[AVBC 2025] Effectiveness - Post-discharge Transitional Care Programmes to Reduce Fluid Overload Readmissions
Care Process & Redesign
Appropriate & Value-based Care Conference
SingHealth
28 November 2025
Hospitalizations for fluid overload are common in chronic kidney disease (CKD) and are expected to increase healthcare. Post-discharge TCPs may reduce 90-day readmissions for fluid overload and can be a cost-effective strategy to reduce healthcare.
Year Submitted: 2025
Published Date: 28 November 2025
Tags: Care Process ＆ Redesign, Productivity, Cost Saving, Access To Care, Readmission Rate
About this Content
Aims
Hospitalizations for fluid overload are common in chronic kidney disease (CKD) and are expected to increase healthcare utilization.
Background
Hospitalizations for fluid overload are common in chronic kidney disease (CKD) and are expected to increase healthcare utilization.
Methods
There was a trend towards reduced 90-day readmissions in the TCP group compared to the standard care group (7.25% vs 12.9%, p=0.08). The base case probabilistic sensitivity analysis showed an overall net monetary benefit of S$1,968, with TCPs being 98.7% cost-effective when evaluated against the S$45,000 willingness-to-pay threshold.
Results
There was a trend towards reduced 90-day readmissions in the TCP group compared to the standard care group (7.25% vs 12.9%, p=0.08). The base case probabilistic sensitivity analysis showed an overall net monetary benefit of S$1,968, with TCPs being 98.7% cost-effective when evaluated against the S$45,000 willingness-to-pay threshold.
Conclusion
Post-discharge TCPs may reduce 90-day readmissions for fluid overload and can be a cost-effective strategy to reduce healthcare resource utilization and costs, although its long-term impact requires further investigation.
Lessons Learnt
The study lacks granularity in socio-demographic factors which are known to affect fluid overload readmission risk and patients ability to interact with and benefit from transitional care programs. Longer-term outcomes and associated costs were not evaluated due to lack of data availability, limiting the generalizability of the findings over extended periods.
Keywords
Transitional Care, Fluid Overload, Chronic Kidney Disease, Cost-Effectiveness
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | SingHealth |
Organization(s) Involved | Duke-NUS, Singapore General Hospital |
Platform(s) | Appropriate & Value-based Care Conference |
Healthcare Professional Group(s) | Healthcare Administration |
Applicable Specialty or Discipline | Nephrology |
Project Lead(s) | Wee Soon Nan |
Project Member(s) | Cynthia Lim |
Connect with this contributor!
Chin De Zhi - chin.de.zhi@sgh.com.sg