Observational studyBMJ (Clinical research ed.)2021
Evaluation of an intervention targeted with predictive analytics to prevent readmissions in an integrated health system: observational study.
Observational study in BMJ (Clinical research ed.), 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to trial NCT05765903 (Readmission Risk Score), which is not on this map. Cited by 8 papers, 1 of them a synthesis that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Readmission Risk Score (RecuR Score) Pilot at The University of Maryland Charles Regional Medical Center (UM CRMC)
Who cites it
8 citing papers in PubMed, 1 synthesis or guideline pooled it, 17 citations in OpenAlex.
- Methodological challenges using routine clinical care data for real-world evidence: a rapid review utilizing a systematic literature search and focus group discussion.BMC medical research methodology · 2025Pooled it
- Closing the Equity Gap in Hospital-to-Home Care Transitions with Automated Post-Discharge Calls, Text Messages, and Focused Nursing Outreach.Journal of general internal medicine · 2026Article
- Expanding care coordination in an integrated health system through causal machine learning.NPJ digital medicine · 2025Article
- Prediction of 1 and 2 week nonelective hospitalization and sepsis hospitalization risk in adults.NPJ digital medicine · 2025Article
- Development and validation of a risk prediction model for 30-day readmission in elderly type 2 diabetes patients complicated with heart failure: a multicenter, retrospective study.Frontiers in endocrinology · 2025Article
- Deep learning for cardiovascular management: optimizing pathways and cost control under diagnosis-related group models.Frontiers in artificial intelligence · 2025Review
- Change in healthcare utilisation after surgical treatment: observational study of routinely collected patient data from primary and secondary care.British journal of anaesthesia · 2022Observational
- Prospective evaluation of social risks, physical function, and cognitive function in prediction of non-elective rehospitalization and post-discharge mortality.BMC health services research · 2022Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
6 authors at 3 institutions in 1 country.
Funding
Abstract
objectivesTo 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.
designObservational study.
setting21 hospitals operated by Kaiser Permanente Northern California.
participants1 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.
interventionPatients 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 measuresNon-elective hospital readmissions and all cause mortality in the 30 days after hospital discharge.
resultsDifference-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.
conclusionsIn 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.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.