Objectives: Patients undergoing biliary drainage are at high risk of readmission. We evaluated a Chronic Care Model (CCM)-based transitional care program designed to improve post-discharge outcomes. Methods: This prospective, two-center randomized controlled trial assigned 300 patients requiring biliary drainage to an intervention (CCM-based transitional care) or control (usual care) group. Primary outcomes were 90-day hospital readmission and complication rates. Time-to-readmission was analyzed using the Kaplan–Meier method. Secondary outcomes included patient-reported readiness for hospital discharge, self-care behavior, and quality of life. Predictive models, including logistic regression and support vector machine (SVM), were developed to identify risk factors for readmission. Results: The intervention group had significantly lower 90-day readmission rates (16.3% vs. 37.1%; P = 0.001) and complication rates (12.1% vs. 26.5%; P = 0.010). Intervention patients reported higher mean scores (all P < 0.001) for discharge readiness (88.09 vs. 60.49), self-care behavior (88.04 vs. 59.95), and quality of life (88.16 vs. 60.84). Logistic regression confirmed that these patient-reported scores predicted lower readmission risk (OR: 0.97, 95% CI: 0.95–0.99). Furthermore, the SVM model demonstrated high discriminatory ability (AUC: 0.93; 95% CI: 0.89–0.95). Conclusions: A structured, CCM-based transitional care program effectively reduces readmissions and complications while prolonging community-based stability for patients with biliary drainage. Furthermore, patient-reported metrics integrated into an SVM model accurately predict readmission risk, enabling targeted interventions.
Zhang et al. (Wed,) studied this question.
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