Patient-Centered Care Transitions After Injury Hospitalization: A Comparative Effectiveness Trial

Abstract

Objective: The investigation aimed to compare two approaches to the delivery of care for hospitalized injury survivors, a patient-centered care transition intervention versus enhanced usual care. Method: This pragmatic comparative effectiveness trial randomized 171 acutely injured trauma survivors with three or more early postinjury concerns and high levels of emotional distress to intervention (I; n = 85) and enhanced usual care control (C; n = 86) conditions. The care transition intervention components included care management that elicited and targeted improvement in patients’ postinjury concerns, 24/7 study team cell phone accessibility, and stepped-up care. Posttraumatic concerns, symptomatic distress, functional status, and statewide emergency department (ED) service utilization were assessed at baseline and over the course of the 12 months after injury. Regression analyses assessed intervention and control group outcome differences over time. Results: Over 80% patient follow-up was attained at each time point. Intervention patients demonstrated clinically and statistically significant reductions in the percentage of any severe postinjury concerns expressed when compared to controls longitudinally (Wald chi-square = 11.29, p = 0.01) and at the six-month study time point (C = 74%, I = 53%; Fisher’s exact test, p = 0.02). Comparisons of ED utilization data yielded clinically significant cross-sectional differences (one or more three- to six-month ED visits; C = 30.2%, I = 16.5%, [relative risk (95% confidence interval] C versus I = 2.00 (1.09, 3.70), p = 0.03) that did not achieve longitudinal statistical significance (F (3, 507) = 2.24, p = 0.08). The intervention did not significantly impact symptomatic or functional outcomes. Conclusions: Orchestrated investigative and policy efforts should continue to evaluate patient-centered care transition interventions to inform American College of Surgeons’ clinical guidelines for U.S. trauma care systems.

Funding

This work was (partially) supported through a Patient-Centered Outcomes Research Institute (PCORI) Award (IH-1304-6319)

DISCLAIMER

All statements in this report, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors or Methodology Committee.

Additional information

Funding

This investigation was supported by PCORI contract IH-1304-6319.

Notes on contributors

Douglas Zatzick

Douglas Zatzick, MD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Joan Russo, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Peter Thomas, JD, is affiliated with the American Trauma Society, Falls Church. Doyanne Darnell, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Harry Teter, JD, is affiliated with the American Trauma Society, Falls Church. Leah Ingraham, BS, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Lauren K. Whiteside, MS, MD, is affiliated with the Division of Emergency Medicine, University of Washington School of Medicine, Seattle. Jin Wang, MS, PhD, is affiliated with the Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Roxanne Guiney, BA, Lea Parker, BA, Kirsten Sandgren, MSW, and Margot Kelly Hedrick are affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Erik G. Van Eaton, MD, is affiliated with the Department of Surgery, University of Washington School of Medicine, Seattle. Gregory Jurkovich, MD, is affiliated with the Department of Surgery, University of California Davis School of Medicine.

Joan Russo

Douglas Zatzick, MD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Joan Russo, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Peter Thomas, JD, is affiliated with the American Trauma Society, Falls Church. Doyanne Darnell, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Harry Teter, JD, is affiliated with the American Trauma Society, Falls Church. Leah Ingraham, BS, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Lauren K. Whiteside, MS, MD, is affiliated with the Division of Emergency Medicine, University of Washington School of Medicine, Seattle. Jin Wang, MS, PhD, is affiliated with the Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Roxanne Guiney, BA, Lea Parker, BA, Kirsten Sandgren, MSW, and Margot Kelly Hedrick are affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Erik G. Van Eaton, MD, is affiliated with the Department of Surgery, University of Washington School of Medicine, Seattle. Gregory Jurkovich, MD, is affiliated with the Department of Surgery, University of California Davis School of Medicine.

Peter Thomas

Douglas Zatzick, MD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Joan Russo, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Peter Thomas, JD, is affiliated with the American Trauma Society, Falls Church. Doyanne Darnell, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Harry Teter, JD, is affiliated with the American Trauma Society, Falls Church. Leah Ingraham, BS, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Lauren K. Whiteside, MS, MD, is affiliated with the Division of Emergency Medicine, University of Washington School of Medicine, Seattle. Jin Wang, MS, PhD, is affiliated with the Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Roxanne Guiney, BA, Lea Parker, BA, Kirsten Sandgren, MSW, and Margot Kelly Hedrick are affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Erik G. Van Eaton, MD, is affiliated with the Department of Surgery, University of Washington School of Medicine, Seattle. Gregory Jurkovich, MD, is affiliated with the Department of Surgery, University of California Davis School of Medicine.

Doyanne Darnell

Douglas Zatzick, MD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Joan Russo, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Peter Thomas, JD, is affiliated with the American Trauma Society, Falls Church. Doyanne Darnell, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Harry Teter, JD, is affiliated with the American Trauma Society, Falls Church. Leah Ingraham, BS, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Lauren K. Whiteside, MS, MD, is affiliated with the Division of Emergency Medicine, University of Washington School of Medicine, Seattle. Jin Wang, MS, PhD, is affiliated with the Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Roxanne Guiney, BA, Lea Parker, BA, Kirsten Sandgren, MSW, and Margot Kelly Hedrick are affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Erik G. Van Eaton, MD, is affiliated with the Department of Surgery, University of Washington School of Medicine, Seattle. Gregory Jurkovich, MD, is affiliated with the Department of Surgery, University of California Davis School of Medicine.

Harry Teter

Douglas Zatzick, MD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Joan Russo, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Peter Thomas, JD, is affiliated with the American Trauma Society, Falls Church. Doyanne Darnell, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Harry Teter, JD, is affiliated with the American Trauma Society, Falls Church. Leah Ingraham, BS, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Lauren K. Whiteside, MS, MD, is affiliated with the Division of Emergency Medicine, University of Washington School of Medicine, Seattle. Jin Wang, MS, PhD, is affiliated with the Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Roxanne Guiney, BA, Lea Parker, BA, Kirsten Sandgren, MSW, and Margot Kelly Hedrick are affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Erik G. Van Eaton, MD, is affiliated with the Department of Surgery, University of Washington School of Medicine, Seattle. Gregory Jurkovich, MD, is affiliated with the Department of Surgery, University of California Davis School of Medicine.

Leah Ingraham

Douglas Zatzick, MD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Joan Russo, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Peter Thomas, JD, is affiliated with the American Trauma Society, Falls Church. Doyanne Darnell, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Harry Teter, JD, is affiliated with the American Trauma Society, Falls Church. Leah Ingraham, BS, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Lauren K. Whiteside, MS, MD, is affiliated with the Division of Emergency Medicine, University of Washington School of Medicine, Seattle. Jin Wang, MS, PhD, is affiliated with the Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Roxanne Guiney, BA, Lea Parker, BA, Kirsten Sandgren, MSW, and Margot Kelly Hedrick are affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Erik G. Van Eaton, MD, is affiliated with the Department of Surgery, University of Washington School of Medicine, Seattle. Gregory Jurkovich, MD, is affiliated with the Department of Surgery, University of California Davis School of Medicine.

Lauren K. Whiteside

Douglas Zatzick, MD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Joan Russo, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Peter Thomas, JD, is affiliated with the American Trauma Society, Falls Church. Doyanne Darnell, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Harry Teter, JD, is affiliated with the American Trauma Society, Falls Church. Leah Ingraham, BS, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Lauren K. Whiteside, MS, MD, is affiliated with the Division of Emergency Medicine, University of Washington School of Medicine, Seattle. Jin Wang, MS, PhD, is affiliated with the Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Roxanne Guiney, BA, Lea Parker, BA, Kirsten Sandgren, MSW, and Margot Kelly Hedrick are affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Erik G. Van Eaton, MD, is affiliated with the Department of Surgery, University of Washington School of Medicine, Seattle. Gregory Jurkovich, MD, is affiliated with the Department of Surgery, University of California Davis School of Medicine.

Jin Wang

Douglas Zatzick, MD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Joan Russo, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Peter Thomas, JD, is affiliated with the American Trauma Society, Falls Church. Doyanne Darnell, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Harry Teter, JD, is affiliated with the American Trauma Society, Falls Church. Leah Ingraham, BS, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Lauren K. Whiteside, MS, MD, is affiliated with the Division of Emergency Medicine, University of Washington School of Medicine, Seattle. Jin Wang, MS, PhD, is affiliated with the Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Roxanne Guiney, BA, Lea Parker, BA, Kirsten Sandgren, MSW, and Margot Kelly Hedrick are affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Erik G. Van Eaton, MD, is affiliated with the Department of Surgery, University of Washington School of Medicine, Seattle. Gregory Jurkovich, MD, is affiliated with the Department of Surgery, University of California Davis School of Medicine.

Roxanne Guiney

Douglas Zatzick, MD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Joan Russo, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Peter Thomas, JD, is affiliated with the American Trauma Society, Falls Church. Doyanne Darnell, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Harry Teter, JD, is affiliated with the American Trauma Society, Falls Church. Leah Ingraham, BS, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Lauren K. Whiteside, MS, MD, is affiliated with the Division of Emergency Medicine, University of Washington School of Medicine, Seattle. Jin Wang, MS, PhD, is affiliated with the Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Roxanne Guiney, BA, Lea Parker, BA, Kirsten Sandgren, MSW, and Margot Kelly Hedrick are affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Erik G. Van Eaton, MD, is affiliated with the Department of Surgery, University of Washington School of Medicine, Seattle. Gregory Jurkovich, MD, is affiliated with the Department of Surgery, University of California Davis School of Medicine.

Lea Parker

Douglas Zatzick, MD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Joan Russo, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Peter Thomas, JD, is affiliated with the American Trauma Society, Falls Church. Doyanne Darnell, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Harry Teter, JD, is affiliated with the American Trauma Society, Falls Church. Leah Ingraham, BS, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Lauren K. Whiteside, MS, MD, is affiliated with the Division of Emergency Medicine, University of Washington School of Medicine, Seattle. Jin Wang, MS, PhD, is affiliated with the Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Roxanne Guiney, BA, Lea Parker, BA, Kirsten Sandgren, MSW, and Margot Kelly Hedrick are affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Erik G. Van Eaton, MD, is affiliated with the Department of Surgery, University of Washington School of Medicine, Seattle. Gregory Jurkovich, MD, is affiliated with the Department of Surgery, University of California Davis School of Medicine.

Kirsten Sandgren

Douglas Zatzick, MD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Joan Russo, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Peter Thomas, JD, is affiliated with the American Trauma Society, Falls Church. Doyanne Darnell, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Harry Teter, JD, is affiliated with the American Trauma Society, Falls Church. Leah Ingraham, BS, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Lauren K. Whiteside, MS, MD, is affiliated with the Division of Emergency Medicine, University of Washington School of Medicine, Seattle. Jin Wang, MS, PhD, is affiliated with the Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Roxanne Guiney, BA, Lea Parker, BA, Kirsten Sandgren, MSW, and Margot Kelly Hedrick are affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Erik G. Van Eaton, MD, is affiliated with the Department of Surgery, University of Washington School of Medicine, Seattle. Gregory Jurkovich, MD, is affiliated with the Department of Surgery, University of California Davis School of Medicine.

Margot Kelly Hedrick

Douglas Zatzick, MD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Joan Russo, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Peter Thomas, JD, is affiliated with the American Trauma Society, Falls Church. Doyanne Darnell, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Harry Teter, JD, is affiliated with the American Trauma Society, Falls Church. Leah Ingraham, BS, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Lauren K. Whiteside, MS, MD, is affiliated with the Division of Emergency Medicine, University of Washington School of Medicine, Seattle. Jin Wang, MS, PhD, is affiliated with the Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Roxanne Guiney, BA, Lea Parker, BA, Kirsten Sandgren, MSW, and Margot Kelly Hedrick are affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Erik G. Van Eaton, MD, is affiliated with the Department of Surgery, University of Washington School of Medicine, Seattle. Gregory Jurkovich, MD, is affiliated with the Department of Surgery, University of California Davis School of Medicine.

Erik G. Van Eaton

Douglas Zatzick, MD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Joan Russo, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Peter Thomas, JD, is affiliated with the American Trauma Society, Falls Church. Doyanne Darnell, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Harry Teter, JD, is affiliated with the American Trauma Society, Falls Church. Leah Ingraham, BS, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Lauren K. Whiteside, MS, MD, is affiliated with the Division of Emergency Medicine, University of Washington School of Medicine, Seattle. Jin Wang, MS, PhD, is affiliated with the Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Roxanne Guiney, BA, Lea Parker, BA, Kirsten Sandgren, MSW, and Margot Kelly Hedrick are affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Erik G. Van Eaton, MD, is affiliated with the Department of Surgery, University of Washington School of Medicine, Seattle. Gregory Jurkovich, MD, is affiliated with the Department of Surgery, University of California Davis School of Medicine.

Gregory Jurkovich

Douglas Zatzick, MD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Joan Russo, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Peter Thomas, JD, is affiliated with the American Trauma Society, Falls Church. Doyanne Darnell, PhD, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Harry Teter, JD, is affiliated with the American Trauma Society, Falls Church. Leah Ingraham, BS, is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Lauren K. Whiteside, MS, MD, is affiliated with the Division of Emergency Medicine, University of Washington School of Medicine, Seattle. Jin Wang, MS, PhD, is affiliated with the Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle. Roxanne Guiney, BA, Lea Parker, BA, Kirsten Sandgren, MSW, and Margot Kelly Hedrick are affiliated with the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle. Erik G. Van Eaton, MD, is affiliated with the Department of Surgery, University of Washington School of Medicine, Seattle. Gregory Jurkovich, MD, is affiliated with the Department of Surgery, University of California Davis School of Medicine.