Background
Method
Design and study setting
Study participants
Procedure
Instruments
Ethical issues
Data analysis
Results
Demographic characteristics
Characteristics | |
---|---|
Age in years, mean (SD) | 82.5 (± 6.8) |
Woman, n (%) | 59 (49%) |
Cohabiting with family or others, n (%) | 62 (51%) |
Co-morbidities | n (%) |
Hypertension | 76 (63%) |
MI / ischemic heart disease | 62 (51%) |
Atrial fibrillation | 59 (49%) |
Diabetes without complications | 26 (22%) |
Stroke | 24 (20%) |
COPD | 20 (17%) |
Renal failure | 18 (15%) |
Malignancy | 16 (13%) |
Other | 14 (12%) |
Period of time since diagnosed | n (%) |
< 1 year | 44 (36%) |
1–5 years | 33 (27%) |
> 5 years | 38 (31%) |
Pharmacological treatment at discharge | n (%) |
ACEI/ARB | 91 (75%) |
MRA | 34 (28%) |
Beta-blocker | 100 (83%) |
Total number of medication at discharge mean (SD) | 11.58 (± 4.37) |
Symptoms | n (%) |
---|---|
Breathlessness | 77 (64%) |
Fatigue | 44 (36%) |
Chest pain | 38 (31%) |
Leg edema | 35 (29%) |
Orthopnea | 30 (25%) |
Cough | 20 (17%) |
Weight gain | 13 (11%) |
Dizziness | 12 (10%) |
Nausea | 10 (8%) |
Palpation | 7 (6%) |
Pulmonary edema | 7 (6%) |
Abdominal edema | 2 (2%) |
Health care and community care utilization prior to the index hospital admission
Assistance at home prior index hospitalization | n (%) |
Community care prior hospitalization | 43 (35%) |
Home health care prior hospitalization | 22 (18%) |
Mobile home care team prior hospitalization | 5 (4%) |
Assistance at home after index hospitalization | n (%) |
Community care after hospitalization | 56 (46%) |
Home health after hospitalization | 29 (24%) |
Mobile home care team after hospitalization | 22 (18%) |
Health care facility visits 30 days prior to index hospitalization | n (%) |
No prior visits to health care facility | 62 (52%) |
Primary care | 34 (29%) |
Hospitalized | 16 (13%) |
ER (without being admitted) | 8 (7%) |
Internal medicine outpatient clinic | 3 (3%) |
Health care facility visits 30 days after index hospitalization | n (%) |
Primary care | 27 (22%) |
Rehospitalized | 28 (23%) |
ER (without being admitted) | 19 (16%) |
Internal medicine outpatient clinic | 18 (15%) |
Prior MI, rho (p) | 0.275 | (0.003) |
Chest pain, rho (p) | 0.214 | (0.020) |
Pulmonary edema, rho (p) | 0.206 | (0.025) |
Total number of symptoms, rho (p) | - 0.199 | (0.031) |
Fatigue, rho (p) | - 0.203 | (0.027) |
Leg edema, rho (p) | −0.204 | (0.026) |
Continuity of care
Symptoms | n (%) |
---|---|
Fatigue | 38 (31%) |
Shortness of breath | 15 (12%) |
Dizzy | 7 (6%) |
Lack of appetite | 5 (4%) |
Concerns | n (%) |
Concerns regarding the medications | 13 (11%) |
Not enough community care after discharge | 5 (4%) |
The need of assistive equipment not met | 4 (3%) |
Not enough home health care after discharge | 1 (1%) |
Overburdened relative | 1 (1%) |
Readmissions and health care utilization after discharge
Discussion and conclusion
Discussion
Follow-up in primary care
Problems after discharge
Study limitations
Recommendations to overcome flaws in the continuity of care:
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Ensure that patient has understood the discharge information correctly.
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Discharge information should include contact information of an appropriate health care provider
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Ensure that discharge information or referral is available in primary care immediately after discharge
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Continuity of care should be a prioritized area of improvement work