Comprehensive discharge follow-up in patients’ homes by GPs and district nurses of elderly patients

Figures & data

Figure 1. Patient flow.

Figure 2. Agenda for intervention, participants, contact form.

Table I. Sociodemographic and health characteristics in control and intervention groups at baseline.

Characteristics	Intervention (n = 148)	Control (n = 145)	p-value^1
Sex – female	66%	66%	0.9
Age (median)	84 years	83 years	1.0^2
Housing	95% living in private home	97% living in private home	0.4
Marital status	59% widow/widower	57% widow/widower	0.8
	30% spouse	29% spouse
	11% divorced/single	14% divorced/single
Contact with family and friends	61% daily/weekly	57% daily/weekly	0.4
	29% monthly	36% monthly
	10% more seldom	7% more seldom
Days spent in hospital within the last six months before the actual admission	(n = 166)	(n = 165)
0 days	95 (57%)	95 (58%)	0.5^2
1–7 days	24 (14%)	39 (24%)
8–14 days	16 (10%)	10 (6%)
15–28 days	14 (8%)	12 (7%)
29 days or more	17 (10%)	9 (5%)
Number of daily medications median (interquartile range)	6(4.5–9)	6 (4–8)	0.4
Receiving help
From district nurse	65%	56%	0.1
Home helper	81%	77%	0.3
Self-rated health
Excellent/very good	12 (8%)	16 (11%)	0.5
Good	73 (49%)	81 (56%)
Fair/poor	63 (42%)	47 (33%)
Dementia (MMSE, Max. 30) [24]
Light (20–30 points)	132 (89%)	120 (83%)	0.6
Moderate (10–19 points)	13 (9%)	23 (16%)
Severe (0–9 points)	2 (2%)	2 (1%)
Functional status^3
Timed up and go [25]
< 20 seconds	60 (40%)	56 (38%)	1.0
20–30 seconds	20 (14%)	20 (14%)
> 30 seconds	14 (9%)	13 (9%)
Could not carry out	54 (36%)	56 (38%)
Barthel Index [26]
Insignificant reduction (80–100 points)	115 (78%)	115 (79%)	1.0
Light reduction (79–50 points)	24 (16%)	22 (15%)
Moderate reduction (49–26 points)	7 (5%)	6 (4%)
Severe reduction (25–0 points)	2 (1%)	2 (1%)
Diagnosis
Cardiovascular	45 (30%)	28 (19%)	0.02
Other	103 (70%)	117 (81%)

Notes: ¹Chi-squared test; ²Wilcoxon rank-sum test on non-grouped data; ³activities of daily living (ADL) measures developed by Avlund [27] were used and showed no differences. Data not shown.

Figure 3. Time to first readmission to hospital for any reason (Kaplan–Meyer).

Table II. Follow-up on plan, medication, and health economic data.

Variable	Intervention	Control	p-value^3
Follow-up on plan and medication 12 weeks after discharge	(n = 148)	(n = 145)
GPs’ knowledge regarding the actual medication (prescription)
Patient taking medication that the GP does not know about	51(34%)	70(48%)	0.02
GP reporting medication that patients do not take	42(28%)	57(39%)	0.05
Follow-up on the discharge plan^1
Planned clinical control was completed as recommended	41(95%)	21(72%)	0.02
Planned para-clinical control was completed as recommended	38(88%)	21(68%)	0.09
Number of drugs taken – median (interquartile range)	7(5–10)	6(4–8)	0.0005^4
Number of patients with adjusted medication since discharge^2	84(59%)	63(44%)	0.01
Healthcare costs per patient after 26 weeks (€)	(n = 166)	(n = 165)	Extra cost in intervention group
Cost of intervention at hospital	7	0	7
Cost of GP's 1st home visit^5	102	0	102
Costs of district nurses at first home visit	35	0	35
Total hospital costs	4.414	5.478	-1.064
Other cost in the primary sector (public health insurance)	856	667	190
Costs of medicine	208	146	62
Total	5.622	6.290	−668
			(95% CI € −2.334 to +916 )

Notes: ¹Clinical control was recommended at 45 vs. 36 patients (I vs. C), para-clinical control was recommended at 51 vs. 33 patients. ²Five intervention patients and two control patients had missing values. ³Chi-squared test. ⁴Wilcoxon rank-sum test on non-grouped data. ⁵First visit. Other GP costs from the intervention are included in costs of public health insurance.

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