Objectives To determine the associations between a care coordination intervention (the Transitions Program) targeted to patients after hospital discharge and 30 day readmission and mortality in a large, integrated healthcare system. Design Observational study. Setting 21 hospitals operated by Kaiser Permanente Northern California. Participants 1 539 285 eligible index hospital admissions corresponding to 739 040 unique patients from June 2010 to December 2018. 411 507 patients were discharged post-implementation of the Transitions Program; 80 424 (19.5%) of these patients were at medium or high predicted risk and were assigned to receive the intervention after discharge. Intervention Patients admitted to hospital were automatically assigned to be followed by the Transitions Program in the 30 days post-discharge if their predicted risk of 30 day readmission or mortality was greater than 25% on the basis of electronic health record data. Main outcome measures Non-elective hospital readmissions and all cause mortality in the 30 days after hospital discharge. Results Difference-in-differences estimates indicated that the intervention was associated with significantly reduced odds of 30 day non-elective readmission (adjusted odds ratio 0.91, 95% confidence interval 0.89 to 0.93; absolute risk reduction 95% confidence interval −2.5%, −3.1% to −2.0%) but not with the odds of 30 day post-discharge mortality (1.00, 0.95 to 1.04). Based on the regression discontinuity estimate, the association with readmission was of similar magnitude (absolute risk reduction −2.7%, −3.2% to −2.2%) among patients at medium risk near the risk threshold used for enrollment. However, the regression discontinuity estimate of the association with post-discharge mortality (−0.7% −1.4% to −0.0%) was significant and suggested benefit in this subgroup of patients. Conclusions In an integrated health system, the implementation of a comprehensive readmissions prevention intervention was associated with a reduction in 30 day readmission rates. Moreover, there was no association with 30 day post-discharge mortality, except among medium risk patients, where some evidence for benefit was found. Altogether, the study provides evidence to suggest the effectiveness of readmission prevention interventions in community settings, but further research might be required to confirm the findings beyond this setting. Data sharing: No additional data available.

中文翻译：

---

评估以预测分析为目标的干预措施，以防止综合卫生系统再入院：观察性研究

目的 确定针对出院后患者的护理协调干预（过渡计划）与大型综合医疗系统中 30 天再入院和死亡率之间的关联。设计观察研究。设置由 Kaiser Permanente Northern California 运营的 21 家医院。从 2010 年 6 月到 2018 年 12 月，参与​​者有 1 539 285 名符合条件的指数入院，对应于 739 040 名独特的患者。411 507 名患者在过渡计划实施后出院；这些患者中有 80 424 名（19.5%）处于中或高预测风险，并被分配在出院后接受干预。干预 如果根据电子健康记录数据，入院的患者在 30 天再入院或死亡的预测风险大于 25%，则自动分配到出院后 30 天接受过渡计划。主要结果测量出院后 30 天内非选择性住院再入院和全因死亡率。结果 差异中的差异估计表明干预与 30 天非选择性再入院的几率显着降低相关（调整后的优势比 0.91，95% 置信区间 0.89 至 0.93；绝对风险降低 95% 置信区间 -2.5%，- 3.1% 至 -2.0%）但与出院后 30 天死亡率的几率无关（1.00，0.95 至 1.04）。基于回归不连续估计，在接近用于入组的风险阈值的中等风险患者中，与再入院的关联程度相似（绝对风险降低 -2.7%，-3.2% 至 -2.2%）。然而，与出院后死亡率（-0.7% -1.4% 至 -0.0%）相关的回归不连续性估计是显着的，表明该亚组患者受益。结论 在综合卫生系统中，实施全面的再入院预防干预与降低 30 天再入院率有关。此外，与出院后 30 天死亡率无关，但在中等风险患者中发现了一些有益的证据。总而言之，该研究提供的证据表明社区环境中预防再入院干预措施的有效性，但可能需要进一步的研究来确认超出此设置的发现。数据共享：没有可用的额外数据。