Table 1
Eligibility criteria for the post-discharge follow-up program, Region Zealand, 2014. Patients who were not discharged to an intermediate care facility, with at least 3 of the below listed readmission risk factors, who were additionally clinically assessed to be eligible, were referred to the program.
| Suspected cognitive disturbance or problems |
| Substance abuse that influences functional level |
| Psychiatric disease that influences functional level |
| Disadvantaged social network |
| Large loss in ability to carry out the activities of daily living |
| Malnutrition |
| Severe chronic, progressive, somatic or psychiatric disease |
| Six or more prescription drugs |
| High need for coordination of treatment and care |
| Acute hospital contact within the previous 6 month |
| Inconvenient residential facilities |
| Increased municipal services |
| The patient was not in contact with municipal services |
| History of fall |
| Clinical assessment (mandatory) |
Figure 1
Adherence measures related to the post-discharge follow-up program and potential factors affecting adherence.
* Variables not analysed in relation to adherence step 1.
** Variables not analysed in step 2.
Figure 2
Patient flowchart, describing the patient cohort and different levels of analysis.
Table 2
Analysis of adherence step 1; factors related to referral from hospital to municipal setting. The middle columns show results from logistic regression model adjusted for age and gender, and the right hand columns show results of the full logistic regression model (n = 1659 patients).
| Factor | Value | Absolute numbers (%) | Each variable adjusted for age and gender | Full model analysis | ||
|---|---|---|---|---|---|---|
| OR (CI) | P-value | OR (CI) | P-value | |||
| Demographic | ||||||
| Age | 40–64 years | 59 (4) | 0.70 (0.40–1.20) | 0.54 | 0.66 (0.38–1.17) | 0.42 |
| median = 84 years | 65–77 years | 369 (22) | 0.98 (0.75–1.27) | 1.03 (0.79–1.35) | ||
| 78–89 years | 960 (58) | 1 | 1 | |||
| 90–102 years | 271 (16) | 1.08 (0.80–1.45) | 0.87 (0.63–1.20) | |||
| Gender | Male | 676 (41) | 1 | 0.69 | 1 | 0.56 |
| Female | 983 (59) | 0.96 (0.77–1.19) | 0.93 (0.73–1.18) | |||
| Social | ||||||
| Education | Higher education | 190 (12) | 1 | 0.90 | 1 | 0.71 |
| Vocational education | 474 (29) | 0.92 (0.64–1.33) | 0.87 (0.59–1.27) | |||
| Primary school | 889 (54) | 0.96 (0.68–1.35) | 0.87 (0.61–1.23) | |||
| Missing: 106 (6) | ||||||
| Children living close by | No | 633 (42) | 1 | 0.79 | 1 | 0.87 |
| Yes | 884 (58) | 1.03 (0.83–1.28) | 1.02 (0.82–1.28) | |||
| Missing: 2 (0) | ||||||
| Spouse with or without comorbidity | Spouse with CCI* of 0–1 | 408 (25) | 1 | 0.57 | 1 | 0.69 |
| Spouse with CCI* of 2+ | 150 (9) | 0.96 (0.65–1.44) | 0.92 (0.61–1.39) | |||
| No spouse | 1101 (66) | 1.12 (0.86–1.46) | 1.08 (0.82–1.42) | |||
| Organisational | ||||||
| Hospital | Hospital 1 (south-west) | 110 (7) | 0.42 (0.25–0.72) | <0.0001 | 0.43 (0.25–0.74) | <0.0001 |
| Hospital 5 (north-east) | 117 (7) | 0.54 (0.32–0.91) | 0.60 (0.35–1.05) | |||
| Hospital 6 (mid-east) | 326 (20) | 0.61 (0.39–0.95) | 0.68 (0.43–1.07) | |||
| Hospital 3 (south) | 122 (7) | 1 | 1 | |||
| Hospital 2 (north-west) | 326 (20) | 1.46 (0.92–2.31) | 1.57 (0.97–2.52) | |||
| Hospital 4 (mid-west) | 658 (40) | 1.50 (0.98–2.29) | 1.58 (1.02–2.45) | |||
| Received municipal homecare prior to admission? | No | 770 (46) | 1 | 0.0002 | 1 | 0.01 |
| Yes | 889 (54) | 1.50 (1.21–1.86) | 1.37 (1.10–1.70) | |||
| Health related | ||||||
| Main diagnosis | Other diagnosis | 1199 (72) | 1 | 0.04 | 1 | 0.13 |
| Atypical symptoms | 460 (28) | 1.28 (1.01–1.62) | 1.22 (0.95–1.53) | |||
| Charlson comorbidity index score | 0–1 | 663 (40) | 1 | 0.16 | 1 | 0.08 |
| 2–3 | 591 (36) | 1.18 (0.92–1.51) | 1.19 (0.92–1.54) | |||
| 4+ | 405 (24) | 0.91 (0.70–1.19) | 0.86 (0.64–1.56) | |||
| Previous hospitalization within 3-month period | No | 813 (49) | 1 | 0.40 | 1 | 0.72 |
| Yes | 846 (51) | 0.91 (0.74–1.13) | 0.96 (0.74–1.20) | |||
| Polypharmacy | No | 528 (32) | 1 | 0.61 | 1 | 0.68 |
| Yes | 1131 (68) | 1.06 (0.85–1.32) | 1.05 (0.83–0.83) | |||
[i] * CCI = Charlson Comorbidity Index Score.
Figure 3
Organisational factors. In the top; adjusted odds ratio plots with 95% confidence intervals for successful referral from hospital to municipality (step 1, full model) stratified by hospitals and for receiving post-discharge follow-up visits. Below; adjusted odds ratio plots with 95% confidence intervals for successfully completed post-discharge follow-up visits (step 2, full model) stratified by municipality. Note that municipality no. 372 is not represented in this figure due to the low number of observations (6 observations) and very broad 95% confidence interval.
Table 3
Analysis of adherence, step 2; factors related to odds of receiving post-discharge follow-up visits. The middle columns display results from logistic regression model adjusted for age and gender, and the right-hand columns show results of the full logistic regression model (n = 956 patients).
| Factor | Value | Absolute numbers (%) | Each variable adjusted for age and gender | Full model analysis | ||
|---|---|---|---|---|---|---|
| OR (CI) | P-value | OR (CI) | P-value | |||
| Demographic | ||||||
| Age | 40–64 years | 26 (3) | 0.76 (0.34–1.69) | 0.12 | 0.59 (0.25–1.42) | 0.07 |
| median = 84 years | 65–77 years | 213 (22) | 1.38 (0.999–1.91) | 1.33 (0.94–1.89) | ||
| 78–89 years | 549 (57) | 1 | 1 | |||
| 90–102 years | 168 (18) | 0.89 (0.63–1.26) | 0.77 (0.53–1.13) | |||
| Gender | Male | 562 (59) | 1 | 0.01 | 1 | 0.01 |
| Female | 394 (41) | 1.42 (1.09–1.84) | 1.55 (1.14–2.10) | |||
| Social | ||||||
| Education | Higher education | 110 (12) | 1 | 0.83 | 1 | 0.46 |
| Vocational education | 271 (28) | 1.07 (1.68–1.68) | 1.10 (0.64–1.78) | |||
| Basic school | 517 (54) | 0.98 (0.64–1.48) | 0.90 (0.58–1.41) | |||
| Missing: 58 (6) | ||||||
| Children living close by | No | 405 (42) | 1 | 0.83 | 1 | 0.82 |
| Yes | 551 (58) | 1.03 (0.79–1.34) | 103 (0.78–1.34) | |||
| Spouse with or without comorbidity (based on Charlson Comorbidity Index/CCI) | Spouse with CCI* of 0–1 | 231 (24) | 1 | 0.76 | 1 | 0.47 |
| Spouse with CCI* of 2+ | 83 (9) | 1.12 (0.67–1.85) | 1.15 (0.67–1.98) | |||
| No spouse | 642 (67) | 1.13 (0.81–1.57) | 1.25 (0.88) | |||
| Organisational | ||||||
| Municipality | Municipality no. 390 | 19 (2) | 0.18 (0.05–0.66) | <0.0001 | 0.20 (0.05–0.77) | <0.0001 |
| Municipality no. 265 | 65 (7) | 0.33 (0.16–0.66) | 0.34 (0.16–0.69) | |||
| Municipality no. 259 | 30 (3) | 0.43 (0.18–1.06) | 0.42 (0.17–1.05) | |||
| Municipality no. 336 | 19 (2) | 0.59 (0.21–1.67) | 0.54 (0.19–1.53) | |||
| Municipality no. 320 | 35 (4) | 0.86 (0.39–1.90) | 0.84 (0.37–1.88) | |||
| Municipality no. 306 | 50 (5) | 0.98 (0.49–1.99) | 0.94 (0.46–1.93) | |||
| Municipality no. 316 | 88 (9) | 1 | 1 | |||
| Municipality no. 370 | 40 (4) | 1.02 (0.48–2.18) | 0.96 (0.44–2.08) | |||
| Municipality no. 329 | 67 (7) | 1.13 (059–2.15) | 1.15 (0.60–2.23) | |||
| Municipality no. 350 | 31 (3) | 1.31 (0.57–3.00) | 1.35 (0.58–3.13) | |||
| Municipality no. 253 | 31 (3) | 1.18 (0.51–2.71) | 1.40 (0.59–3.32) | |||
| Municipality no. 360 | 50 (5) | 1.35 (0.66–2.74) | 1.43 (0.68–2.94) | |||
| Municipality no. 269 | 16 (2) | 1.58 (0.52–4.79) | 1.68 (0.54–5.18) | |||
| Municipality no. 326 | 78 (8) | 1.84 (0.98–345) | 1.89 (0.996–3.58) | |||
| Municipality no. 330 | 250 (26) | 1.89 (1.15–3.12) | 1.96 (1.18–3.26) | |||
| Municipality no. 340 | 81 (8) | 2.20 (1.17–4.15) | 2.11 (1.11–4.00) | |||
| Municipality no. 376 | 6 (1) | 6.53 (0.73–58.79) | 7.02 (0.75–65.80) | |||
| Distance to general practitioner (n = 830 patients) | 0–4205 m | 631 (66) | 1 | 0.30 | ||
| 4206–15000 m | 169 (18) | 0.85 (0.61–1.20) | na | na | ||
| 15000 + m | 30 (3) | 0.60 (0.28–1.27) | na | na | ||
| Missing: 126 (13) | ||||||
| Contact with general practitioner within one month prior to index admission | No | 183 (19) | 1 | 0.07 | 1 | 0.19 |
| Yes | 773 (81) | 0.73 (0.53–1.03) | 0.78 (0.54–1.13) | |||
| Type of general practitioner | Shared | 656 (69) | 1 | 0.02 | 0.04 | |
| Solo | 300 (31) | 0.71 (0.54–0.94) | 0.73 (0.54–0.98) | |||
| Contact with emergency doctor within one month prior to index admission | No | 607 (63) | 1 | 0.54 | 1 | 0.58 |
| Yes | 349 (37) | 0.92 (0.71–1.20) | 0.92 (0.69–1.23) | |||
| Received municipal homecare prior to admission? | No | 405 (42) | 1 | 0.97 | 1 | 0.56 |
| Yes | 551 (58) | 1.00 (0.77–1.29) | 0.92 (0.69–1.22) | |||
| Health related | ||||||
| Main diagnosis | Other diagnosis | 662 (69) | 1 | 0.66 | 1 | 0.85 |
| Atypical symptoms | 294 (31) | 1.06 (0.81–1.41) | 0.97 (0.71–1.32) | |||
| Charlson comorbidity index score | 0–1 | 386 (40) | 1 | 0.38 | 1 | 0.40 |
| 2–3 | 356 (37) | 1.19 (0.89–1.60) | 1.23 (0.90–1.68) | |||
| 4+ | 214 (22) | 1.23 (0.87–1.74) | 1.22 (0.83–1.79) | |||
| Previous hospitalization within 3-month period | No | 489 (51) | 1 | 0.51 | 1 | 0.78 |
| Yes | 467 (49) | 0.92 (0.71–1.19) | 0.96 (0.72–1.23) | |||
| Polypharmacy | No | 307 (32) | 1 | 0.93 | 1 | 0.99 |
| Yes | 649 (68) | 0.99 (0.75–1.30) | 1.00 (0.74–1.34) | |||
[i] * CCI = Charlson Comorbidity Index Score.