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Comprehensive Discharge Planning With Postdischarge Support for Older Patients With Congestive Heart Failure
A Meta-analysis
Christopher O. Phillips, MD, MPH;
Scott M. Wright, MD;
David E. Kern, MD, MPH;
Ramesh M. Singa, MPH;
Sasha Shepperd, MS, DPhil;
Haya R. Rubin, MD, PhD
JAMA. 2004;291:1358-1367.
ABSTRACT
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Context Comprehensive discharge planning plus postdischarge support may reduce readmission rates for older patients with congestive heart failure (CHF).
Objective To evaluate the effect of comprehensive discharge planning plus postdischarge support on the rate of readmission in patients with CHF, all-cause mortality, length of stay (LOS), quality of life (QOL), and medical costs.
Data Sources We searched MEDLINE (1966 to October 2003), the Cochrane Clinical Trials Register (all years), Social Science Citation Index (1992 to October 2003), and other databases for studies that described such an intervention and evaluated its effect in patients with CHF. Where possible we also contacted lead investigators and experts in the field.
Study Selection We selected English-language publications of randomized clinical trials that described interventions to modify hospital discharge for older patients with CHF (mean age  55 years), delineated clearly defined inpatient and outpatient components, compared efficacy with usual care, and reported readmission as the primary outcome.
Data Extraction Two authors independently reviewed each report, assigned quality scores, and extracted data for primary and secondary outcomes in an unblinded standardized manner.
Data Synthesis Eighteen studies representing data from 8 countries randomized 3304 older inpatients with CHF to comprehensive discharge planning plus postdischarge support or usual care. During a pooled mean observation period of 8 months (range, 3-12 months), fewer intervention patients were readmitted compared with controls (555/1590 vs 741/1714, number needed to treat = 12; relative risk [RR], 0.75; 95% confidence interval [CI], 0.64-0.88). Analysis of studies reporting secondary outcomes found a trend toward lower all-cause mortality for patients assigned to an intervention compared with usual care (RR, 0.87; 95% CI, 0.73-1.03; n = 14 studies), similar initial LOS (mean [SE]: 8.4 [2.5] vs 8.5 [2.2] days, P = .60; n = 10), greater percentage improvement in QOL scores compared with baseline scores (25.7% [95% CI, 11.0%-40.4%] vs 13.5% [95% CI, 5.1%-22.0%]; n = 6, P = .01), and similar or lower charges for medical care per patient per month for the initial hospital stay, administering the intervention, outpatient care, and readmission (-$359 [95% CI, -$763 to $45]; n = 4, P = .10 for non-US trials and -$536 [95% CI, -$956 to -$115]; n = 4, P = .03, for US trials).
Conclusion Comprehensive discharge planning plus postdischarge support for older patients with CHF significantly reduced readmission rates and may improve health outcomes such as survival and QOL without increasing costs.
INTRODUCTION
In the United States, half of inpatients older than 65 years with congestive heart failure (CHF) are readmitted within 6 months of hospital discharge, with payments totaling 60% of Medicare reimbursements for CHF, the leading diagnosis related group (DRG) for acute hospitalization and readmission in this population.1-6 Readmissions have increased since the introduction of the Medicare Prospective Payment System7-8 and may reflect suboptimal assessment of readiness for discharge, fragmented discharge planning, a breakdown in communication and information transfer between hospital-based and community physicians, inadequate postdischarge care and follow-up, or some combination of these processes,4, 9-17 whose resolution may require better coordination of care or comprehensive discharge planning.14-17
Comprehensive discharge planning plus postdischarge support may reduce readmission rates and improve health outcomes for patients with CHF. Previous reviews of CHF disease management have emphasized beneficial effects of outpatient care and multidisciplinary teams16-17; however, the efficacy of programs incorporating discharge planning, transitional care, and postdischarge management for this patient population has not been established. We sought to extend the results of prior reviews of CHF disease management with the addition of more recently published studies summarizing efficacious components of postdischarge care and clinical outcomes not previously analyzed. The aim of this review was to determine the efficacy of interventions that were described as comprehensive discharge planning plus postdischarge support for older inpatients with CHF and to quantify the effect on readmission rate, all-cause mortality, initial length of stay (LOS), quality of life (QOL), and overall medical costs.
METHODS
Search Strategy
We performed a systematic search of MEDLINE (OVID, 1966 to October 2003) with the assistance of a professional librarian. We also searched the Cochrane Controlled Trials Register (all years), Current Contents (all years), Bioethics (1985 to October 2003), Psych Lit (1974 to October 2003), CINAHL (1982 to October 2003), Social Science Citation Index (1992 to October 2003), and reference lists of articles. We used both Medical Subject Headings (MESH) and text terms for our search including the following: congestive heart failure, comprehensive discharge planning, discharge planning, hospital discharge, patient discharge, patient care planning, after care, multidisciplinary care, social support, disease management programs, patient education, social work, case management, and patient readmission.
Inclusion Criteria
We selected English-language publications of randomized controlled clinical trials with detailed descriptions of interventions intended to modify hospital discharge for older inpatients (mean age55 years). Eligible studies specifically addressed CHF, described components for inpatient care plus postdischarge support, compared the effects with usual care, and reported readmission rates as the primary outcome.
Quality Assessment
Eligibility assessment was performed independently by 2 authors (C.O.P. and R.M.S.) in an unblinded18 standardized manner with detailed examination of the following: randomization generation, allocation concealment, double blinding, and loss to follow-up.19
Data Extraction
Study characteristics, methodological quality, patient demographics (age, left ventricular ejection fraction [LVEF], angiotensin-converting enzyme inhibitor [ACEI] use, duration of follow-up, country of origin), primary outcome (proportion of patients readmitted at least once), and secondary outcomes (all-cause mortality, initial LOS, QOL scores, and medical costs) were tabulated.
Data Synthesis
We used STATA software (version 8, College Station, Tex) to pool data for the primary outcome stratified by postdischarge support, and all-cause mortality, cardiovascular disease (CVD)–specific readmissions, and the combined end point of death and readmission ("metan" command). We used both fixed and random-effects statistical models that used weighting based on inverse variance calculated according to DerSimonian and Laird.20 Due to the high event rates, we chose relative risks (RRs) with 95% confidence intervals (CIs) as the principal measure of association. Analyses were performed on an intention-to-treat basis.
We tested for quantitative heterogeneity using the  2 test. We performed sensitivity analyses and conducted trial level subgroup analysis to assess consistency of intervention effects by patient demographics (2 strata added for LVEF <40% and LVEF 40% and 3 for mean age subgroups <70 years including low outliers, 70 to < 75 years, and 75 years). We stratified results by country of origin to assess potential influence of different health care delivery systems.
We assessed publication bias in primary and secondary outcomes but present the results for readmission using Begg's funnel plot.21 Because publication bias would result in more small positive than negative studies being published, we assessed the effect of such bias by omitting small studies (n<100).
Where appropriate, we used descriptive statistics to summarize data for secondary outcomes, and compared differences in means using the t test. We pooled LOS (mean [SD]) across studies and determined LOS reduction by meta-analysis of continuous data ("meta" command). We standardized the change in QOL scores to percentage improvement (or decline) compared with baseline scores for each group within a study using the following formula: [(final - baseline)/baseline QOL score] x 100%. We averaged percentage improvement (or decline) in QOL in intervention and control groups and performed both weighted and unweighted analyses to compare overall changes in QOL (mean [SE]). For weighted analysis, we multiplied percentage improvement from baseline to follow-up in each study group by the number of observations in that group, summed the numbers across studies, and divided by the total number of observations. For the latter, we set each study as the unit of analysis, summarized the percentage change in QOL across studies, and compared the difference. We divided reported mean charges per patient for medical care by the number of months of observation to arrive at monthly charges per patient per trial for US and non-US studies separately and compared changes in costs. Finally, we converted medical costs to US dollars after adjusting for inflation using year 2003 consumer price index.
RESULTS
Our search for eligible studies is summarized in Figure 1. Of the 3741 potentially relevant reports initially identified, we excluded 2909. We retrieved 832 reports for in-depth screening and selected 107 studies for detailed evaluation, of which 19 reports for 18 studies were eligible for analysis.
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Figure. Studies Evaluated for Inclusion in the Meta-analysis
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Eighteen randomized controlled clinical trials22-40 from 8 countries (Australia, Canada, England, Holland, Ireland, Italy, Sweden, and the United States) reported the primary outcome of CHF readmission. Other outcomes were reported in some but not all studies. Of interest, no studies evaluated the efficacy of comprehensive discharge planning without components for postdischarge support for patients with CHF. We found evidence for publication bias (P<.001) in that small studies with negative results were missing from the upper right quadrant of a Begg's plot (available on request from the authors).
Methodological Quality
The most common reason for point deduction was the absence of double blinding, which was impossible due to the nature of the intervention. Sixteen studies were assigned a Jadad score of 4 (out of 5 possible points),22-25,27-31,33-40 whereas 2 studies26, 32 received a score of 3 because they did not report data for loss to follow-up and blinding. However, most studies reported blinded assessment of outcomes. Ninety percent of trials reported a funding source. The pooled attrition rate due to nonresponse, withdrawals, or loss to follow-up was less than 5% except for 1 study with a rate of 8%.39
Baseline Characteristics
Populations differed by country of origin, but baseline clinical characteristics of patients in the control and interventional arms of each study were well matched. For the pooled population of 3304 patients with CHF, 62% were men and 14% were nonwhite. The mean age of study participants varied little and was 70 years or older in 16 studies and younger than 70 years for 2 studies.27, 40 The presence of LV systolic dysfunction was indicated by a mean LVEF of less than 40% in 8 trials, greater than 40% in 2 trials, and by New York Heart Association Class or not reported in 8 studies. No study reported explicit data for diastolic dysfunction. Baseline use of ACEIs was reported in 14 studies,22-29,34-38,40 and there was no significant difference in the proportion of patients who received ACEIs at baseline in the intervention and control groups (mean [SE] 72% [13%] vs 70% [12%], P = .40, respectively). Ten trials were conducted in the United States.26-28,30-32,34-37,39 The other studies were performed in Australia,22-23 Canada,38 England,33 Holland,24 Ireland,29 Italy,40 and Sweden.25
Interventions
For most studies usual care was not explicitly described. Because the intervention represented a continuum of care, it was not always possible to separate the components for education (CHF specific to enhance self-care behavior) that were conducted before and after hospital discharge. Although the duration of follow-up for each trial was clearly stated, the duration of components for postdischarge support was not consistently reported and varied by study: 1 to 3.5 hours per patient (median duration, 2 hours),22-23,25 for some patients who received a single home visit within 2 weeks of discharge, 2 weeks to 6 months during which home visits and/or frequent telephone contact took place,30-32,34 3 to 6 months for multiple clinic visits and frequent telephone contact,27-29 2 to 12 weeks for extended home care,36-39 and up to 1 year for an intervention in 1 study.40 Explicit data for the intervention duration were not reported in 4 trials.26, 33, 36-37
Components for postdischarge support also varied by study (Table 1). Three studies used a single home visit22-24 during which CHF education and self-care were reviewed and reinforced. Six studies used a home visit and/or frequent telephone contacts30-36 for this purpose and to facilitate rescheduling of missed appointments. One of 4 studies using increased clinic visits and frequent telephone follow-up25-29 also used a home visit (1 hour) for intervention patients.25 Four studies contained components intended to provide continuous multidisciplinary home care.36-39 Finally, 1 study used a day hospital with an available specialized heart failure unit.40
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Table 1. Description of Included Trials
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Readmission Rates
Follow-up was conducted for a range of 3 to 12 months and a mean of 8 months (Table 2). Compared with usual care, fewer patients randomized to comprehensive discharge planning plus some form of postdischarge support experienced a readmission (RR, 0.75; 95% CI, 0.64-0.88; 217 = 49.19, P for heterogeneity <.001); number needed to treat = 12). Most of the observed heterogeneity was accounted for by results from a single large study,27-28 which when omitted from the analysis, substantially reduced the heterogeneity but had minimal effect on the overall estimate (RR, 0.74; 95% CI, 0.67-0.81; 216 = 27.07, P for heterogeneity = .04). Residual heterogeneity was related to variations in sample size between studies (P<.001). Relative consistency in effects were observed for studies with sample sizes less than 100, 100 to 199, and 200 or more (results available on request). Reanalysis excluding results of studies with sample sizes less than 10022, 26, 29, 35-36 to assess the effect of publication bias did not significantly alter the results (RR, 0.78; 95% CI, 0.66-0.93). Among the 3 studies25, 27-28,39 that reported ACEI use at follow-up, the mean use rates were 78% for the intervention group and 68% for the control group (P = .29). The mean readmission rates were 40.3% and 38.3%, respectively (RR, 1.04; 95% CI, 0.76-1.43).
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Table 2. Readmission Rates With Comprehensive Discharge Planning Plus Postdischarge Support Compared With Usual Care*
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Compared with usual care, fewer intervention patients also had a CHF/CVD–specific readmission (RR, 0.65; 95% CI, 0.54-0.79; 26= 11.90, P for heterogeneity = .06, n = 6 studies24, 26, 29, 32, 34-35,39) or the combined end point of death or readmission (RR, 0.73; 95% CI, 0.62-0.87; 25= 16.25, P for heterogeneity = .02, n = 8 studies22-23,25-26,29, 33, 35, 37).
Sensitivity Analysis
Sensitivity analysis comparing fixed and random effects statistical models yielded relatively similar results (Table 3). The effect of sequentially omitting a study and recalculating the pooled estimates for the remaining studies did not significantly alter the effect on readmission.
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Table 3. Sensitivity and Subgroup Analysis of the Effect of Comprehensive Discharge Planning Plus Postdischarge Support on Risk of Readmission*
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Subgroup analysis within different strata for trials defined by patient demographics, methodological quality, and country of origin reproduced relatively similar point estimates suggesting lower readmission for intervention patients (Table 3).
Risk of Readmission Stratified by Types of Postdischarge Support
As shown in Table 2, compared with usual care, each of the types of postdischarge support resulted in significantly fewer readmissions, except for increased clinic visits and frequent telephone contact26-29 (RR, 0.64; 95% CI, 0.32-1.28; 23 = 18.43, P for heterogeneity <.001, n = 4 studies25-29). The 3 studies reporting ACEI use at follow-up,25, 27-28,39 showed no difference in ACEI use at follow-up. The effect of size for these studies was no larger than the rest of the studies (RR, 1.04; 95% CI, 0.76-1.43). There was no difference between interventional and control group patients in ACEI use at baseline for the listed studies (P = .86).25, 27-28,39 In the study by Oddone et al,27-28 ACEI use during follow-up was similar for intervention and control patients (7% vs 72%, P = .28).
Mortality
Data for all-cause mortality were reported in 14 studies (Table 4). Compared with usual care, intervention patients showed a trend toward lower all-cause mortality (RR, 0.87; 95% CI, 0.73-1.03; 213 = 17.79, P for heterogeneity = .06, n = 14 studies22-29,33-35,37-40).
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Table 4. All-Cause Mortality With Comprehensive Discharge Planning Plus Postdischarge Support Compared With Usual Care*
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We confirmed the consistency of study effects toward reduced mortality within subgroups defined by postdischarge support other than for increased clinic follow-up and frequent telephone contacts (Table 4). The trials were not powered to assess changes in secondary outcomes, and the point estimates for mortality were not statistically significant.
Length of Stay
Ten studies reported data for initial LOS,22-24,26-28,30-31,38-39 which was similar for intervention and control patients (LOS, mean [SE]: 8.4 [2.5] vs 8.5 [2.2] days, P = .60, respectively). Compared with controls, the LOS difference favored intervention patients but this difference was not statistically significant (LOS difference -0.37; 95% CI, -0.15 to 0.60).
Quality of Life
Six studies listed in Table 5 reported data for QOL,22-23,38-39 most using instruments that were specifically developed for CHF. Whereas 2 studies used the Minnesota Living With Heart Failure Questionnaire,23, 39 the other instruments used were the Nottingham Health Profile,25 the Heart Failure Self-Care Behavior Scale,24 the Chronic Heart Failure Questionnaire,38 and the SF-3627-28 for measuring QOL. During 8 months of follow-up (range, 3-12 months), QOL scores improved from baseline for patients randomized to an intervention (25.7% [95% CI, 11.0%-40.4%]) or to usual care (13.5% [95% CI, 5.1%-22.0%]), but QOL scores of intervention patients improved significantly more than usual care patients (P = .01).
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Table 5. Quality of Life (QOL) Scores With Comprehensive Discharge Planning Plus Postdischarge Support Compared With Usual Care
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Medical Costs
Eleven studies reported medical costs,22-23,25, 29-31,34-35,37, 39-40 but the components of medical costs reported varied by trial (Table 6). Eight of the 11 trials supplied the most complete data for medical costs including charges for inpatient care, outpatient care, readmissions, and charges for administering the intervention.22-23,29-31,37, 39-40 Stratified by country of origin, the pooled cost difference favored intervention patients (-$359 [95% CI, -$763 to $45]; n = 4, P = .10 for non-US trials and -$536 [95% CI, -$956 to -$115]; n = 4, P = .03 for US trials). The reported average cost for administering the intervention was $80.76 per patient per month for trials conducted in the United States and $55.76 per patient per month for non-US trials.
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Table 6. Medical Costs With Comprehensive Discharge Planning Plus Postdischarge Support Compared With Usual Care*
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COMMENT
Comprehensive discharge planning plus postdischarge support for older patients with CHF resulted in a 25% relative reduction in the risk of readmission, a trend toward 13% relative reduction in all-cause mortality, and for a smaller subset of studies, improvement in QOL scores, without increasing the cost of medical care.
Previous reviews by Parkes and Shepperd41 and Parker et al,42 which summarized the experience of a heterogeneous patient population assigned to discharge planning or usual care, reported mixed results. The first study reported lower 1-month readmission rate for medical patients; however, equivocal results were found for combined medical and surgical patients in the second study. In our review, we selected a clearly defined group of hospitalized patients with CHF, mean age 55 years or older, with moderate to severe heart failure symptoms and moderate to severe LV systolic dysfunction, clinical characteristics that are typical of most patients with heart failure nationwide. Our findings confirm the efficacy of comprehensive discharge planning plus postdischarge support for patients with CHF and demonstrate benefit for a range of important clinical outcomes.
The available evidence did not support the implicit assumption of incremental efficacy with more intensive postdischarge interventions. Comparable benefit resulted from a home visit, home visits and/or frequent telephone follow-up, and extended home care services. Increased clinic visits resulted in a nonsignificant decrease. Divergent results from 2 large clinical trials may provide added support for these conclusions. The Randomized Trial of Telephone Intervention in Chronic Heart Failure (DIAL)43 study of telephone follow-up for outpatients with CHF (N = 1518) reported a 20% relative reduction in the risk of readmission. In contrast, patients randomized to increased clinic visits and frequent telephone contact experienced higher readmission rates at 6 months compared with usual care.27-28 Methodological issues in the latter study may have contributed to the observed lack of benefit, since 9 teams at different sites across the United States administered the intervention, with 1 site reporting protocol violations. By comparison, each of the remaining trials in this review was conducted in a single site with the same team administering the intervention. In addition, confounding due to secular trends in the management of CHF during the enrollment period (1992-1994) are possible. Finally, the control group had a risk of readmission similar to that for intervention patients in other trials reporting positive results and may have experienced a crossover effect or patients may already have been receiving optimal care, thus minimizing the difference in effects of additional treatment.
This meta-analysis complements and extends the findings of McAlister et al16 and Philbin17 and supports consensus for routine application of comprehensive discharge planning plus postdischarge support for patients hospitalized with acutely decompensated CHF. Some have argued that the observed benefit of CHF disease management may have been confounded by preferential use of ACEIs in patients assigned to an intervention.44 We found no significant difference in baseline use of these agents in 14 trials (P = .40), and although reported data for ACEI use during follow-up was limited to 3 studies,25, 27-28,39 beneficial effects were observed in studies with and without them. Studies reporting ACEI use at follow-up did not show a significantly higher rate of ACEI use among the intervention group, although these 3 studies also showed no overall effect of the intervention on readmission rates.
Although our review did not aim to determine cost-effectiveness or cost-benefit of comprehensive discharge planning plus postdischarge support, some policy implications may be of importance to medical care payers and insurers. In the United States approximately 700 000 Medicare beneficiaries with CHF are discharged annually from nonfederal short-stay hospitals,45 and 50% will be readmitted within 6 months1-6 at an average cost of $7000 per readmission.46 Based on the results of this meta-analysis, and assuming a 25% reduction in readmission, postdischarge support with a home visit could prevent 84 000 readmissions with an estimated reduction in Medicare payments of $424 million per year, after adjusting for the cost of discharge planning with a home visit: [(84 000 readmissions prevented x $7000) - ($114 to $116 first month home visit per patient discharged30-31 + $119 per patient current reimbursement by Medicare for discharge planning >30 min)47 x 700 000 patient discharges)]. Based on these calcuations, increasing reimbursement to providers by as much as twice the current Medicare rate could still result in substantial savings and would reinforce the implementation of the interventions. However, our estimates were limited because medical costs from several studies and readmission for patients with CHF from private payers and insurers were missing.
Several limitations of this review should be considered. First, electronic searching and exclusion of non-English language trials may have missed eligible studies, although such language limitation does not always introduce bias.48 Second, while we selected only studies that reported the proportion of readmitted patients, several of these studies did not collect or report information about secondary outcomes such as LOS, QOL scores, and costs. Of note, although we found evidence of publication bias for readmission rates, there were no small studies showing positive outcomes in LOS, QOL scores, or costs, lessening the likelihood of publication bias. Furthermore, excluding small studies (n<100) altered the overall estimates for readmission very little. Third, we were unable to obtain individual patient-level data that could have permitted more precise estimates. Fourth, we observed quantitative heterogeneity among studies in intervention effects and although we believe we have provided plausible accounts for this observation, we urge caution with the overall interpretation and generalization to other patient populations or to discharge arrangements not described in this review. To minimize qualitative heterogeneity and bias due to selection, we included studies with a defined patient population and a clear description of the intervention. Across the range of patients, postdischarge interventions, follow-up periods, and countries, the beneficial effect of this intervention in reducing readmission rates remained stable. We believe that the reproducibility of results, consistency of effect, and strength of assocation of the findings support the validity of our results. Fifth, from the available data, we were unable to ascertain whether events that occurred distant from the index discharge were related to the initial DRG or new problems for patients who were readmitted or those who died. Finally, cost data were incomplete and overall medical costs may be higher than calculated here.
In conclusion, we believe that the reduction in risk of readmission, trend toward improved survival, improvement in QOL, and the potential cost savings determined in this review have important implications for systems change, health outcomes, and resource utilization for older patients with CHF. Although the optimal arrangement for individualized postdischarge support has yet to be determined, the evidence supports routine application of comprehensive discharge planning plus postdischarge support for older inpatients with CHF to optimize the transition from acute hospital care to home.
AUTHOR INFORMATION
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Corresponding Author: Christopher O. Phillips, MD, MPH, Brigham and Women's Hospital, 75 Francis St, Tower 5-509A, Boston, MA 02115 (chr_phi{at}yahoo.com).
Author Contributions: As principal investigator, Dr Phillips had full access to reports containing original data for this study and takes full responsibility for the content, analysis, interpretation, and presentation of the results in this article.
Study concept and design: Phillips, Wright, Kern, Rubin.
Acquisition of data: Phillips.
Analysis and interpretation of data: Phillips, Kern, Singa, Shepperd, Rubin.
Drafting of the manuscript: Phillips, Wright, Kern, Singa.
Critical revision of the manuscript for important intellectual content: Phillips, Wright, Kern, Shepperd, Rubin.
Statistical expertise: Phillips, Singa, Shepperd.
Obtained funding: Phillips.
Administrative, technical, or material support: Phillips, Wright, Kern, Rubin.
Supervision: Wright, Kern, Rubin.
Funding/Support: Dr Wright is an Arnold P. Gold Foundation Associate Professor of Medicine at Johns Hopkins University School of Medicine, Baltimore, Md. Dr Rubin's contribution to this study was supported in part by grant NHLBI K24 HL073347. Dr Phillips is a senior clinical fellow in the Division of General Internal Medicine, the Johns Hopkins University School of Medicine, and receives funding support through a National Research Service Award-HRSA fellowship training grant 2-T32-PE10025.
Role of the Sponsor: The funding organizations had no input in the design and conduct of the study, in the collection, analysis and interpretation of the data, and in the preparation, review, or approval of the manuscript.
Previous Presentation: Presented in part at the 26th Annual Meeting of the Society of General Internal Medicine, Vancouver, British Columbia, April 30-May 3, 2003.
Acknowledgment: We thank Neil Powe, MD, MPH, MBA, Steven N. Goodman, MD, and Sheldon Gottlieb, MD, for advice regarding cost content, qualitative and statistical synthesis, and overall presentation. We are grateful for the contribution of Tillie Horak, an experienced librarian who assisted with the search.
Author Affiliations: Quality of Care Research and General Internal Medicine, Johns Hopkins University School of Medicine (Drs Phillips and Rubin), Division of General Internal Medicine, Johns Hopkins Bayview Medical Center (Drs Wright and Kern), Department of Medicine, Johns Hopkins University Bloomberg School of Public Health (Mr Singa and Dr Rubin), Baltimore, Md; and Institute of Health Sciences, University of Oxford, Oxford, England (Dr Shepperd).
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