Table 1

Complications of care were significantly reduced after implementation of the Transition of Care Team

PreinterventionPostinterventionP values
Age (median)5454Mann-Whitney U test, p=0.133
Gender—female700/1198 (58.4%)696/1135 (61.3%)Two-proportion test, p=0.154
Gender—male498/1198 (41.6%)439/1135 (38.7%)Two-proportion test, p=0.154
Severity 1—minor151/1198 (12.6%)207/1135 (18.2%)χ2, p=0.002,
two-proportion test, p<0.001
Severity 2—moderate451/1198 (37.6%)409/1135 (36.0%)Two-proportion test, p=0.420
Severity 3—major496/1198 (41.4%)422/1135 (37.2%)Two-proportion test, p=0.037
Severity 4—extreme100/1198 (8.3%)96/1135 (8.5%)Two-proportion test, p=0.923
No severity score listed0/1198 (0%)1/1135 (0.1%)Two-proportion test, p=0.317
Length of stay (median)3 Days
(4.4 days average)
3 Days
(4.0 days average)
Mann-Whitney U test, p=0.003
Complications of care18/1198 (1.5%)6/1135 (0.5%)Two-proportion test, p=0.018
30-Day readmission with exclusions (any APR-DRG)*180/1107 (16.3%)141/1058 (13.3%)Two-proportion test, p=0.054
Mortality rate with exclusions*22/1197 (1.8%)19/1132 (1.7%)Two-proportion test, p=0.770
  • Patient characteristics were measured for the Family Medicine Hospitalist service from the Crimson database 12 months before and after the intervention.

  • *Crimson 30-day readmission excluded Centers for Medicare and Medicaid Services (CMS) approved readmissions including chemotherapy, radiotherapy, dialysis, rehabilitation, elective admission, patients discharged against medical advice, mortalities, length of stay greater than 1 year and transfers to other acute-care facilities. All severity adjusted All Patient Refined Diagnosis Related Groups (APR-DRGs) were included in the readmission data. Mortality rate excluded cases with uncertainty of how much influence the physician had on the case including chemotherapy and radiotherapy patients, length of stay over 1 year, inpatient transfers from other acute-care facilities and hospice patients according to Crimson guidelines.