March, 2017 - SUPPORT Summary of a systematic review | print this article |

Are interventions to reduce rehospitalisation within thirty days of discharge effective?

Rehospitalisation following discharge is a frequent event that affects patients’ quality of life and can be associated with poor health outcomes. Avoiding rehospitalization is a goal that may both improve quality of care and reduce healthcare costs.

Key messages


  • It is uncertain whether pre discharge interventions reduce rehospitalisation.
  • Post discharge interventions may lead to little if any difference in rehospitalisation.
  • It is uncertain whether patient centred discharge instructions reduce rehospitalisation.
  • Inpatient–outpatient provider continuity may slightly reduce rehospitalisation.
  • It is uncertain whether interactions between patients and nurses before and after discharge to support patient self care reduce rehospitalisation.
  • No studies conducted in low income countries were identified.

 

Background

Rehospitalization creates considerable burdens for both patients and health systems. Interventions to reduce avoidable hospitalization can be classified into three groups, based on the timing of the intervention:

 

  • Pre discharge interventions: for example, patient education, discharge planning, medication reconciliation, and appointments scheduled before discharge
  • Post discharge interventions: for example, timely patient follow up, timely primary care provider communication, patient hotlines, and home visits
  • Interventions bridging the transition between care settings: for example, transition coaches, patient centered discharge instructions, and provider continuity. Bridging interventions engage the patient and their family in the discharge process and transform the process into an activity done with a patient rather than to a patient.

 



About the systematic review underlying this summary

Review objectives:To estimate the effectiveness of interventions to reduce 30 day rehospitalisation
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials, cohort studies, or uncontrolled before after studies assessing interventions delivered around the time of discharge and applicable to general medical adult populations (rather than disease specific approaches)
43 included studies: 16 randomised trials, 14 non randomised trials, and 13 uncontrolled before after studies. Most studies (56%) tested a single component intervention.
Participants General medical adult acute inpatient populations. Studies of paediatric, obstetric, and psychiatric populations were excluded.
Most studies focused on people admitted to general medicine wards or people with heart failure or chronic obstructive pulmonary disease.
Settings Hospital, ambulatory care and patients’ homes.
USA (28), UK (2), Canada (2), Hong Kong (2), and 1 study in each of the following countries: Australia, Belgium, Denmark, Ireland, Israel, Netherlands, New Zealand, Portugal, and Taiwan.
Outcomes 30 day rehospitalisation
30 day rehospitalisation
Date of most recent search: January 2011.
Limitations: This is well conducted systematic review with only minor limitations.

Hansen LO, Young RS, Hinami K et al. Interventions to reduce 30 day rehospitalization: a systematic review. Ann Intern Med 2011; 155:520-8.

Summary of findings

The review included 43 studies. The effects of interventions are presented in three categories: pre discharge interventions, post discharge interventions and interventions that aim to bridge the transition between care settings. Several of the common discharge interventions were only assessed as part of multicomponent “discharge bundles”.

 

1) Pre discharge Interventions

Pre discharge patient education and discharge planning were the most commonly evaluated interventions (22 of 43 studies), but were evaluated mostly as ‘bundled’ interventions and so do not provide evidence on the effects of pre discharge interventions alone. Three studies assessed pre discharge interventions alone. One study that assessed a patient education intervention found a small decrease in rehospitalisation. The two studies assessing discharge planning had mixed results.

 

  • It is uncertain whether pre discharge interventions reduce rehospitalisation. The certainty of this evidence is very low.

Predischarge interventions

People: People admitted to hospital in Canada and the USA (2 studies).
Settings
:  Hospitals.
Intervention
Patient education or discharge planning.
Comparison
No intervention.
Outcomes Impact Certainty of the evidence
(GRADE)
Rehospitalisation
The studies had mixed results: one study found an 11% reduction in rehospitalisation, one study found a 7.1% reduction, and one study found a 7.8% increase.

 

Very low

 


GRADE: GRADE Working Group grades of evidence (see above and last page).

 

 

2) Postdischarge Interventions

Post discharge interventions included follow up telephone calls (17 studies), patient activated “hotlines” (5), home visits (9), timely outpatient follow up (5), and timely communication of patient information to an outpatient provider (5). Only three studies examined postdischarge interventions alone: one assessed home visits and two assessed follow up telephone calls. The other studies assessed post discharge interventions together with other interventions or did not use randomised designs and so do not provide evidence on the effects of post discharge interventions alone.

  • Post discharge interventions may lead to little or no difference in rehospitalisation. The certainty of this evidence is low.


Post discharge interventions

People: Outpatients in Israel, the United Kingdom, and the USA
Settings
:  Home
Intervention
: Follow up telephone calls or home visits.
Comparison
: No intervention.
Outcomes Impact Certainty of the evidence
(GRADE)
Rehospitalisation
The studies had mixed results: one study found a 2% reduction in rehospitalisation, one study found a 0.5% increase, and one study found a 10% increase.

 

Low
GRADE: GRADE Working Group grades of evidence (see above and last page)

 

3) Interventions bridging the transition from hospital to home

Twelve studies described strategies involving “bridging” interventions, with several studies assessing more than one intervention in ‘bundles’:

  • Patient centred discharge instructions were assessed in eight studies. These instructions are intended to facilitate patient engagement in the transition of care, particularly in the use and transmission of healthcare information. None of these studies examined the effects of this intervention alone.
  • Improvements in inpatient–outpatient provider continuity were assessed in two studies. In these studies, the hospital doctor continued to manage the patient following discharge.
  • Interactions between patients and nurses before and after discharge to support patient self care (‘transition coaches’) were assessed in six studies. None of these studies examined the effects of this intervention alone.
  • It is uncertain whether patient centred discharge instructions reduce rehospitalisation. The certainty of this evidence is very low.
  • Inpatient–outpatient provider continuity may slightly reduce rehospitalisation. The certainty of this evidence is low.
  • It is uncertain whether interactions between patients and nurses before and after discharge to support patient self care reduce rehospitalisation. The certainty of this evidence is very low.

Interventions bridging the transition from hospital to home

People: Inpatients and outpatients in Australia (1), Canada (1), the Netherlands (1), the United Kingdom (1), and the USA (8).
Settings
:  Hospital and home.
Intervention
: Patient centred discharge instructions, as part of a bundle of interventions; inpatient outpatient provider continuity; interactions between patients and nurses, as part of a bundle of interventions.
Comparison
: No intervention.
Outcomes Impact Certainty of the evidence
(GRADE)
Comments
Rehospitalisation
Eight studies assessed patient centred discharge instructions. The results ranged from a 10% reduction in rehospitalisation to a 2% increase.

 

Very low

 


 The certainty of the evidence was assessed as very low due to risk of bias and inconsistency of the results, which include both benefit and harm

Improvements in inpatient outpatient provider continuity may slightly reduce rehospitalisation. The two studies found reductions of 0.7% and 4.4%.

 

Low

 


 
  Six studies assessed interactions between patients and nurses before and after discharge to support patient self care. The reductions in rehospitalisation ranged from 2-12%.

 

Very low

 

The certainty of the evidence was assessed as very low due to risk of bias and inconsistency of the results.
GRADE: GRADE Working Group grades of evidence (see above and last page)

 


 

 

 

 

 

 

 

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

The certainty of the evidence is low or very low.

 

  • All studies were conducted in high income countries, mainly in the USA.

 


In addition to the evidence from high income countries being uncertain, the applicability of that evidence to low income countries is uncertain because the effects of interventions might depend on the capacity and type of health professionals available to deliver interventions before and after hospital discharge; the availability of community based care and support, to ensure continuity of care; other health systems resources needed to implement the interventions; and the resources available in the household to support patient care.

 

  • Some of the interventions rely on a high level of communication between the hospital and providers of services outside of the hospital. This is not always available or possible in low income settings.

 


EQUITY
There was no information in the review regarding the differential effects of the interventions for disadvantaged populations.

The impacts of these interventions on inequities is uncertain. Some of the interventions involve shifts in care from secondary to primary level and to the home. The effects of these interventions may depend on the potential of health systems to address the limited availability of community care, and the capacity of health professionals to provide care for disadvantaged populations.

 

  • Where interventions depend on access to specific technologies such as hotlines, or require high literacy levels, they may disadvantage individuals or communities with few resources or low literacy levels.

 


ECONOMIC CONSIDERATIONS
The systematic review did not address the costs or cost effectiveness of these interventions.
Both costing studies and cost effectiveness studies (for effective interventions) are needed. Detailed information on the resources needed to implement these interventions would be helpful in assessing their applicability to other settings.
MONITORING & EVALUATION
The available evidence on interventions to reduce rehospitalisation is of low or very low certainty, and no eligible studies from low income countries were identified.

Rigorous studies of the effects and cost effectiveness of these interventions are needed in low income countries before scaling up their use.

 

  • Studies should provide details of the intervention components and describe the contexts in which they were delivered.

 


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low income countries. For additional details about how these judgements were made see:www.supportsummaries.org/methods

 

Additional information

Related literature

Scott IA. Preventing the rebound: improving care transition in hospital discharge processes. Aust Health Rev 2010; 34:445-51.

 

Cain CH, Neuwirth E, Bellows J, et al. Patient experiences of transitioning from hospital to home: an ethnographic quality improvement project. J Hosp Med 2012; 7:382-87.

 

Long T, Genao I, Horwitz LI. Reasons for readmission in an underserved high risk population: a qualitative analysis of a series of inpatient interviews. BMJ Open 2013; 3(9):e003212.

 

Gonçalves Bradley DC, Lannin NA, Clemson LM, et al. Discharge planning from hospital. Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD000313.

 

This summary was prepared by

Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by Richard Walker. We did not receive any comments from the review authors.

 

This review should be cited as

Hansen LO, Young RS, Hinami K et al. Interventions to reduce 30 day rehospitalization: a systematic review. Ann Intern Med 2011; 155:520-8.

 

The summary should be cited as

Ciapponi A. Are interventions to reduce rehospitalisation within thirty days of discharge effective? March 2017. www.supportsummaries.org

 

Keywords

evidence informed health policy, evidence based, systematic review, health systems research, health care, low and middle income countries, developing countries, primary health care, hospitalization, readmission, patient discharge, continuity of patient care, transition.

 

 

 

 

 

 

 

 

 



Comments