Key result
Structured telephone follow-up achieves high reach, showing ~9% 1-month readmissions and low 1-year mortality.
Why the study?
Gaps in continuity of care during the post-discharge period may increase adverse outcomes. This study aimed to describe the implementation and outcomes of a structured post-discharge follow-up program at a specialised cardiovascular referral centre in Colombia.
Cohort (n=25,232)
No
A large-scale, structured telephone post-discharge follow-up program at a Colombian cardiovascular referral center demonstrated high 1-month completion (98.9%) and systematically tracked readmissions, mortality, and quality-of-life trajectories up to 12 months.
Answers are grounded in this paper and cite their sources.
Supports feasibility of structured telephone monitoring post-discharge; leaves open impact on readmissions or mortality in randomized trials.
BACKGROUND: The post-discharge period is vulnerable because gaps in continuity of care may increase adverse outcomes. This study aimed to describe the implementation of a structured post-discharge follow-up program and the outcomes observed during follow-up at a specialised cardiovascular referral centre in Colombia. METHODS: We conducted a cohort study of patients enrolled in an institutional prospective post-discharge follow-up program between 2023 and 2025. Trained personnel conducted standardized telephone follow-up at predefined intervals up to 12 months, assessing vital status, readmissions, post-discharge events, outpatient follow-up, and health-related quality of life. Outcomes were summarized descriptively. RESULTS: Of 34,564 identified patients, we included 25,232 (73.0%). Men comprised 54.2% of the cohort. Follow-up completion was 18,876/19,086 (98.9%) at one month and 3,861/5,720 (67.5%) at 12 months. At the one-month follow-up, all-cause readmission to the study institution occurred in 2,141/25,232 patients (8.5%). Cumulative mortality was 191/19,086 (1.0%) at one month, 467/13,749 (3.4%) at six months, and 240/5,720 (4.2%) at 12 months. Median EQ-VAS increased from 70 (IQR 61-80) at baseline to 85 (IQR 75-90) at 12 months; worsening was most frequent in pain/discomfort [1,653/5,720 (28.9%)] and anxiety/depression [986/5,720 (17.2%)]. CONCLUSION: This large-scale program enabled structured post-discharge follow-up and systematic collection of clinically relevant outcomes, with high completion at early scheduled assessments and lower completion at longer-term assessments.
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Licht-Ardila et al. (2026) conducted a cohort in Cardiovascular disease requiring post-discharge care (n=25,232). Structured multidisciplinary telephone post-discharge follow-up program was evaluated on 1-month all-cause readmission and cumulative mortality up to 12 months. Structured telephone post-discharge follow-up achieved 98.9% 1-month completion, observing 8.5% 1-month readmission and 4.2% 12-month cumulative mortality.
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