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Keane Lee, MD

Cardiology, KP Santa Clara

“Many patients vulnerable to adverse outcomes find it difficult to keep in-person appointments, likely due to frailty, lack of social support, or caregiver fatigue. Now we can offer remote alternatives, while maintaining the highest quality of care.”

Heart failure is the leading cause of hospitalization in older adults, and keeping these patients out of the hospital can be a significant challenge, requiring close follow-up. An in-person follow-up visit within 7 days after discharge from a heart failure hospitalization is associated with lower 30-day readmission, for example, yet too many patients never make it to their early post-discharge appointment.

Dr. Lee, who is also a clinical investigator at the KP Division of Research (DOR), wondered whether a telephone visit with a trained nurse or pharmacist within a week of leaving the hospital might be easier for patients and just as effective as seeing their physician in-person.

So with the support of a DOR Delivery Science grant, he designed a randomized trial that compared a structured telephone follow-up with nonphysician practitioners trained in heart failure to an in-person follow-up with their primary care physician. Telephone appointments included a structured protocol for medication titration, lab orders, and booking urgent clinic visits as needed, under physician supervision. The study compared the effect on 30-day readmission and death.

Among nearly 3,000 participants, Dr. Lee and his research team found no significant differences in 30-day heart-failure readmission, all-cause readmission, or all-cause death. In fact, 92% of patients who were randomized to telephone follow-up completed their 7-day visits, compared to 79% in those assigned to physician clinic follow-up. These findings show that remote care with trained non-physicians in an integrated healthcare system improves completion of follow-up and maintains effectiveness for preventing readmission and death, compared with in-person physician appointments.

“Dr. Lee’s success in designing and carrying out a pragmatic, rigorous, randomized trial that answers a fundamental, yet challenging question like how best to do follow-up care with heart failure patients is commendable,” says Betty Suh-Burgmann, MD, chair of the Central Research Committee. “Also commendable is the breadth of the study – the median age was 78 years old, and 41% were non-white, effectively demonstrating that it is indeed possible to recruit an inclusive, diverse population into research studies.”

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