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Olson DWM, Bettger JP, Alexander KP, et al. Transition of Care for Acute Stroke and Myocardial Infarction Patients: From Hospitalization to Rehabilitation, Recovery, and Secondary Prevention. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Oct. (Evidence Reports/Technology Assessments, No. 202.)

Cover of Transition of Care for Acute Stroke and Myocardial Infarction Patients

Transition of Care for Acute Stroke and Myocardial Infarction Patients: From Hospitalization to Rehabilitation, Recovery, and Secondary Prevention.

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Methods

Analytic Framework

The analytic framework (Figure 1) shows how the components of transition of care services (e.g., multiple referrals, continuity and coordination of care, communication) for the postdischarge care of adult patients hospitalized with stroke or MI result in both patient-based and system-based outcomes (e.g., functional status, quality of life, hospital readmission, morbidity, and mortality). In addition, the components of transition of care services are analyzed by both patient-based and system-based characteristics as well as within the context of a theoretical framework. Adverse events, associated risks, or potential harms of transition of care services (both system-based and patient-based) are also addressed.

Figure 1: Analytic Framework. Figure 1 shows how the components of transition of care services (e.g., multiple referrals, continuity and coordination of care, communication) for the postdischarge care of adult patients hospitalized with stroke or MI result in both patient-based and system-based outcomes (e.g., functional status, quality of life, hospital readmission, morbidity, and mortality). In addition, the components of transition of care services are analyzed by both patient-based and system-based characteristics as well as within the context of a theoretical framework. Adverse events, associated risks, or potential harms of transition of care services (both system-based and patient-based) are also addressed.

Figure 1

Analytic Framework. Note: “Multiple referrals” indicates referrals to primary care and other health care providers. Abbreviations: ER = emergency room, KQ = key question, MI = myocardial infarction

Literature Search Strategy

Sources Searched

The comprehensive literature search involved electronic searching of peer-reviewed literature databases from January 1, 2000, to April 21, 2011. These databases included the Cumulative Index to Nursing and Allied Health Literature (CINAHL®), MEDLINE® accessed via PubMed®, the Cochrane Database of Systematic Reviews, and Embase®. Searches of these databases were supplemented with manual searching of reference lists contained in all included articles and in relevant review articles.

Screening for Inclusion and Exclusion

We developed a list of article inclusion and exclusion criteria for the key questions (Table 1) and modified the list after discussion with the TEP.

Table 1. Inclusion and exclusion criteria.

Table 1

Inclusion and exclusion criteria.

Process for Study Selection

Search strategies were specific to each database in order to retrieve the articles most relevant to the key questions. Our basic search strategy used the National Library of Medicine’s Medical Subject Headings (MeSH) key word nomenclature developed for MEDLINE®, limited to articles published in English, and a manual search of retrieved articles and published reviews. Search terms and strategies were developed in consultation with a medical librarian.

We incorporated transition of care studies that specified postacute hospitalization transition of care services as well as prevention of recurrent MI or stroke. Naylor8 identified keywords used in our search strategy (transitional care, discharge planning, car e coordination, case management, continuity of care, referrals, postdischarge followup, patient assessment, patient needs, interventions, and evaluations), and we incorporated and built on this foundation. The exact search strings used in our strategy are given in Appendix A.

Interventions solely comprised of cardiac rehabilitation or stroke rehabilitation were excluded since both are services that can be prescribed independently from a transition of care program. These articles were excluded at the full-text screening stage in the category of “not a system-level transitional intervention.” We did not identify any transition of care interventions that were developed to support patients transitioning from hospital to rehabilitation (either cardiac or stroke) or from rehabilitation to home.

Using the prespecified inclusion and exclusion criteria, titles and abstracts were examined independently by two reviewers for potential relevance to the key questions. Articles included by any reviewer underwent full-text screening. At the full-text screening stage, two independent reviewers read each article to determine if it met eligibility criteria. At the full-text review stage, paired researchers independently reviewed the articles and indicated a decision to “include” or “exclude” the article for data abstraction. When the paired reviewers arrived at different decisions about whether to include or exclude an article, they reconciled the difference through a third-party arbitrator. Articles meeting our eligibility criteria were included for data abstraction.

Data Extraction and Data Management

Data from included reports were abstracted into the database by one reviewer and read over by a second reviewer. Data elements abstracted included study design, setting, geographic location, patient characteristics, transition of care components, outcomes, length of followup, adverse events, and descriptors to assess applicability, quality elements, intervention details, and outcomes. Disagreements were resolved by consensus or by obtaining a third reviewer’s opinion when consensus could not be reached. Appendix B lists the elements used in the data abstraction form. Appendix C contains a bibliography of all included studies organized alphabetically by author.

Individual Study Quality Assessment

We employed internal and external quality-monitoring checks through every phase of the project to reduce bias, enhance consistency, and verify accuracy. Examples of internal monitoring procedures were two progressively stricter screening opportunities for each article (abstract screening, full-text screening, and data abstraction), involvement of two individuals in each data abstraction, and agreement of the two investigators on all included studies. The peer review process was our principal external quality-monitoring device.

The included studies were assessed on the basis of the quality of their reporting of relevant data. We evaluated the quality of individual studies using the approach described in AHRQ’s Methods Guide for Effectiveness and Comparative Effectiveness Reviews (hereafter referred to as the Methods Guide).15 To assess methodological quality, we employed the strategy to (1) apply predefined criteria for quality and critical appraisal and (2) arrive at a summary judgment of the study’s quality. To indicate the summary judgment of the quality of the individual studies, we used the summary ratings of good, fair, or poor. Appendix B describes our quality assessment process, and Appendix D lists our quality assessment for each included study.

To assess applicability, we used data abstracted on the population studied, the intervention and comparator, the outcomes measured, settings, and timing of assessments to identify specific issues that may limit the applicability of individual studies or a body of evidence as recommended in the Methods Guide.15 Appendix B describes our applicability assessment process, and Appendix D lists our applicability assessment for each included study. We used these data to evaluate the applicability to clinical practice, paying special attention to study eligibility criteria, baseline demographic features of the enrolled population (such as age, disease severity, and comorbid conditions) in comparison to the target population, characteristics of the transition of care intervention used in comparison with therapies currently in use in routine clinical practice, and clinical relevance and timing of the outcome measures.

Data Synthesis

The studies included in this review varied in the types of transition of care service, the delivery of the intervention tested, the comparator group, and the outcomes measured. Therefore, we were unable to group studies with similar transitions of care, interventions, and outcomes for a formal meta-analysis. Instead, we grouped studies with similar transition of care components and described the interventions, comparators, and outcomes.

Grading the Body of Evidence for Each Key Question

The strength of evidence for each key question was assessed using the approach described in the Methods Guide.15 The evidence was evaluated using the four required domains: risk of bias (low, medium, or high), consistency (consistent, inconsistent, or unknown/not applicable), directness (direct or indirect), and precision (precise or imprecise). Additionally, when appropriate, the studies were evaluated for coherence, dose-response association, residual confounding, strength of association (magnitude of effect), publication bias, and applicability.

The strength of evidence was assigned an overall grade of High, Moderate, Low, or Insufficient according to the following four-level scale:

  • High—High confidence that the evidence reflects the true effect. Further research is very unlikely to change our confidence in the estimate of effect.
  • Moderate—Moderate confidence that the evidence reflects the true effect. Further research may change our confidence in the estimate of effect and may change the estimate.
  • Low—Low confidence that the evidence reflects the true effect. Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate.
  • Insufficient—Evidence either is unavailable or does not permit estimation of effect.

Peer Review and Public Commentary

Nominations for peer reviewers were solicited from several sources, including the TEP and interested Federal agencies. The list of nominees was forwarded to AHRQ for vetting and approval. A list of reviewers submitting comments on the draft version of this report is included in the Preface of this document.

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