were used in this analysis. |
| H0: There is no difference in the cumulative number of ED visits for day 14 (null hypothesis); H1: The cumulative number of ED visits for the standard discharge group is greater than that for the enhanced discharge group for day 14. | Poisson regression | 0.347 | P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 14, 107 (63 baseline and 44 intervention) patients were used in this analysis. |
| H0: There is no difference in the cumulative number of ED visits for day 21 (null hypothesis); H1: The cumulative number of ED visits for the standard discharge group is greater than that for the enhanced discharge group for day 21. | Poisson regression | 0.250 | P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 21, 101 (59 baseline and 42 intervention) patients were used in this analysis. |
| H0: There is no difference in the cumulative number of ED visits for day 30 (null hypothesis); H1: The cumulative number of ED visits for the standard discharge group is greater than that for the enhanced discharge group for day 30. | Poisson regression | 0.220 | P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 30, 98 (58 baseline and 40 intervention) patients were used in this analysis. |
| H0: There is no difference in the cumulative number of ED visits for day 60 (null hypothesis); H1: The cumulative number of ED visits for the standard discharge group is greater than that for the enhanced discharge group for day 60. | Poisson regression | 0.116 | P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 60, 90 (55 baseline and 35 intervention) patients were used in this analysis. |
| H0: There is no difference in the cumulative number of ED visits for day 90 (null hypothesis); H1: The cumulative number of ED visits for the standard discharge group is greater than that for the enhanced discharge group for day 90. | Poisson regression | 0.126 | P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 90, 86 (51 baseline and 35 intervention) patients were used in this analysis. |
| 7 days after discharge |
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| 14 days after discharge |
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| 21 days after discharge |
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| 30 days after discharge |
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| 60 days after discharge |
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| 90 days after discharge |
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| H0: There is no difference in the proportion of patients with at least one ED visits by day 7; H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 7. | Regression, Logistic | 0.504 | P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 7, 113 (68 baseline and 45 intervention) patients were used in this analysis. |
| H0: There is no difference in the proportion of patients with at least one ED visits by day 14; H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 14. | Regression, Logistic | 0.558 | P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 14, 107 (63 baseline and 44 intervention) patients were used in this analysis. |
| H0: There is no difference in the proportion of patients with at least one ED visits by day 21; H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 21. | Regression, Logistic | 0.472 | Comments (covariates): P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 21, 101 (59 baseline and 42 intervention) patients were used in this analysis. |
| H0: There is no difference in the proportion of patients with at least one ED visits by day 30; H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 30. | Regression, Logistic | 0.462 | P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 30, 98 (58 baseline and 40 intervention) patients were used in this analysis. |
| H0: There is no difference in the proportion of patients with at least one ED visits by day 60; H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 60. | Regression, Logistic | 0.394 | P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 60, 90 (55 baseline and 35 intervention) patients were used in this analysis. |
| H0: There is no difference in the proportion of patients with at least one ED visits by day 90; H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 90. | Regression, Logistic | 0.368 | Comments (covariates): P-values comparing the counts for the 2 groups after adjusting for PAM10. | Superiority | For day 90, 86 (51 baseline and 35 intervention) patients were used in this analysis. |
| 7 days after discharge |
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| 14 days after discharge |
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| 21 days after discharge |
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| 30 days after discharge |
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| 60 days after discharge |
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| 90 days after discharge |
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| H0: There is no difference in the cumulative number of PCP visits for day 7 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 7. | Poisson regression | 0.613 | Superiority | For day 7, 111 (67 baseline and 44 intervention) patients were used in this analysis. |
| H0: There is no difference in the cumulative number of PCP visits for day 14 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 14. | Poisson regression | 0.541 | P-values comparing the counts for the 2 groups after adjusting for sex, age, number in household, county, and LACE+ score. | Superiority | For day 14, 105 (62 baseline and 43 intervention) patients were used in this analysis. |
| H0: There is no difference in the cumulative number of PCP visits for day 21 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 21. | Poisson regression | 0.765 | P-values comparing the counts for the 2 groups after adjusting for sex, age, number in household, county, and LACE score. | Superiority | For day 21, 98 (58 baseline and 40 intervention) patients were used in this analysis. |
| H0: There is no difference in the cumulative number of PCP visits for day 30 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 30. | Poisson regression | 0.919 | P-values comparing the counts for the 2 groups after adjusting for sex, age, number in household, county, and LACE+ score. | Superiority | For day 30, 95 (57 baseline and 38 intervention) patients were used in this analysis. |
| H0: There is no difference in the cumulative number of PCP visits for day 60 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 60. | Poisson regression | P-values comparing the counts for the 2 groups after adjusting for sex, age, number in household, county, and LACE score. | 0.999 | P-values comparing the counts for the 2 groups after adjusting for sex, age, number in household, county, and LACE score. | Superiority | For day 60, 87 (54 baseline and 33 intervention) patients were used in this analysis. |
| H0: There is no difference in the cumulative number of PCP visits for day 90 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 90. | Poisson regression | 0.995 | Superiority | For day 90, 83 (50 baseline and 33 intervention) patients were used in this analysis. |
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| H0: There is no difference in the cumulative number of PCP visits for day 7 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 7. | Regression, Logistic | 0.479 | This Hypothesis was tested with no adjustments for covariates since none were significant. | Superiority | For day 7, 111 (67 baseline and 44 intervention) patients were used in this analysis. |
| H0: There is no difference in the cumulative number of PCP visits for day 14 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 14. | Regression, Logistic | 0.329 | Superiority | For day 14, 105 (62 baseline and 43 intervention) patients were used in this analysis. |
| H0: There is no difference in the cumulative number of PCP visits for day 21 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 21. | Regression, Logistic | 0.780 | Superiority | This Hypothesis was tested with no adjustments for covariates since none were significant. |
| H0: There is no difference in the cumulative number of PCP visits for day 30 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 30. | Regression, Logistic | 0.779 | This Hypothesis was tested with no adjustments for covariates since none were significant. | Superiority | For day 30, 95 (57 baseline and 38 intervention) patients were used in this analysis. |
| H0: There is no difference in the cumulative number of PCP visits for day 60 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 60. | Regression, Logistic | 0.848 | This Hypothesis was tested with no adjustments for covariates since none were significant. | Superiority | For day 60, 87 (54 baseline and 33 intervention) patients were used in this analysis. |
| H0: There is no difference in the cumulative number of PCP visits for day 90 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 90. | Regression, Logistic | 0.857 | This Hypothesis was tested with no adjustments for covariates since none were significant. | Superiority | For day 90, 83 (50 baseline and 33 intervention) patients were used in this analysis. |