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Biomedical subjects

Carl van Walraven

Publications and source records attributed to Carl van Walraven.

At least 19 recordsLinked to original sources
PubMed2006

Effect of provider continuity on test repetition.

BACKGROUND: Provider continuity (PC) occurs when a patient is treated by the same physician over time. A perceived benefit of PC is decreased test repetition. Repeat tests make up a significant proportion of overall laboratory utilization. This study determined whether test repetition increases when PC decreases. METHODS: Cohort study of adults in eastern Ontario, Canada between September 1999 and September 2000 using population-based clinical databases. The primary study outcome was the probability that 7 common laboratory tests (hemoglobin, sodium, creatinine, thyrotropin, total cholesterol, ferritin, and hemoglobin A1C) were repeated at physician visits subsequent to the index test. We determined whether the probability of test repetition changed if the follow-up physician ordered the index test. We adjusted for multiple factors regarding the patient (age, sex, days in hospital, and number of physician visits in previous year), index test (normality and location), follow-up visit (location and time from index test), and follow-up physician (age and specialty). RESULTS: The study included 881,353 patients, 1,419,438 index laboratory tests, and 7,622,938 follow-up physician visits. After adjusting for other important factors, we found that tests were significantly more likely to be repeated if the follow-up physician ordered the index test (adjusted odds ratio range 2.5-5.9). This association was consistent in most subgroups. CONCLUSIONS: For these common laboratory investigations, PC was associated with increased, not decreased, test repetition. This suggests that increased PC alone will likely not decrease test utilization.

Adult↗
PubMed2006

The effect of hospitalization on oral anticoagulation control: a population-based study.

BACKGROUND: For patients taking oral anticoagulants (OAC), the proportion of time spent in the therapeutic range is strongly associated with bleeding and thromboembolic risk. Previous studies examining OAC control may not generalize because the patient population was select or INR capture was incomplete. OBJECTIVES: Measure OAC control for an entire population of elderly people and determine patient factors associated with OAC control. PATIENTS: People in Eastern Ontario without valve replacement aged 65 years or greater who were treated with warfarin between 1 September 1999 and 1 September 2000. DESIGN: Retrospective cohort study using population-based administrative databases. OAC control was measured as the proportion of days in therapeutic range (PDTR), defined as the number days with the INR between 2 and 3 divided by total number of days observation. Linear interpolation was used to determine INR levels between measures. Negative binomial regression was used to identify patient factors independently associated with PDTR. We also determined which factors were associated with proportion of days with a critically low (<1.5) or critically high (>/=5) INR. RESULTS: 7179 people were followed for a total of 3238 years. 15% of people were hospitalized during the study. Overall, PDTR was 59.2% (95% CI 59.1%-59.2%). Independent of all other significant factors, hospitalization was associated with a 15% decrease in the PDTR 15% (rate ratio 0.85, 95% CI 0.83-0.87). Hospitalization was also independently associated with greater proportion of time with a critically low INR (rate ratio 1.68, 95% CI 1.51-1.88) and a critically high INR (1.70, 95% CI 1.38-2.08). CONCLUSIONS: Elderly people in eastern Ontario taking warfarin were therapeutic 59.2% of the time. Independent of other patient factors, patients who are hospitalized have the greatest risk of poor anticoagulation control. Control for anticoagulated patients who get hospitalized should be reviewed to determine if and how it could be improved.

Aged↗
PubMed2006

Adverse events detected by clinical surveillance on an obstetric service.

OBJECTIVE: Adverse events are adverse patient outcomes resulting from medical care. We performed this study to estimate the rate of adverse events and potential adverse events-errors that have a high likelihood of causing patient harm-occurring during obstetric care. METHODS: This was a prospective cohort study of an obstetric unit in a teaching hospital. We included patients admitted consecutively to the hospital. A trained observer monitored patients for 72 triggers, which were predefined occurrences deemed likely to indicate an actual or potential adverse event. When a trigger occurred, the observer captured information describing it. A five-person multidisciplinary team, including the observer, three physicians, and a hospital risk manager, judged whether the trigger represented an adverse event or potential adverse event. Adverse events were further characterized as preventable. RESULTS: The cohort included 425 patients; 47% were in active labor. We identified 110 triggers. Nine were considered adverse events (risk 2%, 95% confidence interval [CI] 1-4%, rate 0.8 events per 100 patient days), and six were preventable (risk 1%, 95% CI 0-3%, rate 0.5 events per 100 patient days). The remaining triggers included 14 potential adverse events (risk 3%, 95% CI 2-5%, rate 1.3 events per 100 patient days). No adverse event resulted in permanent disability or death. Adverse events and potential adverse events were most commonly "system" problems, such as unavailable staff or operating rooms, or poor fetal outcomes, such as trauma to the newborn. CONCLUSION: Serious adverse events occur infrequently on an obstetric service. However, important quality problems are common and should be targeted for improvement. LEVEL OF EVIDENCE: II-2.

Adult↗
PubMed2006

Quantifying the impact of survivor treatment bias in observational studies.

RATIONALE: Observational cohort studies are frequently used to measure the impact of therapies on the time to a particular outcome. Treatment often has a time-variant nature since it is frequently initiated at varying times during a patient's follow-up. Studies in the medical literature frequently ignore the time-dependent nature of treatment exposure. Survivor treatment bias can arise when the time dependent nature of treatment exposure is ignored since patients who survived to receive treatment may be healthier than patients who died prior to receipt of treatment. AIMS AND OBJECTIVES: The objective of the current study was to explicitly quantify the magnitude of survivor-treatment bias. METHODS: Monte Carlo simulations using parameters obtained from an analysis of patients admitted to hospital with a diagnosis of acute myocardial infarction in Ontario, Canada. RESULTS AND CONCLUSIONS: When the true treatment was null (hazard ratio of 1), estimated treatment effects varied from a 4% reduction in mortality to a reduction in mortality of 27% when the time varying nature of the treatment was ignored. Furthermore, survivor-treatment bias increased as the time required foe exposed patients to receive treatment increased. Similarly, survivor treatment bias was amplified as exposure was defined to be exposure at any time prior to mortality compared to exposure within a fixed time interval starting at the time origin. Ignoring the time-dependent nature of treatment results in overly optimistic estimates of treatment effects. Depending on the period required for patients to initiate therapy, treatments with no effect on survival can appear to be strongly associated with improved survival. The current study is the first to explicitly quantify the magnitude of bias that results from ignoring the time-varying nature of treatment exposure in survival studies.

Adrenergic beta-Antagonists↗
PubMed2006

Effect of study setting on anticoagulation control: a systematic review and metaregression.

BACKGROUND: For patients receiving therapy with oral anticoagulants (OACs), the proportion of time spent in the therapeutic range (ie, anticoagulation control) is strongly associated with bleeding and thromboembolic risk. The effect of study-level factors, especially study setting, on anticoagulation control is unknown. OBJECTIVES: Describe anticoagulation control achieved in the published literature. We also used metaregressive techniques to determine which study-level factors significantly influenced anticoagulation control. STUDIES: All published randomized or cohort studies that measured international normalized ratios (INRs) serially in anticoagulated patients and reported the proportion of time between INRs ranging from 1.8 to 2.0 and 3.0 to 3.5. RESULTS: We identified 67 studies with 123 patient groups having 50,208 patients followed for a total of 57,154.7 patient-years. A total of 68.3% of groups were from anticoagulation clinics, 7.3% were from clinical trials, and 24.4% were from community practices. Overall, patients were therapeutic 63.6% of time (95% confidence interval [CI], 61.6 to 65.6). In the metaregression model, study setting had the greatest effect on anticoagulation control with studies in community practices having significantly lower control than either anticoagulation clinics or clinical trials (-12.2%; 95% CI, -19.5 to -4.8; p < 0.0001). Self-management was associated with a significant improvement of time spent in the therapeutic range (+7.0%; 95% CI, 0.7 to 13.3; p = 0.03). CONCLUSIONS: Patients who have received anticoagulation therapy spend a significant proportion of their time with an INR out of the therapeutic range. Patients from community practices showed significantly worse anticoagulation control than those from anticoagulation clinics or clinical trials. This should be considered when interpreting the results of, and generalizing from, studies involving OACs.

Anticoagulants↗
PubMed2005

Identifying individuals with a reduced GFR using ambulatory laboratory database surveillance.

The use of outpatient laboratory databases to identify people with a low GFR may be part of an effective strategy to increase their use of treatments to prevent kidney failure. All renal function data from 17 independent outpatient laboratories in Eastern Ontario were combined to determine the proportion of adults with at least one serum creatinine measurement during a 1-yr period. The detection rates of low GFR were measured using different algorithms, and what proportion of identified low GFR was transient was considered. Canadian census data were used to calculate rates and proportions. Renal function testing was common. Of the 1,090,000 adult residents, 32% of the entire population and 63% of seniors had at least one serum creatinine measured during the study year. Sixteen percent of the population (49% of those with tests performed) had at least one GFR <80 ml/min per 1.73 m2, 5% (16%) had at least one GFR <60 ml/min per 1.73 m2, and 0.6% (1.7%) had at least one GFR <30 ml/min per 1.73 m2. Low GFR were usually not transient: 68% of individuals with subsequent testing at least 30 d later had a similar or worse GFR. Ambulatory laboratory database case finding, particularly in older patients, seems to be a promising method for easily identifying large segments of the population with persistent reductions in GFR. Whether such identification leads to improved health outcomes warrants further study.

Algorithms↗
PubMed2005

Impact of specialist follow-up in outpatients with congestive heart failure.

BACKGROUND: There is uncertainty about whether physician specialty influences the outcomes of outpatients with congestive heart failure after adjustment for differences in case mix. Our objective was to determine the impact of physician specialty on outcomes in outpatients with new-onset congestive heart failure. METHODS: The study was a population-based retrospective cohort study involving patients with new-onset congestive heart failure discharged from 128 acute care hospitals in Alberta between Apr. 1, 1998, and July 1, 2000. Outcomes were resource utilization (clinic visits, emergency department visits and hospital admissions) and survival at 30 days and 1 year. RESULTS: A total of 3136 patients were discharged from hospital with a new diagnosis of congestive heart failure (median age 76 years, 50% men). Of these, 1062 (34%) received no follow-up visits for cardiovascular care, 738 (24%) were seen by a family physician (FP) alone, 29 (1%) by a specialist (cardiologist or general internist) alone and 1307 (42%) by both a specialist and an FP. Compared with patients who received no follow-up cardiovascular care, patients who received regular cardiovascular follow-up visits with a physician had fewer visits to the emergency department (38% v. 80%), fewer were admitted to hospital (13% v. 94%), and the adjusted 1-year mortality was lower (22% v. 37%) (all p < 0.001). Compared with patients who received combined specialist and FP care, patients cared for exclusively by FPs had fewer outpatient visits (median 9 v. 17 in the first year), fewer of these patients presented to the emergency department (24% v. 45% in the first year), and fewer were readmitted for cardiovascular care (7% v. 16%) (all p < 0.001). However, the adjusted mortality at 1 year was lower among patients treated with combined care (17% v. 28%, p < 0.001) despite a higher burden of comorbidities. In a multivariate model adjusting for comorbidities (with no cardiovascular follow-up visits as the reference category), the mortality was lower among patients followed on an outpatient basis by an FP alone (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.53-0.82) or by an FP and a specialist (OR 0.34, 95% CI 0.28-0.42). In a proportional hazards model with time-dependent covariates (with adjustment for frequency of follow-up visits), the risk of all-cause mortality was reduced significantly (hazard ratio 0.98, 95% CI 0.97- 0.99) with each specialist visit compared with FP care alone. INTERPRETATION: Patients with congestive heart failure followed by both specialists and FPs had significantly better survival than those followed by FPs alone (or those who received no specific cardiovascular follow-up care). Methods to improve timely and appropriate access to specialists and to improve collaborative care structures are needed.

Aged↗
PubMed2005

Effect of a nurse team coordinator on outcomes for hospitalized medicine patients.

PURPOSE: Several randomized trials have found that discharge planning improves outcomes for hospitalized patients. We do not know if adding a clinical nurse specialist (CNS) to physician teams in hospitals that already have discharge planning services makes a difference. METHODS: In 2 teaching hospitals, patients were randomly assigned to regular hospital care or care with a clinical nurse specialist. The clinical nurse specialist facilitated hospital care by retrieving preadmission information, arranging in-hospital consultations and investigations, organizing postdischarge follow-up visits, and checking up on patients postdischarge with a telephone call. In-hospital outcomes included mortality and length of stay. Postdischarge outcomes included time to readmission or death, patient satisfaction, and the risk of adverse event. Adverse events were poor outcomes due to medical care rather than the natural history of disease. RESULTS: A total of 620 sequential patients were randomized (CNS n = 307, control n = 313), of which 361 were followed after discharge from hospital (CNS n = 175, control n = 186). The groups were similar for the probability of in-hospital death (CNS 9.3% vs control 9.7%) or being discharged to the community (58.0% vs 60.0%). The groups did not differ for postdischarge outcomes including readmission or death (21.6% vs 15.6%; P = 0.16) or risk of adverse event (23.6% vs 22.8%). Mean [SD] patient ratings of overall quality of care on a scale of 10 was higher in the clinical nurse specialist group (8.2 [2.2] vs 7.6 [2.4]; P = 0.052). CONCLUSION: The addition of a clinical nurse specialist to a medical team improved patient satisfaction but did not impact hospital efficiency or patient safety.

Aged↗
PubMed2005

Diabetic patients with prior specialist care have better glycaemic control than those with prior primary care.

OBJECTIVE: To compare glycaemic control, as reflected in the A1c level, of diabetic patients with primary care vs. with specialist care. METHODS: The study used administrative data from eastern Ontario, Canada, and a database containing the results of all A1c tests from this region between 1 September 1999 and 1 September 2000. To avoid referral bias, diabetic patients with an index specialist visit were selected and separated into those with exclusively primary care previously (n = 974) and those with prior specialist care (n = 3533). We compared A1c levels measured within 30 days of the index visit and hence attributable to the prior care. To control for confounding between the groups, both multiple linear regression and propensity score-based matching were used. RESULTS: After controlling for confounders, patients with prior specialist care had significantly lower A1c levels (P < 0.0001). Other predictors of lower A1c included older age, shorter diabetes duration, rural residence and higher neighbourhood income. In propensity score-matched cohorts, the A1c level was 8.3 +/- 2.0% with prior primary care vs. 7.9 +/- 1.6% with prior specialist care (P < 0.0001). CONCLUSIONS: Specialist care prior to the index visit was associated with a lower A1c level than prior primary care. This difference would result in reductions in diabetes complications for patients with ongoing specialist care.

Aged↗
PubMed2005

Clinical inertia in response to inadequate glycemic control: do specialists differ from primary care physicians?

OBJECTIVE: Diabetic patients with inadequate glycemic control ought to have their management intensified. Failure to do so can be termed "clinical inertia." Because data suggest that specialist care results in better control than primary care, we evaluated whether specialists demonstrated less clinical inertia than primary care physicians. RESEARCH DESIGN AND METHODS: Using administrative data, we studied all non-insulin-requiring diabetic patients in eastern Ontario aged 65 or older who had A1c results >8% between September 1999 and August 2000. Drug intensification was measured by comparing glucose-lowering drug regimens in 4-month blocks before and after the elevated A1c test and was defined as 1) the addition of a new oral drug, 2) a dose increase of an existing oral drug, or 3) the initiation of insulin. Propensity score-based matching was used to control for confounding between groups. RESULTS: There were 591 patients with specialist care and 1,911 with exclusively primary care. In the matched cohorts, 45.1% of patients with specialist care versus 37.4% with primary care had drug intensification (P = 0.009). Most of this difference was attributed to specialists' more frequent initiation of insulin in response to elevated A1c. CONCLUSIONS: Fewer than one-half of patients with high A1c levels had intensification of their medications, regardless of specialty of their physician. Specialists were more aggressive with insulin initiation than primary care physicians, which may contribute to the lower A1c levels seen with specialist care. Interventions assisting patients and physicians to recognize and overcome clinical inertia should improve diabetes care in the population.

Aged↗
PubMed2004

Validation of a discharge summary term search method to detect adverse events.

OBJECTIVE: Adverse events are poor health outcomes caused by medical care. Measuring them is necessary for quality improvements, but current detection methods are inadequate. We performed this study to validate a previously derived method of adverse event detection using term searching in physician-dictated discharge summaries. DESIGN: This was a retrospective, chart review study of a random sample of 245 adult medicine and surgery patients admitted to a multicampus academic medical center in 2002. MEASUREMENTS: The authors used a commercially available search engine to scan discharge summaries for the presence of 104 terms that potentially indicate an adverse event. Summaries with any of these terms were reviewed by a physician to determine the term's context. Screen-positive summaries had a term that was contextually indicative of an adverse event. We used a two-stage chart review as the gold standard to determine the true presence or absence of an adverse event. RESULTS: The average patient age was 62 years (standard deviation 18.6) and 55% were admitted to a medical service. By gold standard criteria, 48 of 245 patients had an adverse event. Term searching classified 27 cases with an adverse event, with 11 true positives; 218 cases were classified as not having an adverse event, with 181 true negatives. The sensitivity, specificity, and positive and negative predictive values were 0.23 (95% confidence interval [CI]=0.11-0.35), 0.92 (95% CI=0.88-0.96), 0.41 (95% CI=0.25-0.59), and 0.83 (95% CI=95% 0.77-0.97), respectively. CONCLUSION: Although the sensitivity of the method is low, its high specificity means that the method could be used to replace expensive manual chart reviews by nurses.

Academic Medical Centers↗
PubMed2004

Selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin.

BACKGROUND: The rate of stroke in atrial fibrillation (AF) depends on the presence of comorbid conditions and the use of antithrombotic therapy. Although adjusted-dose warfarin is superior to aspirin for reducing stroke in AF, the absolute risk reduction of warfarin depends on the stroke rate with aspirin. This prospective cohort study tested the predictive accuracy of 5 stroke risk stratification schemes. METHODS AND RESULTS: The study pooled individual data from 2580 participants with nonvalvular AF who were prescribed aspirin in a multicenter trial (Atrial Fibrillation, Aspirin, Anticoagulation I study [AFASAK-1], AFASAK-2, European Atrial Fibrillation Trial, Primary Prevention of Arterial Thromboembolism in patients with nonrheumatic Atrial Fibrillation in primary care study, and Stroke Prevention and Atrial Fibrillation [SPAF]-III high risk or SPAF-III low risk). There were 207 ischemic strokes during 4887 patient-years of aspirin therapy. All schemes predicted stroke better than chance, but the number of patients categorized as low and high risk varied substantially. AF patients with prior cerebral ischemia were classified as high risk by all 5 schemes and had 10.8 strokes per 100 patient-years. The CHADS(2) scheme (an acronym for Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack) successfully identified primary prevention patients who were at high risk of stroke (5.3 strokes per 100 patient-years). In contrast, patients identified as high risk by other schemes had 3.0 to 4.2 strokes per 100 patient-years. Low-risk patients identified by all schemes had 0.5 to 1.4 strokes per 100 patient-years of therapy. CONCLUSIONS: Patients with AF who have high and low rates of stroke when given aspirin can be reliably identified, allowing selection of antithrombotic prophylaxis to be individualized.

Aged↗
PubMed2004

Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital.

BACKGROUND: Adverse events are poor patient outcomes that are due to medical care. Studies of hospital patients have demonstrated that adverse events are common, but few data describe the timing of them in relation to hospital admission. We evaluated characteristics of adverse events affecting patients admitted to a Canadian teaching hospital, paying particular attention to timing. METHODS: We randomly selected 502 adults admitted to the Ottawa Hospital for acute care of nonpsychiatric illnesses over a 1-year period. Charts were reviewed in 2 stages. If an adverse event was judged to have occurred, a physician determined whether it occurred before or during the index hospitalization. The reviewer also rated the preventability, severity and type of each adverse event. RESULTS: Of the 64 patients with an adverse event (incidence 12.7%, 95% confidence interval [CI] 10.1%-16.0%), 24 had a preventable event (4.8%, 95% CI 3.2%-7.0%), and 3 (0.6%, 95% CI 0.2%-1.7%) died because of an adverse event. Most adverse events were due to drug treatment, operative complications or nosocomial infections. Of the 64 patients, 39 (61%, 95% CI 49%-72%) experienced the adverse event before the index hospitalization. INTERPRETATION: Adverse events were common in this study. However, only one-third were deemed avoidable, and most occurred before the hospitalization. Interventions to improve safety must address ambulatory care as well as hospital-based care.

Adult↗
PubMed2004

Adverse events among medical patients after discharge from hospital.

BACKGROUND: Adverse events (AEs) are adverse outcomes caused by medical care. Several studies have indicated that a substantial number of patients experience AEs before or during hospitalization. However, few data describe AEs after hospital discharge. We determined the incidence, severity, preventability and ameliorability of AEs in patients discharged from the general internal medicine service of a Canadian hospital. METHODS: At a multisite Canadian teaching hospital, we prospectively studied patients who were consecutively discharged home or to a seniors' residence from the general internal medicine service during a 14-week interval in 2002. We used telephone interview and chart review to identify outcomes after discharge. Two physicians independently reviewed each outcome to determine if the patient experienced an AE. The severity, preventability and ameliorability of all AEs were classified. RESULTS: During the study period, outcomes were determined for 328 of the 361 eligible patients, who averaged 71 years of age (interquartile range 54-81 years). After discharge, 76 of the 328 patients experienced at least 1 AE (overall incidence 23%, 95% confidence interval [CI] 19%-28%). The AE severity ranged from symptoms only (68% of the AEs) or symptoms associated with a nonpermanent disability (25%) to permanent disability (3%) or death (3%). The most common AEs were adverse drug events (72%), therapeutic errors (16%) and nosocomial infections (11%). Of the 76 patients, 38 had an AE that was either preventable or ameliorable (overall incidence 12%, 95% CI 9%-16%). INTERPRETATION: Approximately one-quarter of patients in our study had an AE after hospital discharge, and half of the AEs were preventable or ameliorable.

Adverse Drug Reaction Reporting Systems↗
PubMed2004

Time-dependent bias was common in survival analyses published in leading clinical journals.

OBJECTIVE: In survival analysis, "baseline immeasurable" time-dependent factors cannot be recorded at baseline, and change value after patient observation starts. Time-dependent bias can occur if such variables are not analyzed appropriately. This study sought to determine the prevalence of such time-dependent bias in highly-cited medical journals. STUDY DESIGN AND SETTING: We searched Medline databases to identify all observational studies that used a survival analysis in American Journal of Medicine, Annals of Internal Medicine, Archives of Internal Medicine, British Medical Journal, Chest, Circulation, Journal of the American Medical Association, Lancet, and New England Journal of Medicine between 1998 and 2002. Studies with "baseline immeasurable" time-dependent factors were susceptible to time-dependent bias if a time-dependent covariate analysis was not used. RESULTS: Of 682 eligible studies, 127 (18.6%, 95% CI 15.8-21.8%) contained a "baseline immeasurable" time-dependent factor and 52 (7.6% [5.8-9.9%] of all survival analyses/40.9% [32.3-50.0%] of studies with a time-dependent factor) were susceptible to time-dependent bias. In 35 studies (5.1% [3.7-7.1%]/27.6% [20.5-35.9%]), the bias affected a variable highlighted in the study abstract and correction of the bias could have qualitatively changed the study's conclusion in over half of studies. CONCLUSION: In medical journals, time-dependent bias is concerningly common and frequently affects key factors and the study's conclusion.

Bias↗
PubMed2004

Continuity of care and patient outcomes after hospital discharge.

BACKGROUND: Patients are often treated in hospital by physicians other than their regular community doctor. After they are discharged, their care is often returned to their regular community doctor and patients may not see the hospital physician. Transfer of information between physicians can be poor. We determined whether early postdischarge outcomes changed when patients were seen after discharge by physicians who treated them in the hospital. METHODS: This cohort study used population-based administrative databases to follow 938833 adults from Ontario, Canada, after they were discharged alive from a nonelective medical or surgical hospitalization between April 1, 1995, and March 1, 2000. We determined when patients were seen after discharge by physicians who treated them in the hospital, physicians who treated them 3 months prior to admission (community physicians), and specialists. The outcome of interest was 30-day death or nonelective readmission to hospital. RESULTS: Of patients studied, 7.7% died or were readmitted. The adjusted relative risk of death or readmission decreased by 5% (95% confidence interval [CI], 4% to 5%) and 3% (95% CI, 2% to 3%) with each additional visit to a hospital physician rather than a community physician or specialist, respectively. The effect of hospital physician visits was cumulative, with the adjusted risk of 30-day death or nonelective readmission reduced to 7.3%, 7.0%, and 6.7% if patients had 1, 2, or 3 visits, respectively, with a hospital rather than a community physician. The effect was consistent across important subgroups. CONCLUSIONS: Patient outcomes could be improved if their early postdischarge visits were with physicians who treated them in hospital rather than with other physicians. Follow-up visits with a hospital physician, rather than another physician, could be a modifiable factor to improve patient outcomes following discharge from hospital.

Aged↗