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Post-Hospitalization PCP Visits Decrease 30-Day Readmission

November 21, 2016

Recent research in JAMA Internal Medicine showed that patients participating in post-hospitalization visits within seven days of hospital discharge had a reduced risk for 30-day readmission compared to patients without post-hospitalization visits.

“While other studies had mixed results regarding the effectiveness of post-hospitalization visits, our study highlights the value of both routine and more tailored POSH visits in ensuring continuity of care once a patient transitions from hospital to home,” Ernest Shen, PhD, lead study author and research scientist biostatistician at Kaiser Permanente Southern California, said in a press release. “Although any primary care clinician outpatient visit appeared to reduce readmission risk compared to no outpatient visit, the POSH visit provides the added benefit of the care team being alerted to, and therefore better prepared to address, patients' post-discharge needs.”

According to the study, a patient’s post-hospitalization visit is determined while the patient is still hospitalized, and the visit focuses on reinforcing treatment plans. Comparatively, a regular primary care clinician outpatient visit may focus on routine care, and not cover recent hospitalizations.

The researchers examined electronic health records (EHR) of more than 71,000 Medicare Advantage patients who were discharged from 14 Kaiser Permanente hospital between January 1, 2011 and December 21, 2014. In order to address potential bias against patients who may have been less sick than others, researched accounted for factors including, the severity of the condition during hospitalization, underlying illnesses, and functional status.

According to the study, researchers found that patients with post-hospitalization visits had a lower risk for 30-day readmissions compared with non-POSH visits (HR = 0.72; 95% CI, 0.66-0.79). For surgical patients, follow-ups had no affect on readmission. However, patients who completed any outpatient visits within seven days had a 12% to 24% lower risk for 30-day readmission.

The researchers noted that because these findings were limited to Medicare Advantage patients discharged from Kaiser Permanente hospitals, the findings may not extrapolate to patients discharged at other higher-level settings or non-Medicare patients.

“Although we do not know what aspect of the visit was helpful in reducing readmissions, our findings highlight the value of post-discharge visits in integrated systems with a comprehensive EHR,” Dr Shen and colleagues wrote.

Julie Mazurkiewicz



Shen E, Koyama SY, Huynh DN, et al. Association of a Dedicated Post–Hospital Discharge Follow-up Visit and 30-Day Readmission Risk in a Medicare Advantage Population [published November 21, 2016]. Jama Intern Med.

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