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The researchers are investigating if using a risk-based prediction score or benefit-based prediction score to allocate transition of care (TOC) interventions is more effective in reducing the rate of unplanned hospital readmissions or death within 30 days of hospital discharge.
The intervention affects only how the TOC bundle is assigned and does not alter how the telephone calls are delivered. For example, both care navigators and pharmacists receive the same patient information and follow the same call procedures before and after the intervention.
Individuals with predicted benefits greater than the 40% quantile are assigned the phone call bundle while others were not assigned the bundle. During the trial the 40% quantile will be dynamically determined using discharge data from the previous week.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Control Arm/Standard of care | Active Comparator | The Control Arm, in which patients with a LACE Index score of 9 or greater on the day of hospital discharge will receive TOC interventions. This is the currently implemented allocation policy at Michigan Medicine. In this setting, approximately 60% of patients receive the TOC intervention. Thus, we will use a threshold of the 40th percentile for assigning the TOC telephone call bundle. Note that to maintain the 60% intervention rate throughout the study, the score threshold (LACE 9 or greater) will be monitored and dynamically adjusted. The LACE Index has four components: Length of Stay (L), Acuity of the Admission (A), Comorbidities (C), and Emergency Department Visits (E), and estimates the risk of a patient having an unplanned hospital readmission after being discharged from their current encounter. |
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| Experimental Arm | Experimental | The Experimental Arm, in which Causal-Hospital reAdmission Risk Prediction Model (C-HARP) scores will be used to allocate TOC interventions. C-HARP is a machine learning model that leverages routinely collected and stored patient data in the electronic health record (EHR) to estimate how much a patient will benefit from receiving MM's TOC telephone call bundle. The assignment threshold will be defined as the 40th percentile of C-HARP scores within the most recent 100 days of the target cohort, so that approximately 60% of patients are assigned the telephone call bundle. Based on current retrospective data, this threshold corresponds to a C-HARP score of 18. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| C-HARP TOC assignment | Device | The Experimental Arm will allocate TOC interventions based on scores generated by the Causal-Hospital reAdmission Risk Prediction Model (C-HARP), C-HARP is a linear model that leverages routinely collected and stored patient data in the electronic health record (EHR) to estimate how much a patient will benefit from receiving Michigan Medicine's (MM's) TOC telephone call bundle. |
| Measure | Description | Time Frame |
|---|---|---|
| The number of 30-day all-cause unplanned readmission or death | An unplanned readmission is defined as any not canceled inpatient, outpatient, or observation hospital admission with an admission type not recorded as "scheduled." Deaths are determined using the Michigan Death Index and matched to patient records using Social Security numbers. | 30 calendar days following the index discharge |
| Measure | Description | Time Frame |
|---|---|---|
| The number of 90-day all-cause unplanned readmission or death | An unplanned readmission is defined as any not canceled inpatient, outpatient, or observation hospital admission with an admission type not recorded as "scheduled." Deaths are determined using the Michigan Death Index and matched to patient records using Social Security numbers. | 90 calendar days following the index discharge |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Stephanie Shepard, PhD | Contact | 734-647-1098 | sdokeefe@umich.edu |
| Name | Affiliation | Role |
|---|---|---|
| Jenna Wiens, PhD | University of Michigan | Study Chair |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| The University of Michigan | Ann Arbor | Michigan | 48109 | United States |
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| ID | Term |
|---|---|
| D003643 | Death |
| ID | Term |
|---|---|
| D010335 | Pathologic Processes |
| D013568 | Pathological Conditions, Signs and Symptoms |
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Population Health Coordinators, Care Navigators, and Clinical Pharmacists will see a flag indicating whether or not a patient is assigned to receive MM's TOC interventions. To maintain appropriate masking, they will not have knowledge of whether or not this flag is determined by the Control Arm policy or Experimental Arm policy, in some cases they may access the LACE score but will not have access to the C-HARP scores. Patients will only be aware of TOC interventions if they are deemed to be at high risk for an unplanned hospital readmission and are assigned to receive them, which is the current standard of care and operational process at MM. Given the setting of this trial, there are no circumstances in which unblinding will occur.
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| The LACE Index TOC assignment | Other | The LACE Index has four components: Length of Stay (L), Acuity of the Admission (A), Comorbidities (C), and Emergency Department Visits (E), and estimates the risk of a patient having an unplanned hospital readmission after being discharged from their current encounter. |
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| Time to first 90-day all-cause unplanned readmission or death | An unplanned readmission is defined as any not canceled inpatient, outpatient, or observation hospital admission with an admission type not recorded as "scheduled." Deaths are determined using the Michigan Death Index and matched to patient records using Social Security numbers. | 90 calendar days following the index discharge |
| TOC telephone call bundle completion (care navigator call) | A care navigator call is considered complete if a completed call record is observed within 5 calendar days after discharge. Calls are considered incomplete if the corresponding completed call record occurs after an all-cause unplanned readmission. | 5 calendar days after discharge. |
| TOC telephone call bundle completion (clinical pharmacist call) | A clinical pharmacist call is considered complete if a completed call record is observed within 14 calendar days after discharge. Calls are considered incomplete if the corresponding completed call record occurs after an all-cause unplanned readmission. | 14 calendar days after discharge |
| TOC telephone call bundle completion (both calls) | Completed the care navigator call and completed the clinical pharmacist call. Calls are considered incomplete if the corresponding completed call record occurs after an all-cause unplanned readmission. | 14 calendar days after discharge |