Reducing Readmission of Hospitalized Patients With Depressive Symptoms: A Randomized Trial

Abstract

Purpose: To determine if hospitalized patients with depressive symptoms will benefit from post-discharge depression treatment with care transition support.

Methods: This is a randomized controlled trial of hospitalized patients with patient health questionnaire-9 score of 10 or more. We delivered the Re-Engineered Discharge (RED) and randomized participants to groups receiving RED-only or RED for Depression (RED-D), a 12-week post-discharge telehealth intervention including cognitive behavioral therapy, self-management support, and patient navigation. Primary outcomes were hospital readmission and reutilization rates at 30 and 90 days post discharge.

Results: We randomized 709 participants (353 RED-D, 356 RED-only). At 90 days, 265 (75%) intervention participants had received at least 1 RED-D session (median 4). At 30 days, the intention-to-treat analysis showed no differences between RED-D vs RED-only in hospital readmission (9% vs 10%, incidence rate ratio [IRR] 0.92 [95% CI, 0.56-1.52]) or reutilization (27% vs 24%, IRR 1.14 [95% CI, 0.85-1.54]). The intention-to-treat analysis also showed no differences at 90 days in readmission (28% vs 21%, IRR 1.30 [95% CI, 0.95-1.78]) or reutilization (70% vs 57%, IRR 1.22 [95% CI, 1.01-1.49]). In the as-treated analysis, each additional RED-D session was associated with a decrease in 30- and 90-day readmissions. At 30 days, among 104 participants receiving 3 or more sessions, there were fewer readmissions (3% vs 10%, IRR 0.30 [95% CI, 0.07-0.84]) compared with the control group. At 90 days, among 109 participants receiving 6 or more sessions, there were fewer readmissions (11% vs 21%, IRR 0.52 [95% CI, 0.27-0.92]). Intention-to-treat analysis showed no differences between study groups on secondary outcomes.

Conclusions: Care transition support and post-discharge depression treatment can reduce unplanned hospital use with sufficient uptake of the RED-D intervention.

Trial registration: ClinicalTrials.gov NCT01840826.

Keywords: depression; hospitalization; patient discharge; telemedicine.

Figure 1.

Study flowchart. CAGE = 4-item screening for alcohol use: cutting down, annoyance by criticism, guilty feeling, and eye-openers; DAST = 10-item drug abuse screening test; PHQ-9 = patient health questionnaire-9; PHQ-2 = patient health questionnaire-2; RED = re-engineered discharge; RED-D = re-engineered discharge for depression. ^a Medical exclusion occurred in phases. Patients admitted for altered mental status, end-of-life care, sickle cell crisis, or substance use were excluded from the pool immediately. Then, potentially eligible patients were excluded if they were going to be discharged to another inpatient facility, pregnant, under suicide precautions, undergoing cancer treatment; admitted to a surgical trauma unit. ^b Other reasons for exclusion included: incarceration; no access to telephone; no primary care clinician; not staying in the area during the study; aged <18 years; enrolled in another discharge planning program. ^c Medical exclusions after consent were for having a serious mental illness diagnosis, self-reported suicidal ideation, and self-reported alcohol or drug abuse (CAGE score >2, DAST score >5).

Figure 2.

Readmission and reutilization rates for intervention patients by the number of counselling sessions completed at 90 days. IRR = incidence rate ratio. Note: Labeled points indicate predicted values from Poisson regression of 90-day readmission and reutilization rates on cumulative dosage of the intervention. Each value represents the readmission or reutilization rate we would expect at that associated dosage, based on regression models.

Figure 3.

Predicted readmission rate at 90 days by type of post-discharge support for intervention participants receiving 6 or more sessions. Note: Predicted values were generated using Poisson regression. ^a Self-management was counselling focused on chronic disease self-management, including diet/nutrition, exercise, managing medications, talking to your doctor, and coping with exacerbations. ^b Patient navigation includes guidance in navigating difficult aspects of the health care system, such as overcoming financial barriers, scheduling appointments, and coordinating transportation services, as well as adherence to the discharge plan and follow-up care. ^c Brief cognitive behavior therapy includes orientation to the thought-feeling connection, transforming negative thoughts, behavior activation, physical symptoms, and stress management and navigating relationships, and homework.