Using health and long-term care insurance claims data, this study showed that 4.5% of older inpatients in a suburban city received a discharge conference in Japan. We compared the hospital readmission, time spent in community until readmission, and subsequent LOS and costs of readmission, according to whether or not a patient received a discharge conference. Using propensity score matching, we tried to adjust for the baseline difference of patient’s characteristics, and to examine the pure effect of discharge conference. The results confirmed that once the confounding has been controlled, discharge conference has impact on reducing the cost per day for readmission.
Not surprisingly, the patients with discharge conference had worse functional and health status than non-discharge conference group. The patient with discharge conference had a higher proportion of women, 85 years of age and older, prior experience of long-term care services and severer care-needs level, higher proportion of two or more main diagnoses, longer LOS and higher total costs at index hospitalization. The direction of bias by patient characteristics is not clear. Those who were expected to be readmitted were more likely to use discharge conference due to higher needs for medical management and supportive care. On the other hand, discharge conference group were expected to less likely to be readmitted, due to high proportion of women or those with longer LOS. Many older women are living alone, may be less likely to use hospital services under insufficient support from other family members. In addition, longer LOS at the index hospitalization may reduce the probability of readmission within the limited follow-up periods. These suggests the high needs for adjustment of baseline characteristics of patients, because the potential confounders can make biased estimates of the policy effect .
The effect of discharge conference on the probability of readmission was not consistent between before and after matching sample. Only at before marching, it showed a reduced odds ratio of readmission, which is accordance with previous studies [3, 15], but the estimates of after matching group concluded no significant effect. It is well established that discharge planning or a discharge summary has an impact of reducing the rate of hospital readmission for older patients with medical conditions in western countries [2, 5, 6, 24–27], but did not reduce 30-day potentially avoidable readmissions after rehabilitation services in Japan . These gaps might be caused by differences in specific interventions and target population in each studies; such as patients with heart failure [2, 24], pulmonary disease , or acute stroke with functional limitations . In addition, Japan has a generous coverage of health insurance and longer LOS in acute care than other countries , as both acute and post-acute care are provided during the same inpatient episode generally , therefore, the different health systems may induce the gaps in discharge conference effect.
Although we could not find a statistically significant difference on time spent in community until readmission, there were former findings that explained the extended times in community before emergency readmission  or first hospital readmission  among older patients who received comprehensive discharge planning supports. In addition, discharge conference did not have significant effect on LOS in this study. Previous studies also showed that receiving multidisciplinary discharge planning or telephone follow-up did not significantly reduce the number of days in the hospital upon readmission , or hospital nights during 12 months after discharge .
Discharge conference reduced a cost per day of readmission, although it did not have significant effect on total costs for readmission. It might decrease the intensity of care rather than the volume of services for readmission. Discharge conference might increase communication between service providers, while reduce treatment delays or worsening of illness, and it may reduce the need for high-cost care at acute hospital during the readmission. However, we need to careful interpret as the definition of cost is varied by studies, for example, hospitalization cost were estimated using the number of readmission days and emergency department visit [6, 7], some studies included post-acute care (e.g. home health, skilled nursing facility, hospice) , or estimated cost of outpatient visits after discharge . Previous literature found inconclusive results about costs [3, 15], while recent studies reported that there were cost savings in the Care Transitions Intervention or discharge planning at several practical settings [4, 6, 7, 26, 30].
Although the sample size was small, sub-analysis showed that the better continuity of care may work in reducing the readmission for those whom experienced worsening of conditions or needed home services. For example, there were higher portion of patients who experienced a deterioration of care-needs level among the discharge conference group, and they were less re-hospitalized. Moreover, among the LTCI home service users, the discharge conference group experienced lower hospital readmission.
The results of our study suggest that a discharge conference can be a buffer to hospitalization. During a discharge conference, long-term care service providers interact with hospital doctors and nurses to make a plan for community-based home care. For example, home visiting nurses learn how to provide the same treatments as those provided in hospital during the discharge conference. They share information about the patient’s clinical needs and practical skills, as well as visiting schedules and caregiver’s socio-economic situation under an agreement of the patient and/or family members. The findings of this study call for closer coordination between medical providers and long-term care providers for the management of older patients at discharge .
When we interpret the results, we need to consider the diverse function of discharge services and healthcare delivery systems in each country. In North America and European countries, discharge planning has been implemented with a team approach, such as the Integrated Care Pathway [28, 32], but the main professionals were different, involving nurses [24, 26, 33], doctors , pharmacists [34, 35], and social workers . Discharge plan and/or summary emphasizes the connection with outpatient doctors [2, 6], and the discharge coordinator assess patient needs, attend daily rounds, submit progress reports to the primary care provider, and support the patient’s participation [25, 37, 38]. On the other hands, in Japan, a discharge conference has the role of connecting acute hospitals and long-term care services smoothly. Therefore, the effect of discharge conference on readmission and related health care expenditure can be different by countries according to its public financing and coverage system of health and long-term care, and detailed options of policy interventions need to take into account the context of each country.
At the same time, this study showed that service variations within a discharge conference need to be strengthened because majority of services were provided by one service type. For example, more than 90% received services that supporting the linkage with long-term care services as we showed in Table 2. Since 2016, the role of collaboration of healthcare professionals has been enhanced in the fee schedule , therefore, diversification of services needs to be taken attention.
This study suggests that a discharge conference can be a useful to reduce the cost per day of hospital readmission among older patients. Our estimated cost saving per day for readmission was about 20%, in both of before matching and after matching sample. Although the discharge conference users were less than 5% amongst older inpatients, if the 20% decrease is widely acceptable among country, the implementation of discharge conferences can be cost saving. At the same time, as discharge conference could not effect on reducing the amount of LOS, it could not cut down the total costs. If the discharge conference works well for both of reducing the cost per day and LOS of readmission, it may have merit in practice that lower health insurance spending while mitigating highly intensive care among older population.
There were low utilization rates of discharge conference in the suburban city of Japan, compared with the Medicare or Medicaid systems where discharge planning is mandatory . There are no general guidelines for discharge conferences in Japan, and many trainees felt there was a lack of available training curriculums and feedback interventions regarding the discharge process . On the other hands, clinical guidance has been issued by professional bodies in the United Kingdom, the United States, Australia, and Canada . Therefore, policy makers may need profound evidences of the discharge conference using nationally representative sample with more diverse scenario models. In addition, it is recommended that clear standards, relevant training, and routine audit to improve the discharge communication . If proper education and guidelines are provided, the implementation of discharge conferences by diverse healthcare providers can be encouraged in Japan.
This study has several limitations. First, we could not consider the specific diagnoses in DPC group due to lack of available information, therefore we identified simply whether a patient is in DPC group or not. Further work needs to take into account the detailed information of DPC group. Second, this study could not account for the hospital characteristics, even though there is possibility of variations in the quality of discharge services by hospitals . Because the study population was limited to one suburban area, the number of patients per hospital was too small to compare the hospital characteristics. Therefore, future studies need to use nationally representative data, including hospital characteristics.