Care Coordination and Hospitalization in Older Adults With or at Risk for Cardiovascular Disease: A Randomized Clinical Trial.

Importance: Patients with or at risk for cardiovascular disease (CVD) often see many ambulatory physicians who may not communicate with each other. Care coordinators can bridge gaps in communication among physicians, but there are too few of them for all patients who might benefit. Objective: To compare the effectiveness of 2 strategies for allocating patients with or at risk for CVD to care coordination. Design, Setting, and Participants: This randomized clinical trial performed randomization and outreach from May 15 to November 30, 2023, and completed follow-up on May 31, 2024, in an accountable care organization in New York, New York. Participants included patients who were 65 years or older, had CVD or at least 1 CVD risk factor, had highly fragmented ambulatory care the previous year (fragmentation score ≥0.85), and had been attributed by Medicare to the accountable care organization. Intervention: Usual care assigned patients to care coordinators after any hospitalization. The intervention moved the time of care coordination earlier, offering care coordination proactively (without respect to hospitalization) to those who reported problems with care coordination on a telephone survey. Main Outcomes and Measures: The primary outcome was emergency department (ED) visits or hospitalizations during follow-up. The main secondary outcome was acceptability of the intervention, followed by appropriateness, fidelity, and efficiency. Results: A total of 400 participants (202 in the intervention group and 198 in the control group) were included in the analysis. The mean (SD) age of participants was 75.8 (7.0) years; 287 (71.8%) were female. Participants had a median of 14 (IQR, 9-22) visits to 8 (IQR, 6-11) physicians during the previous year. In the intervention group, 13 participants of 49 eligible (26.5%) accepted care coordination, compared with 17 of 17 (100%) in the control group. The most common reason for declining care coordination was that participants were coordinating care themselves. There was no difference in ED visits or hospitalizations (0.25 [95% CI, 0.21-0.31] events per 100 person-days alive in the intervention group vs 0.21 [95% CI, 0.17-0.27] events per 100 person-days alive in the control group; P = .29). Conclusions and Relevance: In this randomized clinical trial, proactive outreach for offering care coordination in advance of hospitalization did not result in better outcomes compared with usual care offering posthospitalization coordination. Many participants declined the proactive outreach offer. Trial Registration: ClinicalTrials.gov Identifier: NCT05820295.