CRD summary

This review concluded that low-strength evidence suggested that bridging strategies (interventions before and after discharge, with dedicated transition provider) reduced readmission or emergency department visits. No conclusions could be reached on adverse events. The strategies hospitals should implement to improve patient safety on discharge remained unclear. The authors' conclusions are likely to be reliable.

Authors' objectives

To assess the effectiveness of hospital-initiated care transition strategies, in preventing adverse outcomes, after discharge.

Searching

MEDLINE, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for studies, reported in English, from January 1990 to September 2012. The search strategy was reported in an online supplement.

Study selection

Randomised controlled trials (RCTs) and controlled clinical trials that assessed a transitional care strategy, initiated before hospital discharge, were eligible for inclusion. A transitional care strategy was defined as one or more interventions aimed at ensuring a safe and effective transition of the patient from an acute in-patient setting to home. Trials that focused on transition from hospital to another acute or subacute care setting were excluded. Trials had to enrol an unselected population of adult general medical patients. Outcomes eligible for inclusion were adverse events after discharge, emergency department use, or readmission after discharge home. Primary outcomes were events within 30 days of discharge. Secondary outcomes were events within one year of discharge.

Approximately half the included trials were conducted in the USA; the locations for the other trials were not reported. Just over half the trials were of older adult populations, while a quarter were of individuals at a high risk of readmission or adverse events. A few trials were of patients receiving polypharmacy or a "high-risk" medication. Definitions of all the risk factors, including older adults, varied considerably between trials. A median of four strategies were investigated (range one to eight), and most trials had intervention components before and after discharge (bridging strategy). The most common strategies involved patient engagement, outreach after discharge, and (in interventions with a bridging strategy) a designated transition provider. Details were reported in the paper.

Two reviewers independently assessed the full papers for inclusion.

Assessment of study quality

Two reviewers independently assessed the trials, using the Cochrane Collaboration's Effective Practice and Organisation of Care checklist. Trials were rated, and the strength of evidence was assessed, using the methods of the Agency for Healthcare Research and Quality. Disagreements were resolved by consensus and in consultation with a third reviewer, if necessary.

Data extraction

The study characteristics and outcome incidences were extracted by two independent reviewers. Disagreements were resolved by consensus and a third reviewer was consulted, where necessary.

Methods of synthesis

Variation in trial characteristics meant that a narrative synthesis was conducted.

Results of the review

Forty-seven trials were included in the review. Twenty-eight were RCTs (with 11,938 patients) and 19 were controlled clinical trials. Most were of fair methodological quality.

Adverse events after discharge: Three of nine trials reported statistically significant reductions in the rate of adverse events, after discharge, with their interventions. All three of these trials were of interventions led by pharmacists. Two other pharmacist-led intervention trials reported reductions that were not statistically significant; these trials did not have sufficient patients to produce significant results.

Thirty-day readmission and emergency department visits: Eight of 22 trials (four of 12 RCTs) reported statistically significant reductions in readmissions, emergency department visits, or a composite of these outcomes. Six of the eight trials used a bridging intervention. Fourteen trials (eight RCTs) reported no statistically significant difference between their groups; four of these used bridging interventions. Trials reporting significant and non-significant findings were broadly comparable in size and quality.

Readmission and emergency department visits beyond 30 days: Twenty-six trials reported intervals ranging from 45 days to one year after discharge. Seven trials reported statistically significant reductions in readmissions; four of these used a bridging intervention.

The factors associated with the successful implementation of transitional care interventions could not be assessed, as the trials did not report these. The Care Transitions Intervention was the only strategy assessed in more than one context.

Cost information

Sixteen trials reported the costs of health care use with the intervention and comparison groups; none reported the cost of the actual intervention. The resource use data were from varying sources and measured over different periods of time. It was not therefore possible to draw firm conclusions on the impact of the interventions on care costs.

Authors' conclusions

Low-strength evidence indicated that a bridging strategy, with interventions before and after discharge, and a dedicated transition provider, reduced hospital readmission or emergency department visits. Due to limited evidence, no conclusions could be reached on the best methods to prevent adverse events after discharge. The strategies hospitals should implement to improve patient safety on discharge remained unclear.

CRD commentary

This review addressed a clear question supported by specific inclusion criteria. Despite the requirement for an unselected general medical population, it appears that most trials selected patients on their age, risk profile or polypharmacy. Most trials excluded patients with cognitive impairment or dementia, so generalisation to an unselected population or to these high-risk groups may be limited. The search was thorough, but it was not clear what impact the restriction to trials in English might have had. The authors reported methods designed to reduce reviewer bias and error at all stages of the review process. Appropriate methods were used to assess trial quality. The narrative synthesis was appropriate.

The authors' conclusions were based on the reasonable quality of the evidence, together with the variability in the interventions, and the effects of the interventions. If this level of variance is borne in mind, the conclusions are likely to be reliable.

Implications of the review for practice and research

Practice: The authors did not state any specific implications for practice, but they noted that the few resource-intensive interventions to reduce hospital readmissions that were successful might be difficult to implement in the context of other pressing safety issues. They stated that the interventions an individual hospital could implement to improve transitional care remain largely undefined.

Research: The authors stated that there was a need for larger trials, of clinical pharmacist-led medication checking interventions, that explicitly plan to measure adverse events. They highlighted the need for standard intervention terminology and reproducibility; to identify target populations most likely to benefit from specific interventions; to measure patient-centred outcomes; and to rigorously report and evaluate the costs and implementation factors.

Funding

Funded by the Agency for Healthcare Research and Quality (AHRQ), USA.

Bibliographic details

Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 433-440. [PubMed: 23460101]

Original Paper URL

http://annals.org/article.aspx?articleid=1656449

Other publications of related interest

Shekelle PG, Wachter RM, Pronovost PJ, Schoelles K, McDonald KM, Dy SM, Shojania K, Reston J, Berger Z, Johnsen B, Larkin JW, Lucas S, Martinez K, Motala A, Newberry SJ, Noble M, Pfoh E, Ranji SR, Rennke S, Schmidt E, Shanman R, Sullivan N, Sun F, Tipton K, Treadwell JR, Tsou A, Vaiana ME, Weaver SJ, Wilson R, Winters BD. Making health care safer II: an updated critical analysis of the evidence for patient safety practices. Rockville, MD, USA: Agency for Healthcare Research and Quality. Comparative Effectiveness Review; 211. 2013.

Weaver SJ, Lubomski LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting a culture of safety as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 369-374.

Reston JT, Schoelles KM. In-facility delirium prevention programs as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 375-380.

Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 397-403.

McDonald KM, Matesic B, Contopoulos-Ioannidis DG, Lonhart J, Schmidt E, Pineda N, Ioannidis JP. Patient safety strategies targeted at diagnostic errors: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 381-389.

Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 390-393.

Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 410-416.

Shekelle PG. Nurse-patient ratios as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 404-409.

Winters BD, Weaver SJ, Pfoh ER, Yang T, Pham JC, Dy SM. Rapid-response systems as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 417-425.

Schmidt E, Goldhaber-Fiebert SN, Ho LA, McDonald KM. Simulation exercises as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 426-432.

Indexing Status

Subject indexing assigned by NLM

MeSH

Emergency Service, Hospital /statistics & numerical data; Hospital Administration; Hospital Costs; Humans; Patient Discharge /standards; Patient Readmission /statistics & numerical data; Patient Safety; Risk Assessment; Safety Management /economics /methods /organization & administration

AccessionNumber

12013013336

Database entry date

14/03/2013

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.