Study PDF

JBI Database of Systematic Reviews & Implementation Reports 2016;14(2):106-173
Effectiveness of discharge interventions from hospital to home on

hospital readmissions: a systematic review
Anja Braet1,2
Caroline Weltens3,4
Walter Sermeus1,5
1. KU Leuven-University of Leuven, Department of Public Health and Primary Care, Leuven,

Belgium
2. az Sint-Blasius, Dendermonde, Belgium
3. Flemish Hospital Network KU Leuven, Leuven, Belgium
4. University Hospitals Leuven, Leuven, Belgium
5. Belgian Interuniversity Collaboration for Evidence-based Practice (BICEP): an Affiliate Center
of The Joanna Briggs Institute
Corresponding author:
Anja Braet
[email protected]
Executive summary
Background
Many discharge interventions are developed to reduce unplanned hospital readmissions, but it
is unclear which interventions are more effective.
Objectives
The objective of this review was to identify discharge interventions from hospital to home that
reduce hospital readmissions within three months and to understand their effect on secondary
outcome measures.
Inclusion criteria
Types of participants
Participants were adults (18 years or older) discharged from a medical or surgical ward.
Types of intervention(s)/phenomena of interest
The included interventions had to be designed to ease the care transition from hospital to home
or to prevent problems after hospital discharge.
Braet et al.Effectiveness of discharge interventions from hospital to home on hospital readmissions: a systematic
review © the authors 2016 doi: 10.11124/jbisrir-2016-2381 Page 106
Types of studies
This review considered only randomized controlled trials.
Types of outcomes
The primary outcome measure was hospital readmission within three months after discharge.
Secondary outcomes included patient satisfaction, return to emergency departments and
mortality.
Search strategy
Studies in English between January 1990 and July 2014 were considered for inclusion. The
databases searched were PubMed, Web of Science, Embase and CINAHL.
Methodological quality
Methodological validity was assessed by two reviewers prior to inclusion using the standardized
critical appraisal instruments from the Joanna Briggs Institute.
Data extraction
Quantitative data were independently extracted by the two reviewers using the standardized
data extraction tool from the Joanna Briggs Institute.
Data synthesis
Meta-analysis was performed by using a random effect model; data were pooled using
Mantel-Haenszel methods. For subgroups analysis only papers with critical appraisal score of
seven or more were selected.
Results
Meta-analysis was performed on 47 studies. The overall relative risk for hospital readmission
was 0.77 [95% CI, 0.70-0.84] (p<0.00001). The relative risk for return to the emergency
department was 0.75 [95% CI, 0.55-1.01] (p=0.06) and for mortality 0.70 [95% CI, 0.48-1.01]
(p=0.06). Patient satisfaction improved in favor of the intervention group in five out of the six
studies evaluating patient satisfaction.
Exploratory subgroup analysis found that interventions starting during hospital stay and
continuing after discharge were more effective in reducing readmissions compared to
interventions starting after discharge (between subgroup difference p=0.01). Multicomponent
interventions were not more effective compared to single component interventions (between
subgroup difference p=0.54). Interventions oriented towards patient empowerment were more
effective compared to all other interventions (between subgroup difference p=0.02).
Conclusions
Interventions designed to improve the care transition from hospital to home are effective in
reducing hospital readmission. These interventions preferably start in the hospital and continue
after discharge rather than starting after discharge. Enhancing patient empowerment is a key
factor in reducing hospital readmissions.
Implications for practice
Interventions to reduce hospital readmissions should start during hospital stay and continue in
the community (grade A recommendation). This requires financial systems to support and
facilitate collaboration between hospitals and home care.
Interventions that support patient empowerment are more effective in reducing hospital
readmissions (grade B recommendation). To promote patient empowerment caregivers must
be trained to increase patients’ capacity to self-care.
Implications for research
Future research should focus on interventions that improve patient empowerment and the
effects of discharge interventions after more than three months.
Keywords
care transition; continuity of care; discharge intervention; hospital readmission; meta-analysis
Background
Unplanned hospital readmissions after discharge occur frequently and are very costly. In 2004, almost
one-fifth of the US Medicare patients were readmitted within 30 days and the cost of these readmissions
was $17.4 billion out of $102.6 billion in total hospital payments.1 Early unplanned readmissions can be
seen as a quality indicator associated with the process of inpatient care. 2-5 Defects in the quality of care,
not only during hospitalization but also during the care transition from hospital to home, can lead to
readmissions.6,7 Transitional care is defined by Coleman as “a set of actions designed to ensure the
coordination and continuity of healthcare as patients transfer between different locations or different
levels of care within the same location”.8(p556)
To improve care transitions and diminish hospital readmissions, multiple discharge interventions have
been developed and tested. Discharge interventions in this paper are defined as interventions
performed, at least partly, by hospital professionals, explicitly targeted to ease the transition from
hospital to home or to prevent or alleviate problems after hospital discharge.9 Discharge interventions
can be one single action like a telephone call after discharge, but also complex interventions. Some
examples of complex interventions are:
- Care Transitions Intervention, developed by Dr Eric Coleman: this model, based on four pillars
(medication self-management, patient centered record, follow-up and use of red flags), starts during
hospitalization and is followed by a home visit and follow-up telephone calls.10-12
- Advanced nurse practitioner care coordination.13
- Ideal Transition Home Model: this model was created as part of the “Transforming Care at the
Bedside” project for patients with congestive heart failure (Institute for Healthcare Improvement and
Robert Wood Johnson Foundation).6,14 The four core elements of the Ideal Transition Home Model are:
enhanced admission assessment of post-discharge needs, enhanced teaching and learning, enhanced
communication at discharge and timely post-acute care follow-up.
- BOOST (Better Outcomes for Older adults through Safe Transitions): a program based in Michigan.
The program consists of identifying high-risk patients, educating patients, scheduling follow-up
appointments and medication reconciliation at discharge.15
To choose the most efficient intervention for reducing hospital readmissions is difficult for managers or
clinicians. The aim of this systematic review was to facilitate this choice by synthesizing the best
available evidence.
Before starting the research, a preliminary search of the Joanna Briggs Database of Systematic
Reviews and Implementation Reports, Cochrane Library, Medline and CINAHL databases for
systematic reviews published in the last five years and review protocols studying discharge
interventions was conducted. Four JBI systematic reviews,16-19 one Cochrane systematic review20 and
also three other recent systematic meta-reviews were located.9,21,22
Lee and Slyer studied the effectiveness of discharge interventions for patients with heart failure and
found a positive effect with telephone based post-discharge nurse care16 and nurse coordinated
transitioning of care.18 Domingo and her colleagues evaluated the impact of discharge interventions on
hospital readmissions for patients admitted with community acquired pneumonia and found an effect
with medication reconciliation combined with follow-up telephone calls.19 The effect of caregiver
education on readmissions for patients admitted with community acquired pneumonia was the focus of
the study by McLeod-Sordjan and her colleagues, but they were unable to identify an effect due to
problems of isolating caregiver education as a direct intervention. 17 Shepperd and colleagues
conducted a systematic review to determine the effectiveness of discharge planning.20 They concluded
that hospital length of stay and readmissions to hospital were significantly reduced for patients allocated
to discharge planning. The meta-review conducted by Mistiaen examined the effectiveness of
discharge interventions in reducing post-discharge problems.9 They found limited evidence that some
interventions could reduce readmissions, especially interventions that combine discharge planning and
discharge support (aftercare). In a meta-review conducted by Scott, the efficacy of peridischarge
interventions was investigated.21 The author found that mostly multi-component interventions with pre-
and post-discharge elements were beneficial. This study, however, was carried out by only one
reviewer and the primary outcome measure (readmission) was not specified. Hansen published a
systematic review examining interventions aimed at reducing readmissions.22 The authors concluded
that no single intervention was associated with reduced risk of readmission. The only meta-analysis on
discharge interventions was published by Leppin and colleagues.23 They confirmed that complex
interventions consisting of five or more different intervention components were more effective than
interventions consisting of less than five components in reducing hospital readmissions within 30 days
after discharge, and confirmed the hypothesis that interventions supporting patient capacity for
self-care were more effective compared to interventions that did not increase patient capacity. Both
Hansen and Leppin limited the search to readmissions within an interval of 30 days after discharge.
Although a recent systematic review and meta-analysis was available, the reviewers wanted to extend
the time span to three months based on the observation that in many studies the intervention lasted
more than a month. The second reason to widen the time span is the expectation that effective
discharge interventions reduce hospital utilization over a longer time instead of inducing only a
short-term effect.
This review was conducted according to an a priori published protocol.24
Objectives
The objective of this review was to identify discharge interventions from hospital to home that have been
demonstrated to be effective in reducing hospital readmissions within three months in medical/surgical
adult patients and to understand their effect on secondary outcome measures.
The specific review questions are:
a. Which discharge interventions can reduce hospital readmissions within three months after discharge
from the hospital?
b. In addition to reducing readmissions, what is the effect of these discharge interventions on mortality,
use of emergency departments (EDs) and patient satisfaction?
Inclusion criteria
Types of participants
This review considered studies that include adult patients discharged from a medical or surgical ward of
an acute hospital. Studies with participants aged 18 years or older, male and female were included.
Studies with discharges from EDs or intensive care units and patients receiving palliative care,
psychiatric care or obstetrical stays were excluded.
Types of intervention(s)/phenomena of interest
This review considered studies that evaluated discharge interventions. The included interventions must
have been performed – at least partly – by hospital professionals with the intention of easing the care
transition out of the hospital to home, or to prevent or alleviate problems after hospital discharge.
Disease specific approaches were not considered.
Types of studies
This review considered only randomized controlled trials.
Types of outcomes
The primary outcome measure was hospital readmission within three months after discharge from
hospital.
Hospital readmissions were defined as hospitalizations to the same or another hospital for any reason
within three months after discharge. Longer discharge intervals were excluded because the more time
that passes between discharge and readmission, the less likely that the readmission is linked with the
first admission, inducing false positive or unlinked readmissions.25 Studies that did not measure hospital
readmission rates were excluded.
Secondary outcomes included patient satisfaction, return to EDs and mortality.
Search strategy
The search strategy aimed to find both published and unpublished studies. A three-step search strategy
was used. First an initial limited search of MEDLINE and CINAHL was undertaken followed by an
analysis of text words in titles and abstracts and of index terms used to describe the papers. A second
search used all identified keywords and index terms, and was done across all included databases.
Thirdly, the reference lists of all full text papers were searched for additional studies. Studies published
in English between January 1990 and July 2014 were considered for inclusion. Before 1990 practically
no studies were published on discharge interventions.22
The databases searched were PubMed, Web of Science, Embase and CINAHL. The search strategy is
documented in Appendix I. Unpublished studies were retrieved by searching proceedings and meeting
abstracts in Web of Science. To manage the references EndNote was used. Records were retrieved
and added to the library by the primary reviewer. Two reviewers screened titles and abstracts
independently. Conflicts were resolved by discussion. To assess the screening procedure compliance
interrater reliability was measured by categorizing each study as “included” or “excluded” for a specific
reason. Reasons for exclusion were listed in descending order: population, intervention, study
characteristics and outcome. For each excluded study the first listed reason for exclusion was
registered. For papers with missing primary outcomes or primary outcomes that were not clearly
described, the authors were contacted in November 2014 to provide additional information. All
decisions about rejecting or obtaining documents were recorded by the same person, responsible for
the library of references. Most full text articles were available from the internet; otherwise documents
were ordered by the University of Leuven Library. To be able to replicate the search process, all
searches, decisions and steps were documented. A list of the papers that were retrieved is given in
Appendix II.
Assessment of methodological quality

Quantitative papers selected for retrieval were assessed by two independent reviewers for
methodological validity prior to inclusion in the review using a standardized critical appraisal instrument
from the Joanna Briggs Institute (Meta-Analysis of Statistics Assessment and Review Instrument
(JBI-MAStARI) (Appendix III). Before starting critical appraisal the two reviewers agreed on the criteria
for a positive or negative appraisal: negative evaluation (answer= “no”) on questions 1,7,8,9 and 10
needed to be clarified in the comments section, questions 3 and 5 were evaluated as “unclear” unless
clearly described in the paper, and finally, question 6 was only answered negatively when this was
mentioned by the author or evaluated as a possible source of bias. Disagreements between the
reviewers were resolved through discussion. For papers that did not describe clearly how the primary
outcome was measured, the authors were contacted in November 2014 for further clarification.
Data extraction
Quantitative data independently extracted by the two reviewers were included in the review using the
standardized data extraction tool from JBI-MAStARI (Appendix IV). The data included specific details
about the interventions, populations, study methods and outcomes of significance to the review
question and specific objectives. Any disagreement was resolved by discussion.
Data synthesis
To estimate the effect size of discharge interventions on hospital readmission rates a meta-analysis
was conducted. Between-trial heterogeneity was explored using I2 and expressed as low when I2 was
smaller than 25% and high for I2 greater than 75%.26 Because patient characteristics varied between
the different studies, weighted mean effect sizes were computed using a random effects model. The
number of hospital readmissions in the comparison groups of each study was used to calculate relative
risks using the Mantel-Haenszel method. Relative risks were preferred over odds ratios to eliminate the
risk for misinterpretation. The possibility of publication bias was minimized by also including proceeding
papers and meeting abstracts and by identifying meticulously duplicated reports.
To explore the effect of specific intervention characteristics, a post hoc subgroup analysis on studies of
the highest quality (critical appraisal score of seven or more) was conducted. Because previous
systematic reviews showed evidence of beneficial effect of timing of intervention components
(pre-discharge, post-discharge or both), the number of components, implementation of patient
empowerment, and discharge planning, we decided to analyze these interventions as subgroups in a
meta-analysis. For subgroup analysis we used a random effect model to calculate within- and between
subgroup effects.27 Analysis – combined and on subgroups – was conducted with Review Manager 5.3
and 95% confidence intervals were used.
Results
Description of studies
Search of keywords in databases identified 4659 papers. Screening of titles and abstracts resulted in
exclusion of 4328 papers and inclusion of 331 papers. The interrater reliability of this first screening was
moderate, but statistically significant (Kappa 0.417, p=0.000). 28
The review of the reference lists of the 331 papers identified 97 additional papers for full-text screening.
Hence a total of 428 papers were retrieved for full text screening and comprehensive evaluation against
the eligibility criteria. Because the primary outcome (readmission within three months) was not or not
unambiguously recorded in some papers, 37 authors were contacted by email, resulting in nine useful
answers29-37 and additional inclusion of seven papers.29,31,32,34-37 Following this step (full text screening
and contacting authors), 375 papers were excluded because the studies did not meet the inclusion
criteria (17 papers were not original publications and two were not RCTs) (see Figure 1).
Methodological quality of the 51 papers was assessed and no studies were excluded based on quality.
To understand how readmissions were measured 16 authors were contacted, resulting in two useful
answers.38,39 One of the 51 included papers was a conference proceeding.40 Details of included and
excluded studies are summarized in Appendix VI and Appendix VII.
Records identified through

Identification
database searching
(n=4659) Records excluded (n = 4328)
 Duplicates 21
 Inclusion Criteria not met for:
o Population:1082
o Intervention: 2833
Papers retrieved for full-text
screening (n=331) o Study Characteristics:
338
o Outcome: 29
Screening
 Not available: 25
Additional records
identified through
screening reference lists
(n=97)
Full-text papers excluded, with

Full-text papers assessed for
reasons (n=377)
Screening
eligibility (n=428)
 Second Publication: 17
 Inclusion Criteria not met for:
o Population: 38
o Intervention: 114
o Study
Characteristics: 161
o Outcome: 45
Studies included in qualitative o Wrong study design:
Included
synthesis (n=51) 2
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic
Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097
Figure 1: Flowchart of study selection process
Study characteristics
The selected papers were published between 1990 and 2014, with 86% of them published after 2000.
Thirty-four out of the 51 included papers were published after 2004, hence this review proved to be
complementary to the meta-analysis of Mistiaen (1994-2004).9 All papers described unique studies.
Most of the studies were conducted in North America and Canada (55%), followed by Europe (25%)
and Asia (10%). Sample sizes varied between 10 and 3988 patients (median =175 patients).
Patient characteristics
Studies included patients with cardiac disease (n=21), patients admitted for an orthopedic problem
(n=3), patients with pulmonary diseases (n=3), patients with stroke (n=1) and mixed groups (n=23).
Often, only a population at risk was studied: in 17 papers only elderly or older adults were included, for
Riegel the population at risk was a minority population41 and in other papers chronically ill or other
patients with high risk for readmission were studied. Study and patient characteristics are presented in
Table 1 and in Appendix VI.
Intervention characteristics
In this review we compared a wide variety of interventions. To handle this, the different interventions
were categorized based on a taxonomy introduced by Hansen and adapted by Leppin (see Table 2 and
Appendix V).22,23 This taxonomy makes it possible to describe interventions based on their different
components. Interventions were classified in three domains as interventions that took place in the
hospital before discharge (pre-discharge), outside the hospital after discharge (post-discharge) or both
(pre/post-discharge).
Table 1: Study and patient characteristics for the 51 included studies
Author, year Setting Intervention Patient groups Number of Quality Domains Number of Number of
patients criteria intervention different
(intervention / satisfied components disciplines
usual care) (N=10),n
Balaban RB, 2008 42 Community Discharge-transfer Medical or 96 (47/49) 6 Pre and 4 3

teaching hospital, intervention surgical patients post
US
Basoor A, 2013 43 Community Checklist Heart failure 96 (48/48) 6 Pre 2 2

teaching hospital,
US
Braun E, 2009 44 Teaching hospital, Telephone follow-up General 309 4 Post 1 NA

Israel medicine (153/156)
Burns ME, 2014 45 Academic medical Community health Patients at risk 423 5 Pre and 6 1
center safety-net worker -intervention (110/313) post
hospital and 10
afﬁliated adult
primary care
practices
Chiantera A, 2005 40 Public hospital, Telecardiology Acute coronary 200 (99/101) 2 Post 1 2
Italy syndrome
Coleman EA, 2006 10 Integrated delivery Care transitions Chronically ill 750 8 Pre and 8 1
system, US intervention older patients (379/371) post
Courtney M, 2009 29 Tertiary referral Exercise and Older medical 168 (64/64) 7 Pre and 7 2
hospital, Australia telephone follow-up patients at risk post
program
Braet et al.Effectiveness of discharge interventions from hospital to home on hospital readmissions: a systematic review © the authors 2016 doi:
10.11124/jbisrir-2016-2381 Page 115
Dendale P, 2012 31 7 large hospitals, Telemonitoring Heart failure 160 (80/80) 7 Post 2 2
Belgium facilitated
collaboration
Domingues FB, 2011 39 Tertiary university Education and Heart failure 120 (57/63) 5 Post 1 1
hospital, Brazil telephone monitoring
Dowsey MM,1999 38 Tertiary university Clinical pathway Hip and knee 175 (94/81) 6 Pre 2 2
hospital, US arthroplasty
Dudas V, 2001 46 Academic teaching Telephone follow-up General 221 6 Post 1 1

hospital and medicine (110/111)
referral center, US
Eaton T, 2009 47 Public hospital, Early pulmonary COPD 97 (47/50) 9 Pre and 2 3
New Zealand rehabilitation post
Evans RL, 1993 48 Department of Discharge planning Patients at risk 835 3 Pre 1 3
Veterans Affairs, (417/418)
US
Forster AJ, 2005 49 Tertiary care Nurse team Medicine 361 6 Pre and 4 1
teaching hospital, coordinator patients (175/186) post
Canada
Gonzalez-Guerrero JL, General hospital, Disease Heart failure 117 (59/58) 10 Post 3 3
2014 32 Spain management
program in a geriatric
daycare hospital
Gurwitz JH, 2014 50 Large Electronic health Medical-surgical 3661 8 Post 2 NA

multispecialty record-based (1870/1791)
group practice, US intervention
10.11124/jbisrir-2016-2381 Page 116
Harrison MB, 2002 51 Teaching hospital, Transitional care Heart failure 192 (92/100) 7 Pre and 6 2
Canada post
Huang T, 2005 52 Medical center, Discharge planning Hip fracture 122 (63/59) 5 Pre and 8 1
Taiwan post
Jaarsma T, 1999 53 University hospital, Education and Heart failure 179 (84/95) 7 Pre and 5 1
the Netherlands support post
Jack BW, 2009 54 Safety-net hospital, Reengineered General 738 9 Pre and 7 2
US discharge medicine (370/368) post
intervention
Kangovi S, 2014 55 Two academically Intervention with General 446 8 Pre and 6 1
affiliated hospitals, community health medicine (222/224) post
US workers
Koehler BE, 2009 56 University medical Care bundle High-risk elderly 41 (20/21) 8 Pre and 8 1
center, US medical patients post
Lannin NA, 2007 57 Rehabilitation unit, Pre-discharge home Rehabilitation 10 (5/5) 7 Pre 1 1
Australia visits unit, older adults
Laramee AS, 2003 58 Academic medical Case management Heart failure 256 5 Pre and 7 1
center, US (131/125) post
Legrain S, 2011 59 Five Discharge-planning Older adults 665 8 Pre and 4 1

university-affiliated intervention (317/348) post
hospitals and one
private clinic,
France
Leventhal ME, 2011 60 University hospital, Interdisciplinary Heart failure 42 (22/20) 7 Post 7 1
Switzerland Management
10.11124/jbisrir-2016-2381 Page 117
Program
Li H, 2012 35 Regional hospital, CARE (Creating Older adults 407 7 Pre 1 1

US Avenues for Relative (202/205)
Empowerment)
Lopez Cabezas C, 2006 34 General hospital Active information Heart failure 134 (70/64) 8 Pre and 3 1
and municipal program post
hospital, Spain
Man WD, 2004 61 Teaching hospital, Rehabilitation COPD 34 (18/16) 5 Post 2 3

UK program
Marusic S, 2013 62 University hospital, Pharmacotherapeutic Older medical 160 (80/80) 7 Pre 1 1
Croatia counseling patients
Mayo NE, 2008 63 Five acute-care Case management Stroke 186 (93/93) 8 Post 4 1
hospitals within an
university hospital
network, Canada
McDonald K, 2002 64 University hospital, Multidisciplinary care Heart failure 98 (51/47) 4 Pre and 4 2
Ireland post
Melton LD, 2012 65 Hospitals in 50 Prioritized Patients at risk 3,988 8 Post 1 1

states of US post-discharge (1,994/1,994)
telephonic outreach
Naylor MD, 1990 66 Medical center, US Comprehensive Elderly patients, 40 (20/20) 6 Pre and 6 1
discharge planning medical/surgical post
unit
Naylor MD, 1994 67 University hospital, Comprehensive Elderly 142 (72/70) 4 Pre and 6 1
US discharge planning patients/4 cardial post
10.11124/jbisrir-2016-2381 Page 118
DRGs
Nazareth I, 2001 68 Three acute Pharmacy discharge Elderly patients 340 7 Pre and 6 1
general and one plan (164/176) post
long-stay hospital,
UK
Osman LM, 2002 69 Acute teaching Self-management Acute asthma 280 7 Pre 2 1
hospital, UK program (135/145)
Parry C, 2009 12 Two community Care transitions Elderly patients 98 (49/49) 7 Pre and 6 1
based hospitals, intervention post
US
Rich MW, 1993 70 University hospital, Comprehensive Elderly patients, 98 (63/35) 4 Pre and 6 1
US multidisciplinary heart failure post
treatment
Rich MW, 1995 71 University hospital, Comprehensive Elderly patients, 274 5 Pre and 6 1
US multidisciplinary heart failure (136/138) post
treatment
Riegel B, 2006 41 Two community Telephone case Hispanics of 134 (69/65) 8 Post 2 1
hospitals, US management Mexican origin
with heart failure
Saleh S, 2012 72 General hospital, Comprehensive Elderly patients 333 3 Pre and 6 1
US post-discharge care (160/173) post
transition program
Sales VL, 2013 73 Teaching hospital, Trained volunteers Heart failure 137 (70/67) 4 Pre and 5 1
US post
Sethares KA, 2004 74 Community Tailored message Heart failure 70 (33/37) 7 Pre and 1 1
10.11124/jbisrir-2016-2381 Page 119
hospital, US intervention post
Shyu Y, 2005 75 1 hospital, Taiwan Interdisciplinary Elderly patients, 137 (69,68) 5 Pre and 4 2
intervention program hip fracture post
Strömberg A, 2003 76 1 university Nurse-led heart Heart failure 106 (52/54) 8 Post 3 1
hospital and 2 failure clinic
county hospitals,
Sweden
Weaver LA, 2001 77 Community Telephone follow-up Cardiac surgery 90 (44/46) 3 Post 1 1
hospital, US
Wong FK, 2011 36 Acute regional Health-social Patients 555 8 Pre and 5 2
hospital, China partnership admitted to (272/283) post
transitional program medical units
Wong FK, 2014 37 Acute general Transitional care Patients 610 (196 9 Pre and 5 2
hospital, China program: home visit admitted to (home post
group + call group medical units visit)/204
(call)/210)
Woodend AK, 2008 78 University hospital, Telehome monitoring Cardiac disease 249 3 Post 1 1
Canada (124/125)
Zhao Y, 2009 79 Comprehensing Post-discharge Coronary heart 200 5 Pre and 4 2

hospital, China transitional care disease (100/100) post
program
DRG= diagnosis related group, COPD=chronic obstructive pulmonary disease, pre=pre-discharge intervention, post=post-discharge intervention, Pre
and post=Pre and post-discharge intervention, NA=not available
10.11124/jbisrir-2016-2381 Page 120
Table 2: Taxonomy to categorize discharge interventions
Intervention components Description of the component
Education Education of patient about diagnosis or treatment, not focused on

self-management
Discharge planning Development of an individualized discharge plan for patient prior

to leaving hospital for home80
Medication intervention Medication reconciliation (creating the most accurate list possible
of all medications) or medication review (evaluating critically all
medications to optimize therapy)
Appointment scheduled Follow-up appointment scheduled or patient is adviced to

schedule an appointment
Rehabilitation Rehabilitation aimed at improving functional status
Streamlining Streamlining of services or logistical coordination
Home visit Visit to patient’s home or place of residence
Patient empowerment Interventions with the intention to increase patient’s control over
his illness or stimulate participation in the medical
decision-making process or reinforce his/her psychosocial skills
Transition coach Health worker who interacts with patient before and after
discharge providing a transition between inpatient and outpatient
settings
Patient-centered Adapted and individualized discharge materials or care plans to

documents be used by patients
Timely communication Efforts by the care providers in the hospital to communicate early
with other primary care providers (physicians or nurses) in
regards to the patient’s discharge
Timely follow-up Follow-up visits after discharge by physician or nurse as part of

the intervention
Telephone call Patients or caregivers are contacted by telephone after

discharge
Patient hotline Presence of a direct telephone line for patient initiated

communication
Telemonitoring An automated process for the transmission of data on a patient’s

health status from home to the respective health care setting 81
Methodological quality
The quality of the selected studies varied widely, ranging from two to 10 on the critical appraisal scale
for randomized controlled trials (see Table 4). A critical appraisal score of 7 corresponded with the 75th
percentile of all critical appraisal scores. Studies with a critical appraisal score of 7 or more were defined
as high-quality studies. Blinding of patients (Q2 in Table 4) and assessors (Q5) was clearly described in
10% and 31% of the included papers, respectively. In most papers (63%), blinding of the assessors was
not mentioned, leaving it unclear as to whether this was done or not. Studies with ill-defined or weak
randomization processes were not excluded.
Readmission rate measurement was assessed as reliable in 63% of the papers (Q9). Measurement of
readmissions based only on patient or caregiver self-report was assumed as not
reliable.35,44,51,52,62,75,77-79 In one paper the readmission interval was not fixed; this outcome
measurement was also evaluated as not reliable.49 We had no description of how readmission rate was
measured for nine papers.39,40,48,57,64,67,70-72 Although assessed as reliable, in some papers only medical
records or administrative data were used to evaluate the number of readmissions, possibly resulting in
underestimation of the outcome measure.10,36,37,42,43,46,56,68 In four papers only disease specific
readmissions were counted.43,47,64,73 In some studies only readmissions to the same hospital were
counted,36-38,42,43,60,69,72,73,76 contributing to a risk of underestimation. In other studies it was not clear
whether readmissions to all hospitals or only the primary hospital were counted. 40,44,46,47,53,56,57,64,68,75
Riegel and colleagues studied the effect of a discharge intervention on a specific population, i.e.
Hispanics living on the US-Mexico border.41 Because of the specific socio-economic and cultural
characteristics of this ethnic minority, such as language and education, the external validity of this
research is questionable. Also in the study by Lopez Cabezas, the low educational level of the study
population could be a problem for external validity.34 The high degree of illiteracy in that study (22% of
patients in intervention group and 9% of patients in control group) will probably have an impact on
education of patients. In some studies only small percentages of the total population were included
inducing the risk of selection bias by inducing sampling bias.12,44,46
MAStARI
Table 3: Number of studies included and excluded
Number of studies included Number of studies excluded
51 2
Table 4: Critical appraisal of included studies using the MAStARI appraisal instrument (see
Appendix III)
Citation Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10
Balaban RB, 2008 42 U N U Y U Y Y Y Y Y
Basoor A, 2013 43 U N U Y U Y Y Y Y Y
Braun E, 2009 44 N N U N U Y Y Y N Y
Burns ME, 2014 45 U N U U U Y Y Y Y Y
Chiantera A, 2005 40 U N U U U U Y Y U N
Coleman EA, 2006 10 Y N U Y Y Y Y Y Y Y
Courtney M, 2009 29 Y N Y N Y N Y Y Y Y
Dendale P, 2012 31 U N Y Y U Y Y Y Y Y
Domingues FB, 2011

39 Y N U N U Y Y Y U Y
Dowsey MM, 1999 38 U N Y U U Y Y Y Y Y
Dudas V, 2001 46 U N U Y U Y Y Y Y Y
Eaton T, 2009 47 Y N Y Y Y Y Y Y Y Y
Evans RL, 1993 48 U N U Y U Y N U U Y
Forster AJ, 2005 49 Y Y Y N Y N U Y N Y
Gonzalez-Guerrero
Y Y Y Y Y Y Y Y Y Y
JL, 2014 32
Gurwitz JH, 2014 50 Y N Y N Y Y Y Y Y Y
Harrison MB, 2002 51 Y N Y Y U Y Y Y N Y
Huang T, 2005 52 Y N U N N Y Y Y N Y
Jaarsma T, 1999 53 Y N U Y N Y Y Y Y Y
Jack BW, 2009 54 Y N Y Y Y Y Y Y Y Y
Kangovi S, 2014 55 Y N Y Y Y N Y Y Y Y
Koehler BE, 2009 56 Y N Y Y U Y Y Y Y Y
Lannin NA, 2007 57 Y N Y N Y Y Y Y U Y
Laramee AS, 2003 58 U N U Y U N Y Y Y Y
Legrain S, 2011 59 Y N Y Y Y N Y Y Y Y
Leventhal ME, 2011

60 Y N Y N Y Y Y Y Y N
Li H, 2012 35 Y Y Y Y U U Y Y N Y
Lopez Cabezas C,
Y N Y Y U Y Y Y Y Y
2006 34
Man WD, 2004 61 Y N U N N U Y Y Y Y
Marusic S, 2013 62 Y N Y Y Y N Y Y N Y
Mayo NE, 2008 63 U N Y Y Y Y Y Y Y Y
McDonald K, 2002 64 U N U Y U Y Y U U Y
Melton LD, 2012 65 U Y Y Y U Y Y Y Y Y
Naylor MD, 1990 66 Y N Y N U N Y Y Y Y
Naylor MD, 1994 67 U N U N U Y Y Y U Y
Nazareth I, 2001 68 Y N Y N U Y Y Y Y Y
Osman LM, 2002 69 U N Y Y Y N Y Y Y Y
Parry C, 2009 12 Y N U Y U Y Y Y Y Y
Rich MW, 1993 70 U N U Y U Y U Y U Y
Rich MW, 1995 71 Y N Y Y U N U Y U Y
Riegel B, 2006 41 Y N Y Y U Y Y Y Y Y
Saleh S, 2012 72 Y N U N U N Y U U Y
Sales VL, 2013 73 U N U U U Y N Y Y Y
Sethares KA, 2004 74 U N Y Y U Y Y Y Y Y
Shyu Y, 2005 75 Y U N N U Y Y Y N Y
Strömberg A, 2003 76 Y N Y Y Y N Y Y Y Y
Weaver LA, 2001 77 U N U Y U U Y Y N U
Wong FK, 2011 36 Y N Y Y U Y Y Y Y Y
Wong FK, 2014 37 Y Y Y Y U Y Y Y Y Y
Woodend AK, 2008

78 U N U N U U Y Y N Y
Zhao Y, 2009 79 Y N U N Y U Y Y N Y
60. 94.1
% 9.80 54.90 60.78 31.37 66.67 90.20 94.12 62.75
78 2
Q1=was the assignment to treatment groups truly random? Q2=were participants blinded to treatment allocation?
Q3=was allocation to treatment groups concealed from the allocator? Q4=were the outcomes of people who
withdrew described and included in the analysis?, Q5=were those assessing outcomes blind to treatment
allocation?, Q6=were the control and treatment groups comparable at entry?, Q7=were groups treated identically
other than for the named interventions?, Q8=were outcomes measured in the same way for all groups?, Q9=were
outcomes measured in a reliable way?, Q10=was appropriate statistical analysis used?
Y=yes, U=unclear, N=no
Results
Quantitative research findings
Readmission rate
In two studies, the readmission rate was expressed as a compound result: Forster 49 included any
post-discharge event (ED visit, death or readmission) and Weaver77 the number of readmissions
together with the number of ED visits. For meta-analysis the composite results were used.
In four studies39,54,58,78 only the total number of readmissions was mentioned but not the number of
patients readmitted at least once within the readmission interval. The pooled relative risk for hospital
readmissions in these studies was 0.84 [95% CI, 0.66-1.06]. The four papers for meta-analysis were
excluded although the subgroup difference with papers using readmission rates was not statistically
significant (Chi2=0.46, p=0.50), leaving 47 studies for further meta-analysis.
In 12 studies, hospital readmission was measured both after one and three months. No difference in risk
for readmission could be detected between both groups (RR, 0.64 [95% CI, 0.52-0.79] after one month
and RR, 0.71 [95% CI, 0.62-0.82] after three months; p=0.39). For meta-analysis the longest available
readmission interval (maximum three months) was used.
The overall relative risk for hospital readmission in the 47 papers was 0.77 [95% CI, 0.70-0.84]
(p<0.00001) (see Figure 2). Although heterogeneity was not absent (p=0.02), inconsistency between
trials was moderate (I2 = 34%). Heterogeneity in the included studies was present in populations
(different ages, pathology groups, risk factors), interventions (different discharge interventions were
tested, but also the usual care differed between studies) and context of the studies (different healthcare
and financial systems).
M-H =Mantel-Haenszel; CI = confidence interval
Figure 2: Meta-analysis for hospital readmission rate comparing discharge interventions

(experimental) to usual care (control)
Analyzing subgroups
Post hoc subgroup analysis was used to evaluate if interventions in specific domains were more
effective, if multicomponent interventions were more effective than single component interventions and
if specific interventions were more effective in reducing hospital readmissions.
By exploring the subgroups, a high discrepancy in the amount of high-quality studies (critical appraisal
score of 7 or more) in the different subgroups was observed. This was especially found in subgroups
comparing interventions testing patient empowerment to interventions without patient empowerment
(10 out of 11 studies testing patient empowerment were high-quality studies compared to 16 out of 36
studies without patient empowerment). To eliminate the possibility of bias due to low study quality, only
studies of the highest quality (critical appraisal score of seven or more) were selected for subgroup
analysis, leaving 26 high-quality papers to analyze (Table 5). To compare single component
interventions with multicomponent interventions, there was a need to define a cut-off to identify these
multicomponent interventions. Similar to a previous meta-analysis on this topic, the cutoff according to
the 75th percentile was defined, in this case, at six components.23 Readmission intervals of one and
three months were analyzed separately. Subgroups with less than three studies were not analyzed.
Interventions with only components before discharge (pre-discharge interventions) and interventions
with only components after discharge (post-discharge interventions) were compared to interventions
with components both before and after discharge (pre/post-discharge interventions). This identified a
statistically significant difference after three months of pre/post-discharge interventions compared to
post-discharge interventions (between subgroup difference p=0.01).
No difference in risk reduction could be identified after one month for multicomponent interventions
compared to single component interventions (between subgroup difference p=0.54).
We also tested the effects of two intervention components: patient empowerment and discharge
planning. The group of interventions testing patient empowerment was both after one and after three
months more effective in reducing hospital readmissions compared to the group of interventions not
testing patient empowerment (between subgroup difference p=0.008 after one month and p=0.02 after
three months).
The group of interventions testing discharge planning was more effective in reducing hospital
readmissions in the first month after discharge than the group of interventions not testing discharge
planning (between subgroup difference p=0.0004). This positive effect of discharge planning, however,
disappeared three months after discharge (between subgroup difference p=0.57).
Table 5: Meta-analysis of subgroups in 26 papers with high critical appraisal score
Description of Description of Interval Number of Relative risk for hospital P†

subgroup comparison studies readmission [95% CI]
(subgroup/
comparison)
Subgroup Comparison
Domains
Pre-discharge Pre/post- 1 mo 3/9 0.79 0.67 0.75

[0.30-2.07] [0.51-0.88]
discharge
Post-discharge Pre/post- 1 mo 4/9 0.83 0.67 0.07

[0.66-1.02] [0.51-0.88]
discharge
3 mo 5/10 1.00 0.70 0.01

[0.78-1.28] [0.61-0.81]
Pre-discharge Post-discharge 1 mo 3/4 0.79 0.83 0.93

[0.30-2.07] [0.66-1.02]
Interventions
Multicomponent Single 1 mo 5/3 0.67 0.79 0.54

interventions‡ component [0.42-1.07] [0.63-0.99]
interventions
Patient No patient 1 mo 7/9 0.59 0.87 0.008

empowerment empowerment [0.46-0.76] [0.56-1.18]
3 mo 8/9 0.70 0.93 0.02

[0.57-0.84] [0.79-1.09]
Discharge planning All other papers 1 mo 4/12 0.53 0.88 0.004

[0.38-0.73] [0.79-0.97]
3 mo 5/12 0.73 0.80 0.57

[0.54-0.98] [0.70-0.92]
Pre-discharge = interventions with only components before discharge; post-discharge = interventions with only
components after discharge; pre/post-discharge = interventions with components both before and after discharge;
mo = months
† between subgroup difference
‡: interventions with 6 or more components
Secondary outcomes: return to emergency departments, mortality and satisfaction
In addition to the effect on readmission rates, the effects of discharge interventions on ED visits and
mortality were assessed. Table 6 presents the risk ratios of ED visits and mortality. The effect of
discharge interventions on admissions to the ED was assessed in 10 papers. In three papers, a
statistically significant reduction in ED visits was observed after discharge. The overall effect was not
statistically significant (RR, 0.75 [95% CI, 0.55-1.01]; p=0.06). The effect on mortality was assessed in
14 papers. The discharge interventions had no overall effect on mortality (RR, 0.70 [95% CI, 0.48-1.01];
p=0.06).
Patient satisfaction was measured in six studies, using six different sets of questions. Because of the
lack of a standard questionnaire, meta-analysis was not performed. In five studies, statistically
significant results were reported in favor of the intervention group based on the individual questions or
the questionnaire; this is presented in Table 6.
Table 6: Risk ratio for emergency department visits and mortality
First author, year Intervention ED visits Mortality
Risk ratio Risk ratio
[95% CI] [95% CI]
(n=10) (n=14)
Balaban RB, 2008 42 Discharge-transfer intervention 1.04 -

[0.07-16.19]
Burns ME, 2014 45 Community health worker intervention 1.35 [0.83-2.20] -
Courtney M, 2009 29 Exercise and telephone follow-up - 0.67 [0.12-3.86]

program
Dudas V, 2011 46 Telephone follow-up 0.41 [0.21-0.79] -
Forster AJ, 2005 49 Nurse team coordinator - 0.82 [0.19-3.59]
Harrison MB, 2002 Transitional care 0.63 [0.41-0.96] -

51
Huang T, 2005 52 Discharge planning - 0.11 [0.01-2.02]
Jaarsma T,1999 53 Education and support 0.85 [0.41-1.75] -
Legrain S, 2011 59 Discharge planning intervention 1.01 [0.45-2.25] 0.91 [0.61-1.36]
Lopez Cabezas C, Active information program - 0.15 [0.02-1.23]

2006 34
Man WD, 2004 61 Rehabilitation program 0.23 [0.06-0.95] 0.53 [0.05-5.35]
Marusic S, 2013 62 Pharmacotherapeutic counseling 0.64 [0.35-1.15] 0.20 [0.01-4.10]
Mayo NE, 2008 63 Case management 1.15 [0.58-2.29] 1.00

[0.06-15.75]
Nazareth I, 2001 68 Pharmacy discharge plan - 2.15 [0.75-6.15]
Rich MW, 1995 71 Comprehensive multidisciplinary - 0.46 [0.19-1.09]

treatment
Sales VL, 2013 73 Trained volunteers - 0.96 [0.29-3.16]
Shyu Y, 2005 75 Interdisciplinary intervention program 0.50 [0.16-1.58] 0.33 [0.01-8.03]
Strömberg A, 2003 Nurse-led heart failure clinic - 0.24 [0.07-0.79]

76
Wong FK, 2014 37 Transitional care program: home visit - 1.03

group and call group [0.06-16.35]
Total: 0.75 [0.55-1.01] 0.70 [0.48-1.01]
Table 7: Results of patient satisfaction questionnaires
First author, Questionnaire Interval† Result

year
Braun E, 2009 Survey to evaluate 3 months Statistically significant better scores

44 satisfaction with: for intervention group compared to
usual care for satisfaction with
- Information on how to
information on how to take medication
take medication
(p<0.0001) and satisfaction with
- Medical and nursing
medical treatment (p<0.001). No
treatment
difference was found for the other
- Information at
questions.
discharge
Dudas V, 2011 Survey to evaluate: 2 or 6 weeks Statistically significant better scores

46 for intervention group compared to
- Satisfaction with care
usual care for satisfaction with
- Satisfaction with
medication instructions (p=0.007). No
discharge information
difference was found for the other
- Length of hospital stay
questions.
Forster AJ, Survey based on a locally 30 days Statistically significant better scores
2005 49 used survey to measure for intervention group compared to
perception of usual care for:
hospitalization processes
- Physician having sufficient
and satisfaction of care
information about medical history
(p=0.03)
- More patients recalled being
contacted by hospital personnel
after discharge (p<0.001)
No statistically significant difference
for questions about medication, written

list of appointments, preparation for
transition and quality of care.
Lopez Cabezas Satisfaction survey used 2 months Intervention group had statistically
C, 2006 34 by the Catalan Health significant better scores on
Department satisfaction with information compared
to usual care (p=0.026)
Nazareth I, Validated 7-item 3 months No statistical significant difference

2001 68 questionnaire to measure between intervention and control
satisfaction with health groups (mean difference = 0)
services
Wong FK, 2014 Validated 15-item 4 weeks Intervention groups had statistical
37 questionnaire significant better total scores
compared to control group (p<0.001) -
not specified on what items the
difference was noted
†: interval between discharge and patient satisfaction questionnaire
Discussion
In this systematic review, the review team searched for evidence to determine which discharge
interventions reduce hospital readmissions within three months after discharge. Fifty-one randomized
controlled trials were included. Meta-analysis indicates that interventions developed to smooth the
transition from hospital to home are effective in reducing readmissions. Subgroup analysis confirms that
discharge interventions that start before discharge and continue after discharge are more effective in
reducing hospital readmissions than interventions that only start after hospital discharge. Also
interventions that support patient empowerment are more effective in reducing hospital readmissions
compared to interventions that did not include patient empowerment.
When interpreting the results of the subgroup meta-analysis, it is important to consider that the tested
component was mostly not the sole component. Furthermore, these results need to be interpreted as
exploratory, keeping in mind that the differences found were not always related to the effects of the
intervention characteristic being assessed.
Another factor influencing the data was heterogeneity. Heterogeneity was present in the studied
populations, discharge interventions, interventions in the usual care group and context of the studies.
Discharge interventions as well as interventions in the usual care group differed between the studies. A
factor influencing the classification was that not all interventions were described clearly. Also the way
hospital readmissions were measured and counted differed and was not always described well.
It can be concluded that interventions to enhance discharge from hospital to home need to start in the
hospital and continue after discharge rather than stopping at the moment of discharge or starting after
discharge. This was already mentioned in previous reviews, emphasizing the importance of combining
elements from the pre- and post-discharge phases.9,21
Based on this study, it cannot be concluded that multicomponent interventions are more effective in
reducing hospital readmissions compared to single component interventions. This is contrary to the
conclusion of the meta-analysis conducted by Leppin.23 One possible explanation for this difference is
that the classification of the different components was not the same. It is difficult to define the
components of an intervention and one can argue that even single component interventions were not
truly single component ones. An example is the single component intervention in Braun’s study.44
Participants in the intervention group were communicated by telephone one week and one month after
discharge. During the telephone call the patient was asked how the recommendations at discharge
were followed and about medication compliance. Even though there were two intentions behind the call,
the intervention was classified as single component. The finding that multicomponent interventions are
not always more effective is also applicable for other knowledge translation interventions.82 Wensing
and colleagues suggested that multicomponent interventions are not always superior to single
component interventions, but are more effective when they address different types of barriers.
Another important finding is that interventions that facilitate patient’s capacity for self-care (patient
empowerment) are effective in preventing hospital readmissions. This finding was also confirmed by
Leppin.23 Facilitating the patient’s self-capacity is important as it reinforces the need for caregivers to
evolve from a traditional model of patient education to one that is centered on empowering patients.83 In
the first traditional model, healthcare professionals educating the patient about his/her condition is the
most important goal. In the second model, the goal of patient education is to enable patients to make
informed choices.
Conclusion
Meta-analysis indicates that discharge interventions reduce hospital readmission rates. Discharge
interventions that start before discharge and continue after discharge are more effective in reducing
hospital readmissions than interventions that only start after hospital discharge.
Implications for practice
Interventions to reduce hospital readmissions should start during the hospital stay, bridge the transition
and continue in the community (grade A recommendation). Financial systems must support and
facilitate collaboration between hospitals and home care.
Interventions that support patient empowerment are more effective in reducing hospital readmissions
(grade B recommendation). Training caregivers and introducing processes to raise patients’ capacity to
self-care are important in order to reduce hospital readmissions.
Implications for research
As hospital readmissions pose a burden to the community, hospitals and individual patients, it is
important to escalate research to identify effective discharge interventions. Focusing on interventions to
improve patient empowerment will be important in the future. Also more there is a need for more
research to assess the effects of discharge interventions after more than three months.
Conflict of Interest
The authors declare that there were no conflicts of interest.
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intervention in hospitalized elders with hip fracture due to falling. J Clin Nurs. 2005; 14(10):
1193-201.
53. Jaarsma T, Halfens R, Abu-Saad HH, Dracup K, Gorgels T, van Ree J, et al. Effects of education
and support on self-care and resource utilization in patients with heart failure. Eur Heart J. 1999;
20(9): 673-82.
54. Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. A reengineered
hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med.
2009; 150(3): 178-87.
55. Kangovi S, Mitra N, Grande D, White ML, McCollum S, Sellman J, et al. Patient-centered
community health worker intervention to improve posthospital outcomes: a randomized clinical
trial. JAMA Intern Med. 2014; 174(4): 535-43.
56. Koehler BE, Richter KM, Youngblood L, Cohen BA, Prengler ID, Cheng D, et al. Reduction of
30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk
elderly medical patients through delivery of a targeted care bundle. J Hosp Med. 2009; 4(4):
211-8.
57. Lannin NA, Clemson L, McCluskey A, Lin CWC, Cameron ID, Barras S. Feasibility and results of
a randomised pilot-study of pre-discharge occupational therapy home visits. BMC Health Serv
Res. 2007; 7:42.58. Laramee AS, Levinsky SK, Sargent J, Ross R, Callas P. Case
management in a heterogeneous congestive heart failure population: a randomized controlled
trial. Arch Intern Med. 2003; 163(7): 809-17.
59. Legrain S, Tubach F, Bonnet-Zamponi D, Lemaire A, Aquino JP, Paillaud E, et al. A new
multimodal geriatric discharge-planning intervention to prevent emergency visits and
rehospitalizations of older adults: The optimization of medication in aged multicenter randomized
controlled trial. J Am Geriatr Soc. 2011; 59(11): 2017-28.
60. Leventhal ME, Denhaerynck K, Brunner-La Rocca HP, Burnand B, Conca-Zeller A, Bernasconi
AT, et al. Swiss Interdisciplinary Management Programme for Heart Failure (SWIM-HF): a
randomised controlled trial study of an outpatient inter-professional management programme for
heart failure patients in Switzerland. Swiss Med Wkly. 2011; 141(w13171).
61. Man WD, Polkey MI, Donaldson N, Gray BJ, Moxham J. Community pulmonary rehabilitation
after hospitalisation for acute exacerbations of chronic obstructive pulmonary disease:
randomised controlled study. BMJ. 2004; 329(7476): 1209.
62. Marusic S, Gojo-Tomic N, Erdeljic V, Bacic-Vrca V, Franic M, Kirin M, et al. The effect of
pharmacotherapeutic counseling on readmissions and emergency department visits. Int J Clin
Pharm. 2013; 35(1): 37-44.
63. Mayo NE, Nadeau L, Ahmed S, White C, Grad R, Huang A, et al. Bridging the gap: the
effectiveness of teaming a stroke coordinator with patient's personal physician on the outcome of
stroke. Age Ageing. 2008; 37(1): 32-8.
64. McDonald K, Ledwidge M, Cahill J, Quigley P, Maurer B, Travers B, et al. Heart failure
management: Multidisciplinary care has intrinsic benefit above the optimization of medical care. J
Card Fail. 2002; 8(3): 142-8.
65. Melton LD, Foreman C, Scott E, McGinnis M, Cousins M. Prioritized Post-Discharge Telephonic
Outreach Reduces Hospital Readmissions for Select High-Risk Patients. Am J Manag Care.
2012; 18(12): 838-44.
66. Naylor MD. Comprehensive discharge planning for hospitalized elderly: a pilot study. Nurs Res.
1990; 39(3): 156-61.
67. Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge

planning for the hospitalized elderly: a randomized clinical trial. Ann Intern Med. 1994; 120(12):
999-1006.
68. Nazareth I, Burton A, Shulman S, Smith P, Haines A, Timberal H. A pharmacy discharge plan for
hospitalized elderly patients--a randomized controlled trial. Age Ageing. 2001; 30(1): 33-40.
69. Osman LM, Calder C, Godden DJ, Friend JAR, McKenzie L, Legge JS, et al. A randomised trial
of self-management planning for adult patients admitted to hospital with acute asthma. Thorax.
2002; 57(10): 869-74.
70. Rich MW, Vinson JM, Sperry JC, Shah AS, Spinner LR, Chung MK, et al. Prevention of
readmission in elderly patients with congestive-heart-failure - Results of a prospective,
randomized pilot-study. J Gen Intern Med. 1993; 8(11): 585-90.
71. Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A multidisciplinary
intervention to prevent the readmission of elderly patients with congestive-heart-failure. N Engl J
Med. 1995; 333(18): 1190-5.
72. Saleh SS, Freire C, Morris-Dickinson G, Shannon T. An effectiveness and cost-benefit analysis
of a hospital-based discharge transition program for elderly Medicare recipients. J Am Geriatr
Soc. 2012; 60(6): 1051-6.
73. Sales VL, Ashraf MS, Lella LK, Huang J, Bhumireddy G, Lefkowitz L, et al. Utilization of trained
volunteers decreases 30-day readmissions for heart failure. J Card Fail. 2013; 19(7): 842-50.
74. Sethares KA, Elliott K. The effect of a tailored message intervention on heart failure readmission
rates, quality of life, and benefit and barrier beliefs in persons with heart failure. Heart Lung. 2004;
33(4): 249-60.
75. Shyu YI, Liang J, Wu CC, Su JY, Cheng HS, Chou SW, et al. A pilot investigation of the
short-term effects of an interdisciplinary intervention program on elderly patients with hip fracture
in Taiwan. J Am Geriatr Soc. 2005; 53(5): 811-8.
76. Stromberg A, Martensson J, Fridlund B, Levin LA, Karlsson JE, Dahlstrom U. Nurse-led heart
failure clinics improve survival and self-care behaviour in patients with heart failure: results from a
prospective, randomised trial. Eur Heart J. 2003; 24(11): 1014-23.
77. Weaver LA, Doran KA. Telephone follow-up after cardiac surgery: facilitating the transition from
hospital to home. Am J Nurs. 2001; 101(5): 24OO.
78. Woodend AK, Sherrard H, Fraser M, Stuewe L, Cheung T, Struthers C. Telehome monitoring in
patients with cardiac disease who are at high risk of readmission. Heart Lung. 2008; 37(1): 36-45.
79. Zhao Y, Wong FKY. Effects of a postdischarge transitional care programme for patients with
coronary heart disease in China: a randomised controlled trial. J Clin Nurs. 2009; 18(17):
2444-55.
80. Shepperd S, McClaran J, Phillips CO, Lannin NA, Clemson LM, McCluskey A, et al. Discharge
planning from hospital to home. Cochrane Database Syst Rev. 2010; (1).
81. Pare G, Jaana M, Sicotte C. Systematic review of home telemonitoring for chronic diseases: the
evidence base. J Am Med Inform Assoc. 2007; 14(3): 269-77.
82. Wensing M, Bosch M, Grol R. Developing and selecting interventions for translating knowledge
to action. CMAJ. 2010; 182(2): E85-8.
83. Funnell MM, Tang TS, Anderson RM. From DSME to DSMS: Developing Empowerment-Based
Diabetes Self-Management Support. Diabetes Spectr. 2007; 20(4): 221-6.
Appendix I: Search strategy

Search ID Search terms Search limits Database
S1 -
patient readmission AND all adult>19 years PubMed
(patient discharge -
OR published between 1/1/1990 and 07/31/2014
-
continuity of patient care OR English language
communication) - MeSH terms
S2 (readmission -
OR all adult>19 years PubMed
rehospitalization -
OR published between 1/1/1990 and 07/31/2014
rehospitalization) -
AND English language
(discharge OR -
continuity free text
OR transition OR “case
management”) NOT
psychiatry
S3 (readmission -
OR published between 1990 and 2014 Web of
rehospitali?ation$) -
AND English language Science
(discharge OR -
continuity excluding subject areas: psychiatry,
OR transition OR “case pediatrics, emergency medicine, psychology,
management”) anesthesiology, reproductive biology,
rehabilitation, substance abuse, criminology,
dermatology, dentistry, rheumatology,
immunology, primary health care, law,
pathology, biology, biophysics, genetics and
heredity, cell biology, microbiology, critical
care medicine, allergy, medicine legal,
physiology and biochemistry molecular
biology
S4 -
hospital readmission AND English language Embase
(hospital discharge -
OR humans
continuity of care -
OR publications from 1990 to 2014
transition OR -
case age groups: adults 18-64 years, aged +65
management) years
- areas of focus: NOT anatomy and
development, biochemistry, genetics,
medical instrumentation, microbiology,
pathology and forensic science, paediatrics,
pharmacology and pharmacy, radiology and
nuclear medicine, toxicology and drug
dependence
S5 (readmission -
OR English language CINAHL
rehospitali?ation$) -
AND human
(hospital discharge -
OR all adult
-
continuity of patient care OR publication date from January 1990 to July
case management) 2014
Appendix II: Studies selected for retrieval

Balaban, RB. Redefining and redesigning hospital discharge to enhance patient care: A randomized
controlled study. Journal of General Internal Medicine.2008; 23(8): 1228-1233.
Basoor, A. Decreased readmissions and improved quality of care with the use of an inexpensive
checklist in heart failure. Congestive Heart Failure.2013; 19(4): 200-206.
Braun, E. Telephone follow-up improves patients satisfaction following hospital discharge. European
Journal of Internal Medicine.2009; 20(2): 221-225.
Burns, ME. Feasibility and evaluation of a pilot community health worker intervention to reduce hospital
readmissions. International Journal for Quality in Health Care.2014; 26(4): 358-365.
Chiantera, A. Role of telecardiology in the assessment of angina in patients with recent acute coronary
syndrome. Journal of Telemedicine and Telecare.2005; 11(Suppl. 1): 93-94.
Coleman, EA. The care transitions intervention: results of a randomized controlled trial. Archives of
Internal Medicine.2006; 166(17): 1822-1828.
Counsell, SR. Effects of a multicomponent intervention on functional outcomes and process of care in
hospitalized older patients: a randomized controlled trial of acute care for elders (ACE) in a community
hospital. Journal of the American Geriatrics Society.2000; 48(12): 1572-1581.
Courtney, M. Fewer Emergency Readmissions and Better Quality of Life for Older Adults at Risk of
Hospital Readmission: A Randomized Controlled Trial to Determine the Effectiveness of a 24-Week
Exercise and Telephone Follow-Up Program. Journal of the American Geriatrics Society.2009; 57(3):
395-402.
Dendale, P. Effect of a telemonitoring-facilitated collaboration between general practitioner and heart

failure clinic on mortality and rehospitalization rates in severe heart failure: The TEMA-HF 1
(telemonitoring in the management of heart failure) study. European Journal of Heart Failure.2012;
14(3): 330-340.
Deschodt, M. Effect of an inpatient geriatric consultation team on functional outcome, mortality,

institutionalization, and readmission rate in older adults with hip fracture: A controlled trial. Journal of the
American Geriatrics Society.2011; 59(7): 1299-1308.
Diem, SJ. Effects of a post discharge clinic on house staff satisfaction and utilization of hospital
services. Journal of General Internal Medicine.1996; 11(3): 179-181.
Domingues, FB. Education and telephone monitoring by nurses of patients with heart failure:
Randomized clinical trial. Arquivos Brasileiros De Cardiologia.2011; 96(3): 233-239.
Dowsey, MM. Clinical pathways in hip and knee arthroplasty: a prospective randomized controlled
study. Medical Journal of Australia.1999; 170(2): 59-62.
Dudas, V. The impact of follow-up telephone calls to patients after hospitalization. Am J Med.2001;
111(9B): 26S-30S.
Eaton, T. Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients
admitted with an exacerbation? A randomized controlled study. Respirology.2009; 14(2): 230-238.
Evans, RL. Evaluating hospital discharge planning - a randomized clinical-trial. Medical Care.1993;
31(4): 358-370.
Finn, KM. Improving the discharge process by embedding a discharge facilitator in a resident team.
Journal of Hospital Medicine.2011; 6(9): 494-500.
Forster, AJ. Effect of a nurse team coordinator on outcomes for hospitalized medicine patients.
American Journal of Medicine.2005; 118(10): 1148-1153.
Gonzalez-Guerrero, JL. Effectiveness of a follow-up program for elderly heart failure patients after
hospital discharge. A randomized controlled trial. European Geriatric Medicine.2014; 5(4): 252-257.
Gurwitz, JH. An electronic health record-based intervention to increase follow-up office visits and
decrease rehospitalization in older adults. Journal of the American Geriatrics Society.2014; 62(5):
865-871.
Harrison, MB. Quality of life of individuals with heart failure: a randomized trial of the effectiveness of
two models of hospital-to-home transition. Medical Care.2002; 40(4): 271-282.
Huang, T. A randomized clinical trial of the effectiveness of a discharge planning intervention in

hospitalized elders with hip fracture due to falling. Journal of Clinical Nursing.2005; 14(10): 1193-1201.
Jaarsma, T. Effects of education and support on self-care and resource utilization in patients with heart
failure. European Heart Journal.1999; 20(9): 673-682.
Jack, BW. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.
Annals of Internal Medicine.2009; 150(3): 178-187.
Kangovi, S. Patient-centered community health worker intervention to improve post hospital outcomes:
a randomized clinical trial. JAMA Internal Medicine.2014; 174(4): 535-543.
Koehler, BE. Reduction of 30-day postdischarge hospital readmission or emergency department (ED)
visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. Journal of
Hospital Medicine.2009; 4(4): 211-218.
Kulshreshtha, A. Use of remote monitoring to improve outcomes in patients with heart failure: A pilot
trial. International Journal of Telemedicine and Applications.2010.
Lannin, NA. Feasibility and results of a randomized pilot-study of pre-discharge occupational therapy
home visits. Bmc Health Services Research.2007; 7(42).
Laramee, AS. Case management in a heterogeneous congestive heart failure population: a randomized
controlled trial. Archives of Internal Medicine.2003; 163(7): 809-817.
Legrain, S. A new multimodal geriatric discharge-planning intervention to prevent emergency visits and
rehospitalizations of older adults: The optimization of medication in aged multicenter randomized
controlled trial. Journal of the American Geriatrics Society.2011; 59(11): 2017-2028.
Leventhal, ME. Swiss Interdisciplinary Management Programme for Heart Failure (SWIM-HF): a
randomized controlled trial study of an outpatient inter-professional management programme for heart
failure patients in Switzerland. Swiss Medical Weekly.2011; 141(w13171).
Li, H. Randomized controlled trial of CARE: an intervention to improve outcomes of hospitalized elders
and family caregivers. Research in Nursing & Health.2012; 35(5): 533-549.
Lopez Cabezas, C. Randomized clinical trial of a postdischarge pharmaceutical care program vs.
regular follow-up in patients with heart failure. Farmacia Hospitalaria.2006; 30(6): 328-342.
Makowsky, MJ. Capturing outcomes of clinical activities performed by a rounding pharmacist practicing
in a team environment: The COLLABORATE study. Medical Care.2009; 47(6): 642-650.
Man, WD. Community pulmonary rehabilitation after hospitalization for acute exacerbations of chronic
obstructive pulmonary disease: randomized controlled study. British Medical Journal.2004; 329(7476):
1209.
Marusic, S. The effect of pharmacotherapeutic counseling on readmissions and emergency department

visits. International Journal of Clinical Pharmacy.2013; 35(1): 37-44.
Maslove, DM. Electronic Versus Dictated Hospital Discharge Summaries: a Randomized Controlled
Trial. Journal of General Internal Medicine.2009; 24(9): 995-1001.
Mayo, NE. Bridging the gap: the effectiveness of teaming a stroke coordinator with patient's personal
physician on the outcome of stroke. Age & Ageing.2008; 37(1): 32-38.
McDonald, K. Heart failure management: Multidisciplinary care has intrinsic benefit above the
optimization of medical care. Journal of Cardiac Failure.2002; 8(3): 142-148.
Melton, LD. Prioritized Post-Discharge Telephonic Outreach Reduces Hospital Readmissions for Select
High-Risk Patients. American Journal of Managed Care.2012; 18(12): 838-844.
Naylor, M. Comprehensive discharge planning for the hospitalized elderly: a randomized clinical trial.
Annals of Internal Medicine.1994; 120(12): 999-1006.
Naylor, MD. Comprehensive discharge planning for hospitalized elderly: a pilot study. Nursing
Research.1990; 39(3): 156-61.
Nazareth, I. A pharmacy discharge plan for hospitalized elderly patients--a randomized controlled trial.
Age & Ageing.2001; 30(1): 33-40.
Osman, LM. A randomized trial of self-management planning for adult patients admitted to hospital with
acute asthma. Thorax.2002; 57(10): 869-874.
Parry, C. Further application of the care transitions intervention: results of a randomized controlled trial
conducted in a fee-for-service setting. Home Health Care Services Quarterly.2009; 28(2-3): 84-99.
Rich, MW. Prevention of readmission in elderly patients with congestive-heart-failure - results of a

prospective, randomized pilot-study. Journal of General Internal Medicine.1993; 8(11): 585-590.
Rich, MW. A multidisciplinary intervention to prevent the readmission of elderly patients with
congestive-heart-failure. New England Journal of Medicine.1995; 333(18): 1190-1195.
Riegel, B. Randomized Controlled Trial of Telephone Case Management in Hispanics of Mexican Origin
With Heart Failure. Journal of Cardiac Failure.2006; 12(3): 211-219.
Riegel, B. Effect of a standardized nurse case-management telephone intervention on resource use in

patients with chronic heart failure. Archives of Internal Medicine.2002; 162(6): 705-712.
Saleh, S. An effectiveness and cost-benefit analysis of a hospital-based discharge transition program

for elderly Medicare recipients. Journal of the American Geriatrics Society.2012; 60(6): 1051-6.
Sales, VL. Utilization of trained volunteers decreases 30-day readmissions for heart failure. Journal of
Cardiac Failure.2013; 19(7): 842-850.
Sethares, KA. The effect of a tailored message intervention on heart failure readmission rates, quality of
life, and benefit and barrier beliefs in persons with heart failure. Heart & Lung.2004; 33(4):
249-260.
Shyu, Y. A pilot investigation of the short-term effects of an interdisciplinary intervention program on

elderly patients with hip fracture in Taiwan. Journal of the American Geriatrics Society.2005; 53(5):
811-818.
Stromberg, A. Nurse-led heart failure clinics improve survival and self-care behavior in patients with
heart failure: results from a prospective, randomized trial. European Heart Journa.2003; 24(11):
1014-1023.
Weaver, LA. Telephone follow-up after cardiac surgery: facilitating the transition from hospital to home.
American Journal of Nursing.2001; 101(5): 24OO.
Wong, FK. Effects of a health-social partnership transitional program on hospital readmission: a

randomized controlled trial. Social Science & Medicine.2011; 73(7): 960-9.
Wong, FK. Comparison of effects between home visits with telephone calls and telephone calls only for
transitional discharge support: A randomized controlled trial. Age and Ageing.2014; 43(1): 91-97.
Woodend, AK. Telehome monitoring in patients with cardiac disease who are at high risk of
readmission. Heart and Lung: Journal of Acute and Critical Care.2008; 37(1): 36-45.
Zhao, Y. Effects of a post discharge transitional care programme for patients with coronary heart
disease in China: a randomized controlled trial. Journal of Clinical Nursing.2009; 18(17): 2444-2455.
Appendix III: Appraisal instruments

MAStARI appraisal instrument
Appendix IV: Data extraction instruments

MAStARI data extraction instrument
Appendix V: Classification of the interventions
patient-centered
transition coach
timely follow-up
communication
empowerment
telemonitoring
patient hotline
telephone call
rehabilitation
Streamlining
appointment
intervention
documents
medication
scheduled
home visit
education
discharge
planning
patient
timely
other
PRE-DISCHARGE INTERVENTIONS
Basoor A, 2013 43 x x
Dowsey MM,1999 38 x x
Evans RL, 1993 48 x
Lannin NA, 2007 57 x
Li H, 2012 35 training of FCG
Marusic S, 2013 62 x
Osman LM, 2002 69 x x
POST-DISCHARGE INTERVENTIONS
Braun E, 2009 44 x
Chiantera A, 2005 40 x
Dendale P, 2012 31 x x
Domingues FB, 2011 39 x
Dudas V, 2001 46 x
Gonzalez-Guerrero JL, 2014 32 x x x
Gurwitz JH, 2014 50 x x
Leventhal ME, 2011 60 x x x x x x care plan
10.11124/jbisrir-2016-2381 Page 147
patient-centered
transition coach
timely follow-up
communication
empowerment
telemonitoring
patient hotline
telephone call
rehabilitation
Streamlining
appointment
intervention
documents
medication
scheduled
home visit
education
discharge
planning
patient
timely
other
Man WD, 2004 61 x x
Mayo NE, 2008 63 x x x x
Melton LD, 2012 65 x
Riegel B, 2006 41 x x
Strömberg A, 2003 76 x x x
Weaver LA, 2001 77 x
Woodend AK, 2008 78 x
PRE-& POST-DISCHARGE INTERVENTIONS
Balaban RB, 2008 42 x x x x
Burns ME, 2014 45 x x x x x x
Coleman EA, 2006 10 x x x x x x x
Courtney M,2009 29 x x x x x x x
Eaton T, 2009 47 x x
Forster AJ, 2005 49 x x x x
Harrison MB, 2002 51 x x x x x x
Huang T, 2005 52 x x x x x x x x
Jaarsma T, 1999 53 x x x x x
Jack BW, 2009 54 x x x x x x x
Kangovi S, 2014 55 x x x x x x
10.11124/jbisrir-2016-2381 Page 148
patient-centered
transition coach
timely follow-up
communication
empowerment
telemonitoring
patient hotline
telephone call
rehabilitation
Streamlining
appointment
intervention
documents
medication
scheduled
home visit
education
discharge
planning
patient
timely
other
Koehler BE, 2009 56 x x x x x x x x
Laramee AS, 2003 58 x x x x x x x
Legrain S, 2011 59 x x x x
Lopez Cabezas C, 2006 34 x x x
McDonald K, 2002 64 x x x x
Naylor MD, 1990 66 x x x x x x
Naylor MD, 1994 67 x x x x x x
Nazareth I, 2001 68 x x x x x x
Parry C, 2009 12 x x x x x x
Rich MW, 1993 70 x x x x x x
Rich MW, 1995 71 x x x x x x
Saleh S, 2012 72 x x x x x x
Sales VL, 2013 73 x x x x x
Sethares KA, 2004 74 x
Shyu Y, 2005 75 x x x x
Wong FK, 2011 36 x x x x x
Wong FK, 2014 37 x x x x x
Zhao Y, 2009 79 x x x x
FCG = family caregiver
10.11124/jbisrir-2016-2381 Page 149
Appendix VI: Included studies

MAStARI
Study Participants Intervention A Intervention B Notes
Balaban RB, 2008 Inclusion: Discharge-transfer intervention: Usual care: - small study population (47
42
- admission to medical-surgical - comprehensive, user-friendly - discharge intervention, 49 usual
department Patient Discharge Form instructions care)
- medical home at one of the - electronic transfer of the Patient handwritten in - readmission to 1 of the 3
two primary care sites Discharge Form to the primary English hospitals of an alliance
- discharge to home care RNs - communication - readmission abstracted
Exclusion: - telephone contact by a primary between the from the EMR or progress
- elective admissions care RN to the patient discharging notes
- PCP review and modification of physician and the
the discharge-transfer plan PCP when needed
- no communication
between inpatient
and outpatient RNs
Basoor A, 2013 43 Inclusion : - use of a checklist with various - Usual care: no - small study population (48
- primary diagnosis of acute evidence-based pharmacologic checklist used intervention, 48 usual
decompensated heart failure and nonpharmacologic care)
Exclusion: therapeutic measures - patients in intervention
- age (<18 years) - counseling of patients about the group were not at random
- pregnancy interventions in the checklist selected. Patients in the
usual care group were at
random selected from all
patients who did not
receive the checklist
intervention
- readmission measured via
hospital records; risk of
underestimation
- only disease specific
readmissions
10.11124/jbisrir-2016-2381 Page 150
Braun E, 2009 44 Inclusion: Telephone calls one week and one Usual care: discharge - large study population
- admission to department of month after discharge report for PCP given (200 intervention, 200
medicine with patients usual care)
Exclusion: - patient satisfaction not
- no telephone access measured by a validated
- language: not speaking questionnaire
Hebrew, Arabic, Russian or - only 400 patients out of
English 1878 patients were
- discharge within two days included; after inclusion
- cognitive impairment patients who did not had
- patients were excluded after full contact were excluded
inclusion when they failed to from analysis; risk of
answer at least one of the selection bias
telephone calls - low qualitative appraisal
- readmission was
measured by telephone
interview; risk of
underestimation
Burns ME, 2014 45 Inclusion: Community Health Worker Usual care: - large study population
- One or more risk factors: intervention: - comprehensive, (110 intervention, 313
pathology (chronic heart - introductory visits during hospital individualized home usual care)
failure, COPD or pneumonia), stay care plan reviewed - weekly phone calls only in
age (60 years or older), length - CHW participation in the hospital with the patient 38% of intervention
of stay >3 days, weekend discharge process - electronic patients
discharge, hospitalization - weekly telephone calls to elicit transmission of the - readmission measured via
within the previous 6 months, patient concerns plan to primary care medical records of health
discharge to home - liaison calls to primary care nursing staff alliance (2 hospitals); risk
- PCP in affiliated primary care nurses as needed - telephone call from a of underestimation
practice primary care nurse
within 72 h of
discharge to
address medical
questions or needs
10.11124/jbisrir-2016-2381 Page 151
Chiantera A, 2005 Inclusion: Telecardiology: ECG send Usual care: follow-up - critical appraisal: low
40
- acute coronary syndrome spontaneously for symptoms and visit after discharge methodological quality of
Exclusion: weekly as scheduled paper
- bundle branch block and - not mentioned how
permanent pacemaker readmission was
measured
- no statistical analysis on
readmission rates
Coleman E A, 2006 Inclusion: Care transitions intervention Usual care: not - large study population
10
- age (65 years or older) - assistance with medication described (379 intervention, 371
- discharge to home self-management usual
- no documentation of dementia - patient-centered record owned - care)
- no plans to enter a hospice and maintained by the patient to - intervention based on
- at least one of 11 predefined facilitate cross-site information patient empowerment
diagnoses is documented transfer - readmission abstracted
Exclusion: - timely follow-up with primary or from administrative
- no telephone access specialty care records of contracted and
- language: not English - a list of “red flags” non-contracted hospitals
speaking - transition coach met with the
- not within geographic area patient in the hospital, conducted
- admission for a psychiatric a home visit and telephoned 3
condition times during a 28-day discharge
period
10.11124/jbisrir-2016-2381 Page 152
Courtney M, 2009 29 Inclusion: Exercise and telephone follow-up Usual care: not - intervention lasted longer
- age (65 years or older) program: described than 3 months after
- admitted with a medical - individualized care plan discharge (6 months)
diagnosis - individualized exercise
- at least one risk factor for intervention
readmission - pre-discharge: transitional care
Exclusion: plan, assistance with the exercise
- not able to participate in the program, written guidelines
intervention - post-discharge: home visit within
48 hours, follow-up telephone
calls, availability of nurse for
contact
Dendale P, 2012 31 Inclusion: Telemonitoring facilitated Usual care:

- admission of heart failure collaboration: - no telemonitoring
Exclusion - telemonitoring of a set of - patients followed by
- reversible heart failure and parameters with actions of PCP’s PCP
some other specified types and heart failure clinic in case of
- major cognitive dysfunction deterioration
- previous residency in nursing - patients were followed in the
home heart-failure clinic at 3 and 6
- cardiac rehabilitation program months
- severe kidney insufficiency or
pulmonary obstructive
disease
- planned pacemaker or cardiac
surgery
- compromised survival
10.11124/jbisrir-2016-2381 Page 153
Domingues FB, Inclusion: Telephone calls after discharge Usual care: - not mentioned how
2011 39 - heart failure - inpatients: readmission was
- age (18 years or older) educational nursing measured
Exclusion: intervention (3-5 - not used in meta-analysis
- no telephone access visits), educational because number of
manual, readmissions counted and
self-monitoring not readmission rate
charts for weight
- after discharge:
follow-up visits
Dowsey MM, 1999 Inclusion: Clinical pathway: daily goals, daily Usual care: absence - readmission only to
38
- hip or knee joint arthroplasty evaluation of discharge plan of clinical pathway primary hospital
Exclusion:
- revision arthroplasty
- simultaneous bilateral joint
arthroplasty
- arthroplasty for acute trauma
or complex tumor surgery
10.11124/jbisrir-2016-2381 Page 154
Dudas V, 2001 46 Inclusion: follow-up phone call by a pharmacy facilitated - approximately 70% of the
- general medicine patients pharmacist 2 days after discharge discharge without patients did not receive
- pharmacy-facilitated for patients with pharmacy follow-up telephone pharmacy-facilitated
discharge facilitated discharge call discharge and were not
- discharge to home eligible for inclusion; risk
Exclusion: for selection bias
- language: not English - only 79 of the 110 patients
speaking in the telephone group
- unable to participate in a were contacted by
telephone conversation or telephone; risk for
complete a written satisfaction underestimation of the
survey effect
- intervention lasted until 2
days after discharge
- readmission measured via
hospital records; risk for
underestimation
Eaton T, 2009 47 Inclusion: inpatient and outpatient Usual care: - small study population (47
- COPD rehabilitation program with standardized care and intervention, 50 usual
- exertional dyspnea interfering exercises and educational sessions education in care)
with daily activity accordance with the - only 40% attended ≥ 75%
Exclusion: COPD guidelines of the rehabilitation
- not able to complete sessions (a priori definition
questionnaire of adherence)
- major cognitive dysfunction - in results only attendees in
- comorbidities precluding the the intervention group
ability to participate in were mentioned
rehabilitation - unscheduled emergency
visits (not only ED, but
also primary care) were
recorded, but results were
not mentioned
- only COPD related
readmissions
10.11124/jbisrir-2016-2381 Page 155
Evans RL, 1993 48 Inclusion: early discharge planning that starts Usual care: no - large study population
- patients at risk for long length on third day of admission assessment by social (417 intervention, 418
of stay worker or only upon usual care)
- readmission or discharge to referral - control group could also
nursing home: risk-screening receive discharge
index ≥ 3 planning at request of the
Exclusion: physician
none - not mentioned how
readmissions were
measured
Forster AJ, 2005 49 Inclusion: Clinical nurse specialists retrieved Usual care: not - large study population
Patients admitted to one of the prehospital information, arranged described (157 intervention, 151
four general medicine teams inhospital consultations and tests, usual care)
Exclusion: arranged follow-up visits, provided - intervention lasted until 3
none patient education, telephoned days after discharge
patients after discharge - composite outcome
(readmission + ED visits
+/- death)
- readmission interval
approximately 30 days,
but it could be longer
Gonzalez-Guerrero Inclusion: disease management program in a Usual care: - high critical appraisal
JL, 2014 32 - acute heart failure geriatric daycare hospital (GDCH): - manual with HF score (8/10)
- admission to geriatric service - pre-discharge: evaluation by team education - intervention lasted longer
- hospital stay more than 2 days - post-discharge: telephone call - follow-up by PCP than 3 months after
Exclusion: within 48h, evaluation in GDCH discharge (6 months)
- discharge to retirement home after 10 days, 1 month and 6
- bedridden patients months, geriatrician available by
- cognitive impairment telephone (9-14h) and telephone
- psychiatric condition follow-up by geriatrician after 3
- compromised survival months
- impossibility to follow-up
10.11124/jbisrir-2016-2381 Page 156
Gurwitz JH, 2014 50 Inclusion: Electronic Health Record (EHR)– Usual care: no EHR - large study population
- PCP within medical group Based Intervention: (1870 intervention, 1791
- age (65 years or older) - facilitate the information flow to usual care)
- discharge to community PCP’s about dates, medication - intervention not focused
Exclusion: - alerts to schedule follow-up visits on patients
- psychiatric condition within 1 week after discharge - intervention organized by
- discharge to hospice a primary care medical
group, but hospital is also
involved
Harrison MB, 2002 Inclusion: - supportive care for Usual care: - no additional providers:
51
- congestive heart failure self-management: In-hospital collaboration of hospital
- home nursing care evidence-based education - early assessment and home RN
- stay > 24hours program, education map and discharge plan - outcomes measured by
Exclusion: - linkages between hospital and - weekly discharge patient self-report; risk of
- language: not English or home nurses and patients: planning meetings underestimation
French speaking nursing transfer letter, telephone - consult of a regional
- not within geographic area call within 24 hours of discharge, home care
- cognitive impairment telephone advice from hospital co-coordinator as
RN, education booklet used at required
home, community RN consult with - referral for home
hospital RN care, and necessary
- balance of care between the services
patient and family and After discharge:
professional healthcare workers - Usual home nursing
care with
assessment and
monitoring, health
teaching, direct care
10.11124/jbisrir-2016-2381 Page 157
Huang T, 2005 52 Inclusion: - pre-discharge: discharge plan, Usual care: patients - outcomes measured by
- hip fracture education, summaries of received no brochures patient self-report; risk of
- age (60 years or older) discharge plan are provided to nor written discharge underestimation
Exclusion: patients and caregivers summaries
- not within geographic area - post-discharge: home visit,
- too ill available by telephone, nurse
- cognitive impairment initiated contacts
Jaarsma T, 1999 53 Inclusion: supportive-educative intervention: Usual care: - intervention lasted until 10
- heart failure NYHA class III Intensive, systematic and planned information for days after discharge
and IV education during hospital stay and patients dependent on
- diagnosis at least 3 months after discharge. Study nurse insight of individual
before telephoned patients, did home visit nurses or physicians
- age (50 years or older) and was available by telephone
Exclusion:
- Language: not Dutch
speaking.
- co-existing, severe chronic
disease
- discharge towards nursing
home
- psychiatric diagnosis
- CABG/PTCA or valve surgery
in last 6 months or expected
within 3 months
10.11124/jbisrir-2016-2381 Page 158
Jack BW, 2009 54 Inclusion: The RED intervention Usual care: not - high critical appraisal
- admission to medical (reengineered discharge): described score (8/10)
department - during hospital stay: a nurse - large study population
- discharge to community discharge advocate (DA) (370 intervention, 368
Exclusion: arranged follow-up appointments, usual care)
- no telephone access confirmed medication - not used in meta-analysis
- language: not English reconciliation, and conducted because number of
speaking patient education with an readmissions counted and
- admission from skilled nursing individualized instruction booklet not readmission rate
facility/other hospital that was sent to their primary care
- planned hospitalization provider
- the DA created an after-hospital
care plan (AHCP)
- after discharge: a clinical
pharmacist called patients 2 to 4
days after discharge to reinforce
the discharge plan and review
medications
Kangovi S, 2014 55 Inclusion: Individualized Management for Usual care: - large study population
- general medicine service Patient-Centered Targets - discharge needs (222 intervention, 224
- age (18-64 years) (IMPaCT): discussed in daily usual care)
- discharge towards home - during hospital stay: set goals, multidisciplinary - protocol for CHW’s
- low socio-economic status: create a plan, liaison between rounds recruitment and training
Exclusion: patients and care team - reconciliation of - well-established usual
- language: not English - after discharge: support by home medication changes care
speaking visits, telephone calls, coach by nurses
patients to schedule and attend - written discharge
appointments instructions for
patients
- discharge summary
within 30 days to
PCP
10.11124/jbisrir-2016-2381 Page 159
Koehler BE, 2009 56 Inclusion: Intervention group care bundle: Usual care: not - small study population (20
- one of 20 DRGs - medication described intervention, 21 usual
- ≥3 chronic comorbidity counseling/reconciliation care)
conditions - condition specific - intervention lasted until 1
- age (70 years or older) education/enhanced discharge week after discharge
- use of ≥5 medications planning - composite outcome
- assistance for ≥1 ADL - phone follow-up (readmission + ED visits)
- discharge towards home - personal health record to engage - outcome measurement via
Exclusion: patients and promote information the hospital’s electronic
- no telephone access transfer to outpatient settings reporting system; risk of
- language: not English underestimation
speaking - effect on outcome greatest
- primarily surgical admission after 1 month and smaller
- compromised survival after 2 months
Lannin NA, 2007 57 Inclusion: Pre-discharge home visit: a single Usual care: single - small study population (5
- admission to rehabilitation unit home-based occupational therapy functional assessment intervention, 5 usual care)
- referred to occupational session and educational - pilot study
therapy session during - intervention lasted until
- discharge towards home hospital stay discharge
- age (65 years or older)
Exclusion:
- cognitive impairment
- medical contraindication
Laramee AS, 2003 Inclusion: Case management intervention: Usual care: - large study population
58
- congestive heart failure (CHF) - early discharge planning and Inpatient: (131 intervention, 125
- at risk for readmission coordination of care - standard care usual care)
- discharge towards home - individualized and comprehensive - ancillary services - not used in meta-analysis
patient and family education provided on request because number of
Exclusion: - 12 weeks of enhanced telephone - medication and CHF readmissions counted and
- planned cardiac surgery follow-up and surveillance education by staff not readmission rate
- cognitive impairment - promotion of optimal CHF nurses
- compromised survival medications and medication Post-discharge care:
- hemodialysis doses follow-up by PCP
10.11124/jbisrir-2016-2381 Page 160
Legrain S, 2011 59 Inclusion: Discharge-planning intervention: Usual care: - large study population
- admission to geriatric unit in - comprehensive chronic - standard care plan (317 intervention, 348
an emergency medication review from acute geriatric usual care)
- age (70 years or older) - education on self-management of unit team - multi-centric study
Exclusion: disease - comprehensive - not stated how long
- expected LOS < 5 days - detailed transition-of-care geriatric assessment intervention lasted
- compromised survival communication with outpatient - usually also a
- language: not French health professionals rehabilitation
speaking component
Leventhal M E, Inclusion: Interdisciplinary management Usual care:: - small study population (22
2011 60 - heart failure program: post-discharge: - normal medical and intervention, 20 usual
- age (adult) - home visit nursing care care)
- discharge to home - telephone calls - lifestyle - study stopped due to
Exclusion: - educational kit recommendations prolonged recruiting time
- severe concurrent cardiac - care plan with patient and nurse - communication with - protocol changed during
diseases identified goals; discussed with PCP study: inclusion criteria
- cognitive impairment PCP - educational booklet and time of randomization
- not able to comprehend a - follow-up by PCP - only readmissions to same
telephone conversation hospital: risk for
- compromised survival underestimation
- language: not German
speaking
10.11124/jbisrir-2016-2381 Page 161
Li H, 2012 35 Inclusion patients: CARE (Creating Avenues for Attention control - readmission measured
- age (65 years or older) Relative Empowerment): intervention: only by self-report of FCG
- expected hospital stay of Two informational and educational - two sessions with
more than 4 days sessions for FCG to empower, informational and
Inclusion family care givers educate and inform them. FCG’s educational
(FCG): are assisted to develop a health materials about
- age (21 years or older) care plan. hospital and hospital
- strongly related to patient services
- primary FCG
Exclusion patients:
- admission from a long-term
care facility
- diagnosis of dementia
- hospice care
Exclusion FCG:
- language: cannot read and
speak English
- not within geographic area
- mental or physical impairment
- paid care providers
Lopez Cabezas C, Inclusion: Active information program: Usual care: not - low educational level of
2006 34 - heart failure Patients received information about described study population could be
Exclusion: the disease, drug therapy, diet a problem for external
- not within geographic area education and active telephone validity
- nursing home follow-up - not mentioned how
- cognitive impairment readmission was
measured
10.11124/jbisrir-2016-2381 Page 162
Man WD, 2004 61 Inclusion: Outpatient rehabilitation program Usual care: no - small study population (18
- admission for an acute with exercises and education rehabilitation program intervention, 16 usual
exacerbation of COPD care)
Exclusion: - one third of the patients
- comorbidity that could limit included in the
exercise training rehabilitation program did
- attendance of a pulmonary not attend 50% of the
rehabilitation program in the sessions; risk for selection
preceding year bias
Marusic S, 2013 62 Inclusion: Pharmacotherapeutic counseling Usual care: - post-discharge outcomes

- admission to medical clinic during hospital stay - discharge letter measured by patient
- age (65 years or older) given with patient for self-report; risk of
- discharge to community PCP underestimation
- prescription of at least 2 - information of - External validity: can we
medications for chronic medications by extrapolate this result to
diseases physician western European
Exclusion: countries?
- discharge to long-term care
facility
- inability to be followed-up
Mayo NE, 2008 63 Inclusion: Case management: Usual care: patients

- stroke patients returning - home visits were instructed to
home directly - telephone contact make an appointment
- one of the criteria indicating - contact with personal physician: with the PCP
specific need for health care give information and make
supervision post-discharge appointment
Exclusion: - patient hotline
- discharge to inpatient
rehabilitation facility or
long-term care
10.11124/jbisrir-2016-2381 Page 163
McDonald K, 2002 Inclusion: Multidisciplinary care Usual care: - small study population (51
64
- congestive heart failure (CHF) - Inpatient: nurse led education, - ancillary services intervention, 47 usual
- age (18 years or older) dietician consults when requested care)
Exclusion: - After discharge: telephone - clinical criteria to be - methodology poorly
- CHF in setting of MI or follow-up, follow-up in heart failure fulfilled before described; patient
unstable angina clinic discharge selection not clear
- compromised survival - optimal medical - control group could also
therapy receive some
- follow-up by PCP interventions at request of
the physician
- not mentioned how
readmission was
measured
- readmissions only for
heart failure
Melton LD, 2012 65 Inclusion: Prioritized group: Unprioritized group: - large study population
- patients with active private - 2 post-discharge phone calls by a - call by a CM 3 days (1994 intervention, 1994
health insurance coverage case manager (CM) within 24 after discharge usual care)
- length of stay ≥ 3 days hours of discharge - calls were not made - not stated how long
- ICD-9-CM major diagnosis of - calls were made in descending in any health risk intervention lasted
Heart/Circulatory, Lower health risk order order - number of days to
Respiratory or post-discharge contact
Gastrointestinal varied widely
Exclusion: - mean number of phone
- none calls was 1.8 in both
groups
10.11124/jbisrir-2016-2381 Page 164
Naylor MD, 1990 66 Inclusion: Comprehensive discharge planning Usual care: general - small study population (20
- admission to medical and by gerontological nurse specialist = discharge planning intervention, 20 usual
surgical units general discharge planning coordinated by care)
- alert and oriented at expanded with: primary or associate - difference in race between
admission - assessment of needs nurse both groups with in
- from home - assessment of knowledge and experimental group 90%
- telephone access availability teaching, white people and in control
Exclusion: - telephone contact within first two group 40%
- no telephone access weeks after discharge
- language: not English
speaking
- not able to respond questions
Naylor MD, 1994 67 Inclusion: Comprehensive discharge planning: Routine discharge - not mentioned how
- 2 medical DRGs (congestive - comprehensive assessment of planning: readmission was
heart failure or AMI) or 2 discharge planning needs - complicated measured
surgical DRGs (coronary - development of a discharge plan discharge planning
artery bypass graft or cardiac - validation of patient and caregiver was coordinated by
valve replacement) education the social worker
- age (70 years or older) - coordination of discharge plan and community
- from home (until 2 weeks after discharge) nursing coordinator.
- alert and oriented at moment - interdisciplinary communication
of admission regarding discharge status
Exclusion: - evaluation of effectiveness of
- no telephone access discharge plan
speaking
10.11124/jbisrir-2016-2381 Page 165
Nazareth I, 2001 68 Inclusion: Integrated discharge plan of Usual care: - large study population
- age (75 years or older) hospital and community discharge summary to (164 intervention, 176
- four or more medicines at pharmacists: PCP usual care)
discharge - hospital pharmacists: assessment - readmission data based
Exclusion: of medication, rationalization of on hospital’s
- language: not English drug treatment, assessment of administrative system: risk
speaking patients' ability to manage for underestimation
- too ill medication, information, liaison
with carers, copy of discharge
plan to patient, community
pharmacist and PCP.
- community pharmacists: visit at
home
Osman LM, 2002 69 Inclusion: Self-management program: Usual care: not - large study population
- admission with acute asthma - education: pathophysiology, described (280)
- age (14–60 years) symptoms, risk factors, medicines - more women in
- development of written intervention group: risk for
self-management plan (symptom underestimation
and peak flow based) with readmission rate in
patients intervention group
(women traditionally have
lower readmission rates)
10.11124/jbisrir-2016-2381 Page 166
Parry C, 2009 12 Inclusion: Care transitions intervention: Usual care: standard - small study population (49
- fee-for-service Medicare - reliable medication discharge planning intervention, 49 usual
patients self-management system care)
- age (65 years or older) - patient-centered record - high refuse rate to
- community-dwelling - timely follow-up with primary or participate (27%) could
- have at least one of 11 specialty care have induced selection
diagnoses - a list of “red flags” and instructions bias
Exclusion: on how to respond to them
- no telephone access
speaking
- admission for a psychiatric
condition
Rich MW, 1993 70 Inclusion: Comprehensive multidisciplinary Usual care: ancillary - small study population (63
- age (70 years or older) treatment: services at request of intervention, 35 usual
- admission to medical ward - teaching physician care)
- discharge towards home - medication review - control group could also
- high risk for readmission - early discharge planning receive elements of
Exclusion: - discharge summary form intervention group
- not within geographic area transmitted to home-care nurse - not stated how long
- risk for unpreventable - enhanced follow-up through home intervention lasted
readmission care and telephone contacts - not mentioned how
- cognitive impairment readmission was
measured
10.11124/jbisrir-2016-2381 Page 167
Rich MW, 1995 71 Inclusion: Comprehensive multidisciplinary Usual care: eligible for - usual care is not
- admission to medical unit treatment: standard treatments standardized
- heart failure - teaching and services ordered - not stated how long
- four or more hospitalizations - medication review by physician intervention lasted
in preceding five years - early discharge planning - not mentioned how
Exclusion: - discharge summary form readmission was
- not within geographic area transmitted to home-care nurse measured
- discharge to long-term-care - enhanced follow-up through home
facility care and telephone contacts
Riegel B, 2006 41 Inclusion: Telephone follow-up by bilingual Usual care: education - specific population
- heart failure nurse case managers before discharge and (Hispanics on US-Mexico
- Hispanics discharge instructions, border) -> external
- living in community often only written validity?
Exclusion: information
none
Saleh S, 2012 72 Inclusion: elderly Medicare Comprehensive post-discharge Regular discharge - large study population
patients care transition program process: not described (160 intervention, 173
Exclusion: - patient-centered health record usual care)
- dementia without a caregiver - structured discharge preparation - not mentioned how
- severe psychiatric conditions - patient self-activation and readmission was
- planned readmission management sessions measured
- end-stage renal disease or - follow-up appointment with a
primary diagnosis of tumors physician provider within 7 days
- assisted living with a coached - coordination of data flow
caregiver
- residence in a nursing home
10.11124/jbisrir-2016-2381 Page 168
Sales VL, 2013 73 Inclusion: - during hospital stay: Usual care: - low critical appraisal score
- heart failure  education - standardized (4/10)
- age (18 years or older)  review of medication discharge sheet - patients discharged
Exclusion:  review of discharge instructions - appointment with towards home with or
- dementia  personalized discharge sheet PCP scheduled without visiting nurse
- severe psychiatric conditions  encourage follow-up home care, inpatient
- transfer to other hospital - weekly phone calls rehabilitation facility or
skilled nursing facility
- only disease specific
readmissions in same
hospital measured: risk for
underestimation
Sethares KA, 2004 Inclusion: Tailored message intervention Usual care: - randomization process not
74
- heart failure based on results on Health Belief - discharge described
- discharge to home Scales instructions by nurse - small study population (33
Exclusion: - educational sheets intervention, 37 usual
- language: not English care)
speaking
Shyu Y, 2005 75 Inclusion: Interdisciplinary intervention Usual care: without - low critical appraisal score
- age (60 years or older) program well-organized, (5/10)
- hip fracture (arthroplasty or - geriatric consultation service: interdisciplinary care - post-discharge outcomes
fixation) geriatric assessment, protocols measured by patient
- minimal level of activity development of postoperative self-report; risk of
- within geographic area plan, postoperative follow-up underestimation
Exclusion: - rehabilitation program: early
- severe cognitive impairment postoperative rehabilitation, home
- compromised survival visits
- discharge planning
10.11124/jbisrir-2016-2381 Page 169
Strömberg A, 2003 Inclusion: Nurse-led heart failure clinic: Usual care: follow up
76
- Heart failure - evaluation of status in primary care
Exclusion: - standardized education
- severe chronic pulmonary - structured follow-up
disease - telephone availability during
- cognitive impairment weekdays
- discharge to geriatric clinic or
home care
- already patient at the
nurse-led failure clinic
Weaver LA, 2001 77 Inclusion: Telephone follow-up Usual care: routine - small study population (44
- cardiac surgery postoperative care intervention, 46 usual
- age (21 years or older) without telephone care)
- discharge to home 3-7 days follow-up - outcome measured by
after surgery patient self-report; risk for
Exclusion: underestimation
speaking
Wong FK, 2011 36 Inclusion: Health-social partnership Usual care: - large study population
- admission to medical unit transitional care management - health advice (272 intervention, 283
- age (60 years or older) program (HSTCMP) - medication usual care)
- telephone access availability - pre-discharge assessment instructions - outcome measured by
- discharge to home - post-discharge: home visits and - arrangements for hospital’s administrative
Exclusion: telephone calls by nurse and follow-up system; risk for
- no telephone access volunteers during 4 weeks after - support services if underestimation
- language: not Cantonese discharge needed
speaking
- inability to communicate
- MMSE <= 20
10.11124/jbisrir-2016-2381 Page 170
Wong FK, 2014 37 Inclusion: - pre-discharge assessment Usual care: - Large study population
- admission for respiratory, - home visit group: post-discharge - health advice (196 home visit group, 204
diabetic, cardiac or renal 2 telephone calls and 2 home - medication call group, 210 usual care)
conditions visits addressing patients’ needs instructions - control group received
Exclusion: on different domains - arrangements for placebo calls
- no telephone access - call group: post-discharge 4 follow-up - intervention group with 2
- discharge to assisted care telephone calls arms
facilities 2 placebo calls - outcome measured by
- language: not Cantonese hospital’s administrative
speaking system; risk for
- not within geographic area underestimation
- inability to communicate
- MMSE <= 20
Woodend AK, 2008 Inclusion: Telehome monitoring: Usual care: - no clinical data other than
78 - Symptomatic heart failure - video conferencing and daily - patients were cardiologic data
- or angina transmission of data referred to - outcome measured by
- discharge to home community patient report; risk for
Exclusion: practitioner or underestimation
- language: not capable of cardiologist - not used in meta-analysis
reading and writing English or - all patients received because number of
French telephone number of readmissions counted and
- not within geographic area APN not readmission rate
10.11124/jbisrir-2016-2381 Page 171
Zhao Y, 2009 79 Inclusion: Transitional care program (TCP): Usual care: - results not generalizable
- age (60 years or older) - pre-discharge: health advice (diet, - discharge to Western context
- angor or myocardial infarction medication, exercise, life-style), instructions by - outcome measured by
- discharge to home document advice and sent to physician patient self-report; risk for
Exclusion: community nurse - educational underestimation
- no telephone access - post-discharge: home visits, pamphlets available
- language: not Mandarin telephone follow-up
speaking
- not able to communicate
- transferred to another unit
during stay in hospital
RN = registered nurse, PCP = primary care physician, APN = advanced practice nurse, ED = emergency department
10.11124/jbisrir-2016-2381 Page 172
Appendix VII: Excluded studies

MAStARI
Deschodt M, Effect of an inpatient geriatric consultation team on functional outcome, mortality,

institutionalization, and readmission rate in older adults with hip fracture: A controlled trial
Reason for exclusion: not randomized
Kulshreshtha A, Use of remote monitoring to improve outcomes in patients with heart failure: A pilot trial
Reason for exclusion: not truly random (week on – week off)

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JBI Database of Systematic Reviews & Implementation Reports 2016;14(2):106-173

Effectiveness of discharge interventions from hospital to home on

1. KU Leuven-University of Leuven, Department of Public Health and Primary Care, Leuven,

Types of intervention(s)/phenomena of interest

Implications for practice

Implications for research

care transition; continuity of care; discharge intervention; hospital readmission; meta-analysis

- Advanced nurse practitioner care coordination.13

This review was conducted according to an a priori published protocol.24

The specific review questions are:

Types of intervention(s)/phenomena of interest

This review considered only randomized controlled trials.

Secondary outcomes included patient satisfaction, return to EDs and mortality.

Assessment of methodological quality

Records identified through

Full-text papers excluded, with

Figure 1: Flowchart of study selection process

Table 1: Study and patient characteristics for the 51 included studies

Balaban RB, 2008 42 Community Discharge-transfer Medical or 96 (47/49) 6 Pre and 4 3

Basoor A, 2013 43 Community Checklist Heart failure 96 (48/48) 6 Pre 2 2

Braun E, 2009 44 Teaching hospital, Telephone follow-up General 309 4 Post 1 NA

Dudas V, 2001 46 Academic teaching Telephone follow-up General 221 6 Post 1 1

Gurwitz JH, 2014 50 Large Electronic health Medical-surgical 3661 8 Post 2 NA

Legrain S, 2011 59 Five Discharge-planning Older adults 665 8 Pre and 4 1

Li H, 2012 35 Regional hospital, CARE (Creating Older adults 407 7 Pre 1 1

Man WD, 2004 61 Teaching hospital, Rehabilitation COPD 34 (18/16) 5 Post 2 3

Melton LD, 2012 65 Hospitals in 50 Prioritized Patients at risk 3,988 8 Post 1 1

hospital, US intervention post

Zhao Y, 2009 79 Comprehensing Post-discharge Coronary heart 200 5 Pre and 4 2

Table 2: Taxonomy to categorize discharge interventions

Intervention components Description of the component

Education Education of patient about diagnosis or treatment, not focused on

Discharge planning Development of an individualized discharge plan for patient prior

Appointment scheduled Follow-up appointment scheduled or patient is adviced to

Rehabilitation Rehabilitation aimed at improving functional status

Streamlining Streamlining of services or logistical coordination

Home visit Visit to patient’s home or place of residence

Patient-centered Adapted and individualized discharge materials or care plans to

Timely follow-up Follow-up visits after discharge by physician or nurse as part of

Telephone call Patients or caregivers are contacted by telephone after

Patient hotline Presence of a direct telephone line for patient initiated

Telemonitoring An automated process for the transmission of data on a patient’s

Number of studies included Number of studies excluded

Balaban RB, 2008 42 U N U Y U Y Y Y Y Y

Burns ME, 2014 45 U N U U U Y Y Y Y Y

Coleman EA, 2006 10 Y N U Y Y Y Y Y Y Y

Domingues FB, 2011

Dowsey MM, 1999 38 U N Y U U Y Y Y Y Y

Evans RL, 1993 48 U N U Y U Y N U U Y

Forster AJ, 2005 49 Y Y Y N Y N U Y N Y

Gurwitz JH, 2014 50 Y N Y N Y Y Y Y Y Y

Harrison MB, 2002 51 Y N Y Y U Y Y Y N Y

Jack BW, 2009 54 Y N Y Y Y Y Y Y Y Y

Koehler BE, 2009 56 Y N Y Y U Y Y Y Y Y

Lannin NA, 2007 57 Y N Y N Y Y Y Y U Y

Laramee AS, 2003 58 U N U Y U N Y Y Y Y

Leventhal ME, 2011

Man WD, 2004 61 Y N U N N U Y Y Y Y

Mayo NE, 2008 63 U N Y Y Y Y Y Y Y Y