Effectiveness of a chronic care model-based transitional care program for patients with biliary drainage: a randomized controlled trial.

Objectives: Patients undergoing biliary drainage are at high risk of readmission. We evaluated a Chronic Care Model (CCM)-based transitional care program designed to improve post-discharge outcomes. Methods: This prospective, two-center randomized controlled trial assigned 300 patients requiring biliary drainage to an intervention (CCM-based transitional care) or control (usual care) group. Primary outcomes were 90-day hospital readmission and complication rates. Time-to-readmission was analyzed using the Kaplan-Meier method. Secondary outcomes included patient-reported readiness for hospital discharge, self-care behavior, and quality of life. Predictive models, including logistic regression and support vector machine (SVM), were developed to identify risk factors for readmission. Results: The intervention group had significantly lower 90-day readmission rates (16.3% vs. 37.1%; Conclusions: A structured, CCM-based transitional care program effectively reduces readmissions and complications while prolonging community-based stability for patients with biliary drainage. Furthermore, patient-reported metrics integrated into an SVM model accurately predict readmission risk, enabling targeted interventions.