Bridging the Discharge Gap Effectively (BRIDGE): A Novel Approach to Transitional Care for Patients with Acute Coronary Syndrome.

Abstract

Background: Bridging the Discharge Gap Effectively (BRIDGE) is a program that aims to provide patients with cardiovascular disease quality evidence-based care through their hospital-to-home transition. The BRIDGE nurse practitioners assess patients’ clinical status, make adjustments in their therapeutic regimens as needed, educate patients and families about health promotive activities and refer when necessary. This study aimed to determine if the BRIDGE model was effective in improving six-month medication persistence rates (for secondary prevention medications), lowering 30-day hospital readmission rates, and reducing overall health care costs associated with readmission. Methods: Data were collected retrospectively on all patients referred to the BRIDGE program. Medication persistence was analyzed using logistic regression, rates were calculated for hospital readmissions, and a cost model was developed to compare BRIDGE costs against avoided hospital readmission costs. All eligible patients referred to BRIDGE received an appointment within 14 days of discharge. Analyses compared attendees with non-attendees. Results: Of 500 patients referred to the BRIDGE program, 74 were excluded due to early adverse events. Of those remaining, 25.2% (n=107) had a discharge diagnosis of acute coronary syndrome (ACS), and 72.2% (70) attended BRIDGE. The mean age of study participants was 62.4 years and the majority were female (59.8%) and white (85.6%). With the exception of dyslipidemia there were no baseline differences between groups. Most patients were prescribed aspirin, β-blockers, ACE-inhibitors, statins, and clopidogrel at discharge (range 75.0% to 97.9%) and remained on therapy at six months (range 80.6% to 95.5%). There were no differences in persistence rates between groups. BRIDGE participants had lower readmission rates at 30 (9.7 vs. 27.8. p=.112), 60 (11.3 vs. 38.9, p=.012), 90 (16.1 vs. 38.9, p=.052), and 180 (27.4 vs. 50, p=0.72) days post-discharge. On average, the program saved $4,944 per-patient or $306,537 overall in avoided readmissions. Conclusion: Most ACS patients require early post-discharge follow-up. BRIDGE fulfills this need with demonstrated success in reducing 30-day readmissions at a cost value. The BRIDGE model is thus a novel and practical approach to addressing transitional care and the vexing nation-wide problem of hospital readmissions for ACS patients.