Integrated Multidisciplinary Post-Discharge Follow-Up in a Colombian Cardiovascular Referral Center: Real-World Implementation and Outcomes

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.