Large Medicare Data Study Shows Big Benefits with Primary Care Follow-Up
By Melinda Young
New research shows Medicare patients who are hospitalized with a condition that could require emergency general surgery are far less likely to be readmitted if they receive follow-up care with a primary care provider (PCP) within 30 days of discharge.1
“Our group had looked at primary care in emergency general surgery patients, and that led us to believe we’d see some [benefits],” says Adora Moneme, lead study author and an MD/MSHP student at the University of Pennsylvania Perelman School of Medicine. “The results were striking and significant, and it shows the role primary care can play in making sure their meds are correct and addressing their comorbidities. Primary care is really good at that, and it makes sense they’d have reduced the need of readmission.”
Patients who underwent surgery during their hospital admission and followed up with a PCP within 30 days after discharge reported 79% reduced odds of readmission. The patients who did not undergo surgery also reported fewer readmissions if they visited a PCP soon after discharge.
Moneme and colleagues studied data from more than 345,000 Medicare beneficiaries nationwide. The patients’ average age was 74 years. They had been hospitalized with an emergency general surgery condition. Fewer than half (45.4%) followed up with a PCP. Thirty-one percent received surgical treatment, while 68.6% did not.
These conditions did not include trauma cases, such as falls. They were primarily cases of appendicitis, colitis, and diverticulitis, says Rachel Kelz, MD, MSCE, MBA, study co-author and vice chair of clinical research and a physician in the department of surgery at Perelman School of Medicine.
The findings reinforce the tactic of assigning care coordination, nurse navigators, and social workers to care teams, ensuring patients receive safe and effective care.
“In this study, we can’t see those details for patients, but we recognize the need for [support] beyond traditional medical needs,” Kelz adds. “Patients also need social support and [someone to] reiterate educational points of managing a wound.”
Although the study’s findings are dramatic, it is possible some of the patients who visited a PCP within the first 30 days were healthier and savvier patients. That could have contributed to the readmission rate.
Navigators are needed because follow-up can be overlooked in the busy lives of hospital and ambulatory physicians, and patients often need reminders.
“A lot of people don’t have the wherewithal to navigate their own healthcare, especially [among] an older population,” Kelz explains. “[Care coordinators] are the glue of the system, and they make a tremendous difference in helping people navigate the system.”
Also, care coordination is essential in remote parts of the country with few PCPs. “Primary care providers are just so overwhelmed with their clinical responsibilities, so those allied health professionals are so helpful,” Kelz says. “People working in less resourced areas are so overwhelmed.”
Moneme, Kelz, and colleagues focused on Medicare patients because claims data can show patients’ comorbidities, along with primary care and hospital care. It also pertains to a population of older adults who tend to report more readmissions and complications. “That’s why we wanted to focus on this population,” Moneme says.
Researchers compared patients who underwent surgery with those who did not. Some patients with emergency general surgery conditions were treated with antibiotics. Patients in both groups could be rehospitalized within 30 days of discharge, Kelz says.
“Patients are also vulnerable to readmission if they have a recurrence of their acute condition or if they have an exacerbation of a medical problem as a result of underlying illness,” Kelz explains. “They also could have complications of treatment, like wound infection or a blood clot.”
Blood clots do not necessarily mean the patient has to return to the hospital. “Even for blood clots, many primary care physicians are comfortable with initiating treatment, depending on the patient,” Kelz says.
The reason 30-day readmissions tend to be high — 17.5% of the Medicare population studied — is partly due to patients’ underlying health problems.1 “Patients who have surgery have many medical problems before they come into the hospital,” Kelz notes.
For example, a patient could experience abdominal issues and not eat properly. This could cause low blood pressure when they are admitted to the hospital. Physicians may adjust their blood pressure medication to accommodate the acute change in their condition.
“But it can be tricky to know when to restart all the medications, so the primary care physician can help the patient transition back to the home setting and see if the medications need to be adjusted to baseline,” Kelz says.
If the patient does not see a PCP soon after discharge, they may need to be rehospitalized because their chronic conditions are not well managed due to medication differences.
“One of the most important things to highlight is the importance of transitions in care from inpatient hospitalization and under direct monitoring — making sure someone is on top of their recovery — and transitioning back to home,” Moneme says. “That phase is often times where some things are falling through the cracks. Primary care fills in the cracks and makes sure patients continue on their recovery trajectory.”
Comorbid conditions can cause a patient’s overall health to falter, especially after a hospitalization. That is when the PCP can help the patient adjust medications and ensure all their conditions are managed well, Moneme says.
Helping patients meet with PCPs can mitigate unnecessary readmissions to the hospital. Some hospitals will ask case managers or care coordinators to set up a PCP appointment for the patient. Others will ask the care coordination team to talk with patients about scheduling their own appointments within two weeks of discharge.
“Each member of the healthcare team can do their part to educate patients on what might make their recovery the best recovery possible,” Kelz says.
Another good tactic is to make sure patients know everything they need to do when they leave the hospital and to give them a primary form of contact. “Primary care is so important, and patients need access to primary care,” Moneme adds.
If patients live in a remote area and cannot find transportation to a PCP, the care coordination team could help them set up an alternative way to meet with a PCP, such as through telemedicine, Moneme suggests.
“It takes a village to safely get a patient from acute surgical emergency to home and to stay home, which is the ideal state,” Kelz says. “Remember the value of care coordination with the healthcare team and establish that post-discharge visitation prior to the patient leaving the hospital.”
- Moneme AN, Wirtalla CJ, Roberts SE, et al. Primary care physician follow-up and 30-day readmission after emergency general surgery admissions. JAMA Surg 2023:e234534.
New research shows Medicare patients who are hospitalized with a condition that could require emergency general surgery are far less likely to be readmitted if they receive follow-up care with a primary care provider within 30 days of discharge.
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