Care transitions between the inpatient and outpatient settings are a known period of risk in a patient's care. For instance, 1 in 5 medical patients suffers an adverse event during the first several weeks after hospital discharge, with half of these requiring the use of additional healthcare resources.1 Additionally, medication and lab monitoring errors occur in up to half of all discharged patients.2 Nearly 1 in 5 hospitalized patients, admitted with 1 of 16 different conditions including asthma, diabetes, congestive heart failure and urinary tract infection is readmitted to the hospital within six months. Up to 60% of resources are used in rehospitalized patients.3, 4 In Medicare beneficiaries, the readmission rate is as high as 20% at 30 days. The same study suggests that up to half of Medicare patients readmitted within 30 days are not seen in the outpatient setting following discharge.5 Such statistics underscore the need for seamless post‐discharge care.

Studies of post‐discharge primary care provider (PCP) follow‐up highlight the gaps in current practice within the transition from the hospital to PCP follow‐up. For instance, while more than 1 in 4 discharged patients (27.6%) at one large teaching hospital had outpatient work‐ups recommended by their hospital physicians, more than a third (35.9%) of these recommendations were ultimately not completed. Furthermore, at this same center, an increased time interval between hospital discharge and PCP follow‐up decreased the likelihood that a work‐up recommended by a hospital physician was completed.6 In patients who do have a PCP, post‐hospitalization follow‐up is frequently impacted by a variety of factors, including co‐payment requirements, transportation issues, lack of health insurance, as well as scheduling a follow‐up appointment while in the hospital.710 Uninsured patients are at particular risk for failures in transitions, have poorer health outcomes and higher mortality than insured counterparts, and are nearly 3 times more likely to make an ED visit following hospital discharge.1113

In order to better understand the role of post‐discharge PCP follow‐up, we sought to identify: (1) the percentage of general medical inpatients lacking timely PCP follow‐up after discharge from the hospital, and (2) the impact of patients lacking timely PCP follow‐up on 30‐day readmission rate and hospital length of stay (LOS). For the purposes of this study, we have defined timely PCP follow up as occurring within 4 weeks of hospital discharge.

Methods

Results

Sixty‐five patients completed this study. The mean age of the study population was 55.3 years and approximately half (52.3%) of the study participants were female. Fifty‐two subjects reported having an established PCP on admission to the hospital (80%). The rate of timely PCP follow‐up overall was 49.2%. Table 1 shows the study population characteristics stratified by presence of timely PCP follow‐up. Patients lacking timely PCP follow‐up were much younger (48.4 vs. 62.4 years; P < 0.001) than those with timely PCP follow‐up; there were also non‐significant trends toward patients lacking timely PCP follow‐up being non‐white: (33.3% vs. 25%, P = 0.23) and having lower education level (72.7% with high school or lower education vs. 56.2% for those with PCP follow‐up, P = 0.15) than those with timely PCP follow‐up. Of the 32 patients having timely PCP follow‐up, 15.6% were uninsured. In comparison, among the 33 patients lacking timely PCP follow‐up after hospital discharge, over a third (36%) were uninsured (P = 0.06). Among the uninsured, a large majority (70.5%) lacked timely PCP follow‐up (P = 0.06). In contrast, only 11 of the 26 Medicare patients (42.3%) lacked timely PCP follow‐up (P = 0.13).

Discussion

A growing body of work highlights the role of multiple, varied interventions at, or following discharge, in improving outcomes during the transition from inpatient to outpatient care. Examples include care coordination by advanced nurse practitioners, follow‐up pharmacist phone calls, and involvement of a transition coach encouraging active patient involvementall are known to improve patient outcomes following a hospitalization.1418 The active involvement of a PCP is central to a number of these proven interventions to ensure effective completion of ongoing patient care. And while some previous studies suggest increased overall resource utilization when PCP follow‐up occurs after hospitalization,19 the level of fragmented care that occurs in today's hospitalized patient, as well as the fact many patients lack PCP care at all, raises questions about clinical outcomes after hospitalization related to timely PCP follow‐up. The issue of appropriateness of resources utilized has also not been adequately explored.

Within this context, this study examines the role that PCP follow‐up might play in such interventions and its' effects on patient outcomes. Notably, in this urban academic medical center, we found that timely PCP follow‐up after hospital discharge occurred in fewer than half of general medical inpatients. Lack of timely PCP follow‐up was associated with increased hospital readmission for the same condition and a trend toward a longer index hospital LOS.

While this small study cannot fully elucidate the impact of lack of timely PCP follow‐up on post‐discharge care, our findings suggest some mechanisms by which lack of timely PCP follow‐up might result in poor outcomes. For instance, patients lacking a PCP visit after discharge may not obtain needed follow‐up care in the post‐discharge period, leading to clinical deterioration and hospital readmission. Uninsured patients may be at particular risk for failed transition because they are less likely to have consistent PCP access, whether as an already established patient or one newly assigned.20, 21 Perhaps a larger study would better demonstrate statistical significance in reflecting the association between uninsured patients, lack of a PCP, and post‐discharge follow‐up deficiencies. There may, in fact, be issues related to patient attitudes and beliefs, such as subjectively feeling better or even an implicit distrust of the healthcare system among the uninsured, that exist as well. Even among patients with a PCP prior to hospitalization, PCP follow‐up after hospital discharge may be lacking due to modifiable factors such as patient attitudes and beliefs and logistical barriers in arranging follow‐up.

Patients without potential for timely PCP follow‐up might be kept in the hospital longer to ensure they are well enough medically to sufficiently meet their own follow‐up needs. Hospital LOS might be increased by providers to compensate for the lack of PCP follow‐up. Alternatively, these patients may be sicker with their index hospitalization.

It is not surprising that payer source appears to influence a patients' ability to obtain timely PCP follow‐up. It is well documented that uninsured patients have higher healthcare resource utilization.2224 Lack of access to primary care in such patients contributes to a cycle of using the most expensive sites of care. In our study, we found many of the patients lacking timely PCP follow‐up were younger, perhaps reflecting the same patient population who have higher rates of being uninsured. Conversely, older patients are more likely to have PCP access, in large part due to having Medicare benefits (although this dynamic has shown a shift in recent years). The uninsured may present sicker as a result of lacking pre‐hospital PCP access or transportation to a PCP visit.

Care transitions between the inpatient and outpatient settings are a known period of risk in a patient's care. For instance, 1 in 5 medical patients suffers an adverse event during the first several weeks after hospital discharge, with half of these requiring the use of additional healthcare resources.1 Additionally, medication and lab monitoring errors occur in up to half of all discharged patients.2 Nearly 1 in 5 hospitalized patients, admitted with 1 of 16 different conditions including asthma, diabetes, congestive heart failure and urinary tract infection is readmitted to the hospital within six months. Up to 60% of resources are used in rehospitalized patients.3, 4 In Medicare beneficiaries, the readmission rate is as high as 20% at 30 days. The same study suggests that up to half of Medicare patients readmitted within 30 days are not seen in the outpatient setting following discharge.5 Such statistics underscore the need for seamless post‐discharge care.

Studies of post‐discharge primary care provider (PCP) follow‐up highlight the gaps in current practice within the transition from the hospital to PCP follow‐up. For instance, while more than 1 in 4 discharged patients (27.6%) at one large teaching hospital had outpatient work‐ups recommended by their hospital physicians, more than a third (35.9%) of these recommendations were ultimately not completed. Furthermore, at this same center, an increased time interval between hospital discharge and PCP follow‐up decreased the likelihood that a work‐up recommended by a hospital physician was completed.6 In patients who do have a PCP, post‐hospitalization follow‐up is frequently impacted by a variety of factors, including co‐payment requirements, transportation issues, lack of health insurance, as well as scheduling a follow‐up appointment while in the hospital.710 Uninsured patients are at particular risk for failures in transitions, have poorer health outcomes and higher mortality than insured counterparts, and are nearly 3 times more likely to make an ED visit following hospital discharge.1113

In order to better understand the role of post‐discharge PCP follow‐up, we sought to identify: (1) the percentage of general medical inpatients lacking timely PCP follow‐up after discharge from the hospital, and (2) the impact of patients lacking timely PCP follow‐up on 30‐day readmission rate and hospital length of stay (LOS). For the purposes of this study, we have defined timely PCP follow up as occurring within 4 weeks of hospital discharge.

Methods

Results

Sixty‐five patients completed this study. The mean age of the study population was 55.3 years and approximately half (52.3%) of the study participants were female. Fifty‐two subjects reported having an established PCP on admission to the hospital (80%). The rate of timely PCP follow‐up overall was 49.2%. Table 1 shows the study population characteristics stratified by presence of timely PCP follow‐up. Patients lacking timely PCP follow‐up were much younger (48.4 vs. 62.4 years; P < 0.001) than those with timely PCP follow‐up; there were also non‐significant trends toward patients lacking timely PCP follow‐up being non‐white: (33.3% vs. 25%, P = 0.23) and having lower education level (72.7% with high school or lower education vs. 56.2% for those with PCP follow‐up, P = 0.15) than those with timely PCP follow‐up. Of the 32 patients having timely PCP follow‐up, 15.6% were uninsured. In comparison, among the 33 patients lacking timely PCP follow‐up after hospital discharge, over a third (36%) were uninsured (P = 0.06). Among the uninsured, a large majority (70.5%) lacked timely PCP follow‐up (P = 0.06). In contrast, only 11 of the 26 Medicare patients (42.3%) lacked timely PCP follow‐up (P = 0.13).

Discussion

A growing body of work highlights the role of multiple, varied interventions at, or following discharge, in improving outcomes during the transition from inpatient to outpatient care. Examples include care coordination by advanced nurse practitioners, follow‐up pharmacist phone calls, and involvement of a transition coach encouraging active patient involvementall are known to improve patient outcomes following a hospitalization.1418 The active involvement of a PCP is central to a number of these proven interventions to ensure effective completion of ongoing patient care. And while some previous studies suggest increased overall resource utilization when PCP follow‐up occurs after hospitalization,19 the level of fragmented care that occurs in today's hospitalized patient, as well as the fact many patients lack PCP care at all, raises questions about clinical outcomes after hospitalization related to timely PCP follow‐up. The issue of appropriateness of resources utilized has also not been adequately explored.

Within this context, this study examines the role that PCP follow‐up might play in such interventions and its' effects on patient outcomes. Notably, in this urban academic medical center, we found that timely PCP follow‐up after hospital discharge occurred in fewer than half of general medical inpatients. Lack of timely PCP follow‐up was associated with increased hospital readmission for the same condition and a trend toward a longer index hospital LOS.

While this small study cannot fully elucidate the impact of lack of timely PCP follow‐up on post‐discharge care, our findings suggest some mechanisms by which lack of timely PCP follow‐up might result in poor outcomes. For instance, patients lacking a PCP visit after discharge may not obtain needed follow‐up care in the post‐discharge period, leading to clinical deterioration and hospital readmission. Uninsured patients may be at particular risk for failed transition because they are less likely to have consistent PCP access, whether as an already established patient or one newly assigned.20, 21 Perhaps a larger study would better demonstrate statistical significance in reflecting the association between uninsured patients, lack of a PCP, and post‐discharge follow‐up deficiencies. There may, in fact, be issues related to patient attitudes and beliefs, such as subjectively feeling better or even an implicit distrust of the healthcare system among the uninsured, that exist as well. Even among patients with a PCP prior to hospitalization, PCP follow‐up after hospital discharge may be lacking due to modifiable factors such as patient attitudes and beliefs and logistical barriers in arranging follow‐up.

Patients without potential for timely PCP follow‐up might be kept in the hospital longer to ensure they are well enough medically to sufficiently meet their own follow‐up needs. Hospital LOS might be increased by providers to compensate for the lack of PCP follow‐up. Alternatively, these patients may be sicker with their index hospitalization.

It is not surprising that payer source appears to influence a patients' ability to obtain timely PCP follow‐up. It is well documented that uninsured patients have higher healthcare resource utilization.2224 Lack of access to primary care in such patients contributes to a cycle of using the most expensive sites of care. In our study, we found many of the patients lacking timely PCP follow‐up were younger, perhaps reflecting the same patient population who have higher rates of being uninsured. Conversely, older patients are more likely to have PCP access, in large part due to having Medicare benefits (although this dynamic has shown a shift in recent years). The uninsured may present sicker as a result of lacking pre‐hospital PCP access or transportation to a PCP visit.

Care transitions between the inpatient and outpatient settings are a known period of risk in a patient's care. For instance, 1 in 5 medical patients suffers an adverse event during the first several weeks after hospital discharge, with half of these requiring the use of additional healthcare resources.1 Additionally, medication and lab monitoring errors occur in up to half of all discharged patients.2 Nearly 1 in 5 hospitalized patients, admitted with 1 of 16 different conditions including asthma, diabetes, congestive heart failure and urinary tract infection is readmitted to the hospital within six months. Up to 60% of resources are used in rehospitalized patients.3, 4 In Medicare beneficiaries, the readmission rate is as high as 20% at 30 days. The same study suggests that up to half of Medicare patients readmitted within 30 days are not seen in the outpatient setting following discharge.5 Such statistics underscore the need for seamless post‐discharge care.

Studies of post‐discharge primary care provider (PCP) follow‐up highlight the gaps in current practice within the transition from the hospital to PCP follow‐up. For instance, while more than 1 in 4 discharged patients (27.6%) at one large teaching hospital had outpatient work‐ups recommended by their hospital physicians, more than a third (35.9%) of these recommendations were ultimately not completed. Furthermore, at this same center, an increased time interval between hospital discharge and PCP follow‐up decreased the likelihood that a work‐up recommended by a hospital physician was completed.6 In patients who do have a PCP, post‐hospitalization follow‐up is frequently impacted by a variety of factors, including co‐payment requirements, transportation issues, lack of health insurance, as well as scheduling a follow‐up appointment while in the hospital.710 Uninsured patients are at particular risk for failures in transitions, have poorer health outcomes and higher mortality than insured counterparts, and are nearly 3 times more likely to make an ED visit following hospital discharge.1113

In order to better understand the role of post‐discharge PCP follow‐up, we sought to identify: (1) the percentage of general medical inpatients lacking timely PCP follow‐up after discharge from the hospital, and (2) the impact of patients lacking timely PCP follow‐up on 30‐day readmission rate and hospital length of stay (LOS). For the purposes of this study, we have defined timely PCP follow up as occurring within 4 weeks of hospital discharge.

Methods

Results

Sixty‐five patients completed this study. The mean age of the study population was 55.3 years and approximately half (52.3%) of the study participants were female. Fifty‐two subjects reported having an established PCP on admission to the hospital (80%). The rate of timely PCP follow‐up overall was 49.2%. Table 1 shows the study population characteristics stratified by presence of timely PCP follow‐up. Patients lacking timely PCP follow‐up were much younger (48.4 vs. 62.4 years; P < 0.001) than those with timely PCP follow‐up; there were also non‐significant trends toward patients lacking timely PCP follow‐up being non‐white: (33.3% vs. 25%, P = 0.23) and having lower education level (72.7% with high school or lower education vs. 56.2% for those with PCP follow‐up, P = 0.15) than those with timely PCP follow‐up. Of the 32 patients having timely PCP follow‐up, 15.6% were uninsured. In comparison, among the 33 patients lacking timely PCP follow‐up after hospital discharge, over a third (36%) were uninsured (P = 0.06). Among the uninsured, a large majority (70.5%) lacked timely PCP follow‐up (P = 0.06). In contrast, only 11 of the 26 Medicare patients (42.3%) lacked timely PCP follow‐up (P = 0.13).

Discussion

A growing body of work highlights the role of multiple, varied interventions at, or following discharge, in improving outcomes during the transition from inpatient to outpatient care. Examples include care coordination by advanced nurse practitioners, follow‐up pharmacist phone calls, and involvement of a transition coach encouraging active patient involvementall are known to improve patient outcomes following a hospitalization.1418 The active involvement of a PCP is central to a number of these proven interventions to ensure effective completion of ongoing patient care. And while some previous studies suggest increased overall resource utilization when PCP follow‐up occurs after hospitalization,19 the level of fragmented care that occurs in today's hospitalized patient, as well as the fact many patients lack PCP care at all, raises questions about clinical outcomes after hospitalization related to timely PCP follow‐up. The issue of appropriateness of resources utilized has also not been adequately explored.

Within this context, this study examines the role that PCP follow‐up might play in such interventions and its' effects on patient outcomes. Notably, in this urban academic medical center, we found that timely PCP follow‐up after hospital discharge occurred in fewer than half of general medical inpatients. Lack of timely PCP follow‐up was associated with increased hospital readmission for the same condition and a trend toward a longer index hospital LOS.

While this small study cannot fully elucidate the impact of lack of timely PCP follow‐up on post‐discharge care, our findings suggest some mechanisms by which lack of timely PCP follow‐up might result in poor outcomes. For instance, patients lacking a PCP visit after discharge may not obtain needed follow‐up care in the post‐discharge period, leading to clinical deterioration and hospital readmission. Uninsured patients may be at particular risk for failed transition because they are less likely to have consistent PCP access, whether as an already established patient or one newly assigned.20, 21 Perhaps a larger study would better demonstrate statistical significance in reflecting the association between uninsured patients, lack of a PCP, and post‐discharge follow‐up deficiencies. There may, in fact, be issues related to patient attitudes and beliefs, such as subjectively feeling better or even an implicit distrust of the healthcare system among the uninsured, that exist as well. Even among patients with a PCP prior to hospitalization, PCP follow‐up after hospital discharge may be lacking due to modifiable factors such as patient attitudes and beliefs and logistical barriers in arranging follow‐up.

Patients without potential for timely PCP follow‐up might be kept in the hospital longer to ensure they are well enough medically to sufficiently meet their own follow‐up needs. Hospital LOS might be increased by providers to compensate for the lack of PCP follow‐up. Alternatively, these patients may be sicker with their index hospitalization.

It is not surprising that payer source appears to influence a patients' ability to obtain timely PCP follow‐up. It is well documented that uninsured patients have higher healthcare resource utilization.2224 Lack of access to primary care in such patients contributes to a cycle of using the most expensive sites of care. In our study, we found many of the patients lacking timely PCP follow‐up were younger, perhaps reflecting the same patient population who have higher rates of being uninsured. Conversely, older patients are more likely to have PCP access, in large part due to having Medicare benefits (although this dynamic has shown a shift in recent years). The uninsured may present sicker as a result of lacking pre‐hospital PCP access or transportation to a PCP visit.

Fully 19% of Medicare patients are readmitted to the hospital within 30 days of discharge.1 This represents a large amount of potentially avoidable morbidity and cost. Indeed, projects to improve the discharge process and post‐hospital care have shown that as much as one‐third of hospital utilization in the month after discharge can be avoided.2 Consequently, the rate of early, unplanned hospital utilization after discharge has emerged as an important indicator of hospital quality and the Centers for Medicare and Medicaid Services (CMS) has proposed a policy to decrease payments to hospitals with high rates of early unplanned hospital utilization. Thus, there is great interest in identifying modifiable risk factors for rehospitalization that could be used to refine intervention models and lead to improvements in quality of care, patient outcomes, and cost savings.

To date, known predictors of readmission include: lower socioeconomic status,3 history of prior hospitalization4 and advanced age,5 length of stay greater than 7 days,6 a high burden of comorbid illnesses (based on Charlson score),7 poor social support,8 and specific diagnoses (eg, congestive heart failure, chronic obstructive pulmonary disease [COPD] and myocardial infarction).5, 9, 10 In addition, unplanned readmissions and emergency department (ED) visits have been linked to polypharmacy and adverse drug events related to treatment with medications such as warfarin, digoxin and narcotics.11, 12 Another characteristic that has also been linked to readmission is depression;13 however5 reports supporting this association are from studies of elderly patients or with patients who have specific diagnoses (eg, congestive heart failure [CHF], COPD, myocardial infarction).1416

Depression is common, affecting 13% to 16% of people in the US, and is recognized as an important risk factor for poor outcomes among patients with various chronic illnesses.1719 The mechanisms by which depression can be linked to health outcomes and health service utilization have been studied in age‐specific or disease‐specific cohorts such as cardiac patients or frail elders and include both physiologic factors such as hypercoagulability and hyperinflammatory conditions, as well as behavioral factors such as poor self‐care behaviors and heightened sensitivity to somatic symptoms. How these mechanisms link depression to health outcomes and hospital utilization in a general medical population is not clearly understood. Kartha et al.13 reported findings indicating that depression is a risk factor for rehospitalization in general medical inpatients, but the study sample was relatively small and the study design methodology significantly limited its generalizability.12 It would be useful to provide supporting evidence showing depression as an important risk factor for readmission in the general medical in‐patient population using more rigorous study methods and a larger cohort.

We hypothesized that depressive symptoms would be an independent risk factor for early unplanned hospital utilization after discharge for all medical patients. Therefore, we conducted a secondary analysis of the Project RED clinical trial dataset to assess the association between a positive depression screen during inpatient hospitalization and the rate of subsequent hospital utilization.

Methods

Data from the Project RED clinical trial were reviewed for inclusion in a secondary analysis. Complete data were available for 738 of the 749 subjects recruited for Project RED.

Results

A total of 28% of subjects were categorized as having a positive depression screen. More women (36%) had positive depression screens than men (28%). Among patients with a positive depression screen, 58% had a history of depression and 53% were currently taking medications at the time of enrollment, compared with 25% and 22% respectively for subjects with a negative depression screen. Table 1 presents the means or percentages for baseline characteristics by depression status in the analytic cohort. Subjects with Medicaid for insurance had a higher rate of depression (61%) than subjects with Medicare (13%), private insurance (9%), or those who qualified for the Free Care pool (17%) which is the Massachusetts state funding for healthcare to uninsured persons. Subjects who were unemployed, unmarried, or who reported earnings less than $10,000 per year were also more likely to screen positive for depression. In addition, depressed subjects had a higher severity of co‐morbid disease and longer length of stay for the index hospitalization. Patients categorized as frequent utilizers (2 or more prior admissions) for the 6 months prior to the index hospitalization were also more likely to be depressed. Of further note, is the relatively younger average age among both depressive patients (49.6 years) and non‐depressive patients (49.9) of these study subjects.

The unadjusted hospital utilization rate at 30, 60, and 90 days post‐discharge by depression status is shown in Table 2. At 30 days post‐discharge, those with depressive symptoms had a higher rate of hospital utilization than those without depressive symptoms (0.563 vs. 0.296). In other words, 56 utilization events occurred per 100 patients with depressive symptoms, compared with 30 utilization events per 100 patients without depressive symptoms. The unadjusted 30‐day post‐discharge hospital utilization rate among those with depressive symptoms was higher compared with those without symptoms (IRR, 1.90, 95% confidence interval [CI], 1.242.71). A similar trend was found among subjects at 60 and 90 days post‐discharge.

Poisson regression analyses were conducted to control for potential confounding in the relationship between depressive symptoms and hospital utilization rate within 30 days after discharge (Table 3). After controlling for relevant confounders, including age, gender, employment status, frequent prior hospitalization status, marital status, Charlson score, Project RED study group assignment and the interaction variable for RED study group assignment and depression, the association between symptoms of depression, and hospital utilization rate remained significant (IRR, 1.73; 95% CI, 1.272.36).

Figure 1 depicts the Kaplan‐Meier hazard curve generated for time to first hospital utilization, stratified by depression status. While 21% of participants without symptoms of depression had a hospital utilization within 30 days, fully 29% of participants with symptoms of depression had a hospital utilization within 30 days (P = 0.011).

Figure 1

Discussion

Our study shows hospitalized patients who screen positive for depressive symptoms are significantly more likely to have a hospital visit (emergency room or rehospitalization) within 30 days of discharge than those who do not screen positive for depressive symptoms among medical patients admitted to an urban, academic, safety‐net hospital. These findings are consistent with, and extend, prior reports regarding depression and rehospitalization in specific populations (ie, geriatrics) and specific diagnoses (ie, cardiovascular disease [CVD] and COPD).1012 We observed a 73% higher incidence rate for hospital utilization within 30 days of discharge for those with symptoms of depression. This puts symptoms of depression on par with frequent prior rehospitalization, advanced age and low social support, as known risk factors for rehospitalization.4, 5, 23

Also of significance is the relatively young age of this study population (49.9 years non‐depressive patients and 49.6 years for depressive patients) compared with the study cohorts used for research in the majority of the existing literature. The chief reason for the young age of our cohort is that potential subjects were excluded if they came from a skilled nursing facility or other hospital. This may limit the generalizability of our findings; however, it seems likely that interventions relating to depression and transitions of care will need to be quite different for patients that reside in long‐term care facilities vs. patients that live in the community. For example, patients living in the community may have significant barriers to access post‐discharge services due to insurance status and are more likely to be sensitive to variations in social support.

Early rehospitalization is associated with significant morbidity, mortality, and expense. It is also a potential marker for poor quality of care.24 Concerns for patient safety, escalating healthcare costs, and possible change in hospital reimbursement mechanisms are fueling the search for modifiable risk factors associated with early rehospitalization. Our data provide evidence that symptoms of depression may be an important focus of attention. We do not know, however whether treating hospitalized patients who screen positive for depression will decrease early rehospitalization and emergency room utilization rates.

Various physiologic and behavioral mechanisms may link symptoms of depression to hospital utilization after discharge. For example, depressed patients with features of somatization may be more likely to experience worrisome physical symptoms after discharge and present prematurely for reevaluation. Patients who are sicker in some fashion not captured by our measured confounders may have symptoms of depression related to chronic, debilitating disease warranting early return to the hospital. Depression may also yield nonadherence to aspects of the discharge treatment plan leading to rehospitalization as a result of poor post‐discharge disease management. For example, research shows that patients with depression following coronary artery bypass surgery are less likely to adhere with cardiac rehabilitation programs.25 Likewise, depression among chronically ill patients such as diabetics, asthmatics, or human immunodeficiency virus (HIV)‐positive patients impairs medication adherence and self‐care behavior which may lead to disease relapse or recurrence.2628 One study examining depression effects on hypertensive medicine adherence in African Americans identified self‐efficacy as a mediating factor between depression and nonadherence.29 This implies that interventions such as self‐management education, a program through which chronically‐ill patients learn to better manage their illnesses through enhanced self‐confidence and problem‐solving strategies (including mood disorder challenges) may reduce early rehospitalization among depressed patients.30

There is also evidence that depression may have direct physiologic consequences. In patients with CVD, depression is associated with poor outcomes possibly related to decreased heart rate variability, hypercoagulability, high burdens of inflammatory markers, and severity of left ventricular dysfunction.3134 Similarly, depression among HIV/acquired immune deficiency syndrome (AIDS), diabetics and multiple sclerosis (MS) patients is linked to heightened levels of proinflammatory markers and less favorable outcomes that may signal a more severe form of the disease or an impaired response to treatment.3538 Indeed, MS investigators now hypothesize that the proinflammatory environment associated with the neurologic manifestations of MS are also causing depression symptoms among MS patients.34 This theory contrasts the common belief that depression in the chronically ill manifests independent of the chronic illness or in response to living with chronic disease.

A major strength of the current study is the large dataset and the broad range of covariates available for analyses. However, several limitations should be noted. First, data on hospital utilization outside Boston Medical Center were determined by patient self‐report and were not confirmed by document review. Second, we do not know the direction of the associations we report. If symptoms of depression are merely the consequence of having a higher disease burden, treatment of the underlying disease may be the most important response. While this is possible, our model does include several variables (eg, Charlson score and length of stay) that are likely to adjust for disease severity, pointing to the likelihood that symptoms of depression truly predict hospital utilization in a fashion that is independent of disease severity. Third, our results may not be generalizable to populations other than those served by urban safety‐net hospitals or other populations excluded from the Project RED trial (eg, non‐English speaking patients and patients from nursing homes). Finally, social factors such as substance use and social support system variables may residually confound the relationship between depression and hospital reutilization demonstrated in this study. While this dataset does not include a measure of social support other than marital status and housing status, data is available on substance use. Analyses conducted by our colleagues using Project RED data found that in this study population depression was significantly more prevalent among substance users (29% vs. 14%) compared with non‐users and that substance use is an independent risk factor for hospital reutilization (unpublished data).

Our findings linking depression to increased hospital utilization also warrant further consideration from healthcare policymakers. Central to the Obama Administration's February 2009 healthcare reform proposal is the pursuit of cost savings through reductions in unplanned hospital readmissions.39 Thus, identifying potentially modifiable risk factors for readmission, such as depression, is of great concern to healthcare providers and policymakers across the nation. If, through testing of interventions, depression proves to be a modifiable risk for readmission, policymakers, while negotiating healthcare reform measures, must provide for the services required to address this comorbidity at the time of discharge. For example, if a patient screens positive for depressive symptoms during a hospitalization for COPD exacerbation, will the proposed payment reforms allow for mental health services during the immediate post‐discharge period in order to reduce the likelihood of hospital readmission? Will those mental health services be readily available? Payment reforms that account for all necessary transitional care services will indeed help reduce readmission costs with less risk for untoward consequences.

In conclusion, our results indicate that a positive depression screen is a significant risk factor for early post‐discharge hospital utilization among hospitalized adults on a general medical service, even after controlling for relevant confounders. Screening for depression during acute hospitalizations may be an important step in identifying patients at increased risk for readmission. Future research should focus on further characterizing and stratifying populations at highest risk for depression. Efforts should also include developing and evaluating targeted interventions for patients with symptoms of depression among hospitalized patients as part of discharge planning. Timely depression therapy during the hospitalization or following hospital discharge might reduce costly readmissions and enhance patient safety.

Fully 19% of Medicare patients are readmitted to the hospital within 30 days of discharge.1 This represents a large amount of potentially avoidable morbidity and cost. Indeed, projects to improve the discharge process and post‐hospital care have shown that as much as one‐third of hospital utilization in the month after discharge can be avoided.2 Consequently, the rate of early, unplanned hospital utilization after discharge has emerged as an important indicator of hospital quality and the Centers for Medicare and Medicaid Services (CMS) has proposed a policy to decrease payments to hospitals with high rates of early unplanned hospital utilization. Thus, there is great interest in identifying modifiable risk factors for rehospitalization that could be used to refine intervention models and lead to improvements in quality of care, patient outcomes, and cost savings.

To date, known predictors of readmission include: lower socioeconomic status,3 history of prior hospitalization4 and advanced age,5 length of stay greater than 7 days,6 a high burden of comorbid illnesses (based on Charlson score),7 poor social support,8 and specific diagnoses (eg, congestive heart failure, chronic obstructive pulmonary disease [COPD] and myocardial infarction).5, 9, 10 In addition, unplanned readmissions and emergency department (ED) visits have been linked to polypharmacy and adverse drug events related to treatment with medications such as warfarin, digoxin and narcotics.11, 12 Another characteristic that has also been linked to readmission is depression;13 however5 reports supporting this association are from studies of elderly patients or with patients who have specific diagnoses (eg, congestive heart failure [CHF], COPD, myocardial infarction).1416

Depression is common, affecting 13% to 16% of people in the US, and is recognized as an important risk factor for poor outcomes among patients with various chronic illnesses.1719 The mechanisms by which depression can be linked to health outcomes and health service utilization have been studied in age‐specific or disease‐specific cohorts such as cardiac patients or frail elders and include both physiologic factors such as hypercoagulability and hyperinflammatory conditions, as well as behavioral factors such as poor self‐care behaviors and heightened sensitivity to somatic symptoms. How these mechanisms link depression to health outcomes and hospital utilization in a general medical population is not clearly understood. Kartha et al.13 reported findings indicating that depression is a risk factor for rehospitalization in general medical inpatients, but the study sample was relatively small and the study design methodology significantly limited its generalizability.12 It would be useful to provide supporting evidence showing depression as an important risk factor for readmission in the general medical in‐patient population using more rigorous study methods and a larger cohort.

We hypothesized that depressive symptoms would be an independent risk factor for early unplanned hospital utilization after discharge for all medical patients. Therefore, we conducted a secondary analysis of the Project RED clinical trial dataset to assess the association between a positive depression screen during inpatient hospitalization and the rate of subsequent hospital utilization.

Methods

Data from the Project RED clinical trial were reviewed for inclusion in a secondary analysis. Complete data were available for 738 of the 749 subjects recruited for Project RED.

Results

A total of 28% of subjects were categorized as having a positive depression screen. More women (36%) had positive depression screens than men (28%). Among patients with a positive depression screen, 58% had a history of depression and 53% were currently taking medications at the time of enrollment, compared with 25% and 22% respectively for subjects with a negative depression screen. Table 1 presents the means or percentages for baseline characteristics by depression status in the analytic cohort. Subjects with Medicaid for insurance had a higher rate of depression (61%) than subjects with Medicare (13%), private insurance (9%), or those who qualified for the Free Care pool (17%) which is the Massachusetts state funding for healthcare to uninsured persons. Subjects who were unemployed, unmarried, or who reported earnings less than $10,000 per year were also more likely to screen positive for depression. In addition, depressed subjects had a higher severity of co‐morbid disease and longer length of stay for the index hospitalization. Patients categorized as frequent utilizers (2 or more prior admissions) for the 6 months prior to the index hospitalization were also more likely to be depressed. Of further note, is the relatively younger average age among both depressive patients (49.6 years) and non‐depressive patients (49.9) of these study subjects.

The unadjusted hospital utilization rate at 30, 60, and 90 days post‐discharge by depression status is shown in Table 2. At 30 days post‐discharge, those with depressive symptoms had a higher rate of hospital utilization than those without depressive symptoms (0.563 vs. 0.296). In other words, 56 utilization events occurred per 100 patients with depressive symptoms, compared with 30 utilization events per 100 patients without depressive symptoms. The unadjusted 30‐day post‐discharge hospital utilization rate among those with depressive symptoms was higher compared with those without symptoms (IRR, 1.90, 95% confidence interval [CI], 1.242.71). A similar trend was found among subjects at 60 and 90 days post‐discharge.

Poisson regression analyses were conducted to control for potential confounding in the relationship between depressive symptoms and hospital utilization rate within 30 days after discharge (Table 3). After controlling for relevant confounders, including age, gender, employment status, frequent prior hospitalization status, marital status, Charlson score, Project RED study group assignment and the interaction variable for RED study group assignment and depression, the association between symptoms of depression, and hospital utilization rate remained significant (IRR, 1.73; 95% CI, 1.272.36).

Figure 1 depicts the Kaplan‐Meier hazard curve generated for time to first hospital utilization, stratified by depression status. While 21% of participants without symptoms of depression had a hospital utilization within 30 days, fully 29% of participants with symptoms of depression had a hospital utilization within 30 days (P = 0.011).

Figure 1

Discussion

Our study shows hospitalized patients who screen positive for depressive symptoms are significantly more likely to have a hospital visit (emergency room or rehospitalization) within 30 days of discharge than those who do not screen positive for depressive symptoms among medical patients admitted to an urban, academic, safety‐net hospital. These findings are consistent with, and extend, prior reports regarding depression and rehospitalization in specific populations (ie, geriatrics) and specific diagnoses (ie, cardiovascular disease [CVD] and COPD).1012 We observed a 73% higher incidence rate for hospital utilization within 30 days of discharge for those with symptoms of depression. This puts symptoms of depression on par with frequent prior rehospitalization, advanced age and low social support, as known risk factors for rehospitalization.4, 5, 23

Also of significance is the relatively young age of this study population (49.9 years non‐depressive patients and 49.6 years for depressive patients) compared with the study cohorts used for research in the majority of the existing literature. The chief reason for the young age of our cohort is that potential subjects were excluded if they came from a skilled nursing facility or other hospital. This may limit the generalizability of our findings; however, it seems likely that interventions relating to depression and transitions of care will need to be quite different for patients that reside in long‐term care facilities vs. patients that live in the community. For example, patients living in the community may have significant barriers to access post‐discharge services due to insurance status and are more likely to be sensitive to variations in social support.

Early rehospitalization is associated with significant morbidity, mortality, and expense. It is also a potential marker for poor quality of care.24 Concerns for patient safety, escalating healthcare costs, and possible change in hospital reimbursement mechanisms are fueling the search for modifiable risk factors associated with early rehospitalization. Our data provide evidence that symptoms of depression may be an important focus of attention. We do not know, however whether treating hospitalized patients who screen positive for depression will decrease early rehospitalization and emergency room utilization rates.

Various physiologic and behavioral mechanisms may link symptoms of depression to hospital utilization after discharge. For example, depressed patients with features of somatization may be more likely to experience worrisome physical symptoms after discharge and present prematurely for reevaluation. Patients who are sicker in some fashion not captured by our measured confounders may have symptoms of depression related to chronic, debilitating disease warranting early return to the hospital. Depression may also yield nonadherence to aspects of the discharge treatment plan leading to rehospitalization as a result of poor post‐discharge disease management. For example, research shows that patients with depression following coronary artery bypass surgery are less likely to adhere with cardiac rehabilitation programs.25 Likewise, depression among chronically ill patients such as diabetics, asthmatics, or human immunodeficiency virus (HIV)‐positive patients impairs medication adherence and self‐care behavior which may lead to disease relapse or recurrence.2628 One study examining depression effects on hypertensive medicine adherence in African Americans identified self‐efficacy as a mediating factor between depression and nonadherence.29 This implies that interventions such as self‐management education, a program through which chronically‐ill patients learn to better manage their illnesses through enhanced self‐confidence and problem‐solving strategies (including mood disorder challenges) may reduce early rehospitalization among depressed patients.30

There is also evidence that depression may have direct physiologic consequences. In patients with CVD, depression is associated with poor outcomes possibly related to decreased heart rate variability, hypercoagulability, high burdens of inflammatory markers, and severity of left ventricular dysfunction.3134 Similarly, depression among HIV/acquired immune deficiency syndrome (AIDS), diabetics and multiple sclerosis (MS) patients is linked to heightened levels of proinflammatory markers and less favorable outcomes that may signal a more severe form of the disease or an impaired response to treatment.3538 Indeed, MS investigators now hypothesize that the proinflammatory environment associated with the neurologic manifestations of MS are also causing depression symptoms among MS patients.34 This theory contrasts the common belief that depression in the chronically ill manifests independent of the chronic illness or in response to living with chronic disease.

A major strength of the current study is the large dataset and the broad range of covariates available for analyses. However, several limitations should be noted. First, data on hospital utilization outside Boston Medical Center were determined by patient self‐report and were not confirmed by document review. Second, we do not know the direction of the associations we report. If symptoms of depression are merely the consequence of having a higher disease burden, treatment of the underlying disease may be the most important response. While this is possible, our model does include several variables (eg, Charlson score and length of stay) that are likely to adjust for disease severity, pointing to the likelihood that symptoms of depression truly predict hospital utilization in a fashion that is independent of disease severity. Third, our results may not be generalizable to populations other than those served by urban safety‐net hospitals or other populations excluded from the Project RED trial (eg, non‐English speaking patients and patients from nursing homes). Finally, social factors such as substance use and social support system variables may residually confound the relationship between depression and hospital reutilization demonstrated in this study. While this dataset does not include a measure of social support other than marital status and housing status, data is available on substance use. Analyses conducted by our colleagues using Project RED data found that in this study population depression was significantly more prevalent among substance users (29% vs. 14%) compared with non‐users and that substance use is an independent risk factor for hospital reutilization (unpublished data).

Our findings linking depression to increased hospital utilization also warrant further consideration from healthcare policymakers. Central to the Obama Administration's February 2009 healthcare reform proposal is the pursuit of cost savings through reductions in unplanned hospital readmissions.39 Thus, identifying potentially modifiable risk factors for readmission, such as depression, is of great concern to healthcare providers and policymakers across the nation. If, through testing of interventions, depression proves to be a modifiable risk for readmission, policymakers, while negotiating healthcare reform measures, must provide for the services required to address this comorbidity at the time of discharge. For example, if a patient screens positive for depressive symptoms during a hospitalization for COPD exacerbation, will the proposed payment reforms allow for mental health services during the immediate post‐discharge period in order to reduce the likelihood of hospital readmission? Will those mental health services be readily available? Payment reforms that account for all necessary transitional care services will indeed help reduce readmission costs with less risk for untoward consequences.

In conclusion, our results indicate that a positive depression screen is a significant risk factor for early post‐discharge hospital utilization among hospitalized adults on a general medical service, even after controlling for relevant confounders. Screening for depression during acute hospitalizations may be an important step in identifying patients at increased risk for readmission. Future research should focus on further characterizing and stratifying populations at highest risk for depression. Efforts should also include developing and evaluating targeted interventions for patients with symptoms of depression among hospitalized patients as part of discharge planning. Timely depression therapy during the hospitalization or following hospital discharge might reduce costly readmissions and enhance patient safety.

Fully 19% of Medicare patients are readmitted to the hospital within 30 days of discharge.1 This represents a large amount of potentially avoidable morbidity and cost. Indeed, projects to improve the discharge process and post‐hospital care have shown that as much as one‐third of hospital utilization in the month after discharge can be avoided.2 Consequently, the rate of early, unplanned hospital utilization after discharge has emerged as an important indicator of hospital quality and the Centers for Medicare and Medicaid Services (CMS) has proposed a policy to decrease payments to hospitals with high rates of early unplanned hospital utilization. Thus, there is great interest in identifying modifiable risk factors for rehospitalization that could be used to refine intervention models and lead to improvements in quality of care, patient outcomes, and cost savings.

To date, known predictors of readmission include: lower socioeconomic status,3 history of prior hospitalization4 and advanced age,5 length of stay greater than 7 days,6 a high burden of comorbid illnesses (based on Charlson score),7 poor social support,8 and specific diagnoses (eg, congestive heart failure, chronic obstructive pulmonary disease [COPD] and myocardial infarction).5, 9, 10 In addition, unplanned readmissions and emergency department (ED) visits have been linked to polypharmacy and adverse drug events related to treatment with medications such as warfarin, digoxin and narcotics.11, 12 Another characteristic that has also been linked to readmission is depression;13 however5 reports supporting this association are from studies of elderly patients or with patients who have specific diagnoses (eg, congestive heart failure [CHF], COPD, myocardial infarction).1416

Depression is common, affecting 13% to 16% of people in the US, and is recognized as an important risk factor for poor outcomes among patients with various chronic illnesses.1719 The mechanisms by which depression can be linked to health outcomes and health service utilization have been studied in age‐specific or disease‐specific cohorts such as cardiac patients or frail elders and include both physiologic factors such as hypercoagulability and hyperinflammatory conditions, as well as behavioral factors such as poor self‐care behaviors and heightened sensitivity to somatic symptoms. How these mechanisms link depression to health outcomes and hospital utilization in a general medical population is not clearly understood. Kartha et al.13 reported findings indicating that depression is a risk factor for rehospitalization in general medical inpatients, but the study sample was relatively small and the study design methodology significantly limited its generalizability.12 It would be useful to provide supporting evidence showing depression as an important risk factor for readmission in the general medical in‐patient population using more rigorous study methods and a larger cohort.

We hypothesized that depressive symptoms would be an independent risk factor for early unplanned hospital utilization after discharge for all medical patients. Therefore, we conducted a secondary analysis of the Project RED clinical trial dataset to assess the association between a positive depression screen during inpatient hospitalization and the rate of subsequent hospital utilization.

Methods

Data from the Project RED clinical trial were reviewed for inclusion in a secondary analysis. Complete data were available for 738 of the 749 subjects recruited for Project RED.

Results

A total of 28% of subjects were categorized as having a positive depression screen. More women (36%) had positive depression screens than men (28%). Among patients with a positive depression screen, 58% had a history of depression and 53% were currently taking medications at the time of enrollment, compared with 25% and 22% respectively for subjects with a negative depression screen. Table 1 presents the means or percentages for baseline characteristics by depression status in the analytic cohort. Subjects with Medicaid for insurance had a higher rate of depression (61%) than subjects with Medicare (13%), private insurance (9%), or those who qualified for the Free Care pool (17%) which is the Massachusetts state funding for healthcare to uninsured persons. Subjects who were unemployed, unmarried, or who reported earnings less than $10,000 per year were also more likely to screen positive for depression. In addition, depressed subjects had a higher severity of co‐morbid disease and longer length of stay for the index hospitalization. Patients categorized as frequent utilizers (2 or more prior admissions) for the 6 months prior to the index hospitalization were also more likely to be depressed. Of further note, is the relatively younger average age among both depressive patients (49.6 years) and non‐depressive patients (49.9) of these study subjects.

The unadjusted hospital utilization rate at 30, 60, and 90 days post‐discharge by depression status is shown in Table 2. At 30 days post‐discharge, those with depressive symptoms had a higher rate of hospital utilization than those without depressive symptoms (0.563 vs. 0.296). In other words, 56 utilization events occurred per 100 patients with depressive symptoms, compared with 30 utilization events per 100 patients without depressive symptoms. The unadjusted 30‐day post‐discharge hospital utilization rate among those with depressive symptoms was higher compared with those without symptoms (IRR, 1.90, 95% confidence interval [CI], 1.242.71). A similar trend was found among subjects at 60 and 90 days post‐discharge.

Poisson regression analyses were conducted to control for potential confounding in the relationship between depressive symptoms and hospital utilization rate within 30 days after discharge (Table 3). After controlling for relevant confounders, including age, gender, employment status, frequent prior hospitalization status, marital status, Charlson score, Project RED study group assignment and the interaction variable for RED study group assignment and depression, the association between symptoms of depression, and hospital utilization rate remained significant (IRR, 1.73; 95% CI, 1.272.36).

Figure 1 depicts the Kaplan‐Meier hazard curve generated for time to first hospital utilization, stratified by depression status. While 21% of participants without symptoms of depression had a hospital utilization within 30 days, fully 29% of participants with symptoms of depression had a hospital utilization within 30 days (P = 0.011).

Figure 1

Discussion

Our study shows hospitalized patients who screen positive for depressive symptoms are significantly more likely to have a hospital visit (emergency room or rehospitalization) within 30 days of discharge than those who do not screen positive for depressive symptoms among medical patients admitted to an urban, academic, safety‐net hospital. These findings are consistent with, and extend, prior reports regarding depression and rehospitalization in specific populations (ie, geriatrics) and specific diagnoses (ie, cardiovascular disease [CVD] and COPD).1012 We observed a 73% higher incidence rate for hospital utilization within 30 days of discharge for those with symptoms of depression. This puts symptoms of depression on par with frequent prior rehospitalization, advanced age and low social support, as known risk factors for rehospitalization.4, 5, 23

Also of significance is the relatively young age of this study population (49.9 years non‐depressive patients and 49.6 years for depressive patients) compared with the study cohorts used for research in the majority of the existing literature. The chief reason for the young age of our cohort is that potential subjects were excluded if they came from a skilled nursing facility or other hospital. This may limit the generalizability of our findings; however, it seems likely that interventions relating to depression and transitions of care will need to be quite different for patients that reside in long‐term care facilities vs. patients that live in the community. For example, patients living in the community may have significant barriers to access post‐discharge services due to insurance status and are more likely to be sensitive to variations in social support.

Early rehospitalization is associated with significant morbidity, mortality, and expense. It is also a potential marker for poor quality of care.24 Concerns for patient safety, escalating healthcare costs, and possible change in hospital reimbursement mechanisms are fueling the search for modifiable risk factors associated with early rehospitalization. Our data provide evidence that symptoms of depression may be an important focus of attention. We do not know, however whether treating hospitalized patients who screen positive for depression will decrease early rehospitalization and emergency room utilization rates.

Various physiologic and behavioral mechanisms may link symptoms of depression to hospital utilization after discharge. For example, depressed patients with features of somatization may be more likely to experience worrisome physical symptoms after discharge and present prematurely for reevaluation. Patients who are sicker in some fashion not captured by our measured confounders may have symptoms of depression related to chronic, debilitating disease warranting early return to the hospital. Depression may also yield nonadherence to aspects of the discharge treatment plan leading to rehospitalization as a result of poor post‐discharge disease management. For example, research shows that patients with depression following coronary artery bypass surgery are less likely to adhere with cardiac rehabilitation programs.25 Likewise, depression among chronically ill patients such as diabetics, asthmatics, or human immunodeficiency virus (HIV)‐positive patients impairs medication adherence and self‐care behavior which may lead to disease relapse or recurrence.2628 One study examining depression effects on hypertensive medicine adherence in African Americans identified self‐efficacy as a mediating factor between depression and nonadherence.29 This implies that interventions such as self‐management education, a program through which chronically‐ill patients learn to better manage their illnesses through enhanced self‐confidence and problem‐solving strategies (including mood disorder challenges) may reduce early rehospitalization among depressed patients.30

There is also evidence that depression may have direct physiologic consequences. In patients with CVD, depression is associated with poor outcomes possibly related to decreased heart rate variability, hypercoagulability, high burdens of inflammatory markers, and severity of left ventricular dysfunction.3134 Similarly, depression among HIV/acquired immune deficiency syndrome (AIDS), diabetics and multiple sclerosis (MS) patients is linked to heightened levels of proinflammatory markers and less favorable outcomes that may signal a more severe form of the disease or an impaired response to treatment.3538 Indeed, MS investigators now hypothesize that the proinflammatory environment associated with the neurologic manifestations of MS are also causing depression symptoms among MS patients.34 This theory contrasts the common belief that depression in the chronically ill manifests independent of the chronic illness or in response to living with chronic disease.

A major strength of the current study is the large dataset and the broad range of covariates available for analyses. However, several limitations should be noted. First, data on hospital utilization outside Boston Medical Center were determined by patient self‐report and were not confirmed by document review. Second, we do not know the direction of the associations we report. If symptoms of depression are merely the consequence of having a higher disease burden, treatment of the underlying disease may be the most important response. While this is possible, our model does include several variables (eg, Charlson score and length of stay) that are likely to adjust for disease severity, pointing to the likelihood that symptoms of depression truly predict hospital utilization in a fashion that is independent of disease severity. Third, our results may not be generalizable to populations other than those served by urban safety‐net hospitals or other populations excluded from the Project RED trial (eg, non‐English speaking patients and patients from nursing homes). Finally, social factors such as substance use and social support system variables may residually confound the relationship between depression and hospital reutilization demonstrated in this study. While this dataset does not include a measure of social support other than marital status and housing status, data is available on substance use. Analyses conducted by our colleagues using Project RED data found that in this study population depression was significantly more prevalent among substance users (29% vs. 14%) compared with non‐users and that substance use is an independent risk factor for hospital reutilization (unpublished data).

Our findings linking depression to increased hospital utilization also warrant further consideration from healthcare policymakers. Central to the Obama Administration's February 2009 healthcare reform proposal is the pursuit of cost savings through reductions in unplanned hospital readmissions.39 Thus, identifying potentially modifiable risk factors for readmission, such as depression, is of great concern to healthcare providers and policymakers across the nation. If, through testing of interventions, depression proves to be a modifiable risk for readmission, policymakers, while negotiating healthcare reform measures, must provide for the services required to address this comorbidity at the time of discharge. For example, if a patient screens positive for depressive symptoms during a hospitalization for COPD exacerbation, will the proposed payment reforms allow for mental health services during the immediate post‐discharge period in order to reduce the likelihood of hospital readmission? Will those mental health services be readily available? Payment reforms that account for all necessary transitional care services will indeed help reduce readmission costs with less risk for untoward consequences.

In conclusion, our results indicate that a positive depression screen is a significant risk factor for early post‐discharge hospital utilization among hospitalized adults on a general medical service, even after controlling for relevant confounders. Screening for depression during acute hospitalizations may be an important step in identifying patients at increased risk for readmission. Future research should focus on further characterizing and stratifying populations at highest risk for depression. Efforts should also include developing and evaluating targeted interventions for patients with symptoms of depression among hospitalized patients as part of discharge planning. Timely depression therapy during the hospitalization or following hospital discharge might reduce costly readmissions and enhance patient safety.

Recently, there has been an increased focus on improving communication during care transitions for older patients as they leave the hospital. One reason for this focus is the increasing utilization of hospitalists, or hospital‐based physicians, caring for patients in the United States.1 As a result, many primary care physicians (PCPs) no longer care for their patients while in the hospital and may not be informed of their patients' hospitalization.2 Additionally, with an emphasis on shorter lengths of hospital stay, more extensive post‐discharge follow‐up is often warranted for patients, which often becomes the responsibility of a patient's PCP. Recently 6 societies (American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society of Academic Emergency Medicine) have recommended that a patient's PCP is notified during all steps in care transitions and that patient‐centered approaches are employed.3 Despite the increased need for improved inpatient‐ambulatory care transitions, the communication between hospitalists and PCPs has been characterized as being poor and ineffective.4 Prior studies have shown that PCPs are not aware of test results that require follow‐up, may not receive timely or high quality discharge materials, and have an overall poor perception of the quality of communication.46 Ensuring adequate communication is considered important due to the increased risk of adverse events that patients experience after discharge from the hospital.79 Furthermore, recent studies have shown that patients are often able to identify and report adverse events that would not be detected by medical record review alone.10, 11 Eliciting patient perspectives on their experiences after discharge and their expectations of communication between PCPs and hospital physicians can help clinical teams design more patient‐centered solutions for care transitions.

The aim of this study is to report older patients' experiences with problems after hospital discharge and their understanding and expectation of communication between hospital physicians and their PCP. We also explored the relationship between patient experiences and whether their PCPs were aware of their hospitalization.

Methods

Results

Of the 114 eligible patients recruited between February and July 2008, 64 patient interviews were completed (56%). The average patient age was 73 years. Most patients were female (69%), African American (70%), live at home (75%), and have a PCP located at the University of Chicago (70%). There were also several who were low income (23% below a median yearly income of $15,000), and did not attend any college (52%). These patients had an average length of stay of 5.3 days, nearly half (48%) having been hospitalized in the past year, and 6 patients (9%) required a proxy to complete the interview (Table 1). There were no significant differences between responders and nonresponders with respect to race, gender, education, income, admission in the past 12 months, residence, PCP location, mental status, length of stay, or discharge status. Responders were more likely to be older than nonresponders (73 years [95% confidence interval {CI} 6976 years] vs. 63 years for nonresponders [95% CI 5769 years]; [P < 0.01]).

Forty‐two percent (27) of patients reported experiencing a post‐discharge problem. These 27 patients reported 42 distinct problems, each of which fell into 1 of 5 broad categories (Table 2). The most common of these were patients having difficulty obtaining follow‐up tests or appointments. These patients either had delay in getting, or were unable to get, follow‐up appointments, or follow‐up tests and test results. There were also many patients who needed reevaluation and thus, were either readmitted to the hospital or had to return to the Emergency Department. Another major category was those who had problems getting medication or therapy. For example, one of (the patients) treatment medswas very hard to find and it delayed us giving her her meds. Others reported they were not properly prepared for discharge. Most of these patients did not receive proper discharge materials which then caused other issues. As one proxy reported, The services were supposed to be provided for (the patient) through her social worker, no one has been informed to her being discharged or her being sent home. We have not gotten any services. Lastly, a few patients reported having hospital complications, such as post‐procedural complications, or questions, such as diagnosis questions.0

Patients were often uncertain of whether and how communication between the inpatient physician and PCP (Table 3) took place. One patient said, I don't know what the procedure is as far as giving him the message. Does she fax it to him? I don't know She told me that she was going to call and inform him on everything that happened. I don't know anything from there. The second most commonly expressed perception was from patients who assumed good communication had taken place between his or her physicians. This assumption was grounded in a belief that good communication naturally occurred between physicians. For example 1 patient expressed: (doctors) let the other doctors in too. That's the way to take care of stuff. Lastly, many patients expressed the feeling that their physicians were obligated to communicate with each other. As 1 patient reported, I think that they should have let (my PCP) know that I was in the hospital.

Two new themes emerged from the inductive analysis (Table 4). Forty‐five percent of patients reported experiencing negative emotions. These negative emotions were most often expressed as frustration or confusion. For example, 1 patient expressed confusion by saying, When I usually have lab work done I have prescription signedmaybe they changed the way of doing it. Now the pharmacy called me. But I'm supposed to have a note or something. Patients who reported a post‐discharge problem were more likely to report negative emotions (67% vs. 26%, P < 0.01). Feelings of empowerment were reported by 31% of patients. Empowerment was expressed most often as the patient being proactive in communicating with the PCP. One patient reported, We informed (my PCP) and we filled in all of the information that we wanted him to know about. Empowerment was also expressed as being proactive in advocating for communication between the inpatient team and the PCP (Table 3). Some patients expressed feeling empowered through the support of a third party, such as a home nurse. In addition, patients who have a third party advocate are more likely to report being empowered. Empowerment was expressed by 26% of patients with no third party advocate compared with 71% of patients with a third party advocate (P = 0.02).

From our sample of patients who completed a 2‐week post‐discharge interview, we were able to obtain PCP surveys for 40 (63%) of these patients (Figure 1). Thirty percent (12) of PCPs reported being unaware of the hospitalization. In all but 4 cases, PCPs had communicated with the medical team during hospitalization. Examining the association between PCP knowledge and patient reported post‐discharge problems showed that patients whose PCPs were not aware of the hospitalization were 2 times more likely to report a post‐discharge problem. A post‐discharge problem was reported by 67% of patients whose PCP was not aware of the hospitalization, while a post‐discharge problem was reported by 32% of patients whose PCP was aware (P < 0.05). Six patients reported returning to the ED or being readmitted. Four patients (33%) of PCPs who were unaware of hospitalization reported returning for reevaluation whereas 7% (n = 2) of patients whose PCP was aware of hospitalization reported returning for evaluation (P = 0.055). Interestingly, patients whose PCPs were not aware of the hospitalization reported feeling more empowered (58%) than those patients whose PCP were aware of the hospitalization (21%, P = 0.03). Because of possible confounding (patient report of problems post‐discharge problems may be affected by PCP awareness of hospitalization), we examined whether patients whose PCPs were aware of their hospitalization differed from those that did not. Patients whose PCPs were aware of their hospitalization were often older (75 vs. 69 years old), white (80% white vs. 65% nonwhite) and female (75% female vs. 54% male). While this small sample size prohibits examining for statistical significance, the magnitude of these differences suggests the need for a larger study to examine patient predictors of PCP awareness of hospitalization.

Figure 1

Discussion

In this sample of frail, older hospitalized patients, nearly half reported at least 1 post‐discharge problem. Most patients have perceptions of what communication did or did not take place between their physicians. While most do not understand the communication process, many expect good communication to occur, and feel that physicians are obligated to communicate with each other. However, patients' perceptions of communication highlight that patient expectations are far from the actual practice in some cases. Nearly half of patients reported feeling negative emotions, such as confusion and frustration, and patients were more likely to experience negative emotions when they also reported a post‐discharge problem. One‐third of patients reported feeling empowered. Empowerment was associated with having a third party who helped advocate for them. Paradoxically, patients whose PCP were not aware of their hospitalization were more likely to feel empowered. Lastly, more patients reported a post‐discharge problem when their PCP was not aware of the hospitalization.

Because this is predominantly a qualitative observational study, it is important to consider the mechanism for these findings since we cannot assume causal relationships. The association of negative emotions, like confusion and frustration, with post‐discharge problems could be explained due to additional stress of the problem itself or that a distressed frame of mind is associated with reporting more problems that may have been overlooked otherwise. In addition, the association between patient empowerment and lack of PCP awareness could be due to the fact that patients are forced to assume a more proactive role in contacting their PCP if they feel that their PCP was not aware. It is equally possible that PCP communication is selectively initiated by hospital physicians when the patients are least empowered. For example, our comparison of demographics for patients whose PCP was aware versus those that were not do suggest that patient characteristics might play a role in whether a patient's PCP is contacted. The association between a third party advocate and patient empowerment is likely explained as the third party is able to keep the patient informed and empowered.

This study has implications for efforts to design a more patient‐centered care transition for hospitalized older patients. First, patients and their proxies should be advocates for good communication to avoid the risks of care transitions. Prior interventions such as use of coaches to boost patient empowerment have had positive results for hospitalized older patients. Moreover, hospitals should keep in mind that problems after discharge are common and are linked to negative emotions, which may lower patient satisfaction or increase liability risk. Similarly, these findings also highlight the importance of keeping PCPs aware of patient hospitalization. For example, PCPs that are aware of hospitalization are better prepared to properly follow‐up on medications, tests, and appointments. The PCP can also help to better prepare the patient for discharge and ease the transition for the patient.

There are several limitations to our study. First and foremost, our small sample size limits our ability to examine statistical significance. This study was part of a short planning grant to design interventions to improve communication with PCPs during hospitalization. Efforts are currently underway to design a communication solution and educational intervention to highlight the importance of contacting PCPs during hospitalization. Because these patients were hospitalized on the teaching service, the resident with the guidance of the teaching attending is responsible for communicating with the PCP. The teaching attending was either a generalist, hospitalist, or specialist who routinely had no a priori relationship with patients prior to the hospitalization. Only 53% of patients were reached by telephone which raises the concern for nonresponse bias. Our low response rate highlights the challenge of doing this type of work with recently discharge patients in low income, underserved areas. In comparing responders and nonresponders, the only difference between the 2 groups was that responders were more likely to be older. One possible reason for this difference may be that older people are more likely to be at home and easier to contact over the phone. Similarly, since data were collected through interviews and adverse events were discussed, these results are subject to recall bias. Efforts were made to reduce this by calling within 2 to 3 weeks after discharge. Lastly, these findings are limited by generalizability. All the patients included in this study were from the University of Chicago Medical Center, which serves largely underserved, African American patients. The experiences of these patients may be unique to this site. In addition, we only studied patients who had a PCP, excluding a population of patients that are at inherent risk due to lack of a coordinating physician to guide ongoing care.

In conclusion, this study suggests that many frail, older patients reported experiencing a post‐discharge problem and patients whose PCPs did not know about their admission were more likely to report a post‐discharge problem. Systematic interventions to improve communications with PCPs during patient care transitions in and out of the hospital are needed.

Recently, there has been an increased focus on improving communication during care transitions for older patients as they leave the hospital. One reason for this focus is the increasing utilization of hospitalists, or hospital‐based physicians, caring for patients in the United States.1 As a result, many primary care physicians (PCPs) no longer care for their patients while in the hospital and may not be informed of their patients' hospitalization.2 Additionally, with an emphasis on shorter lengths of hospital stay, more extensive post‐discharge follow‐up is often warranted for patients, which often becomes the responsibility of a patient's PCP. Recently 6 societies (American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society of Academic Emergency Medicine) have recommended that a patient's PCP is notified during all steps in care transitions and that patient‐centered approaches are employed.3 Despite the increased need for improved inpatient‐ambulatory care transitions, the communication between hospitalists and PCPs has been characterized as being poor and ineffective.4 Prior studies have shown that PCPs are not aware of test results that require follow‐up, may not receive timely or high quality discharge materials, and have an overall poor perception of the quality of communication.46 Ensuring adequate communication is considered important due to the increased risk of adverse events that patients experience after discharge from the hospital.79 Furthermore, recent studies have shown that patients are often able to identify and report adverse events that would not be detected by medical record review alone.10, 11 Eliciting patient perspectives on their experiences after discharge and their expectations of communication between PCPs and hospital physicians can help clinical teams design more patient‐centered solutions for care transitions.

The aim of this study is to report older patients' experiences with problems after hospital discharge and their understanding and expectation of communication between hospital physicians and their PCP. We also explored the relationship between patient experiences and whether their PCPs were aware of their hospitalization.

Methods

Results

Of the 114 eligible patients recruited between February and July 2008, 64 patient interviews were completed (56%). The average patient age was 73 years. Most patients were female (69%), African American (70%), live at home (75%), and have a PCP located at the University of Chicago (70%). There were also several who were low income (23% below a median yearly income of $15,000), and did not attend any college (52%). These patients had an average length of stay of 5.3 days, nearly half (48%) having been hospitalized in the past year, and 6 patients (9%) required a proxy to complete the interview (Table 1). There were no significant differences between responders and nonresponders with respect to race, gender, education, income, admission in the past 12 months, residence, PCP location, mental status, length of stay, or discharge status. Responders were more likely to be older than nonresponders (73 years [95% confidence interval {CI} 6976 years] vs. 63 years for nonresponders [95% CI 5769 years]; [P < 0.01]).

Forty‐two percent (27) of patients reported experiencing a post‐discharge problem. These 27 patients reported 42 distinct problems, each of which fell into 1 of 5 broad categories (Table 2). The most common of these were patients having difficulty obtaining follow‐up tests or appointments. These patients either had delay in getting, or were unable to get, follow‐up appointments, or follow‐up tests and test results. There were also many patients who needed reevaluation and thus, were either readmitted to the hospital or had to return to the Emergency Department. Another major category was those who had problems getting medication or therapy. For example, one of (the patients) treatment medswas very hard to find and it delayed us giving her her meds. Others reported they were not properly prepared for discharge. Most of these patients did not receive proper discharge materials which then caused other issues. As one proxy reported, The services were supposed to be provided for (the patient) through her social worker, no one has been informed to her being discharged or her being sent home. We have not gotten any services. Lastly, a few patients reported having hospital complications, such as post‐procedural complications, or questions, such as diagnosis questions.0

Patients were often uncertain of whether and how communication between the inpatient physician and PCP (Table 3) took place. One patient said, I don't know what the procedure is as far as giving him the message. Does she fax it to him? I don't know She told me that she was going to call and inform him on everything that happened. I don't know anything from there. The second most commonly expressed perception was from patients who assumed good communication had taken place between his or her physicians. This assumption was grounded in a belief that good communication naturally occurred between physicians. For example 1 patient expressed: (doctors) let the other doctors in too. That's the way to take care of stuff. Lastly, many patients expressed the feeling that their physicians were obligated to communicate with each other. As 1 patient reported, I think that they should have let (my PCP) know that I was in the hospital.

Two new themes emerged from the inductive analysis (Table 4). Forty‐five percent of patients reported experiencing negative emotions. These negative emotions were most often expressed as frustration or confusion. For example, 1 patient expressed confusion by saying, When I usually have lab work done I have prescription signedmaybe they changed the way of doing it. Now the pharmacy called me. But I'm supposed to have a note or something. Patients who reported a post‐discharge problem were more likely to report negative emotions (67% vs. 26%, P < 0.01). Feelings of empowerment were reported by 31% of patients. Empowerment was expressed most often as the patient being proactive in communicating with the PCP. One patient reported, We informed (my PCP) and we filled in all of the information that we wanted him to know about. Empowerment was also expressed as being proactive in advocating for communication between the inpatient team and the PCP (Table 3). Some patients expressed feeling empowered through the support of a third party, such as a home nurse. In addition, patients who have a third party advocate are more likely to report being empowered. Empowerment was expressed by 26% of patients with no third party advocate compared with 71% of patients with a third party advocate (P = 0.02).

From our sample of patients who completed a 2‐week post‐discharge interview, we were able to obtain PCP surveys for 40 (63%) of these patients (Figure 1). Thirty percent (12) of PCPs reported being unaware of the hospitalization. In all but 4 cases, PCPs had communicated with the medical team during hospitalization. Examining the association between PCP knowledge and patient reported post‐discharge problems showed that patients whose PCPs were not aware of the hospitalization were 2 times more likely to report a post‐discharge problem. A post‐discharge problem was reported by 67% of patients whose PCP was not aware of the hospitalization, while a post‐discharge problem was reported by 32% of patients whose PCP was aware (P < 0.05). Six patients reported returning to the ED or being readmitted. Four patients (33%) of PCPs who were unaware of hospitalization reported returning for reevaluation whereas 7% (n = 2) of patients whose PCP was aware of hospitalization reported returning for evaluation (P = 0.055). Interestingly, patients whose PCPs were not aware of the hospitalization reported feeling more empowered (58%) than those patients whose PCP were aware of the hospitalization (21%, P = 0.03). Because of possible confounding (patient report of problems post‐discharge problems may be affected by PCP awareness of hospitalization), we examined whether patients whose PCPs were aware of their hospitalization differed from those that did not. Patients whose PCPs were aware of their hospitalization were often older (75 vs. 69 years old), white (80% white vs. 65% nonwhite) and female (75% female vs. 54% male). While this small sample size prohibits examining for statistical significance, the magnitude of these differences suggests the need for a larger study to examine patient predictors of PCP awareness of hospitalization.

Figure 1

Discussion

In this sample of frail, older hospitalized patients, nearly half reported at least 1 post‐discharge problem. Most patients have perceptions of what communication did or did not take place between their physicians. While most do not understand the communication process, many expect good communication to occur, and feel that physicians are obligated to communicate with each other. However, patients' perceptions of communication highlight that patient expectations are far from the actual practice in some cases. Nearly half of patients reported feeling negative emotions, such as confusion and frustration, and patients were more likely to experience negative emotions when they also reported a post‐discharge problem. One‐third of patients reported feeling empowered. Empowerment was associated with having a third party who helped advocate for them. Paradoxically, patients whose PCP were not aware of their hospitalization were more likely to feel empowered. Lastly, more patients reported a post‐discharge problem when their PCP was not aware of the hospitalization.

Because this is predominantly a qualitative observational study, it is important to consider the mechanism for these findings since we cannot assume causal relationships. The association of negative emotions, like confusion and frustration, with post‐discharge problems could be explained due to additional stress of the problem itself or that a distressed frame of mind is associated with reporting more problems that may have been overlooked otherwise. In addition, the association between patient empowerment and lack of PCP awareness could be due to the fact that patients are forced to assume a more proactive role in contacting their PCP if they feel that their PCP was not aware. It is equally possible that PCP communication is selectively initiated by hospital physicians when the patients are least empowered. For example, our comparison of demographics for patients whose PCP was aware versus those that were not do suggest that patient characteristics might play a role in whether a patient's PCP is contacted. The association between a third party advocate and patient empowerment is likely explained as the third party is able to keep the patient informed and empowered.

This study has implications for efforts to design a more patient‐centered care transition for hospitalized older patients. First, patients and their proxies should be advocates for good communication to avoid the risks of care transitions. Prior interventions such as use of coaches to boost patient empowerment have had positive results for hospitalized older patients. Moreover, hospitals should keep in mind that problems after discharge are common and are linked to negative emotions, which may lower patient satisfaction or increase liability risk. Similarly, these findings also highlight the importance of keeping PCPs aware of patient hospitalization. For example, PCPs that are aware of hospitalization are better prepared to properly follow‐up on medications, tests, and appointments. The PCP can also help to better prepare the patient for discharge and ease the transition for the patient.

There are several limitations to our study. First and foremost, our small sample size limits our ability to examine statistical significance. This study was part of a short planning grant to design interventions to improve communication with PCPs during hospitalization. Efforts are currently underway to design a communication solution and educational intervention to highlight the importance of contacting PCPs during hospitalization. Because these patients were hospitalized on the teaching service, the resident with the guidance of the teaching attending is responsible for communicating with the PCP. The teaching attending was either a generalist, hospitalist, or specialist who routinely had no a priori relationship with patients prior to the hospitalization. Only 53% of patients were reached by telephone which raises the concern for nonresponse bias. Our low response rate highlights the challenge of doing this type of work with recently discharge patients in low income, underserved areas. In comparing responders and nonresponders, the only difference between the 2 groups was that responders were more likely to be older. One possible reason for this difference may be that older people are more likely to be at home and easier to contact over the phone. Similarly, since data were collected through interviews and adverse events were discussed, these results are subject to recall bias. Efforts were made to reduce this by calling within 2 to 3 weeks after discharge. Lastly, these findings are limited by generalizability. All the patients included in this study were from the University of Chicago Medical Center, which serves largely underserved, African American patients. The experiences of these patients may be unique to this site. In addition, we only studied patients who had a PCP, excluding a population of patients that are at inherent risk due to lack of a coordinating physician to guide ongoing care.

In conclusion, this study suggests that many frail, older patients reported experiencing a post‐discharge problem and patients whose PCPs did not know about their admission were more likely to report a post‐discharge problem. Systematic interventions to improve communications with PCPs during patient care transitions in and out of the hospital are needed.

Recently, there has been an increased focus on improving communication during care transitions for older patients as they leave the hospital. One reason for this focus is the increasing utilization of hospitalists, or hospital‐based physicians, caring for patients in the United States.1 As a result, many primary care physicians (PCPs) no longer care for their patients while in the hospital and may not be informed of their patients' hospitalization.2 Additionally, with an emphasis on shorter lengths of hospital stay, more extensive post‐discharge follow‐up is often warranted for patients, which often becomes the responsibility of a patient's PCP. Recently 6 societies (American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society of Academic Emergency Medicine) have recommended that a patient's PCP is notified during all steps in care transitions and that patient‐centered approaches are employed.3 Despite the increased need for improved inpatient‐ambulatory care transitions, the communication between hospitalists and PCPs has been characterized as being poor and ineffective.4 Prior studies have shown that PCPs are not aware of test results that require follow‐up, may not receive timely or high quality discharge materials, and have an overall poor perception of the quality of communication.46 Ensuring adequate communication is considered important due to the increased risk of adverse events that patients experience after discharge from the hospital.79 Furthermore, recent studies have shown that patients are often able to identify and report adverse events that would not be detected by medical record review alone.10, 11 Eliciting patient perspectives on their experiences after discharge and their expectations of communication between PCPs and hospital physicians can help clinical teams design more patient‐centered solutions for care transitions.

The aim of this study is to report older patients' experiences with problems after hospital discharge and their understanding and expectation of communication between hospital physicians and their PCP. We also explored the relationship between patient experiences and whether their PCPs were aware of their hospitalization.

Methods

Results

Of the 114 eligible patients recruited between February and July 2008, 64 patient interviews were completed (56%). The average patient age was 73 years. Most patients were female (69%), African American (70%), live at home (75%), and have a PCP located at the University of Chicago (70%). There were also several who were low income (23% below a median yearly income of $15,000), and did not attend any college (52%). These patients had an average length of stay of 5.3 days, nearly half (48%) having been hospitalized in the past year, and 6 patients (9%) required a proxy to complete the interview (Table 1). There were no significant differences between responders and nonresponders with respect to race, gender, education, income, admission in the past 12 months, residence, PCP location, mental status, length of stay, or discharge status. Responders were more likely to be older than nonresponders (73 years [95% confidence interval {CI} 6976 years] vs. 63 years for nonresponders [95% CI 5769 years]; [P < 0.01]).

Forty‐two percent (27) of patients reported experiencing a post‐discharge problem. These 27 patients reported 42 distinct problems, each of which fell into 1 of 5 broad categories (Table 2). The most common of these were patients having difficulty obtaining follow‐up tests or appointments. These patients either had delay in getting, or were unable to get, follow‐up appointments, or follow‐up tests and test results. There were also many patients who needed reevaluation and thus, were either readmitted to the hospital or had to return to the Emergency Department. Another major category was those who had problems getting medication or therapy. For example, one of (the patients) treatment medswas very hard to find and it delayed us giving her her meds. Others reported they were not properly prepared for discharge. Most of these patients did not receive proper discharge materials which then caused other issues. As one proxy reported, The services were supposed to be provided for (the patient) through her social worker, no one has been informed to her being discharged or her being sent home. We have not gotten any services. Lastly, a few patients reported having hospital complications, such as post‐procedural complications, or questions, such as diagnosis questions.0

Patients were often uncertain of whether and how communication between the inpatient physician and PCP (Table 3) took place. One patient said, I don't know what the procedure is as far as giving him the message. Does she fax it to him? I don't know She told me that she was going to call and inform him on everything that happened. I don't know anything from there. The second most commonly expressed perception was from patients who assumed good communication had taken place between his or her physicians. This assumption was grounded in a belief that good communication naturally occurred between physicians. For example 1 patient expressed: (doctors) let the other doctors in too. That's the way to take care of stuff. Lastly, many patients expressed the feeling that their physicians were obligated to communicate with each other. As 1 patient reported, I think that they should have let (my PCP) know that I was in the hospital.

Two new themes emerged from the inductive analysis (Table 4). Forty‐five percent of patients reported experiencing negative emotions. These negative emotions were most often expressed as frustration or confusion. For example, 1 patient expressed confusion by saying, When I usually have lab work done I have prescription signedmaybe they changed the way of doing it. Now the pharmacy called me. But I'm supposed to have a note or something. Patients who reported a post‐discharge problem were more likely to report negative emotions (67% vs. 26%, P < 0.01). Feelings of empowerment were reported by 31% of patients. Empowerment was expressed most often as the patient being proactive in communicating with the PCP. One patient reported, We informed (my PCP) and we filled in all of the information that we wanted him to know about. Empowerment was also expressed as being proactive in advocating for communication between the inpatient team and the PCP (Table 3). Some patients expressed feeling empowered through the support of a third party, such as a home nurse. In addition, patients who have a third party advocate are more likely to report being empowered. Empowerment was expressed by 26% of patients with no third party advocate compared with 71% of patients with a third party advocate (P = 0.02).

From our sample of patients who completed a 2‐week post‐discharge interview, we were able to obtain PCP surveys for 40 (63%) of these patients (Figure 1). Thirty percent (12) of PCPs reported being unaware of the hospitalization. In all but 4 cases, PCPs had communicated with the medical team during hospitalization. Examining the association between PCP knowledge and patient reported post‐discharge problems showed that patients whose PCPs were not aware of the hospitalization were 2 times more likely to report a post‐discharge problem. A post‐discharge problem was reported by 67% of patients whose PCP was not aware of the hospitalization, while a post‐discharge problem was reported by 32% of patients whose PCP was aware (P < 0.05). Six patients reported returning to the ED or being readmitted. Four patients (33%) of PCPs who were unaware of hospitalization reported returning for reevaluation whereas 7% (n = 2) of patients whose PCP was aware of hospitalization reported returning for evaluation (P = 0.055). Interestingly, patients whose PCPs were not aware of the hospitalization reported feeling more empowered (58%) than those patients whose PCP were aware of the hospitalization (21%, P = 0.03). Because of possible confounding (patient report of problems post‐discharge problems may be affected by PCP awareness of hospitalization), we examined whether patients whose PCPs were aware of their hospitalization differed from those that did not. Patients whose PCPs were aware of their hospitalization were often older (75 vs. 69 years old), white (80% white vs. 65% nonwhite) and female (75% female vs. 54% male). While this small sample size prohibits examining for statistical significance, the magnitude of these differences suggests the need for a larger study to examine patient predictors of PCP awareness of hospitalization.

Figure 1

Discussion

In this sample of frail, older hospitalized patients, nearly half reported at least 1 post‐discharge problem. Most patients have perceptions of what communication did or did not take place between their physicians. While most do not understand the communication process, many expect good communication to occur, and feel that physicians are obligated to communicate with each other. However, patients' perceptions of communication highlight that patient expectations are far from the actual practice in some cases. Nearly half of patients reported feeling negative emotions, such as confusion and frustration, and patients were more likely to experience negative emotions when they also reported a post‐discharge problem. One‐third of patients reported feeling empowered. Empowerment was associated with having a third party who helped advocate for them. Paradoxically, patients whose PCP were not aware of their hospitalization were more likely to feel empowered. Lastly, more patients reported a post‐discharge problem when their PCP was not aware of the hospitalization.

Because this is predominantly a qualitative observational study, it is important to consider the mechanism for these findings since we cannot assume causal relationships. The association of negative emotions, like confusion and frustration, with post‐discharge problems could be explained due to additional stress of the problem itself or that a distressed frame of mind is associated with reporting more problems that may have been overlooked otherwise. In addition, the association between patient empowerment and lack of PCP awareness could be due to the fact that patients are forced to assume a more proactive role in contacting their PCP if they feel that their PCP was not aware. It is equally possible that PCP communication is selectively initiated by hospital physicians when the patients are least empowered. For example, our comparison of demographics for patients whose PCP was aware versus those that were not do suggest that patient characteristics might play a role in whether a patient's PCP is contacted. The association between a third party advocate and patient empowerment is likely explained as the third party is able to keep the patient informed and empowered.

This study has implications for efforts to design a more patient‐centered care transition for hospitalized older patients. First, patients and their proxies should be advocates for good communication to avoid the risks of care transitions. Prior interventions such as use of coaches to boost patient empowerment have had positive results for hospitalized older patients. Moreover, hospitals should keep in mind that problems after discharge are common and are linked to negative emotions, which may lower patient satisfaction or increase liability risk. Similarly, these findings also highlight the importance of keeping PCPs aware of patient hospitalization. For example, PCPs that are aware of hospitalization are better prepared to properly follow‐up on medications, tests, and appointments. The PCP can also help to better prepare the patient for discharge and ease the transition for the patient.

There are several limitations to our study. First and foremost, our small sample size limits our ability to examine statistical significance. This study was part of a short planning grant to design interventions to improve communication with PCPs during hospitalization. Efforts are currently underway to design a communication solution and educational intervention to highlight the importance of contacting PCPs during hospitalization. Because these patients were hospitalized on the teaching service, the resident with the guidance of the teaching attending is responsible for communicating with the PCP. The teaching attending was either a generalist, hospitalist, or specialist who routinely had no a priori relationship with patients prior to the hospitalization. Only 53% of patients were reached by telephone which raises the concern for nonresponse bias. Our low response rate highlights the challenge of doing this type of work with recently discharge patients in low income, underserved areas. In comparing responders and nonresponders, the only difference between the 2 groups was that responders were more likely to be older. One possible reason for this difference may be that older people are more likely to be at home and easier to contact over the phone. Similarly, since data were collected through interviews and adverse events were discussed, these results are subject to recall bias. Efforts were made to reduce this by calling within 2 to 3 weeks after discharge. Lastly, these findings are limited by generalizability. All the patients included in this study were from the University of Chicago Medical Center, which serves largely underserved, African American patients. The experiences of these patients may be unique to this site. In addition, we only studied patients who had a PCP, excluding a population of patients that are at inherent risk due to lack of a coordinating physician to guide ongoing care.

In conclusion, this study suggests that many frail, older patients reported experiencing a post‐discharge problem and patients whose PCPs did not know about their admission were more likely to report a post‐discharge problem. Systematic interventions to improve communications with PCPs during patient care transitions in and out of the hospital are needed.

Narrative Description

This Case Report reviews the presentation, the differential diagnosis and the treatment modalities used to treat calciphylaxis. It emphasizes the poor prognosis and that there is inadequate clinical experience to guide a physician as to what the most appropriate treatment is despite promising anecdotal reports about a variety of agents. The report demonstrates that intravenous sodium thiosulfate is tolerated.

Key Points

• Calciphylaxis occurs in 1 to 4% of patients with end stage renal failure.

• Two patterns of presentation are generally recognizedcentral and peripheral.

• Pain is a prominent symptom and eschar formation is usually present.

• The role of surgery is controversial.

• Several promising modalities for the treatment of this condition have been described in anecdotal reports.

Calciphylaxis is a rare condition. It is seen most frequently in patients with chronic kidney disease and can affect any part of the body.14 Calciphylaxis is increasingly being referred to as calcific uremic arteriolopathy as this term more accurately reflects the histology of vascular calcification in small‐ and medium‐sized arteries, intimal arterial hypertrophy, and small vessel thrombosis associated with panniculitis, dermal necrosis, and eschar formation.5 Pain is a prominent symptom. The most effective treatment for this condition remains uncertain.

Case Report

A 68‐year‐old female presented with an 8‐month history of increasing lower extremity edema, and numerous large, painful, necrotic ulcers with an associated foul odor. She had a past medical history of type 2 diabetes mellitus, hypertension, end stage renal disease requiring hemodialysis 3 times a week for the previous 6 months, severe peripheral vascular disease, coronary artery disease for which she had previously undergone coronary artery bypass surgery, multiple myocardial infarctions, and congestive heart failure with an ejection fraction of 20%. She had also suffered from numerous infections including septicemia, endocarditis, and a sternal wound infection in the past with no current evidence of septicemia or endocarditis. The patient was not on calcium supplements, Vitamin D, warfarin or calcium‐containing phosphate binders.

Eight months prior to admission she developed vesicles on the left thigh that slowly progressed to large, extremely painful, violaceous, indurated plaques with central ulceration and eschar (Figure 1). She subsequently developed several smaller lesions with similar morphology on her legs and feet and gangrene of her left big toe (Figure 2). A biopsy from the left thigh was consistent with calciphylaxis with associated necrosis of the deep dermis and subcutaneous tissues. The patient's lesions were aggressively debrided, broad spectrum antibiotics given, and the patient dialyzed with low calcium dialysates. Ultimately intravenous sodium thiosulfate (25 g intravenously, over 60 minutes), was given which she tolerated with no side effect. Sodium thiosulfate is thought to act by forming highly soluble calcium thiosulfate salts and therefore mobilizing tissue calcium.5 Hyperbaric oxygen was contraindicated because of the patient's left ventricular ejection fraction (LVEF) of 20% and previous history of congestive heart failure as this treatment modality may precipitate congestive heart failure in a patient with a low LVEF particularly with a past history of congestive heart failure. Her condition continued to deteriorate and she died a few days after initiation of intravenous sodium thiosulfate infusion secondary to a massive gastrointestinal bleed.

Figure 1

Figure 2

Discussion

The differential diagnosis for painful necrotic cutaneous ulcerations with eschar formation includes: calciphylaxis, cryoglobulinemia, cryofibrinogenema, peripheral vascular disease, embolic phenomenon (endocarditis, septic, cholesterol), warfarin skin necrosis, brown recluse spider bites, hypercoagulable states, hyperoxaluria, and necrotizing vasculitis.14

Calciphylaxis is a rare entity that affects approximately 1% to 4% of end stage renal failure patients.1, 3 The typical patient is a morbidly obese, female with longstanding end stage renal disease, diabetes, hyperphosphatemia and an elevated calcium‐phosphate product usually greater than 60 mg²/dL².1, 3 It has also been described in patients with alcoholic cirrhosis and acute reversible renal failure,6 primary and secondary hyperparathyroidism,7 and metastatic breast cancer.8

Patients typically present with symmetric lesions that evolve from erythematous to violaceous, livedo‐reticularis like patches or plaques with occasional bullae to painful, indurated, necrotic plaques that subsequently ulcerate. The ulcerations are slow to heal and covered with eschar.4, 9

There are 2 patterns of involvement. The central/proximal pattern involves the abdomen, gluteal region, and thighs while the peripheral/distal pattern involves the extremities distal to the elbows and knees.1, 2, 4 The central pattern tends to carry a worse prognosis,9, 10 though this has not been validated in all reports and recent literature suggests that patients with both patterns have the worst prognosis.11

A biopsy may be required to exclude other diagnoses. The histology demonstrates an obliterative vasculopathy secondary to the vascular intimal changes and endovascular fibrosis.12 A suggestive finding is calcification of the medial wall of small‐ and medium‐sized arteries and arterioles with associated intimal hyperplasia and fibrosis. Necrosis of the surrounding tissue, panniculitis, and soft tissue calcification are often present.9, 13 The trauma of the biopsy can lead to worsening of the disease.

Secondary to its association with end stage renal disease, laboratory data often reveals elevated blood urea nitrogen (BUN), creatinine, parathyroid hormone, and calcium‐phosphate product. Bone scans show increased uptake in the subcutaneous calcified plaques.14 X‐rays utilizing mammogram technique have demonstrated arteriolar calcification.15

Besides chronic kidney disease, other potential risk factors include protein C and S deficiencies, obesity, warfarin use, high calcium containing dialysates, liver disease, and systemic corticosteroids.4, 9, 11, 16

Calciphylaxis is a difficult disease to treat with a mortality of 60% to 70%9 and a 1‐year survival rate of 45.8%.11 There is no consistently effective treatment.5 Therapy therefore, is focused on symptom control, debridement, and treatment of infection. Mortality is most commonly due to wound infections and resulting septicemia. Meticulous wound care is important with any infection treated early and aggressively. Though trauma and surgical procedures have been known to precipitate ulcerations, given their high rate of infection early surgical debridement of wounds is often required and has been shown to improve mortality.11, 17 Because of the poor healing of the involved tissues, wounds are often left to close by secondary intention or in some circumstances with vacuum assistance.2

As secondary hyperparathyroidism is common, attempts are often made to lower the calcium‐phosphate product. This often requires parathyroidectomy.18 Calcium containing phosphate binders are avoided and low calcium dialysate used.19 However, the above interventions do not consistently improve mortality.5, 11

Other potential treatments include: hyperbaric oxygen therapy,20 intravenous sodium thiosulfate,14 low‐dose tissue plasminogen activator,21 cinacalcet,22 etidronate disodium,23 and maggots.24 Because of the rarity of the condition, most of the literature to date is anecdotal and based on case reports and small retrospective studies.

Conclusions

As the number of patients who develop chronic kidney disease and require hemodialysis increases, it is likely that the number of patients who develop calciphylaxis will also increase. Hospitalists, besides nephrologists, should therefore become familiar with the presentation of this disease as it is possible, although unproven, that treatment in the early stage of the disease may result in a better response. Although several treatment modalities have been used to treat calcific uremic arteriolopathy or calciphylaxis, it remains unclear what is the best treatment for these patients. Carefully done clinical trials using some of the treatment modalities mentioned will help physicians decide what the most appropriate treatment is for patients with this debilitating and often fatal disease.

Narrative Description

This Case Report reviews the presentation, the differential diagnosis and the treatment modalities used to treat calciphylaxis. It emphasizes the poor prognosis and that there is inadequate clinical experience to guide a physician as to what the most appropriate treatment is despite promising anecdotal reports about a variety of agents. The report demonstrates that intravenous sodium thiosulfate is tolerated.

Key Points

• Calciphylaxis occurs in 1 to 4% of patients with end stage renal failure.

• Two patterns of presentation are generally recognizedcentral and peripheral.

• Pain is a prominent symptom and eschar formation is usually present.

• The role of surgery is controversial.

• Several promising modalities for the treatment of this condition have been described in anecdotal reports.

Calciphylaxis is a rare condition. It is seen most frequently in patients with chronic kidney disease and can affect any part of the body.14 Calciphylaxis is increasingly being referred to as calcific uremic arteriolopathy as this term more accurately reflects the histology of vascular calcification in small‐ and medium‐sized arteries, intimal arterial hypertrophy, and small vessel thrombosis associated with panniculitis, dermal necrosis, and eschar formation.5 Pain is a prominent symptom. The most effective treatment for this condition remains uncertain.

Case Report

A 68‐year‐old female presented with an 8‐month history of increasing lower extremity edema, and numerous large, painful, necrotic ulcers with an associated foul odor. She had a past medical history of type 2 diabetes mellitus, hypertension, end stage renal disease requiring hemodialysis 3 times a week for the previous 6 months, severe peripheral vascular disease, coronary artery disease for which she had previously undergone coronary artery bypass surgery, multiple myocardial infarctions, and congestive heart failure with an ejection fraction of 20%. She had also suffered from numerous infections including septicemia, endocarditis, and a sternal wound infection in the past with no current evidence of septicemia or endocarditis. The patient was not on calcium supplements, Vitamin D, warfarin or calcium‐containing phosphate binders.

Eight months prior to admission she developed vesicles on the left thigh that slowly progressed to large, extremely painful, violaceous, indurated plaques with central ulceration and eschar (Figure 1). She subsequently developed several smaller lesions with similar morphology on her legs and feet and gangrene of her left big toe (Figure 2). A biopsy from the left thigh was consistent with calciphylaxis with associated necrosis of the deep dermis and subcutaneous tissues. The patient's lesions were aggressively debrided, broad spectrum antibiotics given, and the patient dialyzed with low calcium dialysates. Ultimately intravenous sodium thiosulfate (25 g intravenously, over 60 minutes), was given which she tolerated with no side effect. Sodium thiosulfate is thought to act by forming highly soluble calcium thiosulfate salts and therefore mobilizing tissue calcium.5 Hyperbaric oxygen was contraindicated because of the patient's left ventricular ejection fraction (LVEF) of 20% and previous history of congestive heart failure as this treatment modality may precipitate congestive heart failure in a patient with a low LVEF particularly with a past history of congestive heart failure. Her condition continued to deteriorate and she died a few days after initiation of intravenous sodium thiosulfate infusion secondary to a massive gastrointestinal bleed.

Figure 1

Figure 2

Discussion

The differential diagnosis for painful necrotic cutaneous ulcerations with eschar formation includes: calciphylaxis, cryoglobulinemia, cryofibrinogenema, peripheral vascular disease, embolic phenomenon (endocarditis, septic, cholesterol), warfarin skin necrosis, brown recluse spider bites, hypercoagulable states, hyperoxaluria, and necrotizing vasculitis.14

Calciphylaxis is a rare entity that affects approximately 1% to 4% of end stage renal failure patients.1, 3 The typical patient is a morbidly obese, female with longstanding end stage renal disease, diabetes, hyperphosphatemia and an elevated calcium‐phosphate product usually greater than 60 mg²/dL².1, 3 It has also been described in patients with alcoholic cirrhosis and acute reversible renal failure,6 primary and secondary hyperparathyroidism,7 and metastatic breast cancer.8

Patients typically present with symmetric lesions that evolve from erythematous to violaceous, livedo‐reticularis like patches or plaques with occasional bullae to painful, indurated, necrotic plaques that subsequently ulcerate. The ulcerations are slow to heal and covered with eschar.4, 9

There are 2 patterns of involvement. The central/proximal pattern involves the abdomen, gluteal region, and thighs while the peripheral/distal pattern involves the extremities distal to the elbows and knees.1, 2, 4 The central pattern tends to carry a worse prognosis,9, 10 though this has not been validated in all reports and recent literature suggests that patients with both patterns have the worst prognosis.11

A biopsy may be required to exclude other diagnoses. The histology demonstrates an obliterative vasculopathy secondary to the vascular intimal changes and endovascular fibrosis.12 A suggestive finding is calcification of the medial wall of small‐ and medium‐sized arteries and arterioles with associated intimal hyperplasia and fibrosis. Necrosis of the surrounding tissue, panniculitis, and soft tissue calcification are often present.9, 13 The trauma of the biopsy can lead to worsening of the disease.

Secondary to its association with end stage renal disease, laboratory data often reveals elevated blood urea nitrogen (BUN), creatinine, parathyroid hormone, and calcium‐phosphate product. Bone scans show increased uptake in the subcutaneous calcified plaques.14 X‐rays utilizing mammogram technique have demonstrated arteriolar calcification.15

Besides chronic kidney disease, other potential risk factors include protein C and S deficiencies, obesity, warfarin use, high calcium containing dialysates, liver disease, and systemic corticosteroids.4, 9, 11, 16

Calciphylaxis is a difficult disease to treat with a mortality of 60% to 70%9 and a 1‐year survival rate of 45.8%.11 There is no consistently effective treatment.5 Therapy therefore, is focused on symptom control, debridement, and treatment of infection. Mortality is most commonly due to wound infections and resulting septicemia. Meticulous wound care is important with any infection treated early and aggressively. Though trauma and surgical procedures have been known to precipitate ulcerations, given their high rate of infection early surgical debridement of wounds is often required and has been shown to improve mortality.11, 17 Because of the poor healing of the involved tissues, wounds are often left to close by secondary intention or in some circumstances with vacuum assistance.2

As secondary hyperparathyroidism is common, attempts are often made to lower the calcium‐phosphate product. This often requires parathyroidectomy.18 Calcium containing phosphate binders are avoided and low calcium dialysate used.19 However, the above interventions do not consistently improve mortality.5, 11

Other potential treatments include: hyperbaric oxygen therapy,20 intravenous sodium thiosulfate,14 low‐dose tissue plasminogen activator,21 cinacalcet,22 etidronate disodium,23 and maggots.24 Because of the rarity of the condition, most of the literature to date is anecdotal and based on case reports and small retrospective studies.

Conclusions

As the number of patients who develop chronic kidney disease and require hemodialysis increases, it is likely that the number of patients who develop calciphylaxis will also increase. Hospitalists, besides nephrologists, should therefore become familiar with the presentation of this disease as it is possible, although unproven, that treatment in the early stage of the disease may result in a better response. Although several treatment modalities have been used to treat calcific uremic arteriolopathy or calciphylaxis, it remains unclear what is the best treatment for these patients. Carefully done clinical trials using some of the treatment modalities mentioned will help physicians decide what the most appropriate treatment is for patients with this debilitating and often fatal disease.

Narrative Description

This Case Report reviews the presentation, the differential diagnosis and the treatment modalities used to treat calciphylaxis. It emphasizes the poor prognosis and that there is inadequate clinical experience to guide a physician as to what the most appropriate treatment is despite promising anecdotal reports about a variety of agents. The report demonstrates that intravenous sodium thiosulfate is tolerated.

Key Points

• Calciphylaxis occurs in 1 to 4% of patients with end stage renal failure.

• Two patterns of presentation are generally recognizedcentral and peripheral.

• Pain is a prominent symptom and eschar formation is usually present.

• The role of surgery is controversial.

• Several promising modalities for the treatment of this condition have been described in anecdotal reports.

Calciphylaxis is a rare condition. It is seen most frequently in patients with chronic kidney disease and can affect any part of the body.14 Calciphylaxis is increasingly being referred to as calcific uremic arteriolopathy as this term more accurately reflects the histology of vascular calcification in small‐ and medium‐sized arteries, intimal arterial hypertrophy, and small vessel thrombosis associated with panniculitis, dermal necrosis, and eschar formation.5 Pain is a prominent symptom. The most effective treatment for this condition remains uncertain.

Case Report

A 68‐year‐old female presented with an 8‐month history of increasing lower extremity edema, and numerous large, painful, necrotic ulcers with an associated foul odor. She had a past medical history of type 2 diabetes mellitus, hypertension, end stage renal disease requiring hemodialysis 3 times a week for the previous 6 months, severe peripheral vascular disease, coronary artery disease for which she had previously undergone coronary artery bypass surgery, multiple myocardial infarctions, and congestive heart failure with an ejection fraction of 20%. She had also suffered from numerous infections including septicemia, endocarditis, and a sternal wound infection in the past with no current evidence of septicemia or endocarditis. The patient was not on calcium supplements, Vitamin D, warfarin or calcium‐containing phosphate binders.

Eight months prior to admission she developed vesicles on the left thigh that slowly progressed to large, extremely painful, violaceous, indurated plaques with central ulceration and eschar (Figure 1). She subsequently developed several smaller lesions with similar morphology on her legs and feet and gangrene of her left big toe (Figure 2). A biopsy from the left thigh was consistent with calciphylaxis with associated necrosis of the deep dermis and subcutaneous tissues. The patient's lesions were aggressively debrided, broad spectrum antibiotics given, and the patient dialyzed with low calcium dialysates. Ultimately intravenous sodium thiosulfate (25 g intravenously, over 60 minutes), was given which she tolerated with no side effect. Sodium thiosulfate is thought to act by forming highly soluble calcium thiosulfate salts and therefore mobilizing tissue calcium.5 Hyperbaric oxygen was contraindicated because of the patient's left ventricular ejection fraction (LVEF) of 20% and previous history of congestive heart failure as this treatment modality may precipitate congestive heart failure in a patient with a low LVEF particularly with a past history of congestive heart failure. Her condition continued to deteriorate and she died a few days after initiation of intravenous sodium thiosulfate infusion secondary to a massive gastrointestinal bleed.

Figure 1

Figure 2

Discussion

The differential diagnosis for painful necrotic cutaneous ulcerations with eschar formation includes: calciphylaxis, cryoglobulinemia, cryofibrinogenema, peripheral vascular disease, embolic phenomenon (endocarditis, septic, cholesterol), warfarin skin necrosis, brown recluse spider bites, hypercoagulable states, hyperoxaluria, and necrotizing vasculitis.14

Calciphylaxis is a rare entity that affects approximately 1% to 4% of end stage renal failure patients.1, 3 The typical patient is a morbidly obese, female with longstanding end stage renal disease, diabetes, hyperphosphatemia and an elevated calcium‐phosphate product usually greater than 60 mg²/dL².1, 3 It has also been described in patients with alcoholic cirrhosis and acute reversible renal failure,6 primary and secondary hyperparathyroidism,7 and metastatic breast cancer.8

Patients typically present with symmetric lesions that evolve from erythematous to violaceous, livedo‐reticularis like patches or plaques with occasional bullae to painful, indurated, necrotic plaques that subsequently ulcerate. The ulcerations are slow to heal and covered with eschar.4, 9

There are 2 patterns of involvement. The central/proximal pattern involves the abdomen, gluteal region, and thighs while the peripheral/distal pattern involves the extremities distal to the elbows and knees.1, 2, 4 The central pattern tends to carry a worse prognosis,9, 10 though this has not been validated in all reports and recent literature suggests that patients with both patterns have the worst prognosis.11

A biopsy may be required to exclude other diagnoses. The histology demonstrates an obliterative vasculopathy secondary to the vascular intimal changes and endovascular fibrosis.12 A suggestive finding is calcification of the medial wall of small‐ and medium‐sized arteries and arterioles with associated intimal hyperplasia and fibrosis. Necrosis of the surrounding tissue, panniculitis, and soft tissue calcification are often present.9, 13 The trauma of the biopsy can lead to worsening of the disease.

Secondary to its association with end stage renal disease, laboratory data often reveals elevated blood urea nitrogen (BUN), creatinine, parathyroid hormone, and calcium‐phosphate product. Bone scans show increased uptake in the subcutaneous calcified plaques.14 X‐rays utilizing mammogram technique have demonstrated arteriolar calcification.15

Besides chronic kidney disease, other potential risk factors include protein C and S deficiencies, obesity, warfarin use, high calcium containing dialysates, liver disease, and systemic corticosteroids.4, 9, 11, 16

Calciphylaxis is a difficult disease to treat with a mortality of 60% to 70%9 and a 1‐year survival rate of 45.8%.11 There is no consistently effective treatment.5 Therapy therefore, is focused on symptom control, debridement, and treatment of infection. Mortality is most commonly due to wound infections and resulting septicemia. Meticulous wound care is important with any infection treated early and aggressively. Though trauma and surgical procedures have been known to precipitate ulcerations, given their high rate of infection early surgical debridement of wounds is often required and has been shown to improve mortality.11, 17 Because of the poor healing of the involved tissues, wounds are often left to close by secondary intention or in some circumstances with vacuum assistance.2

As secondary hyperparathyroidism is common, attempts are often made to lower the calcium‐phosphate product. This often requires parathyroidectomy.18 Calcium containing phosphate binders are avoided and low calcium dialysate used.19 However, the above interventions do not consistently improve mortality.5, 11

Other potential treatments include: hyperbaric oxygen therapy,20 intravenous sodium thiosulfate,14 low‐dose tissue plasminogen activator,21 cinacalcet,22 etidronate disodium,23 and maggots.24 Because of the rarity of the condition, most of the literature to date is anecdotal and based on case reports and small retrospective studies.

Conclusions

As the number of patients who develop chronic kidney disease and require hemodialysis increases, it is likely that the number of patients who develop calciphylaxis will also increase. Hospitalists, besides nephrologists, should therefore become familiar with the presentation of this disease as it is possible, although unproven, that treatment in the early stage of the disease may result in a better response. Although several treatment modalities have been used to treat calcific uremic arteriolopathy or calciphylaxis, it remains unclear what is the best treatment for these patients. Carefully done clinical trials using some of the treatment modalities mentioned will help physicians decide what the most appropriate treatment is for patients with this debilitating and often fatal disease.