In-person patient follow-up with a family doctor after leaving hospital

7 day in-person follow-up after leaving hospital for selected conditions

Percentage

Numerator divided by the denominator times 100

Number of patients  who had  an in-person primary care physician visit within 7 days  of discharge after hospitalization for any of the following conditions: pneumonia, diabetes, stroke, gastrointestinal disease, congestive heart failure, chronic obstructive pulmonary disease, heart attack  and other cardiac conditions (selected HBAM Inpatient Grouper (HIG) conditions). 

Inclusions:

1. A physician visit is counted if there is a service claim billed:

a. by any primary care physician in the group in which the patient is enrolled;
b. within 0 to 7 days of their discharge from hospital, and;
c. where the fee schedule code is classified as “Professional”.

Note: These criteria allow for the inclusion of inpatient visits; for example, claims with a fee schedule code C124 (Day of discharge visit – most responsible physician), are eligible to be counted (assuming the claim meets the other criteria listed above). Similarly, claims for visits that take place in the Emergency Department are eligible to be counted (again, assuming the claim meets the other criteria listed above).

Exclusions: 

1. Hospital discharge records with missing or invalid discharge date, admission date, health number, age and gender;

2. Ontario Health Insurance Plan (OHIP) claims that are negated, duplicates, physician claims from laboratory groups, and claims paid by the Workplace Safety and Insurance Board (WSIB).

Number of patients discharged from hospital after hospitalization for any of the following conditions: pneumonia, diabetes, stroke, gastrointestinal disease, congestive heart failure, chronic obstructive pulmonary disease, heart attack and other cardiac conditions (selected HBAM Inpatient Grouper (HIG) conditions).

Inclusions:

1. Acute inpatients in the specified HBAM Inpatient Grouper (HIGs) (see "comments detailed" section of this document) enrolled with a primary care physician at the time of discharge;
2. Cases that are typical, transfer in, short stay, long stay or long stay transfer in per the HIG atypical indicator (i.e. the HIG atypical indicator must be ‘00’, ‘01’, ‘09’, ‘10’, ‘11’);
3. Included ages are cohort specific: a. patients ≥ 45 for acute myocardial infarction (AMI), stroke, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF); b. patients ≥ 40 for cardiac HIGs; c. all ages for pneumonia, diabetes, and gastrointestinal (GI).

Exclusions: 

1. Death in hospital, acute transfers, patient sign-outs against medical advice;

2. Records with missing valid data on discharge/admission date, health number, age and gender;

3. Transfers to other hospital care and to other (palliative care/hospice, addiction treatment centre….) as defined by Discharge disposition ‘01’(for FY 2018 and onwards, discharge disposition ‘10’), ‘03’ (for FY 2018 and onwards, discharge disposition ‘20’, ‘30’, ‘40’, ‘90’) or institution to type '2', '3', '7'.

None

Client Agency Program Data (CAPE), Corporate Provider Database (CPDB), Discharge Abstract Database (DAD), Ontario Health Insurance Plan (OHIP) Claims History Database

Ministry of Health

Income, Region, Rurality, Sex, Time

Other types of follow-up (e.g. with a specialist or nurse practitioner) and virtual follow-up visits with any provider are not captured by this indicator. In-person follow-up visit is not condition/discharge-specific and does not necessarily have the same reason for visit as the hospitalization. It captures an in-person visit for any reason within 7 days and may include visits unrelated to the index hospitalization. Due to age restrictions/differences for some conditions the results are not reported by age groups. Deaths which take place in the community within 7 days following discharge are not accounted for and cannot be removed from the calculation. Results for calendar years 2020-2022 should be interpreted with caution, as changes in primary care delivery during the pandemic affected this indicator. This indicator measures in-person follow-up visits only. The proportion of primary care visits that are virtual has greatly increased since the beginning of the COVID-19 pandemic. Results for this indicator for calendar years 2020-2022 are lower than in in the years before 2020 mainly because virtual care visits are not included in this indicator. Additionally, the proportion of virtual care visits was high in 2020 but has been decreasing in subsequent years. As a result, values increased for this indicator in 2021 and 2022 as the proportion of visits shifted more toward in-person visits.

List of Eligible Conditions (HIGs): 1. Acute Myocardial Infarction, AMI (Age 45+): 193a (Myocardial infarction/shock/arrest with coronary angiogram), 193b (Myocardial infarction/shock/arrest with coronary angiogram with comorbid cardiac conditions), 194a (Myocardial infarction/shock/arrest without coronary angiogram), 194b (Myocardial infarction/shock/arrest without coronary angiogram with comorbid cardiac conditions) 2. Stroke (Age 45+): 25 (Hemorrhagic event of central nervous system), 26 (Ischemic event of central nervous system), 28 (Unspecified stroke). 3. COPD (Age 45+): 139c (Chronic obstructive pulmonary disease with lower respiratory infection), 139d (Chronic obstructive pulmonary disease without lower respiratory infection). 4. Pneumonia (all ages): 136 (Bacterial pneumonia), 138 (Viral/unspecified pneumonia), 143 (Disease of pleura). 5. Congestive Heart Failure, CHF (Age 45+): 196 (Heart failure without cardiac catheter). 6. Diabetes (all ages): 437a (Diabetes, other), 437b (Diabetes with renal complications), 437c (Diabetes with ophthalmic, neurological, or circulatory complications), 437d (Diabetes with multiple complications). 7. Cardiac conditions excluding AMI and CHF (Age 40+): 202 (Arrhythmia without coronary angiogram), 204a (Unstable angina/atherosclerotic heart disease without coronary angiogram), 204b (Unstable angina/atherosclerotic heart disease without coronary angiogram with comorbid cardiac conditions), 208a (Angina (except unstable)/chest pain without coronary angiogram), 208b (Angina (except unstable)/chest pain without coronary angiogram with comorbid cardiac conditions). 8. Gastrointestinal (All ages): 231 (Minor upper gastrointestinal intervention), 248 (Severe enteritis), 251 (Complicated ulcer), 253 (Inflammatory bowel disease), 254 (Gastrointestinal hemorrhage), 255 (Gastrointestinal obstruction), 256 (Esophagitis/gastritis/miscellaneous digestive disease), 257 (Symptom/sign of digestive system), 258 (Other gastrointestinal disorder), 285 (Cirrhosis/alcoholic hepatitis), 286 (Liver disease except cirrhosis/malignancy), 287 (Disorder of pancreas except malignancy), 288 (Disorder of biliary tract).

1 Jencks, S.F., Williams, M.V., Coleman, E.A. Rehospitalization among Patients in the Medicare Fee-forService Program. N Engl J Med. 2009; 360(14), 1418-1428. 2 Jackson C. Timeliness of Outpatient Follow-up: An Evidence-Based Approach for Planning After Hospital Discharge. 2015; The Annals of Family Medicine, 13(2), 115-122. 3 Tang N. Primary Care Physician’s Ideal Transitions of Care—Where’s the Evidence? Journal of Hospital Medicine. 2013; 8(8), 472-477. 4 Misky, G. J., Wald, H. L., Coleman, E. A. Post‐hospitalization transitions: Examining the effects of timing of primary care provider follow‐up. Journal of Hospital Medicine. 2010; 5(7), 392-397.

20/06/2024 08:27:00