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Cochrane Database of Systematic Reviews Discharge planning from hospital (Review) Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S.
Discharge planning from hospital.
Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD000313.
DOI: 10.1002/14651858.CD000313.pub5.
www.cochranelibrary.com Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by Jo hn Wiley & Sons, Ltd. T A B L E O F C O N T E N T S1 HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .
6 BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7 OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7 METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9 RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 16 DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18 AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18 ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25 CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
67 DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Effect of discharge planning on hos pital length of stay, Outcome 1 Hospital length of stay - older patients with a medical condition. . . . . . . . . . . . . . . . . . . . . . . . . . 71 Analysis 1.2. Comparison 1 Effect of discharge planning on hos pital length of stay, Outcome 2 Sensitivity analysis imputing missing SD for Kennedy trial. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Analysis 1.3. Comparison 1 Effect of discharge planning on hos pital length of stay, Outcome 3 Hospital length of stay - older surgical patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Analysis 1.4. Comparison 1 Effect of discharge planning on hos pital length of stay, Outcome 4 Hospital length of stay - older medical and surgical patients. . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Analysis 2.1. Comparison 2 Effect of discharge planning on uns cheduled readmission rates, Outcome 1 Within 3 months of discharge from hospital. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Analysis 4.1. Comparison 4 Effect of discharge planning on pat ients’ place of discharge, Outcome 1 Patients discharged from hospital to home. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Analysis 4.4. Comparison 4 Effect of discharge planning on pat ients’ place of discharge, Outcome 4 Older patients admitted to hospital following a fall in residential care at 1 year. . . . . . . . . . . . . . . . . . . . . 81 Analysis 5.1. Comparison 5 Effect of discharge planning on mor tality, Outcome 1 Mortality at 6 to 9 months. . . 81 Analysis 6.4. Comparison 6 Effect of discharge planning on pat ient health outcomes, Outcome 4 Falls at follow-up: patients admitted to hospital following a fall. . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Analysis 8.5. Comparison 8 Effect of discharge planning on hos pital care costs, Outcome 5 Hospital outpatient department attendance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Analysis 8.6. Comparison 8 Effect of discharge planning on hos pital care costs, Outcome 6 First visits to the emergency room. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 97 APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
100 FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
101 WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
101 HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
102 CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
102 DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
102 SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
102 DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .
103 INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. [Intervention Review] Discharge planning from hospital Daniela C. Gonçalves-Bradley1 , Natasha A Lannin 2 , Lindy M Clemson 3 , Ian D Cameron 4 , Sasha Shepperd 1 1 Nuf eld Department of Population Health, University of Oxf ord, Oxford, UK.2 Occupational Therapy, Alfred Health, Prahran, Australia. 3 Faculty of Health Sciences, University of Sydney, Lidcombe, Aus tralia.4 John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District, St Leonards, Australia Contact address: Sasha Shepperd, Nuf eld Department of Popu lation Health, University of Oxford, Oxford, UK.
Editorial group: Cochrane Effective Practice and Organisation of Care Group.
Publication status and date: New search for studies and content updated (no change to conclusion s), published in Issue 1, 2016.
Review content assessed as up-to-date: 5 October 2015.
Citation: Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, She pperd S. Discharge planning from hospital.Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD000313. DOI: 10.1002/14651858.C D000313.pub5.
Copyright © 2016 The Cochrane Collaboration. Published by Jo hn Wiley & Sons, Ltd.
A B S T R A C T Background Discharge planning is a routine feature of health systems in m any countries. The aim of discharge planning is to reduce hospit al length of stay and unplanned readmission to hospital, and to improv e the co-ordination of services following discharge from hospit al.This is the third update of the original review.
Objectives To assess the effectiveness of planning the discharge of indiv idual patients moving from hospital.
Search methods We updated the review using the Cochrane Central Register of C ontrolled Trials (CENTRAL) (2015, Issue 9), MEDLINE, EMBASE, CINAHL, the Social Science Citation Index (last searched in Octobe r 2015), and the US National Institutes of Health trial register (ClinicalTrials.gov).
Selection criteria Randomised controlled trials (RCTs) that compared an individu alised discharge plan with routine discharge care that was not tailored to individual participants. Participants were hospital inpa tients.
Data collection and analysis Two authors independently undertook data analysis and qual ity assessment using a pre-designed data extraction sheet. We grouped studies according to patient groups (elderly medical patients, patients recovering from surgery, and those with a mix of condi tions) and by outcome. We performed our statistical analysis according to the intention-to-treat principle, calculating risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous d ata using xed-effect meta-analysis. When combining outcome data was not possible because of differences in the reporting o f outcomes, we summarised the reported data in the text. 1 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Main results We included 30 trials (11,964 participants), including six identi ed in this update. Twenty-one trials recruited older participants with a medical condition, ve recruited participants with a mix o f medical and surgical conditions, one recruited participants from a psychiatric hospital, one from both a psychiatric hospital an d from a general hospital, and two trials recruited participan ts admitted to hospital following a fall. Hospital length of stay and readm issions to hospital were reduced for participants admitted to hospital with a medical diagnosis and who were allocated to discharge plannin g (length of stay MD−0.73, 95% CI −1.33 to −0.12, 12 trials, moderate certainty evidence; readmission rates RR 0.87, 95% C I 0.79 to 0.97, 15 trials, moderate certainty evidence). It is uncertain whether discharge planning reduces readmission rates for pat ients admitted to hospital following a fall (RR 1.36, 95% CI 0. 46 to 4.01, 2 trials, very low certainty evidence). For elderly patients wi th a medical condition, there was little or no difference betwee n groups for mortality (RR 0.99, 95% CI 0.79 to 1.24, moderate certainty ). There was also little evidence regarding mortality for participants recovering from surgery or who had a mix of medical and surgical co nditions. Discharge planning may lead to increased satisfaction for patients and healthcare professionals (low certainty evid ence, six trials). It is uncertain whether there is any difference in the cost of care when discharge planning is implemented with patients who have a medical condition (very low certainty evidence, ve trials).
Authors’ conclusions A discharge plan tailored to the individual patient probably brings about a small reduction in hospital length of stay and r educes the risk of readmission to hospital at three months follow-up for older people with a medical condition. Discharge planning may l ead to increased satisfaction with healthcare for patients and profe ssionals. There is little evidence that discharge planning reduces costs to the health service.
P L A I N L A N G U A G E S U M M A R Y Discharge planning from hospital Background Discharge planning is the development of a personalised plan for each patient who is leaving hospital, with the aim of contai ning costs and improving patient outcomes. Discharge planning should en sure that patients leave hospital at an appropriate time in their care and that, with adequate notice, the provision of postdischarge se rvices will be organised.
Objectives We systematically searched for trials to see the effect of devel oping personalised plans for patients leaving the hospital. This is the third update of the original review.
Main results We found 30 trials that compared personalised discharge plans versus standard discharge care. Twenty of those studies included older adults.
Authors’ conclusions This review indicates that a personalised discharge plan prob ably brings about a small reduction in hospital length of stay (mean difference −0.73 days) and readmission rates for elderly patients who we re admitted to hospital with a medical condition, and may increase patient satisfaction. It may also increase professio nals’ satisfaction, though there is little evidence to support this. It is not clear if discharge planning reduces costs to the health services. 2 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N[ Explanation ] Ef f e ct of discharge planning on patie nts admitte d to hospital with a me dical condition P atie nt or population: p a t i en t s a d m i t t ed t o h o s p i t a l Se ttings : h o s p i t a l I nte rve ntion : d i s c h a rg e p l a n n i n g Outcome s I llustrative comparative risk s* ( 9 5 % CI ) Re lative e f f e ct ( 9 5 % CI ) No. of participants( studie s) Ce rtainty of the e vi- de nce ( GRADE) Comme nts Assume d risk Corre sponding risk Without discharge planning With discharge plan- ning Unsche dule d re admis- sion within 3 months of discharge f rom hospi- tal Study population admitte d with a me dical con- dition RR 0 . 8 7( 0 . 7 9 t o 0 . 9 7 ) 4 7 4 3( 1 5 ) ⊕⊕⊕ mode rate a - 2 5 4 pe r 1 0 0 0 2 2 1 pe r 1 0 0 0 ( 2 0 0 t o 2 4 6 ) M ode rate risk population 2 8 5 pe r 1 0 0 0 2 4 8 pe r 1 0 0 0( 2 2 5 t o 2 7 6 ) Study population admitte d f ollowing a f all RR 1 . 3 6 ( 0 . 4 6 t o 4 . 0 1 ) 1 1 0 ( 2 ) ⊕ ve ry low b - 9 3 pe r 1 0 0 0 1 2 6 pe r 1 0 0 0 ( 4 3 t o 3 7 1 ) M ode rate risk population 9 2 p er 1 0 0 0 1 2 5 p er 1 0 0 0 ( 4 2 t o 3 6 9 ) 3 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Hospital le ngth of stayFo l l o w -u p : 3 t o 6 m o n t h s Study population admitte d with a me dical con- dition - 2 1 9 3 ( 1 2 s t u d i es ) ⊕⊕⊕ mode rate d - Th e m ea n h o s p i t a l l en g t h o f s t a y ra n g ed a c ro s s c o n t ro l g ro u p s f ro m 5 . 2 to 1 2 . 4 days c Th e m ea n h o s p i t a l l en g t h o f s t a y i n t h e i n - t erven t i o n g ro u p s w a s 0 . 7 3 lowe r ( 9 5 % CI 1 . 3 3 t o 0 . 1 2 l o w er) Satisf action Di s c h a rg e p l a n n i n g m a y l ea d t o i n c rea s ed s a t i s - f a c t i o n f o r p a t i en t s a n d h ea l t h c a re p ro f es s i o n a l s 6 s t u d i es ⊕⊕ low Pa t i en t s a t i s f a c t i o n w a s m ea - s u red i n d i f f eren t w a ys , a n d f i n d i n g s w ere n o t c o n s i s t en t a c ro s s s t u d - i es . On l y 6 / 3 0 s t u d i es rep o rt ed d a t a f o r t h i s o u t c o m e Costs A l o w er rea d m i s s i o n ra t e f o r t h o s e rec ei vi n g d i s c h a rg e p l a n n i n g m a y b e a s s o c i a t ed w i t h l o w er h ea l t h s ervi c e c o s t s i n t h e s h o rt t erm . Di f f eren c es i n u s e o f p ri m a ry c a re va ri ed 5 s t u d i es ⊕ ve ry low Fi n d i n g s w ere i n c o n - s i s t en t . H ea l t h c a re re- s o u rc es t h a t w ere a s - s es s ed va ri ed a m o n g s t u d i es , e. g . , p ri m a ry c a re vi s i t s , rea d m i s - s i o n , l en g t h o f s t a y, l a b - o ra t o ry s ervi c es , m ed i - c a - t i o n , d i a g n o s t i c i m a g - i n g . Th e c h a rg es u s ed t o c o s t t h e h ea l t h c a re res o u rc es a l s o va ri ed * Th e b a s i s f o r t h e assume d risk( e. g . t h e m ed i a n c o n t ro l g ro u p ri s k a c ro s s s t u d i es ) i s p ro vi d ed i n f o o t n o t es . Th ecorre sponding risk( a n d i t s 9 5 % c o n f i d en c e i n t erva l ) i s b a s ed o n t h e a s s u m ed ri s k i n t h e c o m p a ri s o n g ro u p a n d t h e re lative e f f e cto f t h e i n t erven t i o n ( a n d i t s 9 5 % CI) .
CI : Co n f i d en c e i n t erva l ; RR:Ri s k ra t i o . 4 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. GRA DE Wo rk i n g Gro u p g ra d es o f evi d en c eHigh: Th i s res ea rc h p ro vi d es a very g o o d i n d i c a t i o n o f t h e l i k el y e f f ec t . Th e l i k el i h o o d t h a t t h e ef f ec t w i l l b e s u b s t a n t i a l l yd i f f eren t ( i . e. , l a rg e en o u g h t o a f f ec t a d ec i s i o n ) i s l o w . M ode rate : Th i s res ea rc h p ro vi d es a g o o d i n d i c a t i o n o f t h e l i k el y ef f ec t . Th e l i k el i h o o d t h a t t h e ef f ec t w i l l b e s u b s t a n t i a l l y d i f feren t i s m o d era t e.
Low: Th i s res ea rc h p ro vi d es s o m e i n d i c a t i o n o f t h e l i k el y ef f ec t . H o w ever, t h e l i k el i h o o d t h a t i t w i l l b e s u b s t a n t i a l l y d i f feren t i s h i g h .
V e ry low: Th i s res ea rc h d o es n o t p ro vi d e a rel i a b l e i n d i c a t i o n o f t h e l i k el y ef f ec t . Th e l i k el i h o o d t h a t t h e ef f ec t w i l l b e s u b s t a nt i a l l y d i f f eren t i s very h i g h a Th e evi d en c e w a s d o w n g ra d ed t o m o d era t e a s a l l o c a t i o n c o n c e a l m en t w a s u n c l ea r f o r 5 o f t h e 1 5 t ri a l s .
b Th e evi d en c e w a s d o w n g ra d ed b ec a u s e o f i m p rec i s i o n i n t h e re s u l t s d u e t o 2 s m a l l t ri a l s .
c Th e ra n g e exc l u d es l en g t h o f s t a y o f 4 5 d a ys rep o rt ed b y Su l c h , a s t h i s w a s a n o u t l i er.
d Th e evi d en c e w a s d o w n g ra d ed t o m o d era t e a s c o n c ea l m en t o f ra n d o m a l l o c a t i o n w a s u n c l ea r f o r 6 o f t h e 1 1 t ri a l s . xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx 5 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. B A C K G R O U N D Cost containment strategies that aim to limit healthcare-related costs while still promoting quality are a feature of all healt hcare systems, especially for acute hospital services ( Bodenheimer 2005 ).
Recent trends include speci cally targeting those patients who in- cur greater healthcare expenditures, decreasing the length of stay for inpatient care, reducing the number of long-stay beds, movi ng care into the community, increasing the use of day surgery, pro- viding increased levels of acute care at home (’hospital at home’ ) and implementing policies such as discharge planning.
There is evidence to suggest that discharge planning (i.e. an in - dividualised plan for a patient prior to them leaving hospit al for home) combined with additional postdischarge support can re- duce unplanned readmission to hospital for patients with cong es- tive heart failure ( Phillips 2004 ). A reduction in readmissions will decrease inpatient costs; however, this reduction in costs may b e offset by an increase in the provision of community services as a re- sult of planning. In the United States, unplanned hospitali sations accounted for 17% of all Medicare hospital payments in 2004, and one quarter of all hospital admissions were 30-day readmissi ons ( Jencks 2009 ). Even a small reduction in readmission rates could have a substantial nancial impact ( Burgess 2014 ).
Description of the condition It has been estimated that one- fth of all hospital discharges are delayed for non-medical reasons ( McDonagh 2000 ). Despite re- cent advances in electronic records, patient pathways and techno l- ogy-assisted decision support, the following three factors, i denti- ed over 30 years ago ( Barker 1985 ), remain causes of delayed dis- charge from hospital ( Dept of Health 2003 ): inadequate patient assessment by health professionals, resulting in problems such as poor knowledge of the patient’s social circumstances and poor or - ganisation of postdischarge health and social care; the late bo ok- ing of transport services to take a patient home, which prevent s timely discharge from hospital; and poor communication betwee n the hospital, follow-up care and community service providers. O r- ganisational factors, including the number of times a patient is moved while in hospital and the discharge arrangements, are m ore strongly associated with delayed discharge than patient facto rs such as functional limitations or cognitive function ( Challis 2014 ). The transition of patients from hospital to postdischarge healt hcare, residential or the home setting has the potential to disrupt conti- nuity of care and may increase the risk of an adverse event due to an inadequate planning of a patient’s discharge ( Kripalani 2007 ).
Poor communication between the secondary care and the postdis- charge setting can result in key clinical information not reachin g primary care providers, with patients remaining unaware of i nfor- mation that might help them manage their condition and prepar e for discharge from hospital. Description of the intervention Discharge planning is the development of an individualised d is- charge plan for a patient prior to them leaving hospital for ho me.
The discharge plan can be a stand-alone intervention or may be embedded within another intervention, for example, as a comp o- nent of stroke unit care or as part of the comprehensive geriatr ic as- sessment process ( Ellis 2011 ;Langhorne 2002 ;Rubenstein 1984 ).
Discharge planning may also extend across healthcare settings and include postdischarge support ( Parker 2002 ;Phillips 2004 ).
How the intervention might work The aim of discharge planning is to improve the ef ciency and quality of healthcare delivery by reducing delayed discharge f rom hospital, facilitating the transition of patients from a hos pital to a postdischarge setting, providing patients with informatio n about their condition and, if required, postdischarge healthcare. D is- charge planning may contain costs and improve patient outcomes.
For example, discharge planning may in uence both the hospita l length of stay and the pattern of care within the community, in- cluding the follow-up rate and outpatient assessment, by brid ging the gap between hospital and home ( Balaban 2008 ).
Why it is important to do this review The emphasis placed on discharge planning varies between coun- tries. In the USA, discharge planning is mandatory for hospi- tals participating in the Medicare and Medicaid programmes.
In the UK, the Department of Health has published guidance on discharge practice for health and social care ( Dept of Health 2010 ). Clinical guidance issued by professional bodies in the UK ( Future Hospital Comission 2013 ), the USA ( Dept Health Human Services 2013 ), Australia ( Aus NZ Soc Geriat Med 2008 ) and Canada ( Health Qual Ontario 2013 ), all highlight the im- portance of planning discharge as soon as the patient is admitt ed, involving a multidisciplinary team to provide a thorough ass ess- ment, establishing continuous communication with the patient and the care givers, working towards shared decision-making an d self-management, and liaising with health and social services in the community-particularly primary care. However, procedures may vary between specialities and healthcare professionals in th e same hospital ( Ubbink 2014 ). We have conducted a systematic review of discharge planning to categorise the different types of stu dy populations and discharge plans being implemented, and to as sess the effectiveness of organising services in this way. The focus of this review is the effectiveness of discharge planning implem ented in an acute hospital setting. This is the third update of the or iginal review. 6 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. O B J E C T I V E S The main objective was to assess the effectiveness of planningthe discharge of individual patients moving from hospital.
The speci c objectives were as follow:
Does discharge planning improve the appropriate use of acut e care 1. Effect of discharge planning on length of stay in hospital compared to usual care. 2. Effect of discharge planning on unscheduled readmission rates compared to usual care 3. Effect of discharge planning on other process variables:
patients’ place of discharge.
Does discharge planning improve or (at least) have no advers e effect on patient outcome?
1. Effect of discharge planning on mortality rate compared to usual care. 2. Effect of discharge planning on patient health outcomes compared to usual care. 3. Effect of discharge planning on the incidence of complications related to the initial admission compared to usu al care. 4. Effect of discharge planning on the satisfaction of patient, care givers and healthcare professionals compared to usual care .
Does discharge planning reduce overall costs of healthcare ?
1. Effect of discharge planning on hospital care costs compared to usual care.
2. Effect of discharge planning on community care costs compared to usual care. 3. Effect of discharge planning on overall costs of healthcare compared to usual care.
4. Effect of discharge planning on the use of medication.
M E T H O D S Criteria for considering studies for this review Types of studies Randomised controlled trials. Types of participants All patients in hospital (acute, rehabilitation or community) irre- spective of age, gender or condition.
Types of interventions We de ned discharge planning as the development of an individ - ualised discharge plan for a patient prior to them leaving hos pi- tal for home or residential care. Where possible, we divided th e process of discharge planning according to the steps identi ed b y Marks 1994 :
• pre-admission assessment (where possible); • case nding on admission; • inpatient assessment and preparation of a discharge plan based on individual patient needs, for example a multidisciplinary assessment involving the patient and the ir family, and communication between relevant professionals within the hospital; • implementation of the discharge plan, which should be consistent with the assessment and requires documentation of the discharge process; • monitoring in the form of an audit to assess if the discharge plan was implemented.
We excluded studies from the review if they did not include an as - sessment or implementation phase in discharge planning; if i t was not possible to separate the effects of discharge planning fro m the other components of a multifaceted intervention or if discharg e planning appeared to be a minor part of a multifaceted interve n- tion; or if the focus was on the provision of care after discharge from hospital. We excluded interventions where the focus was o n the provision of care after discharge from hospital, and those in which discharge planning was part of a larger package of care but the process and components were poorly described.
The control group had to receive standard care with no individu- alised discharge plan.
Types of outcome measures We addressed the effect of discharge planning across several ar eas:
the use of acute care, patient outcomes and healthcare costs.
Main outcomes 1. Length of stay in hospital 2. Readmission rate to hospital Other outcomes 1. Complications related to the initial admission 2. Place of discharge 3. Mortality rate 4. Patient health status, including psychological health 5. Patient satisfaction 6. Care giver and healthcare professional satisfaction 7. Psychological health of care givers 8. Healthcare costs of discharge planning 7 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. i) Hospital care costs and use ii) Primary and community care cost 9. The use of medication for trials evaluating a pharmacy discharge plan Search methods for identi cation of studies Electronic searches We searched the following databases: the Cochrane Central Reg - ister of Controlled Trials (CENTRAL) (2015, Issue 9), the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register (March 2009), MEDLINE via OvidSP (1946 to October 2015), EMBASE via OvidSP (1974 to October 2015), CINAHL via EbscoHOST (1980 to October 2015), Social Sci- ence Citation Index via ISI Web of Knowledge (1975 to October 2015), EconLit (1969 to 1996), SIGLE (grey literature) (1980 to 1996), PsycLIT (1974 to 1996) and PsycINFO (2012 to October 2015). We detail the search strategies for this update in Appendix 1. Searching other resources We checked the reference lists of included studies and related sy s- tematic reviews using PDQ-Evidence ( PDQ-Evidence 2015 ). We handsearched the US National Institutes of Health trial regi ster ( ClinicalTrials.gov 2015 ) and reviewed the reference lists of all in- cluded studies. When necessary, we contacted individual trialis ts to clarify issues and to identify unpublished data.
Data collection and analysis For this update we followed the same methods de ned in the pro - tocol and used in previous versions of this systematic review . Risk of bias of each included study was assessed using the Cochrane Risk of Bias criteria. We created a summary of ndings table usi ng the following outcomes: unscheduled hospital readmission, h ospi- tal length of stay, satisfaction and costs. We used the ve GRAD E considerations (study limitations, consistency of effect, impr eci- sion, indirectness, and risk of bias) to assess the certainty o f the evidence as it relates to the main outcomes ( Guyatt 2008 ). We used methods and recommendations described in Section 8.5 and Chapter 12 of the Cochrane Handbook ( Higgins 2011 ). We jus- ti ed all decisions to down- or up-grade the certainty of eviden ce using footnotes to aid readers’ understanding of the review where necessary.
Selection of studies For this update, two authors (of DCGB, IC, NL and LC) read all the abstracts in the records retrieved by the electronic searche s toidentify publications that appeared to be eligible for this r eview.
Two authors (of DCGB, IC, NL and LC) then independently assessed the full text of all potentially relevant papers in order to select studies for inclusion. We settled any disagreements by discussion, or by liaising with SS.
We excluded trials when discharge planning was part of a broade r package of inpatient care. We made a post hoc decision to exclude any studies that did not describe the study design or did not re port results for the control group. We report details of why we exclu ded studies in the ’ Characteristics of excluded studies ’ table.
Data extraction and management For this update, two authors working independently (of DCGB, IC, NL and LC) extracted data from each article. For the orig- inal review and two subsequent updates, we used a data extrac- tion form developed by EPOC, modi ed and amended for the purposes of this review. For the current version of the review we used an adapted version of the Cochrane good practice extraction form ( EPOC 2015 ). We extracted information on study charac- teristics ( rst author, year of publication, aim, setting, des ign, unit of allocation, duration, ethical approval, funding sources), p artic- ipant characteristics (method of recruitment, inclusion/exclusi on criteria, total number, withdrawals and drop-outs, socio-demo - graphic indicators, subgroups), intervention (setting, pre-a dmis- sion assessment, case nding on admission, inpatient assess ment and preparation of discharge plan, implementation of dischar ge plan, monitoring phase, and comparison), and outcomes.
Assessment of risk of bias in included studies We assessed the quality of the selected trials using the criter ia pre- sented in the Cochrane Handbook for Systematic Reviews of Inter- ventions ( Higgins 2011 ): random sequence generation, allocation concealment, blinding, incomplete outcome data, selective repo rt- ing, and baseline data. For this update, two reviewers (of DCG B, IC, NL and LC) independently assessed the risk of bias. We re- solved disagreements by discussing each case with a third revie wer (SS).
Unit of analysis issues All the included studies were parallel RCTs, where participan ts were individually allocated to the treatment or control group s.
Dealing with missing data We contacted investigators for missing data; for this update t wo provided unpublished data ( Goldman 2014 ;Lainscak 2013 ). 8 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Assessment of heterogeneity We quanti ed heterogeneity among trials using the I2 statistic and Cochrane’s Q test ( Cochrane 1954 ). The I 2 statistic quanti es the percentage of the total variation across studies that is due to het- erogeneity rather than chance ( Higgins 2003 ); smaller percentages suggest less observed heterogeneity.
Data synthesis The primary analysis was a comparison of discharge planning ve r- sus routine discharge care for each outcome listed in Types of outcome measures . We calculated risk ratios (RR) for the dichoto- mous outcomes mortality, unscheduled readmission and dischar ge destination, with 95% con dence intervals (CI) for all point es - timates; and combined data using the xed effects model. Val- ues under 1 indicated outcomes favouring discharge planning. W e calculated mean differences (MD) for the hospital length of stay .
We judged combining data from the included studies inappro- priate for the other outcomes, including patient health outcom es, satisfaction, medication, healthcare costs, and use of other po st- discharge healthcare services (primary care, outpatient, and em er- gency room), due to the different methods of measuring and re- porting these outcomes. We created a ’Summary of ndings’ tabl e for the main outcomes of hospital length of stay and unschedule d readmission, and for the secondary outcomes of satisfaction an d cost. We used GRADE worksheets to assess the certainty of the evidence ( GRADEpro GDT 2015 ).
Subgroup analysis and investigation of heterogeneity In order to reduce differences between trials, we grouped tria l re- sults by participants’ condition (patients with a medical condit ion, a surgical condition, or patients recruited to a trial with a mix of conditions), as the discharge planning needs for patients admi tted to hospital for surgery might differ from those for patients admit- ted with an acute medical condition or with multiple medical con- ditions. We performed post hoc subgroup analyses for partici pants admitted to hospital following a fall and participants admit ted toa mental health setting, as we found more than one study for ea ch subgroup and considered that these participant groups, as wel l as their discharge needs, might differ from both surgical and med ical patients.
Sensitivity analysis We performed a post hoc sensitivity analysis by imputing a mi ssing standard deviation for one trial ( Kennedy 1987 ).
R E S U L T S Description of studies Results of the search Previous versions of the review identi ed 4676 records, of wh ich we excluded 4526 after screening the title and abstract. The mai n reasons for exclusion were ineligible study design, interve ntion or both. Of the 150 full-text records assessed, we excluded 126 and included 24 ( Balaban 2008 ;Bolas 2004 ;Eggink 2010 ;Evans 1993 ;Harrison 2002 ;Hendriksen 1990 ;Jack 2009 ;Kennedy 1987 ;Laramee 2003 ;Legrain 2011 ;Lin 2009 ;Moher 1992 ;Naji 1999 ;Naughton 1994 ;Naylor 1994 ;Nazareth 2001 ;Pardessus 2002 ;Parfrey 1994 ;Preen 2005 ;Rich 1993a ;Rich 1995a ;Shaw 2000 ;Sulch 2000 ;Weinberger 1996 ). For this review update, we identi ed 1796 records, of which we excluded 1703 after screenin g the title and abstract. After retrieving the full text of the r emaining 93 studies, we identi ed six eligible trials (12 publications ), which we included in this update ( Farris 2014 ;Gillespie 2009 ;Goldman 2014 ;Kripalani 2012 ;Lainscak 2013 ;Lindpaintner 2013 ) (Figure 1 ). These 30 trials recruited a total of 11,964 participants. One of the trials included in the review was translated from Danis h to English ( Hendriksen 1990 ). Follow-up times varied from ve days to 12 months. 9 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Figure 1. PRISMA ow diagram 10 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Included studies The trials included in the review evaluated broadly similar dis- charge planning interventions, which included assessment, pl an- ning, implementation and monitoring phases, although seve n tri- als did not describe a monitoring phase ( Eggink 2010 ;Evans 1993 ; Moher 1992 ;Naji 1999 ;Parfrey 1994 ;Shaw 2000 ;Sulch 2000 ); see Characteristics of included studies . The intervention was im- plemented at varying times during a participant’s stay in hos pital, from admission to three days prior to discharge. For one trial it was not clear when the intervention, which consisted of liaising wi th the community healthcare providers about the patient’s speci c needs, was implemented ( Lainscak 2013 ). Another trial conducted a needs assessment and implementation of the discharge plan i n two separate encounters, but if discharge occurred the same day as enrolment, then both phases occurred in one session ( Kripalani 2012 ). Seven trials evaluated a pharmacy discharge plan imple- mented by a hospital pharmacy. For six of those trials the part ic- ipants’ medication was rationalised and prescriptions checked for errors by the hospital consultant, GP, community pharmacist or all of those. These professionals also received a pharmacy dis charge plan, and participants received information about their medi cation ( Bolas 2004 ;Eggink 2010 ;Farris 2014 ;Gillespie 2009 ;Nazareth 2001 ;Shaw 2000 ). For the seventh trial, the research team con- tacted the physicians treating the participant, both in the hos pital and in the community, but only if they had identi ed medication - related problems during the monitoring phase of the interve ntion ( Kripalani 2012 ). In all but two trials a named healthcare profes- sional coordinated the discharge plan. Of the 30 included trial s, 12 provided a postdischarge phone call, four a visit, and two a phone call and a visit.
The study population differed between the trials. Twenty-on e tri- als recruited participants with a medical condition ( Balaban 2008 ; Bolas 2004 ;Eggink 2010 ;Farris 2014 ;Gillespie 2009 ;Goldman 2014 ;Harrison 2002 ;Jack 2009 ;Kennedy 1987 ;Kripalani 2012 ; Lainscak 2013 ;Laramee 2003 ;Legrain 2011 ;Moher 1992 ; Naughton 1994 ;Nazareth 2001 ;Preen 2005 ;Rich 1993a ;Rich 1995a ;Sulch 2000 ;Weinberger 1996 ), with six of these recruit- ing participants with heart failure ( Eggink 2010 ;Harrison 2002 ; Kripalani 2012 ;Laramee 2003 ;Rich 1993a ;Rich 1995a ). Two trials recruited older people (> 65 years) admitted to hospita l fol- lowing a fall ( Lin 2009 ;Pardessus 2002 ), ve recruited partici- pants with a mix of medical and surgical conditions ( Evans 1993 ; Farris 2014 ;Hendriksen 1990 ;Naylor 1994 ;Parfrey 1994 ), and two recruited participants from an acute psychiatric ward ( Naji 1999 ;Shaw 2000 ), one of which also recruited participants from the elderly care ward ( Shaw 2000 ). Two trials used a questionnaire designed to identify participants likely to require discharg e plan- ning ( Evans 1993 ;Parfrey 1994 ). The majority of trials included a patient education component, and two trials included the parti ci- pant’s care giver in the formal assessment process ( Lainscak 2013 ; Naylor 1994 ). The average age of participants recruited to 10 of the trials was > 75 years; in seven trials, between 70 and 75 ye ars, and in the remaining trials, < 70 years. In two trials, both re cruit- ing participants from a psychiatric hospital, the participant s were under 50 years of age.
The description of the type of care the control group received var - ied. Two trials did not describe the care that the control group received ( Kennedy 1987 ;Shaw 2000 ) and another reported it only as best usual care ( Lindpaintner 2013 ). Twenty-one trials described the control group as receiving usual care with some discharge planning but without a formal link through a coordi- nator to other departments and services, although other serv ices were available on request from nursing or medical staff ( Balaban 2008 ;Eggink 2010 ;Evans 1993 ;Gillespie 2009 ;Goldman 2014 ; Harrison 2002 ;Hendriksen 1990 ;Jack 2009 ;Laramee 2003 ; Legrain 2011 ;Lin 2009 ;Moher 1992 ;Naji 1999 ;Naylor 1994 ; Naughton 1994 ;Pardessus 2002 ;Parfrey 1994 ;Preen 2005 ;Rich 1993a ;Rich 1995a ;Weinberger 1996 ). The control groups in seven trials that evaluated the effectiveness of a pharmacy di s- charge plan did not have access to a review and discharge plan by a pharmacist ( Bolas 2004 ;Eggink 2010 ;Farris 2014 ;Gillespie 2009 ;Kripalani 2012 ;Nazareth 2001 ;Shaw 2000 ). In one trial, the control group received multidisciplinary care that was not d e- ned in advance but was determined by the participants’ progre ss ( Sulch 2000 ). Two trials considered the potential in uence of lan- guage uency ( Balaban 2008 ;Goldman 2014 ), while two looked at health literacy ( Jack 2009 ;Kripalani 2012 ).
Excluded studies The main reason for excluding trials was due to multifaceted in - terventions, of which discharge planning was only a minor part .
Some trials reported interventions of postdischarge care, wh ereas for others the control group also received some component of the discharge planning intervention. We excluded a small number o f trials that did not include an assessment phase ( Characteristics of excluded studies ).
Risk of bias in included studies Eighteen trials reported adequate allocation concealment ( Farris 2014 ;Gillespie 2009 ;Goldman 2014 ;Harrison 2002 ;Jack 2009 ; Kennedy 1987 ;Kripalani 2012 ;Lainscak 2013 ;Legrain 2011 ; Naji 1999 ;Naughton 1994 ;Nazareth 2001 ;Preen 2005 ;Parfrey 1994 ;Rich 1995a ;Shaw 2000 ;Sulch 2000 ;Weinberger 1996 ).
All but two trials collected data at baseline ( Balaban 2008 ; Pardessus 2002 ), and we assessed 21 trials as having a low risk of bias for measurement of the primary outcomes (readmission 11 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. and length of stay), as investigators used routinely collecteddata to measure these outcomes ( Balaban 2008 ;Eggink 2010 ;Evans 1993 ;Farris 2014 ;Gillespie 2009 ;Goldman 2014 ;Hendriksen 1990 ;Jack 2009 ;Kennedy 1987 ;Lainscak 2013 ;Laramee 2003 ; Legrain 2011 ;Moher 1992 ;Naji 1999 ;Naughton 1994 ;Nazareth 2001 ;Pardessus 2002 ;Parfrey 1994 ;Rich 1993a ;Rich 1995a ; Weinberger 1996 ). We assessed one pilot trial as having a high risk of bias for the outcome readmission, which was ascertained by in - terview rather than through routine data collection ( Lindpaintner 2013 ) (Figure 2 ). 12 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Figure 2. Methodological quality summary: review authors’judgements about each methodological quality item for each included study. 13 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Effects of interventions See: Summary of ndings for the main comparisonEffect of discharge planning on readmission and hospital length of sta y Does discharge planning improve the appropriate use of acute care?
Hospital length of stay There was a small reduction in hospital length of stay for thos e allocated to discharge planning in trials recruiting older peo ple following a medical admission (mean difference (MD) −0.73, 95% con dence interval (CI) −1.33 to −0.12; 12 trials, mod- erate certainty evidence, Analysis 1.1 ;Harrison 2002 ;Gillespie 2009 ;Kennedy 1987 ;Laramee 2003 ;Lindpaintner 2013 ;Moher 1992 ;Naughton 1994 ;Naylor 1994 ;Preen 2005 ;Rich 1993a ; Rich 1995a ;Sulch 2000 ). This reduction increased slightly in a sensitivity analysis imputing a missing standard deviati on for Kennedy 1987 (MD−0.98, 95% CI −1.57 to −0.38; Analysis 1.2 ). There was no evidence of statistical heterogeneity. Two tri- als recruiting participants recovering from surgery reported a dif- ference of −0.06 day (95% CI −1.23 to 1.11) ( Analysis 1.3 ; Lin 2009 ;Naylor 1994 ); and two trials recruiting a combination of participants recovering from surgery and those with a medica l condition a mean difference of −0.60 (95% CI −2.38 to 1.18) ( Analysis 1.4 ;Evans 1993 ;Hendriksen 1990 ). We did not include these four trials in the pooled analysis as they recruited par tici- pants from different settings. Parfrey 1994 recruited participants from two hospitals and reported a reduction in length of stay f or those receiving discharge planning in one hospital only (media n difference −0.80 days, P = 0.03).
Readmission rates For elderly participants with a medical condition, there was a lower readmission rate in the discharge planning group at thr ee months of discharge (RR 0.87, 95% CI 0.79 to 0.97; 15 trials, moderate certainty evidence, Analysis 2.1 .1; Balaban 2008 ;Farris 2014 ;Goldman 2014 ;Harrison 2002 ;Jack 2009 ;Kennedy 1987 ; Lainscak 2013 ;Laramee 2003 ;Legrain 2011 ;Moher 1992 ;Naylor 1994 ;Nazareth 2001 ;Rich 1993a ;Rich 1995a ;Shaw 2000 ), with no evidence of statistical heterogeneity. It is uncertain whet her dis- charge planning reduces readmission rates for participants ad mit- ted to hospital following a fall (RR 1.36, 95% CI 0.46 to 4.01, very low certainty evidence, two trials, Analysis 2.1 .2). Evans 1993 recruited a mix of participants, reporting a reduction in readmissions for those receiving discharge planning (diffe rence − 11%, 95% CI −17% to −4%) at four weeks follow-up, but not at nine months follow-up (difference −6%, 95% CI − 12.5% to 0.84%; P = 0.08). One small pilot trial reported similar readmission rates for both groups at 5 and 30 days but did not provide enough data to be included in the pooled analys is ( Lindpaintner 2013; Analysis 2.3 ). One trial recruiting people recovering from surgery reported the difference in readmissi on rates + 3% (95% CI −7% to 13%; Analysis 2.4 ;Naylor 1994 ), and a trial recruiting participants admitted to acute psychiatr ic wards reported a difference +7% (95% CI −1% to 17%; Analysis 2.5 ;Naji 1999 ).
Days in hospital due to unscheduled readmission We are uncertain whether discharge planning has an effect on day s in hospital due to an unscheduled readmission, for patients w ith a medical condition ( Analysis 3.1 ) or surgical patients ( Analysis 3.3 ).
For participants with a mix of medical and surgical conditions, Evans 1993 reported that patients receiving discharge planning spent fewer days in hospital at 9-month follow-up (MD −2.00; 95% CI −3.18 to −0.82), but there was little to no difference for the participants recruited by Hendriksen 1990 and Rich 1993a (Analysis 3.2 ).
Place of discharge Seven trials reported the place of discharge. Discharge planni ng may not affect the proportion of patients discharged to home rather than to residential care (RR 1.03, 95% CI 0.93 to 1.14; Analysis 4.1 ;Moher 1992 ;Sulch 2000 , low certainty evidence) or to a nursing home ( Hendriksen 1990 ;Naughton 1994 ). One other trial reported that there were no differences between treatm ent and control groups regarding the likelihood of being discharg ed into an institutional setting ( Analysis 4.2 ;Goldman 2014 ). One trial reported that all participants allocated to the control g roup were discharged home and 83% of participants in the treatment group were discharged home (difference 17%; 95% CI 2% to 34%; Analysis 4.2 ;Lindpaintner 2013 ). These trials were not in- cluded in the pooled analysis as they excluded patients with a h igh likelihood of being discharged to an institutional setting. Evans 1993 recruited both medical and surgical patients, reporting that a greater proportion of participants allocated to discharge pla nning went home compared with those receiving no formal discharge planning (difference 6%, 95% CI 0.4% to 12%; Analysis 4.3 ). For patients admitted to hospital after a fall, it is uncertain if discharge planning had an effect on place of discharge (OR 0.46, 95% CI 0.15 to 1.40; Analysis 4.4 ).
Does discharge planning improve or (at least) have no adverse effect on patient outcome? 14 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Mortality rate For elderly participants with a medical condition (usually heart failure), and those admitted to hospital following a fall, it is un- certain if discharge planning has an effect on mortality at 4- to 6- month follow-up (RR 1.02, 95% CI 0.83 to 1.27; Analysis 5.1 .1; Goldman 2014 ;Lainscak 2013 ;Laramee 2003 ;Legrain 2011 ; Nazareth 2001 ;Rich 1995a ;Sulch 2000 ) (RR 1.33, 95% CI 0.33 to 5.45; Analysis 5.1 .2; Pardessus 2002 ). Evans 1993 recruited a mix of surgical and medical patients, re- porting data for mortality at 9-month follow-up (treatment: 66 / 417 (15.8%), control: 67/418 (16%); difference −0.2%, 95% CI −0.04% to 0.5%; Analysis 5.2 ).Gillespie 2009 recruited par- ticipants with a medical condition, reporting the number of par - ticipants in the treatment and control groups that died during the 12-month follow-up (treatment: 57/182 (31%), control: 61/186 (33%); difference −2%, 95% CI −11% to 8%; Analysis 5.3 ).
Complication rate No trials reported on the effect of discharge planning on the in ci- dence of complications related to the initial admission.
Patient health status Thirteen trials measured patient-assessed outcomes, includi ng functional status, mental well-being, perception of health, s elf-es- teem, and affect. Information about the scoring systems for pa - tient-assessed health outcomes are provided in the notes of Analysis 6.1 ,Analysis 6.2 and Analysis 6.3 . We are uncertain whether dis- charge planning improves patient-assessed health outcomes. T hree trials did not publish follow-up data ( Kennedy 1987 ;Naylor 1994 ; Weinberger 1996 ), and for ve trials there was little to no differ- ence in mean scores between groups ( Evans 1993 ;Harrison 2002 ; Lainscak 2013 ;Nazareth 2001 ;Preen 2005 ;Analysis 6.1 ).Rich 1995a recruited participants with heart failure, reporting an im- provement on the total score for the Chronic Heart Failure Que s- tionnaire (MD 22.1 (SD 20.8); P = 0.001; a lower score indicates poor quality of life). Sulch 2000 recruited participants recover- ing from a stroke, reporting an improvement in function betwe en weeks 4 and 12 for those allocated to the control group, and sim- ilar scores for the remaining mean point estimates on the Bart hel index. Quality of life, as measured by the EuroQol, showed be - tween-group differences at 26 weeks, favouring the control gro up (72 points for the control group versus 63 points for the treatm ent group; P < 0.005), but the same point estimates were reported f or the Rankin score and the Hospital Anxiety and Depression scale (HADS) ( Sulch 2000 ).Lindpaintner 2013 , recruiting participants with a mixed medical background, reported that there were no differences for patient health-related quality of life or care giver burden at 5 or 30 days (no data reported, other than describing no difference). Lin 2009 , recruiting participants recovering from a hip fracture, measured patient-reported health status with the 36-item Sho rtForm Health Survey (SF-36); investigators reported improveme nts at 3-month follow-up for the treatment group for the mental health aspects of social functioning (MD 15.18 (SD 43.67); P = 0.03), vitality (MD 12.59 (SD 36.66); P = 0.004), the physical aspects of bodily pain (MD 16.58 (SD 48.7); P = 0.009), and general health perceptions (MD 12.76 (SD 36.31); P = 0.03); see Analysis 6.2 .Pardessus 2002 recruited participants admitted for a fall and reported a reduction of autonomy in daily living activ ities in the control group measured by the Functional Autonomy Mea- surement System ,whereas the treatment group maintained their baseline function at 6 months and had a small reduction at 12 months (6-month MD −8.18 (SD 4.94), P < 0.001; 12-month MD −9.73 (SD 5.43), P < 0.001; see Analysis 6.3 ).Pardessus 2002 reported the number of falls at 12-month follow-up (RR 0.87, 95% CI 0.50 to 1.49; Pardessus 2002 ;Analysis 6.4 ). Naji 1999 recruited participants admitted to a psychiatric unit and re- ported that at 1-month postdischarge those who received dischar ge planning had a higher median score on the HADS depression scale (treatment: median: 9.5, IQR: 5.0, 13.3; control: median: 7.0 , IQR: 3.0, 11.0, P = 0.016; Analysis 6.5 ). There was little to no difference between groups for anxiety and behavioural sympt oms ( Analysis 6.5 ).
Satisfaction of patients, care givers and healthcare professionals Discharge planning may lead to increased satisfaction for pati ents and healthcare professionals (six trials, low certainty evide nce due to inconsistent ndings and few studies reporting data for th is out- come). Two trials, recruiting participants with a medical condi- tion, reported increased patient satisfaction for those allo cated to discharge planning. In one trial follow-up was at 1 and 6 months , with the greatest improvement reported for participants’ pe rcep- tions of continuity of care and non- nancial access to medical care (no data reported) ( Weinberger 1996 ). In the second trial, partic- ipants reported increased satisfaction with hospital care, ho spital discharge and home recovery (no data reported; Laramee 2003 ; Analysis 7.1 .1). In two trials evaluating a pharmacy discharge plan, Nazareth 2001 reported patient satisfaction to be the same in both groups (6-month MD 0.20 (SD 1.19), 95% CI −0.01 to 0.4), and Bolas 2004 reported that the pharmacy discharge letter im- proved the standard of information exchange at discharge, as a s- sessed by primary care practitioners (PCP) and community phar- macists (57% and 95% agreed, respectively; Analysis 7.1 .2). In Lindpaintner 2013 , PCPs and visiting nurses providing care to participants in the treatment group reported similar 5-day sa tisfac- tion with the discharge process as PCPs and visiting nurses who se patients were in the control group (PCP: treatment: median = 1, interquartile range (IQR) = 1 to 2; control: median = 2, IQR = 1 to 3; nurses: treatment: median = 1, IQR = 1-2; control: 2, IQR = 1 to 4). The same study reported that at 30-day follow-up, care givers for participants in the treatment group were more sati s ed 15 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. (treatment: median = 1, IQR = 1 to 2; control: median = 2, IQR = 1 to 3). In Moher 1992 , a subgroup of 40 participants admitted to general medical units, mainly for circulatory, respiratory or diges- tive problems, completed a satisfaction questionnaire, repo rting increased satisfaction with discharge planning (difference 27% , P < 0.001, 95% CI 2% to 52%).
Does discharge planning reduce overall costs of healthcare?
Healthcare costs Hospital care costs and use It is uncertain whether there is any difference in hospital care cost when discharge planning is implemented with patients wit h a medical condition (very low certainty evidence, ve trials). A lower readmission rate for those receiving discharge plannin g may be associated with lower health service costs in the short term, but ndings were inconsistent. In Naylor 1994 , recruiting participants with a medical condition, both groups incurred similar costs for their initial hospital stay. A difference was reported for ho spital charges, which included readmission costs, at two weeks follow-u p (difference −USD 170,247, 95% CI −USD 253,000 to −USD 87,000, 276 participants, savings per participant not report ed) and at two to six weeks follow-up (difference −USD 137,508, 95% CI − USD 210,000 to −USD 67,000), with participants receiving discharge planning incurring lower costs ( Analysis 8.1 ).Naughton 1994 reported lower costs for laboratory services for participants receiving discharge planning (MD per participant −GBP 295, 95% CI −GBP 564 to −GBP 26), but not for diagnostic imaging, pharmacy, rehabilitation or total costs ( Analysis 8.1 ). In Jack 2009 , the difference between study groups in total cost for the healt h service (combining actual hospital utilisation cost and estimat ed outpatient cost) for 738 participants was USD 149,995, an aver age of USD 412 per person who received the intervention. In Gillespie 2009 , hospital costs were reported (difference: −USD 400, 95% CI −USD 4000 to USD 3200; Analysis 8.1 ). Difference in costs were not reported in studies recruiting participants with sur gical conditions ( Analysis 8.2 ), admitted to a psychiatric unit ( Analysis 8.3 ) or to a general medical service ( Analysis 8.4 ). Naughton 1994 reported that the overall health service costs were lower for the treatment group, but with a high level of uncer- tainty (MD −USD 1949, 95% CI −USD 4204 to USD 306). Jack 2009 reported a difference between study groups in total cost (combining actual hospital utilisation cost and estimated outp a- tient cost) of USD 149,995 for 738 participants, which translat ed to an average of USD 412 per person who received the interven- tion; this represents a 33.9% lower observed cost for the trea tment group. The cost savings balanced against the cost of the interve n- tion were reported to be EUR 519 per participant in one trial based in Paris ( Legrain 2011 ), and −USD 460 in a trial based in the US ( Rich 1995a ) (RR 0.80, 95% CI 0.61 to 1.07).
One trial reported the number of hospital outpatient visits (RR 1.07, 95% CI 0.74 to 1.56; Nazareth 2001 ;Analysis 8.5 ). Two trials ( Farris 2014 ;Harrison 2002 ) assessed the effect of discharge planning on the number of days from discharge until the rst vi sit to the emergency department, reporting little to no differen ce for those receiving discharge planning or usual care (RR 0.80, 95% CI 0.61 to 1.07; Analysis 8.6 ).
Primary and community care costs It is uncertain if discharge planning impacts on primary and com- munity care costs. Weinberger 1996 measured the use of primary care and reported an increase in the use of primary care by those allocated to discharge planning (median time from hospital dis - charge to rst primary care consultation, treatment = seven day s, control = 13 days; P < 0.001; mean number of visits to general medical clinic for treatment group was 3.7 days, control group 2 .2 days; P < 0.001). Nazareth 2001 reported that the same proportion of participants in both groups consulted with their general pr ac- titioner at three months (MD 2.7%, 95% CI −7.4% to 12.7%) and six months (MD 0.3%, 95% CI −11.6% to 12.3%). Farris 2014 assessed unscheduled of ce visits, reporting a difference of 0% (95% CI −5% to 5%) at 30-days and 4% (95% CI −2% to 9%) at 90-days. Goldman 2014 reported an MD of 4%, 95% CI − 3.7% to 11.5%, at 30 days. See Analysis 9.1 .
Medication use Trials evaluating the effectiveness of a pharmacy discharge pl an measured different outcomes related to medication, including the mean number of problems (e.g., dif culty obtaining a prescrip- tion from the general practitioner) ( Analysis 10.1 ), adherence to medicines ( Analysis 10.2 ), and knowledge about the prescribed medication ( Analysis 10.3 ).Nazareth 2001 reported data related to adherence to medication regimen, knowledge about medicines and hoarding of medicines ( Analysis 10.2 ,Analysis 10.3 ,Analysis 10.4 ). In Eggink 2010 , data on medication errors were reported following a review of medication by a pharmacist; 68% in the con- trol group had at least one discrepancy or medication error com- pared to 39% in the treatment group (RR 0.57, 95% CI 0.37 to 0.88; Analysis 10.5 ).Kripalani 2012 assessed clinically important medication errors, reporting similar results for both group s at 30 days (RR = 0.92, 95% CI 0.77 to 1.10; Analysis 10.5 ).Farris 2014 compared medication appropriateness at 30 and 90 days ( Analysis 10.6 ).
D I S C U S S I O N 16 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Summary of main results This review assessed the effectiveness of discharge planningin hos- pital. Thirty randomised controlled trials met the pre-speci ed cri- teria for inclusion. We were able to pool the data from trials r ecruit- ing older participants with a medical condition and found that discharge planning probably results in a small reduction in ho spi- tal length of stay (just under a day; moderate certainty eviden ce,12 trials) and unscheduled readmission (approximately three fe wer readmissions per 100 participants; moderate certainty evide nce, 15 trials). It is uncertain whether discharge planning reduces r ead- mission rates for patients admitted to hospital following a fall (very low certainty evidence, two trials). Discharge planning may lea d to increased satisfaction for patients and healthcare profess ionals (low certainty evidence, six trials). It is uncertain whether the re is any difference in the cost of care when discharge planning is im- plemented with patients who have a medical condition (very low certainty evidence, ve trials). A lower readmission rate for t hose receiving discharge planning may be associated with lower heal th service costs in the short term, but ndings were inconsistent.
Overall completeness and applicability of evidence A key issue in interpreting the evidence is the de nition of th e in- tervention and the subsequent understanding of the relativ e con- tribution of each element. While authors of all of the trials pr o- vided some description of the intervention, it was not possib le to assess how some components of the process compared between trials. For example, Naylor 1994 and Lainscak 2013 formalised the inclusion of the participants’ care givers into the assessm ent process and the discharge plan. Although some of the other tria ls mentioned this aspect, the degree to which this was done was not always apparent ( Evans 1993 ;Hendriksen 1990 ;Kennedy 1987 ; Laramee 2003 ;Naughton 1994 ). The majority of the trials also in- cluded a patient education component within the discharge plan- ning process. In one trial, which recruited participants admitt ed to hospital following a fall, the discharge plan included a pre -dis- charge home visit that was speci c to this group of patients, by an occupational therapist and rehabilitation doctor ( Pardessus 2002 ).
In another trial, hospital and community nurses worked toget her on the discharge plan ( Harrison 2002 ). Two of the trials used an assessment tool to nd cases eligible for discharge planning ( Evans 1993 ;Parfrey 1994 ). The monitoring of discharge planning also differed. For example, in one trial this was done primarily b y tele- phone, while in Weinberger 1996 participants were given appoint- ments to attend a primary care clinic. Seven trials evaluated th e effectiveness of a pharmacy discharge plan ( Bolas 2004 ;Eggink 2010 ;Farris 2014 ;Gillespie 2009 ;Kripalani 2012 ;Nazareth 2001 ; Shaw 2000 ). Of those seven trials, four reported data for readmis- sion, with no differences between treatment and control group s ( Farris 2014; Gillespie 2009 ;Nazareth 2001; Shaw 2000 ). The evidence was mixed for the use of medication: three trials repo rted improvements with medication use between groups ( Bolas 2004; Eggink 2010 ;Shaw 2000 ), and three trials did not ( Farris 2014; Kripalani 2012 ;Nazareth 2001 ). However, the interpretation of these data is limited by the heterogeneity of the outcomes mea - sured. An additional problem, common to other trials, was the dif culty in assessing if contamination between the treatmen t and control groups occurred. Four trials considered equity, assess ing the potentially disadvantageous effect of language and heal th lit- eracy by performing subgroup analyses of participants whose rst language was not English ( Balaban 2008 ;Goldman 2014 ) and who had low health literacy, respectively ( Jack 2009 ;Kripalani 2012 ). There was mixed evidence for non-English speakers, and the evidence does not seem to support an increased or decreased effect of discharge planning for patients with low health lite racy.
The context in which an intervention such as discharge planning is delivered may also play a role, not only in the way the inter - vention is delivered but in the way services are con gured for t he control group. Thirteen of the trials included in this review w ere based in the USA, ve in the UK, three in Canada, two in France, one in Australia, one in Sweden, one in Denmark, one in the Netherlands, one in Taipei, one in Slovenia, and one in Switz er- land. In each country the orientation of primary care services di f- fers, which may affect communication between services. Differen t perceptions of care by professionals of alternative care setti ngs and country-speci c funding arrangements may also in uence timely discharge. The point in a patient’s hospital admission when d is- charge planning was implemented also varied across studies. T wo trials reported discharge planning commencing from the time a patient was admitted to hospital ( Parfrey 1994 ;Sulch 2000 ), and another stated that discharge planning was implemented thre e days prior to discharge ( Weinberger 1996 ). The timing of delivery of an intervention such as discharge planning, which depends on organising other services, will have some bearing on how quick ly these services can begin providing care. The patient populatio n may also impact on outcome. For example, 99 patients recruited to the trial by Weinberger were experiencing major complicatio ns from their chronic disease and this, combined with an interven - tion also designed to increase the intensity of primary care se rvices, may explain the observed increase in readmission days for tho se receiving the intervention. Similarly, Goldman postulates that ed- ucating patients in the treatment group about medication and s ide effects might have made them more likely to visit the emergency department ( Goldman 2014 ).
Quality of the evidence All studies included in this review were randomised controlle d tri- als, and we considered most of them to have a low risk of bias.
There was consistency among trials recruiting patients with a m ed- ical condition for the main outcomes of readmission and length of stay, and a moderate level of certainty for these outcomes. A 17 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. small number of studies reported data on cost to the health service and potential cost savings; the ndings from these studies ar e less certain due to different mechanisms for costing and charging (ver y low certainty evidence, ve trials). Similarly few studies ass essed patient satisfaction, and of those that did there is some evid ence of increased satisfaction in patients experiencing discharge pla nning.
However, this evidence base is small and the effects of discharg e planning on patient satisfaction are uncertain (low certainty e vi- dence, six trials).
Agreements and disagreements with other studies or reviews Systematic reviews have been published in related areas, fo r exam- ple, Stuck 1993 and Ellis 2011 evaluated geriatric assessment that included discharge planning as part of a broader package of care, and Kwan 2004 looked at integrated care pathways for stroke. This latter review concluded that this type of care may be associated with both positive and negative effects on the organisation o f care and clinical outcomes. Parker 2002 included discharge planning interventions that were implemented in a hospital setting, com- prehensive geriatric assessment, discharge support arrang ements and educational interventions, concluding that intervention s pro- viding an educational component had an effect on reducing read- mission rates. The interventions evaluated by the majority of tri- als included in this review had an element of patient education . Leppin 2014 reviewed interventions aimed at reducing early hos- pital readmissions (< 30 days) for adults discharged home vers us any other comparator. Their results indicated that those inte r- ventions that were more complex, promoted patient self-care an d were conducted less recently were more likely to be effective. Th e authors speculate that an increased standard of care, along wit h a shift on the interventions being tested, might explain thei r nding of more recent interventions being less effective.
A U T H O R S ’ C O N C L U S I O N S Implications for practice This review indicates that a structured discharge plan tailore d to the individual probably brings about a small reduction in hos pital length of stay and unscheduled readmission for elderly patie nts with a medical condition. The impact on health outcomes is un- certain. Even a small reduction in length of stay could free up capacity for subsequent admissions in a system where there is a shortage of acute hospital beds and indicates that discharge pl an- ning does not delay discharge from hospital. This is reassuri ng,as interventions comprised of several components may delay di s- charge if the components are implemented sequentially. Howev er, increasing capacity by reducing length of stay is likely to increa se costs, as acute hospitals will admit more patients who require acute hospital care. It is not clear if costs are reduced or shifted from secondary to primary care or to patients and care givers as a resu lt of discharge planning.
Implications for research Surprisingly, some of the stated policy aims of discharge plan ning, for instance bridging the gap between hospital and home, were not re ected in the trials included in this review. An importan t element of discharge planning is the effectiveness of communica - tion between hospital and community, yet the trials included i n this review did not report on the quality of communication. The expectation is that discharge planning will ensure that patie nts are discharged from hospital at an appropriate time in their care a nd, with adequate notice, will facilitate the organisation and pr ovi- sion of other services. A high level of communication between th e discharge planner and the service providers outside the hospi tal setting is clearly important. Future well-conducted studies sh ould continue to collect data on readmissions and hospital length of stay and promote the application of the results by providing d e- tails of the intervention and the context in which it was delive red.
Investigators should develop safeguards against contamina tion of the control group, for example by appropriately designing clu ster- randomised trials or documenting the adoption of discharge pl an- ning by the control group. Conducting research on the impact of a delayed discharge on overall bed utilisation and cost-effectiv eness to the health service, and of increasing capacity by a reduction in hospital length of stay would improve the evidence base of int er- ventions, such as discharge planning, that are designed to imp rove the ef ciency of healthcare services ( Hawkes 2015 ).
A C K N O W L E D G E M E N T S Diana Harwood for assisting in scanning abstracts retrieved f rom electronic searches for the original review; Andy Oxman for com - menting on all versions of this review; Jeremy Grimshaw and D ar- ryl Wieland for helpful comments on earlier drafts and Luciana Ballini, Tomas Pantoja, Craig Ramsey, Darryl Weiland and Ki rsten Woodend for comments on the previous update; Nia Roberts for conducting the literature searches; and Julie Parkes, Chri sto- pher Phillips, Jacqueline McClaran, Sarah Barras, and Annie M c- Cluskey for contributing to previous versions of this review ( Parkes 2000 ;Shepperd 2010 ,Shepperd 2013 ). 18 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. R E F E R E N C E S References to studies included in this review Balaban 2008 {published data only} Balaban RB, Weissman JS, Samuel PA, Woolhandler S.
Rede ning and redesigning hospital discharge to enhance patient care: a randomized controlled study. Journal of General Internal Medicine 2008;23(8):1228–33.
Bolas 2004 {published data only} Bolas H, Brookes K, Scott M, McElnay J. Evaluation of a hospital-based community liaison pharmacy service in Northern Ireland. Pharmacy World & Science 2004;26(2):
114–20.
Eggink 2010 {published data only} Eggink RN, Lenderink AW, Widdershoven JWMG, Van den Bemt PLMA. The effect of a clinical pharmacist discharge service on medication discrepancies in patients with heart failure. Pharmacy World & Science 2010;32(6):
759–66.
Evans 1993 {published data only} Evans RL, Hendricks RD. Evaluating hospital discharge planning: a randomised controlled trial. Medical Care 1993; 31(4):358–70.
Farris 2014 {published data only} Carter BL, Farris, KB, Abramowitz PW, Weetman DB, Kaboli PJ, Dawson JD, et al. The Iowa Continuity of Care Study: background and methods. American Journal of Health-System Pharmacy 2008;65(17):1631–42.
Farley TM, Shelsky C, Powell S, Farris KB, Carter BL.
Effect of clinical pharmacist intervention on medication discrepancies following hospital discharge. International Journal of Clinical Pharmacy 2014;36(2):430–7.
∗ Farris KB, Carter BL, Xu J, Dawson JD, Shelsky C, Weetman DB, et al. Effect of a care transition intervention by pharmacists: an RCT. BMC Health Services Research 2014; 14:406.
Israel EN, Farley TM, Farris KB, Carter BL. Underutilization of cardiovascular medications: effect of a continuity-of- care program. American Journal of Health-System Pharmacy 2013; 70(18):1592–1600.
Gillespie 2009 {published data only} Gillespie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Archives of Internal Medicine 2009;169(9):849–900.
Goldman 2014 {published and unpublished data} Goldman. Request of extra data for Support From Hospital to Home for Elders [personal communication]. Email to D Gonçalves-Bradley 10 April 2015.
Goldman LE, Sarkar U, Kessell E, Critch eld J, Schneidermann M, Pierluissi E, et al. Support for hospital to home for elders: a randomized control trial of an in- patient discharge intervention among a diverse elderly population. Journal of General Internal Medicine 2013; Vol. 28, issue Supplement 1:S189–S190.
∗ Goldman LE, Sarkar U, Kessell E, Guzman D, Schneidermann M, Pierluissi E, et al. Support from hospital to home for elders: a randomized trial. Annals of Internal Medicine 2014;161(7):472–81.
Greysen SR, Hoi-Cheung D, Garcia V, Kessell E, Sarkar U, Goldman L, et al. “Missing pieces”--functional, social, and environmental barriers to recovery for vulnerable older adults transitioning from hospital to home. Journal of the American Geriatrics Society 2014;62(8):1556–61. [DOI:
10.1111/jgs.12928] Harrison 2002 {published data only} Harrison MB, Browne GB, Roberts J, Tugwell P, Gafni A, Graham I. Quality of life of the effectiveness of two models of hospital-to-home transition. Medical Care2002;40(4):
271–82.
Hendriksen 1990 {published data only} Hendriksen C, Stromgard E, Sorensen K. Current cooperation concerning admission to and discharge from geriatric hospitals [Nyt samarbejde om gamle menneskers syehusindlaeggelse og – udskrivelse]. Nordisk Medicin1990; 105 (2):58–60.
Hendriksen C, Strømgård E, Sørensen KH. Cooperation concerning admission to and discharge of elderly people from the hospital. 1. The coordinated contributions of home care personnel [Samarbejde om gamle menneskers sygehusindlaeggelse og – udskrivelse.
1. Hjemmesygeplejerskens koordinerende indsats pa sygehuset]. Ugeskrift For Laeger 1989;151(24):1531–4.
Jack 2009 {published data only} Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. A reengineered hospital discharge program to decrease rehospitalization. Annals of Internal Medicine 2009;150(3):178–87.
Kennedy 1987 {published data only} Kennedy L, Neidlinger S, Scroggins K. Effective comprehensive discharge planning. Gerontologist1987;27 (5):577–80.
Kripalani 2012 {published data only} Bell SP, Schnipper JL, Goggins KM, Bian A, Shintani A, Roumie CL, et al. Effect of a pharmacist counseling intervention on healthcare utilization after hospital discharge: a randomized controlled trial. Journal of General Internal Medicine 2015;30(Supplement 2):S55.
∗ Kripalani S, Roumie CL, Dalal AK, Cawthon C, Businger A, Eden SK, et al. PILL-CVD (Pharmacist Intervention for Low Literacy in Cardiovascular Disease) Study Group.
Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. Annals of Internal Medicine 2012;157(1):1–10.
Schnipper JL, Roumie CL, Cawthon C, Businger A, Dalal AK, Mugalla I, et al. PILL-CVD Study Group. Rationale and design of the Pharmacist Intervention for Low Literacy 19 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. in Cardiovascular Disease (PILL-CVD) study.Circulation:
Cardiovascular Quality and Outcomes 2010;3(2):212–19.
Lainscak 2013 {published and unpublished data} Farkas J, Kadivec S, Kosnik M, Lainscak M. Effectiveness of discharge-coordinator intervention in patients with chronic obstructive pulmonary disease: study protocol of a randomized controlled clinical trial. Respiratory Medicine 2011; 105(Suppl 1):S26–S30.
Lainscak M. Request of extra data for “Discharge Coordinator intervention” [personal communication].
Email sent to D Gonçalves-Bradley 15 April 2015.
Lainscak M, Kadivec S, Kosnik M, Benedik B, Bratkovic M, Jakhel T, et al. Discharge coordinator intervention prevents hospitalisations in patients with COPD: a randomized controlled trial. European Respiratory Journal 2012;40(S56):
P2895.
∗ Lainscak M, Kadivec S, Kosnik M, Benedik B, Bratkovic M, Jakhel T, et al. Discharge coordinator intervention prevents hospitalizations in patients with COPD: a randomized controlled trial. Journal of the American Medical Directors Association 2013;14(6):450.e1–6.
Laramee 2003 {published data only} Laramee AS, Levinsky SK, Sargent J, Ross R, Callas P. Case management in a heterogeneous congestive heart failure population. Archives of Internal Medicine 2003;163:809–17.
Legrain 2011 {published data only} Bonnet-Zamponi D, D’Arailh L, Konrat C, Delpierre S, Lieberherr D, Lemaire A, et al. Optimzation of Medication in AGEd study group. Drug-related readmissions to medical units of older adults discharged from acute geriatri c units: results of the Optimization of Medication in AGEd multicenter randomized controlled trial. Journal of the American Geriatrics Society 2013;61(1):113–21.
Legrain S, Tubach F, Bonnet-Zamponi D, Lemaire A, Aquino J, 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 multicentre randomised controlled trial. Journal of the American Geriatric Society 2011;59(11):
2017–28.
Lin 2009 {published data only} Lin PC, Wang CH, Chen CS, Liao LP, Kao SF, Wu HF. To evaluate the effectiveness of a discharge planning programme for hip fracture patients. Journal of Clinical Nursing 2009;18(11):1632–9.
Lindpaintner 2013 {published data only} Lindpaintner LS, Gasser JT, Schramm MS, Cina-Tschumi B, Müller B, Beer JH. Discharge intervention pilot improves satisfaction for patients and professionals. European Journal of Internal Medicine 2013;24(8):756–62.
Moher 1992 {published data only} Moher D, Weinberg A, Hanlon R, Runnalls K. Effects of a medical team coordinator on length of hospital stay.
Canadian Medical Association Journal 1992;146(4):511–5. Naji 1999 {published data only} Naji SA, Howie FL, Cameron IM, Walker SA, Andrew J, Eagles JM. Discharging psychiatric in-patients back to primary care: a pragmatic randomized controlled trial of a novel discharge protocol. Primary Care Psychiatry1999;5 (3):109–15.
Naughton 1994 {published data only} Naughton B, Moran M, Feinglass J, Falconer J. Reducing hospital costs for the geriatric patient admitted from the emergency department: a randomised trial. Journal of the American Geriatrics Society 1994;42(10):1045–9.
Naylor 1994 {published data only} Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Annals of Internal Medicine 1994;120(12):999–1006.
Nazareth 2001 {published data only} 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 and Ageing 2001;30(1):33–40.
Pardessus 2002 {published data only} Pardessus V, Puisieux F, Di Pompeo C, Gaudefroy C, Thevenon A, Dewailly P. Bene ts of home visits for falls and autonomy in the elderly: a randomized trial study. American Journal of Physical Medicine & Rehabilitation 2002;81(4):
247–52.
Parfrey 1994 {published data only} Parfrey PS, Gardner E, Vavasour H, Harnett JD, McManamon C, McDonald J, et al. The feasibility and ef cacy of early discharge planning initiated by the admitting department in two acute care hospitals. Clinical and Investigative Medicine 1994;17(2):88–96.
Preen 2005 {published data only} Preen DB, Preen DB, Bailey BES, Wright A, Kendall P, Phillips M, et al. Effects of a multidisciplinary, post discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay:
a randomized controlled trial. International Journal for Quality in Health Care 2005;17(1):43–51.
Rich 1993a {published data only} Rich MW, Vinson JM, Sperry JC, Shah AS, Spinner LR, Chung M, et al. Prevention of readmission in elderly patients with congestive heart failure: results of a prospecti ve randomised pilot study. Journal of General Internal Medicine 1993; 8(11):585–90.
Rich 1995a {published data only} Rich MW, Beckham V, Wittenberg C, Leven C, Freedland KE, Carney RM. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. New England Journal of Medicine 1995;333 (18):1190–5.
Shaw 2000 {published data only} Shaw H, Mackie CA, Sharkie I. Evaluation of effect of pharmacy discharge planning on medication problems 20 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. experienced by discharged acute admission mental health patients.International Journal of Pharmacy Practice 2000;8 (2):144–53.
Sulch 2000 {published data only} Sulch D, Perez I, Melbourn A, Kalra L. Randomized controlled trial of integrated (managed) care pathway for stroke rehabilitation. Stroke2000;31(8):1929–34.
Weinberger 1996 {published data only} Weinberger M, Oddone EZ, Henderson WG. Does increased access to primary care reduce hospital admissions?
Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmissions. New England Journal of Medicine 1996;334(22):1441–7.
References to studies excluded from this review Applegate 1990 {published data only} Applegate WB, Miller ST, Graney MJ, Elam JT, Akins DE. A randomized controlled trial of a geriatric assessment unit in a community rehabilitation hospital. New England Journal of Medicine 1990;322(22):1572–8.
Brooten 1987 {published data only} Brooten D, Kumar S, Brown LP, Butts P, Finkler SA, Bakewell-Sachs S, et al. A randomized clinical trial of early hospital discharge and home follow-up of very-low-birth- weight infants. NLN Publications 1987;21-2194 :95–106.
Brooten 1994 {published data only} Brooten D, Roncoli M, Finkler S, Arnold L, Cohen A, Mennuti M. A randomized trial of early hospital discharge and home follow-up of women having cesarean birth.
Obstetrics and Gynecology 1994;84(5):832–8.
Carty 1990 {published data only} Carty EM, Bradley CF. A randomized, controlled evaluation of early postpartum hospital discharge. Birth1990; 17(4):
199–204.
Casiro 1993 {published data only} Casiro OG, McKenzie ME, McFadyen L, Shapiro C, Seshia MM, MacDonald N, et al. Earlier discharge with community-based intervention for low birth weight infants:
a randomized trial. Pediatrics1993;92(1):128–34.
Choong 2000 {published data only} Choong PFM, Langford AK, Dowsey MM, Santamaria NM. Clinical pathway for fractured neck of femur: a prospective controlled study. Medical Journal of Australia 2000; 172(9):423–6.
Cossette 2015 {published data only} Cossette S, Frasure-Smith N, Vadeboncoeur A, McCusker J, Guertin MC. The impact of an emergency department nursing intervention on continuity of care, self-care capacities and psychological symptoms: secondary outcomes of a randomized controlled trial. International Journal of Nursing Studies 2015;52(3):666–76. [DOI: 10.1016/ j.ijnurstu.2014.12.007] Donahue 1994 {published data only} Donahue D, Brooten D, Roncoli M, Arnold L, Knapp H, Borucki L, et al. Acute care visits and rehospitalization in women and infants after cesarean birth.
Journal of Perinatology 1994;14(1):36–40.
Dudas 2001 {published data only} Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalizatio n.
American Journal of Medicine 2001;111(9b):26s–30s.
Englander 2014 {published data only} Englander H, Michaels L, Chan B, Kansagara D. The care transitions innovation (C-TraIn) for socioeconomically disadvantaged adults: results of a cluster randomized controlled trial. Journal of General Internal Medicine 2014; 29 (11):460–7.
Epstein 1990 {published data only} Epstein AM, Hall JA, Fretwell M, Feldstein M, DeCiantis ML, Tognetti J, et al. Consultative geriatric assessment for ambulatory patients. A randomized trial in a health maintenance organization. JAMA1990;263(4):538–44.
Fretwell 1990 {published data only} Fretwell MD, Raymond PM, McGarvey ST, Owens N, Traines M, Silliman RA, et al. The Senior Care Study.
A controlled trial of a consultative/unit-based geriatric assessment program in acute care. Journal of the American Geriatrics Society 1990;38(10):1073–81.
Gayton 1987 {published data only} Gayton D, Wood-Dauphinee S, De Lorimer M, Tousignant P, Hanley J. Trial of a geriatric consultation team in an acute care hospital. Journal of the American Geriatrics Society 1987; 35(8):726–36.
Germain 1995 {published data only} Germain M, Knoeffel F, Wieland D, Rubenstein LZ. A geriatric assessment and intervention team for hospital inpatients awaiting transfer to a geriatric unit: a randomized trial. Aging (Milan, Italy) 1995;7(1):55–60.
Gillette 1991 {published data only} Gillette Y, Hansen NB, Robinson JL, Kirkpatrick K, Grywalski R. Hospital-based case management for medically fragile infants: results of a randomized trial. Patient Education and Counseling 1991;17(1):59–70.
González-Guerrero 2014 {published data only} González-Guerreroa JL, Alonso-Fernándeza T, García- Mayolín N, Gusi N, Ribera-Casado JM. Effectiveness of a follow-up program for elderly heart failure patients after hospital discharge. A randomized controlled trial. European Geriatric Medicine 2014;5(4):252–7.
Haggmark 1997 {published data only} Häggmark C, Nilsson B. Effects of an intervention programme for improved discharge planning. Nordic Journal of Nursing Research 1997;17(2):4–8.
Hansen 1992 {published data only} Hansen FR, Spedtsberg K, Schroll M. Geriatric follow-up by home visits after discharge from hospital: a randomized controlled trial. Age and Ageing1992;21(6):445–50.
Hickey 2000 {published data only} Hickey ML, Cook FE, Rossi LR, Connor J, Dutkiewicz C, McCabe Hassan S, et al. Effect of case managers with a 21 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. general medical patient population.Journal of Evaluation in Clinical Practice 2000;6(1):23–9.
Hogan 1990 {published data only} Hogan DB, Fox RA. A prospective controlled trial of a geriatric consultation team in an acute-care hospital. Age and Ageing 1990;19(2):107–13.
Jenkins 1996 {published data only} Jenkins HM, Blank V, Miller K, Turner J, Stanwick RS. A randomized single-blind evaluation of a discharge teaching book for pediatric patients with burns. Journal of Burn Care & Rehabilitation 1996;17(1):49–61.
Karppi 1995 {published data only} Karppi P, Tilvis R. Effectiveness of a Finnish geriatric inpatient assessment. Two-year follow up of a randomized clinical trial on community-dwelling patients. Scandinavian Journal of Primary Health Care 1995;13(2):93–8.
Kleinpell 2004 {published data only} Kleimpell RM. Randomized trial of an intensive care unit- based early discharge planning intervention for critically ill elderly patients. American Journal of Critical Care 2004;13 (4):335–45.
Kravitz 1994 {published data only} Kravitz RL, Reuben DB, Davis JW, Mitchell A, Hemmerling K, Kington RS, et al. Geriatric home assessment after hospital discharge. Journal of the American Geriatrics Society 1994; 42(12):1229–34.
Lande eld 1995 {published data only} Lande eld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J. A randomized controlled trial of care in a hospital medical unit especially designed to improve functional outcomes of acutely ill older patients. New England Journal of Medicine 1995;332(20):1338–44.
Linden 2014 {published data only} Linden A, Butterworth S. A comprehensive hospital-based intervention to reduce readmissions for chronically ill patients: a randomized controlled trial. American Journal of Managed Care 2014;20(10):783–92.
Lof er 2014 {published data only} Löf er C, Drewelow E, Paschka SD, Frankenstein M, Eger L, Jatsch L, et al. Optimizing polypharmacy among elderly hospital patients with chronic diseases-study protocol of the cluster randomized controlled POLITE-RCT trial.
Implementation Science 2014;9:151.
Martin 1994 {published data only} Martin F, Oyewole A, Moloney A. A randomized controlled trial of a high support hospital discharge team for elderly people. Age and Ageing 1994;23(3):228–34.
Marusic 2013 {published data only} 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. International Journal of Clinical Pharmacy 2013;35 (1):37–44. McGrory 1994 {published data only} McGrory A, Assmann S. A study investigating primary nursing, discharge teaching, and patient satisfaction of ambulatory cataract patients. Insight1994;19(2):8-13, 29.
McInnes 1999 {published data only} McInnes E, Mira M, Atkin N, Kennedy P, Cullen J. Can GP input into discharge planning result in better outcomes for the frail aged: results from a randomized controlled trial .
Family Practice 1999;16(3):289–93.
Melin 1993 {published data only} Melin AL, Hakansson S, Bygren LO. The cost-effectiveness of rehabilitation in the home: a study of Swedish elderly.
American Journal of Public Health 1993;83:356–62.
Melin 1995a {published data only} Melin AL. A randomized trial of multidisciplinary in-home care for frail elderly patients awaiting hospital discharge.
Aging 1995;7(3):247–50.
Melin 1995b {published data only} Melin AL, Wieland D, Harker JO, Bygren LO. Health outcomes of a post-hospital in-home team care: secondary analysis of a Swedish trial. Journal of the American Geriatrics Society 1995;43(3):301–7.
Murray 1995 {published data only} Murray SK, Garraway WM, Akhtar AJ, Prescott RJ.
Communication between home and hospital in the management of acute stroke in the elderly: results from a controlled trial. Health Bulletin1995;40(5):214–9.
Naylor 1999 {published data only} Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized controlled trial. JAMA1999;281(7):613–20.
Naylor 2004 {published data only} Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Sanford Schwartz J. Transitional care of older adults hospitalized with heart failure: a randomised controlled trial. Journal of the American Geriatrics Society 2004; 52(5):675–84.
Nickerson 2005 {published data only} Nickerson A, McKinnon NJ, Roberst N, Saulnier L. Drug therapy problems, inconsistencies and omissions identi ed during a medication reconciliation and seamless care service.
Healthcare Quarterly 2005;8(Spec No):65–72.
Nikolaus 1995 {published data only} Nikolaus T, Specht-Leible N, Bach M, Wittmann- Jennewein C, Oster P, Schlierf G. Effectiveness of hospital- based geriatric evaluation and management and home intervention team (GEM-HIT): rationale and design of a 5-year randomized trial. Zeitschrift für Gerontologie und Geriatrie 1995;28(1):47–53.
Reuben 1995 {published data only} Reuben DB, Borok GM, Wolde-Tsadik G, Ershoff DH, Fishman LK, Ambrosini VL, et al. A randomized trial of comprehensive geriatric assessment in the care of 22 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. hospitalized patients.New England Journal of Medicine 1995; 332(20):1345–50.
Rich 1993b {published data only} 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. Journal of General Internal Medicine 1993;8(11):585–90.
Rich 1995b {published data only} 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. New England Journal of Medicine 1995;333 (18):1190–5.
Rubenstein 1984 {published data only} Rubenstein LZ, Josephson KR, Wieland GD, English PA, Sayre JA, Kane RL. Effectiveness of a geriatric evaluation unit. A randomized clinical trial. New England Journal of Medicine 1984;311(26):1664–70.
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Sharif 2014 {published data only} Sharif F, Moshkelgosha F, Molazem Z, Naja Kalyani M, Vossughi M. The effects of discharge plan on stress, anxiety and depression in patients undergoing percutaneous transluminal coronary angioplasty: a randomized controlled trial. International Journal of Community Based Nursing & Midwifery 2014;2(2):60–8.
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Siu 1996 {published data only} Siu AL, Kravitz RL, Keeler E, Hemmerling K, Kington R, Davis JW, et al. Postdischarge geriatric assessment of hospitalized frail elderly patients. Archives of Internal Medicine 1996;156(1):76–81.
Smith 1988 {published data only} Smith DM, Weinberger M, Katz BP, Moore PS.
Postdischarge care and readmissions. Medical Care1988;26 (7):699–708. Thomas 1993 {published data only} Thomas DR, Brahan R, Haywood BP. Inpatient community-based geriatric assessment reduces subsequent mortality. Journal of the American Geriatrics Society 1993;41 (2):101–4.
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Tseng 2012 {published data only} Tseng MY, Shyu YI, Liang J. Functional recovery of older hip-fracture patients after interdisciplinary intervention follows three distinct trajectories. The Gerontologist2012;52 (6):833–42.
Victor 1988 {published data only} Victor CR, Vetter NJ. Rearranging the deckchairs on the Titanic: failure of an augmented home help scheme after discharge to reduce the length of stay in hospital. Archives of Gerontology and Geriatrics 1988;7(1):83–91.
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References to ongoing studies NCT02112227 {published data only} NCT02112227. Patient-centered Care Transitions in Heart Failure (PACT-HF). clinicaltrials.gov/ct2/show/ NCT02112227 (accessed 2 June 2015).
NCT02202096 {published data only} NCT02202096. A pilot randomized trial of a comprehensive transitional care program for colorectal cancer patients. clinicaltrials.gov/ct2/show/NCT02202096 (accessed 2 June 2015).
NCT02295319 {published data only} NCT02295319. The impact of individual-based discharges from acute admission units to home. clinicaltrials.gov/ct2/ show/NCT02295319 (accessed 2 June 2015). 23 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. NCT02351648{published data only} NCT02351648. A randomised control trial of a transitional care model in Singapore General Hospital. clinicaltrials.gov / ct2/show/NCT02351648 (accessed 2 June 2015).
NCT02388711 {published data only} NCT02388711. A trial of the C-TraC intervention for dementia patients. clinicaltrials.gov/ct2/show/ NCT02388711 (accessed 2 June 2015).
NCT02421133 {published data only} NCT02421133. Impact of a transitional care program on 30-day hospital readmissions for elderly patients discharged from a short stay geriatric ward (PROUST).
clinicaltrials.gov/ct2/show/NCT02421133 (accessed 2 June 2015).
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Dept of Health 2003 Department of Health. Discharge from Hospital: Pathway, Process and Practice. A Manual of Discharge Practice for Health and Social Care Commissioners, Managers and Practitioners . London: Department of Health, 2003. Dept of Health 2010 Department of Health. Ready to Go? Planning the Discharge and the Transfer of Patients from Hospital and Intermediate Care . London: Department of Health, 2010.
Ellis 2011 Ellis G, Whitehead MA, O’Neill D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews 2011, Issue 7. [DOI: 10.1002/ 14651858.CD006211.pub2] EPOC 2015 Effective Practice, Organisation of Care (EPOC). Data extraction and management. EPOC Resources for review authors. Oslo: Norwegian Knowledge Centre for the Health Services; 2013. Available at: http://epoc.cochrane.org/ epoc-speci c-resources-review-authors.
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New England Journal of Medicine 2009;360(14):1418–28. 24 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Kripalani 2007Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. De cits in communication and information transfer between hospital-based and primary care physicians:
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Parker 2002 Parker SG, Peet SM, McPherson A, Cannaby AM, Abrams K, Baker R, et al. A systematic review of discharge arrangements for older people. Health Technology Assessment 2002; 6(4):1–183.
PDQ-Evidence 2015 PDQ-Evidence. PDQ-Evidence. Retrieved from http:// www.pdq-evidence.org/en/ (accessed 14 April 2015). Phillips 2004 Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with post discharge support for older patients with congestive heart failure: a meta-analysis. JAMA2004;291(11):358–67.
Stuck 1993 Stuck AE, Sui AL, Wieland GD, Adams J, Rubenstein LS.
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Ubbink 2014 Ubbink DT, Tump E, Koenders JA, Kleiterp S, Goslings JC, Brölmann FE. Which reasons do doctors, nurses, and patients have for hospital discharge? A mixed-methods study. PLoS One 2014;9(3):e91333.
References to other published versions of this review Parkes 2000 Parkes J, Shepperd S. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews 2000, Issue 4:CD000313. [DOI: 10.1002/14651858.CD000313] Shepperd 2004 Shepperd S, Parkes J, McClaren J, Phillips C. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews 2004, Issue 1:CD000313. [DOI:
10.1002/14651858.CD000313.pub2] Shepperd 2010 Shepperd S, McClaran J, Phillips CO, Lannin NA, Clemson LM, McCluskey A, et al. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews 2010, Issue 1. [DOI: 10.1002/14651858.CD000313.pub3] Shepperd 2013 Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews 2013, Issue 1. [DOI: 10.1002/14651858.CD000313.pub4] ∗ Indicates the major publication for the study 25 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. C H A R A C T E R I S T I C S O F S T U D I E S Characteristics of included studies[ordered by study ID] Balaban 2008 Methods RCT Participants A culturally and linguistically diverse group of patients who were admitted to hospital as an emergency, and had to have a ’medical home’ de ned as havin g an established primary care provider to be discharged to; patients were exclud ed if previously enrolled in the study, discharged to another institution or residing i n long-term care facility Number of patients recruited: T = 47, C = 49 Number with diabetes: T = 12/47, C = 18/49 Number with heart failure: T = 5/47, C = 5/49 Number with COPD: T = 6/47, C = 6/49 Number with depression: T = 23/47, C = 19/49 Number of patients recruited: T = 47, C = 49 Mean age: T = 58 years, C = 54 years Sex (female): T = 27/47 (57.4%), C = 30/49 (61%) Non-English-speaking: T = 19/47 (40%), C = 9/49 (18.4%) Interventions Setting : a safety net 100 bed community teaching hospital af liated wi th Harvard Med- ical School, USA Pre-admission assessment : no Case nding on admission : not clear Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : A comprehensive Patient Discharge Form was provided to patie nts in one of 3 languages (English, Spanish and Portuguese). The form sou ght to identify commu- nication problems that occur during the transition of care, inclu ding patients’ lack of knowledge about their condition and any gaps in outpatient fo llow-up care or follow- up of test results Implementation of the discharge plan : the Discharge Form was electronically trans- ferred to the RN at the patient’s primary care facility, a prima ry care RN contacted the patient and reviewed the Discharge Form and the medication incl uded in the discharge- transfer plan Monitoring phase : by primary care RN who telephoned the patient to assess their medical status, review the Patient Discharge Form, assess pat ient concerns and con rm scheduled follow-up appointments. Immediate interventions were arranged as needed, and the discharge form and telephone notes were forwarded ele ctronically to the primary care provider who reviewed the form Control : discharged according to existing hospital practice, which consis ted of receiving discharge instructions handwritten in English. Communicatio n between the discharge physician and primary care physician was done on an as-needed bas is Outcomes Hospital length of stay and readmission rates Follow-up: at 21 and 31 d Notes 24/120 patients were excluded after randomisation. 26 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Balaban 2008(Continued) Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Unclear risk Not described Allocation concealment (selection bias) Unclear risk Not described Blinding (performance bias and detection bias) All outcomes Low risk Main outcome measure was readmission rates Incomplete outcome data (attrition bias)All outcomes Low risk Follow-up data for > 80% Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data High risk Comparison at end of treatment only Bolas 2004 Methods RCT Participants Patients recruited within 48 h of an emergency or unplanned adm ission to the medical admissions unit, aged ≥55 years and taking 3 regular drugs or more. Patients were excluded if transferred to another hospital, admitted or tra nsferred to a nursing home, if patient or care giver was unable to communicate with pharmacis t, had mental illness or alcohol-related admission, or if home visit or follow-up was declined on admission Number of patients recruited: T = 119, C = 124 Mean age: T = 73 years, C = 75 years Sex (female): T = 41/119 (34%), C = 42/124 (34%) Living alone: T = 27/119, C = 34/124 Interventions Setting : Antrim Hospital, a 426-bed district general hospital in Nort hern Ireland Pre-admission assessment : no Case nding on admission : not described Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : use of a comprehensive medication history service, provision of an inten- sive clinical pharmacy service including management of patients ’ own drugs brought to hospital, personalised medicines record and patient counsell ing to explain changes at discharge Implementation of the discharge plan : discharge letter outlining complete drug history on admission and explanation of changes to medication during h ospital and variances to discharge prescription. This was faxed to GP and community phar macist. Personalised medicine card, discharge counselling, labelling of dispensed m edications under the same headings for follow-up Monitoring : medicines helpline 27 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Bolas 2004(Continued) Control : standard clinical pharmacy service Outcomes Patient satisfaction, knowledge of medicines, hoarding of me dicines Readmissions and length of stay data not reported Notes - Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Computer-generated random number Allocation concealment (selection bias) Unclear risk Allocation concealment was not described Blinding (performance bias and detection bias) All outcomes High risk Low risk for readmission data and high risk for knowledge of medicines and GP and community pharmacists’ views Incomplete outcome data (attrition bias)All outcomes High risk Follow-up of patients: 67% (162/243) Low response rate in survey of GPs (55% response rate) and community pharmacists (56% response rate) Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data reported Eggink 2010 Methods RCT Participants Patients aged ≥18 years, with heart failure who were prescribed ≥5 medicines at dis- charge; patients were excluded if living in a nursing home or un able to provide informed consent Number of patients recruited: T = 41, C = 44 Mean age (SD): T = 74 (12), C = 72 (10) Sex (female): T = 14/41 (41%), C = 11/44 (25%) Interventions Setting : Department of Cardiology in a teaching hospital in Tilburg, Netherlands Pre-admission assessment : no Case nding on admission : not described Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : the clinical pharmacist identi ed potential prescription err ors in the dis- charge medication, developed a discharge medication list and di scussed with the cardi- ologist Implementation of the discharge plan : patients received verbal and written information about side effects and changes in their hospital drug therapy f rom a clinical pharmacist at 28 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Eggink 2010(Continued) discharge. A discharge medication list was faxed to the communit y pharmacy and given as written information to the patient; this contained inform ation on dose adjustments and discontinued medications Monitoring: not described Control: regular care, verbal and written information about their dru g therapy from a nurse at hospital discharge, the prescription was made by the p hysician and given to the patient to give to the GP Outcomes Adherence to medication, prescribing errors (an error in the pro cess of prescribing) and discrepancies (a restart of a discontinued medication, discontin uation of prescribed dis- charge medication, use of higher or lower dose, more or less fre quent use than prescribed and incorrect time of taking medication) Notes - Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Random number table Allocation concealment (selection bias) Unclear risk Not described Blinding (performance bias and detection bias) All outcomes Low risk Low risk for count of prescribing errors, unclear risk for adher - ence Incomplete outcome data (attrition bias) All outcomes Low risk Loss to follow-up = 2/89 Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Majority of characteristics similar at baseline Evans 1993 Methods RCT Participants Patients aged ≥70 years and admitted with a medical condition, neurological con dition, or recovering from surgery, were screened for risk factors that would prolong their hospital length of stay Number of patients recruited: T = 417, C = 418 Mean age: T = 66.6 years, C = 67.9 years Interventions Setting : Veterans Affairs Hospital, Seattle, USA Pre-admission assessment : no Case nding on admission : patients screened for risk factors that may prolong length 29 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Evans 1993(Continued) of stay, increase risk of readmission, or discharge to a nursin g home Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : during discharge planning. information on support systems , living situa- tion, nances and areas of need were obtained from the medical n otes; interviews with the patient and family, and consulting with the physician and n urse Implementation of the discharge plan : discharge planning initiated on day 3 of hospital admission, and these patients were referred to a social worke r. Plans were implemented with measurable goals using goal attainment scaling.
Monitoring : not reported Control : received discharge planning only if referred by medical staff and usually on the 9 t h day of hospital admission, or not at all Outcomes Hospital length of stay, readmission to hospital, discharge destination, health status Follow-up at 3 months Notes Also validated an instrument to assess high-risk patients Intervention implemented on day 3 of hospital admission Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Unclear risk Not described Allocation concealment (selection bias) Unclear risk Not described Blinding (performance bias and detection bias) All outcomes Low risk Yes, for objective measures Incomplete outcome data (attrition bias)All outcomes Low risk All patients randomised accounted for at follow-up Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data reported Farris 2014 Methods RCT Participants Patients aged ≥18 years, English- or Spanish- speaking, admitted with diag nosis of hypertension, hyperlipidaemia, HF, coronary artery diseas e, MI, stroke, TIA, asthma, COPD or receiving oral anticoagulation, with life expectancy of ≥6 months and without cognitive impairment, dementia or severe psychiatric diagno sis Number of patients recruited: enhanced T = 314, minimum T = 315, C = 316 Mean age (SD): 61.0 (12.2) 30 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Farris 2014(Continued) Interventions Setting : Academic health centre, Iowa, US Pre-admission assessment : no Case nding on admission: electronic medical records screened for eligibility, followed by patient screening Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs: patients in Minimum and Enhanced Intervention received admis sion med- ication reconciliation and pharmacist visits every 2-3 d during i npatient stay for educa- tion Implementation of the discharge plan: patients in Minimum and Enhanced Interven- tion received counselling and discharge medication list; PCP an d community pharmacist of patients in Enhanced Intervention received copy of care plan (6 -24 h postdischarge) with medication list and patient-speci c concerns, among others Monitoring : patients in Enhanced Intervention received call 3-5 d postdisch arge Control : medication reconciliation at admission as per hospital policy , nurse discharge counselling and discharge medication list. The discharge summa ry was transcribed and received in the mail by the PCP several days or weeks after disch arge Outcomes Medication appropriateness, adverse events, preventable adverse events, composite vari- able of combined hospital readmission, emergency department visit or unscheduled of- ce visit. Follow-up at 30 and 90 d postdischarge Notes Fidelity assessment conducted to assess which intervention com ponents were delivered Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Statistician-generated blinded randomisation scheme, sequen- tially numbered envelopes Allocation concealment (selection bias) Low risk Unit of allocation by patient, with sealed opaque envelope Blinding (performance bias and detection bias) All outcomes Unclear risk Pharmacists unaware of patients allocation to Minimum Inter- vention or Enhanced Intervention until discharge; status of R As who assessed baseline and follow-up unclear Incomplete outcome data (attrition bias) All outcomes Low risk 9 patients lost to follow-up (3 per group: Enhanced Interventio n = 311/314; Minimum Intervention = 312/315; Control = 313/ 316) Selective reporting (reporting bias) Unclear risk Some of the secondary outcomes were analysed in aggregate; however, they were also reported separately and it was possi ble to extract suf cient information Baseline data Low risk Baseline data reported, similar characteristics; control grou p less likely to forget medication but not related with main outcome 31 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Gillespie 2009 Methods RCT Participants Patients aged≥80 years, admitted to 2 internal medicine wards; excluded if ad mitted previously to the study wards during the study period or had s cheduled admissions Number of patients recruited: T = 182, C = 186 Mean age (SD): T = 86.6 (4.2), C = 87.1 (14.1) Sex (female): T = 105 (57.7%), C = 111 (59.7%) Interventions Setting : teaching hospital, Upsalla, Sweden Pre-admission assessment : no Case nding on admission : no Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : study pharmacists compiled a comprehensive list of current med ications, after which they reviewed the drugs. Advice on drug selection, d osages, and monitoring needs was given to the patient’s physician, who was responsib le for the nal decision.
Patients were educated and monitored throughout the admissi on process Implementation of discharge plan : PCP contacted and given discharge medications, which included rationale for changes and monitoring needs for n ewly commenced drugs.
All information was approved by ward physicians Monitoring : follow-up telephone call to patients 2 months after discharge Control : standard care without pharmacists’ involvement in the healt hcare team at the ward level Outcomes Frequency of hospital visits 12 months after (last included pat ient) discharge from hos- pital; number of readmissions, ED visits, and costs Notes - Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Randomisation was performed in blocks of 20 (each block con- tained 10 intervention and 10 control allocations) Allocation concealment (selection bias) Low risk Block randomisation with a closed-envelope technique. The ran- domisation process was performed by the clinical trials group a t the Hospital Pharmacy Blinding (performance bias and detection bias) All outcomes Low risk Objective measures of outcome using routine data. Incomplete outcome data (attrition bias)All outcomes Low risk T: 13 died before discharge and 4 withdrew; C: 14 died and 1 withdrew (< 8%) Selective reporting (reporting bias) Low risk Main outcome is the same as reported for the trial registry ( https://clinicaltrials.gov/show/NCT00661310 ) 32 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Gillespie 2009(Continued) Baseline data Low risk Baseline data reported Goldman 2014 Methods RCT Participants Patients aged ≥60 years (later lowered to 55 to improve recruitment), admitted unex- pectedly to the internal or family medicine, cardiology, or neu rology departments; En- glish-, Spanish- or Mandarin-speaking, likely to be discharge d home and able to consent Number of patients recruited: T = 347, C = 352 Mean age (SD): T = 66.5 years (9.0), C = 66.0 years (9.0) Sex (female): T = 159/347 (46%), C = 145/352 (41%) Interventions Setting : safety-net hospital, San Francisco, USA Pre-admission assessment : no Case nding on admission : electronic medical records screened for eligibility, followe d by meeting with attending physician Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : RN provided disease-speci c patient education either in the p atient’s pre- ferred language or via a trained interpreter; motivational interviewing and coaching for engagement; written materials provided Implementation of discharge plan : from admission to discharge, with outreach visit by RN within 24 h of discharge; PCP contacted and given inpatient physicians’ contact Monitoring : NP called patients 1-3 and 6-10 d after discharge to assess adher ence to medication, provide further education if required, help solv e barriers to attending follow- up appointments, among others Control : bedside RN’s review of the discharge instructions, received b y all patients.
If requested by the medical team, the hospital pharmacy provid ed a 10 d medication supply and a social worker assisted with discharge. The admitt ing team was responsible for liaising with the patients’ PCP Outcomes ED visits or readmissions (30, 90 and 180 d), non-ED ambulatory ca re visits, mortality (180 d) Notes Fidelity assessment conducted to measure which intervention co mponents were delivered Age criterion was changed halfway from ≥60 to ≥55 years to increase the number of eligible participants Authors provided supplementary data (readmissions and ED vi sits were presented as an aggregated outcome, access provided to separate outcomes) Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Statistician-generated randomised tables of treatment assi gn- ment in blocks of 50 for each language 33 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Goldman 2014(Continued) Allocation concealment (selection bias) Low risk Pairs of envelopes containing the treatment assignment and l a- belled with the study identi cation number Blinding (performance bias and detection bias) All outcomes Low risk Blinded outcome assessment and objective primary outcome Incomplete outcome data (attrition bias)All outcomes Low risk Follow-up at 180 d = 90% All drop-outs accounted for Selective reporting (reporting bias) Low risk Trial registration provides same primary outcomes as report ed here Baseline data Low risk Baseline data reported Harrison 2002 Methods RCT Participants Patients admitted with CHF, who lived within the regional ho me care radius (60 km), were expected to be discharged to home nursing care and were not co gnitively impaired Number of patients recruited: T = 92, C = 100 Mean age (SD): T = 75.5 years (10.4), C = 75.7 years (9.7) Sex (female): T = 43/92 (47%), C = 44/100 (44%) Interventions Setting : large urban teaching hospital, Ottawa, Canada Pre-admission assessment : no Case nding on admission : patients’ notes were agged as a signal to the primary nurse to follow a checklist for Transitional Care Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : comprehensive discharge planning, which included hospital an d commu- nity nurses working together to smooth transition from hosp ital to home (Transitional Care intervention); a structured evidence based protocol was us ed for counselling and education for heart failure self-management (Partners in Care for Congestive Heart Fail- ure). The protocol followed AHCPR guidelines. Home nursing vi sits - the same number as the control group Implementation of discharge plan : from admission to discharge, with telephone out- reach within 24 h of discharge Monitoring : not reported Control : received usual care for hospital-to-home transfer, which invol ved completion of a medical history, nursing assessment form and a multidisci plinary plan. Discharge planning meetings took place weekly. A regional home care coord inator consulted with the hospital team as required. Patients received the same num ber of home nurse visits as the intervention group Outcomes Health-related quality of life, symptom distress and functio ning. Emergency room visits and readmissions at 12 weeks 34 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Harrison 2002(Continued) Notes - Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Computer-generated schedule of random numbers Allocation concealment (selection bias) Low risk Random allocation by a research co-ordinator Blinding (performance bias and detection bias) All outcomes High risk High risk for patient assessed outcomes Low risk for objective measure of readmission Incomplete outcome data (attrition bias)All outcomes Low risk 157/200 (81%) completed the study Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data reported Hendriksen 1990 Methods RCT Participants Patients aged ≥65 years admitted to 4 wards, including surgical Number of patients recruited: T = 135, C = 138 Mean age: T = 76.5 years, C = 76.6 years Interventions Setting : hospital in suburb of Copenhagen, Denmark Pre-admission assessment : no Case nding on admission : not reported Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : patients had daily contact with the project nurse who discussed their illness with them and discharge arrangements Implementation of the discharge plan: there was liaison between hospital and primary care staff. Project nurse visited patients at home after discha rge and could make one repeat visit Monitoring : not reported Control : described as usual care Outcomes Hospital length of stay, readmission to hospital, discharge destination Notes Details of measures of outcome not provided. Translated from Danish. Intervention implemented at time of admission Risk of bias 35 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Hendriksen 1990(Continued) Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Unclear risk Not described Allocation concealment (selection bias) Unclear risk Not described Blinding (performance bias and detection bias) All outcomes Low risk Yes, for objective outcome measures Incomplete outcome data (attrition bias) All outcomes Unclear risk Not described Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data reported Jack 2009 Methods RCT Participants Patients who were emergency admissions to the medical teaching service and who were going to be discharged home. Participants had to have a telepho ne, comprehend the study details and consent process in English and have plans to b e discharged to a US community Number of participants recruited: T = 373, C = 376 Mean age (SD): T: 50.1 (15.1), C: 49.6 (15.3) Sex (female): T = 178/373 (48%), C = 200/376 ( 53%) Interventions Setting : Large urban safety net hospital with an ethnically diverse p atient population; Boston Medical Centre, Massachusetts, USA Pre-admission assessment : no Case nding on admission : the nurse discharge advocate (DA) completed the (re- engineered discharge) RED intervention components Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs: with information collected from the hospital team and the part icipant, the DA created the after-hospital care plan (AHCP), which contained med ical provider con- tact information, dates for appointments and tests, an appoi ntment calendar, a colour- coded medication schedule, a list of tests with pending results at discharge, an illustrated description of the discharge diagnosis, and information abou t what to do if a problem arises. Information for the AHCP was manually entered into a Microsoft Word template, printed, and spiral-bound to produce an individualised, colou r booklet Implementation of the discharge plan : the DA used scripts from the training manual to review the contents of the AHCP with the participant. On the d ay of discharge the AHCP and discharge summary were faxed to the primary care provi der (PCP) Monitoring phase: clinical pharmacist telephoned the participants 2-4 d after the i ndex discharge to reinforce the discharge plan by using a scripted int erview. The pharmacist 36 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Jack 2009(Continued) had access to the AHCP and hospital discharge summary and, over s everal days, made at least 3 attempts to reach each participant. The pharmacist asked participants to bring their medications to the telephone to review them and address medica tion-related problems; the pharmacist communicated these issues to the PCP or DA Additional information on the intervention available at www.bu.edu/ fammed/ projectred/index.html Control: usual care Outcomes Readmission, patient satisfaction and cost Notes Readmission data obtained from the authors Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Index cards in opaque envelopes randomly arranged Allocation concealment (selection bias) Low risk The authors state that the research assistants could not selec- tively choose potential participants for enrolment or predict as- signment Blinding (performance bias and detection bias) All outcomes Low risk Research staff doing follow-up telephone calls and reviewing hospital records were blinded to study group assignment Incomplete outcome data (attrition bias)All outcomes Low risk Follow-up at 30 d > 80% Similar proportion in both groups Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data collected at recruitment Kennedy 1987 Methods RCT Participants Elderly acute care medical patients Number of patients recruited: T = 39, C = 41 Mean age: T = 80.1 years, C = 80.5 years Sex (female): T = 19/39 (49%), C = 23/41 (56%) Interventions Setting : 500-bed, non-pro t acute care teaching hospital, Texas, USA Pre-admission assessment : no Case nding on admission : not reported Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : discharge planning emphasised communication with the patien t and fam- 37 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Kennedy 1987(Continued) ily. A primary nurse assessed patients’ postdischarge needs . A comprehensive discharge planning protocol was developed, which included an assessment of health status, orienta- tion level, knowledge and perception of health status, patte rn of resource use, functional status, skill level, motivation, and demographic data Implementation of the discharge plan : by the primary nurse and other members of the healthcare team. A follow-up visit was made to assess discha rge placement Monitoring : not reported Control : care not described Outcomes Hospital length of stay, re-admission to hospital, discharge destination, health status Notes Not clear when intervention implemented Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Random number schedule described Allocation concealment (selection bias) Low risk Allocation provided by the statistics department Blinding (performance bias and detection bias) All outcomes Low risk For objective measures of outcome Incomplete outcome data (attrition bias) All outcomes Low risk All patients randomised accounted for at follow-up Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data reported Kripalani 2012 Methods RCT Participants Patients hospitalised for acute coronary syndrome or acute deco mpensated HF, English- or Spanish-speaking, expected to stay in hospital for more tha n 3 h, likely to be discharged home, without dementia, active psychosis, bipolar disorder o r delirium, without hearing or vision impairment Number recruited: T = 423, C = 428 Mean age (SD): T = 61 years (14.4), C = 59 years (13.8) Sex (female): T = 173/423 (41%), C = 179/428 (42%) Interventions Setting : Tertiary care academic hospitals, Nashville and Boston, US Pre-admission assessment : no Case nding on admission : not reported 38 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Kripalani 2012(Continued) Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : at the rst meeting, the pharmacist assessed the patient’s u nderstanding and needs, communicating with the treating physician if medicat ion discrepancies were identi ed Implementation of the discharge plan : second meeting occurred before discharge and patient was given tailored counselling and low-literacy adher ence aids; if discharge oc- curred same day as enrolment, then single session was conducted for assessment and implementation of discharge plan Monitoring : call 1-4 d after discharge by unblinded research assistant; if o utstanding needs identi ed, pharmacist would perform follow-up call, lia ising with in- and outpa- tient physician if necessary Control : physicians and nurses performed medication reconciliation an d provided dis- charge counselling; medication reconciliation was facilitated b y electronic records. At one of the sites there were additional features (reminders to complete a preadmission medication list and integration with order entry) Outcomes Number of clinically important medication errors at 30 d (composi te measure of pre- ventable or ameliorable ADEs and potential ADEs due to medica tion discrepancies or non-adherence); preventable or ameliorable ADEs; potential A DEs due to medication discrepancies or non-adherence; preventable or ameliorable AD Es judged to be serious, life-threatening, or fatal Notes - Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Randomisation was strati ed by study site and diagnosis, in permuted blocks of 2-6 patients, by a computer programme that maintained allocation concealment Allocation concealment (selection bias) Low risk One unblinded research coordinator at each site administered the randomisation, contacted study pharmacists who then de- livered the intervention to eligible patients, and particip ated in the individualised telephone follow-up Blinding (performance bias and detection bias) All outcomes Low risk Main outcome determined by 2 independent clinicians follow- ing standardised validated methodology Incomplete outcome data (attrition bias)All outcomes Low risk Follow-up at 30 d for > 80%; similar % of drop-outs in both groups Selective reporting (reporting bias) Low risk Slight discrepancies between protocol and publication, for sec- ondary outcomes and 1 minor inclusion criterion Baseline data Low risk Intervention group is slightly older, groups similar other than that 39 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Lainscak 2013 Methods RCT Participants Patients admitted with COPD exacerbation with reduced pulmonary function, aged≥ 35 years, not at terminal stages of disease Number recruited: T = 118, C = 135 Mean age (SD): T = 71 years (9), C = 71 years (9) Sex (female): T = 37/118 (31%), C = 34/135 (25%) Living alone: T = 29 (25%), C = 27 (20%) Interventions Setting : specialised pulmonary hospital, Slovenia Pre-admission assessment : no Case nding on admission : not reported Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : the discharge coordinator assessed patient and home care need s, involving both the patient and the care giver Implementation of the discharge plan : the discharge co-ordinator communicated the discharge plan to PCP, community nurses, and other providers o f home services, as required by the patient’s needs Monitoring: phone call at 48 h postdischarge to assess adjustment process, f ollowed by phone calls scheduled as required until a nal home visit at 7-10 d postdischarge Control : care as usual, which included routine patient education with wr itten and verbal information about COPD, supervised inhaler use, respirato ry physiotherapy as indicated, and disease related communication between medical staff with p atients and their care givers Outcomes Number of patients hospitalised due to worsening COPD, time to COPD hospitalisa- tion, all-cause mortality, all-cause hospitalisation, days al ive and out of hospital, health- related quality of life Notes Steering and end-point committee closed enrolment at 83% of the planned sample due to re-hospitalisation of patients already assessed for elig ibility and seasonal variation of COPD Information about the communication between discharge coordin ators and providers of home services, including timing and frequency, was not reporte d in detail. The authors provided supplementary unpublished data Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Software to generate random numbers/allocation sequence Allocation concealment (selection bias) Low risk Allocation independent of researchers and healthcare provide rs Blinding (performance bias and detection bias) All outcomes Low risk Objective measure for primary outcome 40 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Lainscak 2013(Continued) Incomplete outcome data (attrition bias) All outcomes Low risk Follow-up at 180 d for > 80%; similar % of drop-outs in both groups Selective reporting (reporting bias) Low risk One of the secondary outcomes not reported (healthcare costs) , all other outcomes reported Baseline data Low risk Baseline data provided, no differences between groups Laramee 2003 Methods RCT Participants Patients with con rmed congestive heart failure (CHF), who also had to be at risk for early readmission as de ned by the presence of 1 or more of the f ollowing criteria: history of CHF, documented knowledge de cits of treatment plan or dise ase process, potential or ongoing lack of adherence to treatment plan, previous CHF ho spital admission, living alone, and ≥4 hospitalisations in the past 5 years Number recruited: T = 141, C = 146 Mean age (SD): T = 70.6 years (11.4), C = 70.8 years (12.2) Sex ( female) T = 59/141 (42%), C = 72/146 (50%) Support at home: T = 127/141 (90%), C = 140/146 (96%) Interventions Setting : 550-bed academic medical centre, which serves the largely rural geographic areas of Vermont and upstate New York, USA Pre-admission assessment : no Case nding on admission : no Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs: early discharge planning and co-ordination of care and individu alised and comprehensive patient and family education Implementation of the discharge plan : case manager (CM) assisted in the co-ordination of care by facilitating the discharge plan and obtaining needed consultations from social services, dietary services and physical/occupational therapy. When indicated, arrange- ments were made for additional services or support once the pat ient had returned home.
The CM also facilitated communication in the hospital among the patient and family, attending physician, cardiology team, and other medical care pr actitioners through par- ticipating in daily rounds, documenting patient needs in the m edical record, submitting progress reports to the PCP, involving the patient and famil y in developing the plan of care, collaborating with the home health agencies and provid ing informational and emotional support to the patient and family Monitoring : 12 weeks of enhanced telephone follow-up and surveillance Control : inpatient treatments included social service evaluation (25% for usual care group), dietary consultation (15% usual care), PT/OT (17% usual car e), medication and CHF education by staff nurses and any other hospital servi ces. Postdischarge care was conducted by the patient’s own local physician. The home care s ervice gures were 44% Outcomes Readmissions, mortality, hospital bed days, resource use an d patient satisfaction. Follow- up at 3 months 41 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Laramee 2003(Continued) Notes - Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Unclear risk Not described Allocation concealment (selection bias) Unclear risk Not described Blinding (performance bias and detection bias) All outcomes Low risk Objective measure of the primary outcome readmission, and the secondary outcome length of stay Incomplete outcome data (attrition bias)All outcomes Low risk Loss to follow-up: 53/287; ≥81% retained T = 122/141; C = 112/146 Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data reported Legrain 2011 Methods RCT Investigators used the double consent of a Zelen randomised co nsent design after assessing patients for eligibility; informed consent was obtained fol lowing randomisation Participants Medical patients aged≥70 years; patients were excluded if expected to be discharged in less than 5 d, had poor chance of 3-month survival or were receivin g palliative care Mean age (SD): T = 85.8 years (6.0); C = 86.4 years (6.3) Sex (female): T = 221/317 (70%); C = 218/348 (63%) Number of patients randomised using Zelen design: T = 528; C = 517 (total 1,045) and of these T = 317 and C = 348 participated in the RCT Interventions Setting : 5 university-af liated hospitals and 1 private clinic; Paris , France Pre-admission assessment : not possible Case nding on admission : the intervention focused on 3 risk factors: drug related problems, under-diagnosis and untreated depression (screene d with the 4-item Geriatric Depression Scale, and if the DSM-IV criteria were positive) and protein energy malnu- trition Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : the intervention was implemented after admission to the acu te geriatric unit (AGU) and had 3 components, a comprehensive chronic medication re view according to geriatric prescribing principles and which involved the pat ient and their care giver, education on self-management of disease and detailed transit ion of care communication with outpatient health professionals and the GP. These were adapted from disease man- 42 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Legrain 2011(Continued) agement programmes for inpatients with multiple chronic cond itions Implementation of the discharge plan : the intervention was implemented by a dedi- cated geriatrician in addition to the care provided by the usual geriatrician of the AGU.
The dedicated geriatrician provided recommendations to the AG U geriatrician who made nal decisions. GPs were contacted regarding changes in tre atment Monitoring : follow-up by a geriatrician.
Control : received standard medical care from the AGU healthcare team wit hout involve- ment of the intervention-dedicated geriatrician. AGUs are hos pital units with their own physical location and structure that are specialised in the care o f elderly people with acute medical disorders, including acute exacerbations of chronic dis eases. AGUs implement comprehensive geriatric assessment Outcomes Emergency hospitalisation, emergency room visit, mortality , cost Follow-up time: 6 months from discharge Notes - Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Computer-generated ran- domisation scheme in various sized blocks strati ed according to centre Allocation concealment (selection bias) Low risk A central randomisation service in the trial organisation centre Blinding (performance bias and detection bias) All outcomes Low risk Objective measure of the primary outcome of readmission and secondary outcome of costs using hospital days. Data on readmis- sion rates were veri ed by checking admin- istrative databases Incomplete outcome data (attrition bias) All outcomes Low risk Outcome data reported for all participants recruited Selective reporting (reporting bias) Unclear risk Not able to judge from available informa- tion Baseline data Low risk Majority of baseline characteristics similar between groups 43 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Lin 2009 Methods RCT Participants Patients hospitalised with a hip fracture, aged≥65 years, who had a Barthel score of at least 70 points prior to their hip fracture Number of patients recruited: T = 26; C = 24 Sex (female): 18/50 (36%) Mean age (SD): 78.8 years (7.0) Interventions Setting : 4 orthopaedic wards in a 2800 bed medical centre in Taipei, Tai wan Pre-admission assessment : no Case nding on admission : no Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : structured assessment of discharge planning needs within 48 h of admission; systematic individualised nursing instruction based on the individual’s needs Implementation of the discharge plan : nurses coordinated resources and arranged referral placements. 2 postdischarge home visits were conducte d to provide support and consultation Monitoring : nurses monitored services Control : non-structured discharge planning provided by nurses who use d their profes- sional judgement Outcomes Hospital length of stay, readmission, functional status, qu ality of life, patient satisfaction at 2 weeks and 3 months postdischarge Notes - Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Unclear risk Patients were assigned to 1 of 4 wards: 2 were designated the intervention group and 2 the control. The sequence generation of random assignment was not described Allocation concealment (selection bias) Unclear risk Patients were assigned to 1 of 4 wards “by doctors who were not aware of the study process.” Blinding (performance bias and detection bias) All outcomes Unclear risk Blinding of researchers conducted follow-up assessments is not described Incomplete outcome data (attrition bias)All outcomes Low risk Data collected on all recruited patients Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Similar characteristics at baseline 44 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Lindpaintner 2013 Methods Pilot RCT Participants Patients aged≥18 years, taking oral anticoagulation or newly ordered insul in or more than 8 regular medicines or new diagnosis requiring at least 4 long-term medicines, expected to live > 1 month, German-speaking, no cognitive impai rment; excluded if PCP or local visiting nurse association not involved in the stu dy Number of patients recruited: T = 30, C = 30 Mean age (SD): T = 75.1 years (9.49), C = 75.2 (12.4) Sex (female): T = 15/30 (50%), C = 19/30 (63%) Interventions Setting : teaching hospital in Baden, Switzerland Pre-admission assessment : no Case nding on admission : all patients admitted to hospital were screened for eligibi lity Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : the nurse care manager assessed patients with a battery of te sts Implementation of the discharge plan : the NCM liaised with the ward team and jointly developed a discharge plan, which included self-management tech niques; the PCP and community nursing team received a copy of the discharge form, as w ell as a letter at the end of the intervention, and further contacts were done as need ed Monitoring : structured call 24 h postdischarge and home visit at the end of t he inter- vention Control : best usual care (no additional information provided) Outcomes Composite endpoint (death, rehospitalisation, unplanned u rgent medical evaluation within 5 d of discharge, and adverse medicine reaction requirin g discontinuation of the medicine), satisfaction with discharge process, care giver burde n, health-related quality of life Notes Pilot study; insuf cient data to be included in the pooled anal ysis, authors contacted but no further data obtained Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Block randomisation Allocation concealment (selection bias) Unclear risk Not reported Blinding (performance bias and detection bias) All outcomes High risk Interview-based data (patients, nurses, and PCP) Incomplete outcome data (attrition bias)All outcomes Low risk Drop-outs accounted for Selective reporting (reporting bias) Unclear risk Not able to judge from available information 45 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Lindpaintner 2013(Continued) Baseline data High risk Baseline data provided; patients in treatment group had hig her comorbidity (T = 3.2 ± 2.29, C = 2.5 ± 2.45) Moher 1992 Methods RCT Participants Patients admitted to a general medical clinic, excluded if admit ted to intensive care unit or not expected to survive for more than 48 h Number of patients recruited: T = 136, C = 131 Mean age: T = 66.3 years, C = 64.3 years Sex (female): T = 73/136 (54%), C = 72/131 (55%) Interventions Setting: 2 clinical teaching units, Ottawa, Canada Pre-admission assessment : no Case nding on admission : no Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : a nurse employed as a team co-ordinator acted as a liaison betwe en members of the medical team and collected patient information Implementation of the discharge plan : the nurse facilitated discharge planning Monitoring : not reported Control : standard medical care Outcomes Hospital length of stay, readmission to hospital, discharge destination, patient satisfaction Notes Baseline data recorded only on age, sex, diagnosis Not clear when intervention implemented Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Computer-generated blocks Allocation concealment (selection bias) Unclear risk Allocation procedure not described Blinding (performance bias and detection bias) All outcomes Low risk Yes for objective measures of outcome Incomplete outcome data (attrition bias)All outcomes Low risk All patients randomised accounted for at follow-up Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data reported 46 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Naji 1999 Methods RCT Participants Patients admitted to an acute psychiatric ward; patients wereexcluded if previously admitted, too ill, not registered with a GP or had no xed addr ess Number of patients recruited: T = 168, C = 175 Mean age (SD): T = 40 (12), C = 41 (12.8) Sex (female): T = 83/168 (49%), C = 80/175 (46%) Interventions Setting : Acute psychiatric wards, Aberdeen, Scotland Pre admission assessment : no Case nding on admission : no Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient need : not clear Implementation of the discharge plan : psychiatrist telephoned GP to discuss patient and make an appointment for the patient to see the GP within 1 w eek following discharge.
A copy of the discharge summary was given to the patient to hand-d eliver to the GP. A copy was also sent by post Monitoring : no Control : received standard care, patients advised to make an appointm ent to see their GP and were given a copy of the discharge summary to hand-deliver to the GP Outcomes Readmission, mental health status, discharge process, cost. Follow-up at 1 month for patient assessed outcomes, 6 months for readmissions Notes - Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Independent computer programme Allocation concealment (selection bias) Low risk Independent to researchers Blinding (performance bias and detection bias) All outcomes Low risk Objective measures used for readmission, consultations and length of stay. Validated standardised patient assessed ou tcomes also measured Incomplete outcome data (attrition bias) All outcomes Unclear risk Less than 80% for patient assessed: 1 month completion T = 106/168 (63%), C = 111/175 (63%) Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data collected on day of discharge: baseline completio n T = 132/168 (79%), C = 133/175 (76%) 47 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Naughton 1994 Methods RCT Participants Patients aged≥70 years admitted from emergency department who were not recei ving regular care from an attending internist on staff; patients w ere excluded if admitted to intensive care unit or surgical ward Number of patients recruited: T = 51, C = 60 Mean age (SD): T = 80.1 years (6.6), C = 80.1 years (6.4) Sex (female): T = 25/51 (49%), C = 38/60 (63%) Interventions Setting : private, non-pro t, academic medical centre, Chicago, USA Pre-admission assessment : no Case nding on admission : not clear Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : A geriatric evaluation and management team (GEM) assessed t he patients’ mental and physical health status and psychosocial condition to determine level of reha- bilitation required and social needs. A geriatrician and socia l worker were the core team members.
Implementation of the discharge plan : team meetings with the GEM and nurse spe- cialist and physical therapist took place twice a week to discuss p atients’ medical condi- tion, living situation, family and social supports, and pati ent and family’s understanding of the patient’s condition. The social worker was responsible for identifying and co- ordinating community resources and ensuring the posthospita l treatment place was in place at the time of discharge and 2 weeks later. The nurse specia list co-ordinated the transfer to home healthcare. Patients who did not have a prima ry care provider received outpatient care at the hospital Monitoring : not reported Control : received ’usual care’ by medical house staff and an attending p hysician. Social workers and discharge planners were available on request Outcomes Hospital length of stay, discharge destination, health serv ice costs Notes Intervention implemented at time of admission Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Card indicating assignment to the intervention or control gro up were placed sequentially in opaque sealed envelopes Allocation concealment (selection bias) Low risk Sealed envelopes provided by admitting clerk Blinding (performance bias and detection bias) All outcomes Low risk Yes for objective measures of outcome Incomplete outcome data (attrition bias)All outcomes Low risk 141 patients initially randomised, of these 25 were ineligi ble and 5 were transferred to surgical services, leaving 111 to be anal ysed 48 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Naughton 1994(Continued) Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data reported Naylor 1994 Methods RCT Participants Patients aged ≥70 years, admitted to medical ward and cardiac surgery, Englis h-speaking, alert and orientated at admission, and able to use telephone after discharge Number of patients recruited: T = 140, C = 136 Mean age (SD): 76 years Interventions Setting : Hospital of the University of Pennsylvania, USA Pre-admission assessment : no Case nding on admission : not clear Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : the discharge plan included a comprehensive assessment of the needs of the elderly patient and their care giver, an education component fo r the patient and family and interdisciplinary communication regarding discharge stat us Implementation of the discharge plan : implemented by geriatric nurse specialist and extended from admission to 2 weeks postdischarge with ongoin g evaluation of the ef- fectiveness of the discharge plan Monitoring : not reported Control : received the routine discharge planning available in the hos pital Outcomes Hospital length of stay, readmission to hospital, health status, health service costs Notes Intervention implemented at time of admission Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Unclear risk Not described Allocation concealment (selection bias) Unclear risk Not described Blinding (performance bias and detection bias) All outcomes Low risk Yes, for objective measures Incomplete outcome data (attrition bias)All outcomes Low risk All patients included in the nal sample accounted for Selective reporting (reporting bias) Unclear risk Not able to judge from available information 49 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Naylor 1994(Continued) Baseline data Low risk Baseline data reported Nazareth 2001 Methods RCT Participants Patients aged ≥75 years, on 4 or more medicines who were discharged from 3 acute wards and 1 long-stay ward. Each patient had a mean of 3 chronic me dical conditions, and was on a mean of 6 drugs (SD 2) at discharge Number of patients recruited: T = 181, C = 181 Mean age (SD): 84 years (5.2) Sex (female): T = 112/181 (62%), C = 119/181 (66%) Interventions Setting : Three acute and one long-stay hospital, London, UK Pre-admission assessment : no Case nding on admission : not clear Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : a hospital pharmacist assessed patients’ medication, ratio nalised the drug treatment, provided information and liaised with care giver and community profession- als. An aim was to optimise communication between secondary and primary care pro- fessionals Follow-up visit by community hospital at 7-14 d after discharge t o check medication and intervene if necessary. Subsequent visits arranged if ap propriate Implementation of the discharge plan : a copy of the discharge plan was given to the patient, care giver, community pharmacist and GP Monitoring : follow-up in the community by a pharmacist Control : discharged from hospital following standard procedures, wh ich included a letter of discharge to the GP. The pharmacist did not provide a r eview of medications or follow-up in the community Outcomes Hospital readmission, mortality, quality of life, client sa tisfaction, knowledge and adher- ence to prescribed drugs, consultation with GP Notes - Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Computer generated random numbers Allocation concealment (selection bias) Low risk Allocation by independent pharmacist at the health authority ’s central community pharmacy of ce Blinding (performance bias and detection bias) All outcomes Low risk Blinding of objective outcomes 50 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Nazareth 2001(Continued) Incomplete outcome data (attrition bias) All outcomes Low risk At each follow-up time the number of deaths and readmissions were accounted for. 2 control patients moved away prior to 6- month follow-up Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data reported Pardessus 2002 Methods RCT Participants Patients aged ≥65, hospitalised for falling and able to return home; exclude d if cogni- tively impaired (MM < 24), did not have a phone, lived further aw ay than 30 km, or if the falls were secondary to cardiac, neurologic, vascular, or the rapeutic problems Number recruited: T = 30, C = 30 Age (SD): T = 83.5 years (9.1), C = 82.9 years (6.3) Sex (female): T = 23/30 (76%), C = 24/30 (80%) Interventions Setting : acute geriatric department in les Bateliers Hospital; Lill e, France Pre-admission assessment : no Case nding on admission : all admitted patients during the trial period were screened for inclusion and exclusion criteria. Baseline information ob tained at beginning of hos- pitalisation Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : 2 h home visit by occupational therapist and a physical medicine /rehabili- tation doctor to evaluate patient abilities in home environm ent - ADL, IADL, transfers, mobility and environmental hazards. Enabled observation o f patient in real conditions of life. Social supports addressed by social worker Implementation of the discharge plan: modi cation of home hazards and safety advice in home situation, adaptation of recommendations and prescri ptions, particularly for physical therapy, speedy evaluation of technical aids and socia l supports needed Monitoring : telephone follow-up was conducted by an occupational therapist to check if the home modi cations were completed and assist if necessary Control : received physical therapy and were informed of home safety an d social assistance if required. No home visit Outcomes Functional status, falls, readmissions, mortality and resi dential care at 6 and 12 months Notes Intervention includes pre-discharge home visits Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Random number table 51 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Pardessus 2002(Continued) Allocation concealment (selection bias) Unclear risk Not described Blinding (performance bias and detection bias) All outcomes Low risk For objective measure of outcome only (readmission and mor- tality) Incomplete outcome data (attrition bias)All outcomes Low risk All patients randomised accounted for at follow-up Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Unclear risk Baseline data reported Parfrey 1994 Methods RCT Participants Medical and surgical patients, excluded if admitted for short s tay or into units with their own discharge process, previously enrolled in the study, confu sed or intoxicated, and≥ 85 years Number of patients recruited: hospital A: T = 421, C = 420; hosp ital B: T = 375, C = 384 Mean age (SD): hospital A: T = 53 years (19), C = 53 years (18); hospita l B: T = 56 years (18), C = 56 years (18) Sex (female): hospital A: T = 188/421 (45%), C = 184/420 (44%); hospi tal B: T = 217/ 374 (58%), C = 210/384 (55%) Interventions Setting : 2 academic hospitals, Newfoundland, Canada Pre-admission assessment : no Case nding on admission : developed a questionnaire to identify patients requiring discharge planning Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : assessment was based on the questionnaire which covered the p atient’s social circumstances at home; if the admission was an emergency admissi on or a readmission; the use of allied health and community services; mobility and a ctivities of daily living; medical or surgical condition Implementation of the discharge plan : referrals to allied health professionals following completion of the questionnaire for discharge planning Monitoring : not reported Control : did not receive the questionnaire; discharge planning occurre d if the discharge planning nurses identi ed a patient or received a referral Outcomes Hospital length of stay at 6 and 12 months Notes Also validated an instrument to assess high-risk patients Intervention implemented at time of admission Risk of bias 52 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Parfrey 1994(Continued) Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Unclear risk Not described Allocation concealment (selection bias) Low risk Sealed envelopes Blinding (performance bias and detection bias) All outcomes Low risk Yes for objective measures of outcome Incomplete outcome data (attrition bias)All outcomes Low risk All patients randomised accounted for at follow-up Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data reported Preen 2005 Methods RCT Participants Patients with chronic obstructive pulmonary disease, cardiov ascular disease, or both; patients had to be registered with a PCP and have at least two co mmunity care providers Number of patients recruited: T = 91, C = 98 Mean age (SD): T = 74.8years (6.7), C = 75.4 (7.9) years Sex: (female): T = 57/91 (62%), C = 58/98 (59%) Interventions Setting : 2 tertiary hospitals in Western Australia Pre-admission assessment : no Case nding on admission : no Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : Discharge planning was based on the Australian Enhanced Prim ary Care Initiative and tailored to each patient. The discharge plan wa s developed 24-48 h prior to discharge. Problems were identi ed from hospital notes and p atient/care giver consulta- tion, goals were developed and agreed upon with the patient/ care giver based on personal circumstances, and interventions and community service provide rs were identi ed who met patient needs and who were accessible and agreeable to the p atient Implementation of the discharge plan : the discharge plan was faxed to the GP and consultation with the GP was scheduled within 7 d postdischarge . Copies faxed to all service providers identi ed on the care plan Monitoring : research nurse followed up if GP did not respond in 24 h and the GP scheduled a consultation (within 7 d postdischarge) for patient review Control : patients were discharged under the hospitals’ existing pro cesses following stan- dard practice of Western Australia, where all patients have a d ischarge summary com- pleted, which is copied to their GP 53 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Preen 2005(Continued) Outcomes SF-12, patient satisfaction and views of the discharge process a nd GP views of the discharge planning process at 7 d postdischarge Notes - Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Unclear risk Not described Allocation concealment (selection bias) Low risk Described as an “allocation concealment technique” Blinding (performance bias and detection bias) All outcomes High risk Blinding for objective measures of outcome Incomplete outcome data (attrition bias)All outcomes Low risk 61/189 patients did not return surveys (32% drop-out), GP 70.
4% response rate at 7 d postdischarge Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk At discharge from hospital Rich 1993a Methods RCT Participants Patients aged 70 years, with CHF; patients were excluded if at low risk, resided outside the catchment area, discharged to a nursing home or long-term care facility, had other illnesses likely to result in readmission, denied consent, o r other logistic reasons Number of patients recruited: T = 63, C = 35 Mean age (SD): T = 80.0 years (6.3), C = 77.3 years (6.1) Sex (female): T = 38/63 (60%), C = 20/35 (57%) Ethnicity: number white T = 29/63, C = 20/35 Interventions Setting : Jewish Hospital at Washington University Medical Centre, U SA Pre-admission assessment : yes Case nding on admission : screened for CHF and strati ed into readmission risk categories Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : patients were visited daily by RN to discuss CHF using a bookl et developed for the trial and assess and discuss medications, providing a m edication card with timing and dosing of all drugs; dietary advice was provided by dietici an and study nurse, and patients were given a low-sodium diet Implementation of the discharge plan : a social care worker and member of the home care team met with patient to facilitate discharge planning and ease transition. Economic, 54 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Rich 1993a(Continued) social and transport problems were identi ed and managed. Th e home care nurse visited the patient at home within 48 h of hospital discharge and then 3 times in the rst week and at regular intervals thereafter; at each visit the teachin g materials, medication, and diet and activity guidelines were reinforced, and any new prob lems were discussed Monitoring : Study nurse contacted patients by phone, and patients were en couraged to call researchers or personal physician with any new problems or questions Control : all conventional treatments as requested by the patient’s a ttending physician.
These included social service evaluation, dietary and medical t eaching, home care and all other available hospital services. Control group receive d study education materials and formal assessment of medications. The social service consul tations and home care referrals were lower (29% versus 34%) Outcomes Length of stay, readmission to hospital, readmission days q uality of life, cost at 3 months follow-up Notes - Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk 2:1 treatment:control allocated Allocation concealment (selection bias) Unclear risk Not described Blinding (performance bias and detection bias) All outcomes Low risk For objective measures of outcome (readmission, mortality) Incomplete outcome data (attrition bias)All outcomes Low risk All patients randomised accounted for at follow-up Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data reported Rich 1995a Methods RCT Participants Patients aged ≥70 years, with con rmed heart failure and at least 1 of the foll owing risk factors for early readmission: prior history of heart failur e, 4 or more hospitalisations in the preceding 5 years, congestive heart failure precipitated b y acute MI or uncontrolled hypertension. Patients were excluded if resided outside catch ment area, planned discharge to a long-term care facility, severe dementia or psychiatric ill ness, life expectancy of less than 3 months, refused to participate or other logistic reaso ns Number recruited: T = 142, C = 140 Mean age (SD): T = 80.1 years (5,9), C = 78.4 years (6.1) 55 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Rich 1995a(Continued) Sex (female): T = 96/142 (68%), C = 83/140 (59%) Ethnicity: non-white 55% Living alone: T = 58/142 (41%), C = 62/140 (44%) Interventions Setting : Jewish Hospital at Washington University Medical Centre, U S Pre-admission assessment : no Case nding on admission : yes Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : included using a teaching booklet, individualised dietary a ssessment and instruction by a dietician with reinforcement by the cardiovascu lar research nurse, con- sultation with social services to facilitate discharge plannin g and care after discharge, assessment of medications by geriatric cardiologist, intens ive follow-up after discharge though the hospital’s home care services, plus individualise d home visits and telephone contact with the study team Implementation of the discharge plan : with social services Monitoring : not clear Control : received all standard treatment and services ordered by thei r primary physicians Outcomes Mortality, readmission to hospital, quality of life, cost at3 months follow-up. Quality of life and cost data were collected from a subgroup of patients onl y: quality of life = 126, cost = 57 Notes - Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Computer-generated list of random numbers Allocation concealment (selection bias) Low risk Neither patient nor members of the study team were aware of the treatment assignment until after randomisation Blinding (performance bias and detection bias) All outcomes Low risk For objective measures of outcome (mortality, readmissions an d death) Incomplete outcome data (attrition bias) All outcomes Low risk All patients randomised accounted for at follow-up Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data reported 56 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Shaw 2000 Methods RCT Participants Patients discharged from a psychiatric hospital or care of the elderly ward;patients were excluded if they were prescribed medication at discharge, receiv ed a primary diagnosis of drug or alcohol abuse or dementia, and refused home visits a fter discharge Number of patients recruited: T = 51, C = 46 Mean age (SD): 47 (17) Sex (female): 61 (63%) Interventions Setting : psychiatric hospital in South Glasgow, Scotland Pre-admission assessment : no Case nding on admission : no Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : pre-discharge assessment with a pharmacy checklist which assess ed patient’s knowledge and identi ed particular problems, such as therape utic drug monitoring, compliance aid requirements and side effects Implementation of the discharge plan : a pharmacy discharge plan was supplied to the patients’ community pharmacist for the intervention group Monitoring : not clear Control : care not described Outcomes Readmission to hospital, readmission due to non-compliance, m edication problems after being discharged from hospital Notes - Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Table of generated numbers with a randomised permuted block size of 6 Allocation concealment (selection bias) Low risk Randomisation by the project pharmacist Blinding (performance bias and detection bias) All outcomes High risk Not possible to blind patients Incomplete outcome data (attrition bias) All outcomes Unclear risk > 30% attrition at 12 weeks Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data reported 57 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Sulch 2000 Methods RCT Participants Patients admitted to the acute stroke unit and receiving rehabilitation, with persistent impairment and functional limitations. Patients were exclud ed if they had mild de cits or premorbid physical or cognitive disability Number recruited: integrated care pathway (ICP) = 76, multidis ciplinary team (MDT) = 76 Mean age (SD): ICP = 75 (11) years, MDT = 74 (10) years Interventions Setting : stroke rehabilitation unit at a teaching hospital in London , UK Pre-admission assessment : no Case nding on admission : no Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : rehabilitation and discharge planning, with regular revie w of discharge plan Implementation of the discharge plan : senior nurse implemented the ICP. Multidis- ciplinary training preceded implementation of the ICP. ICP wa s piloted for 3 months prior to recruitment to the trial.
Monitoring : not reported Control : multidisciplinary model of care in which patients’ progress d etermined goal setting, rather than short term goals being determined in ad vance. The care received by the control group was reviewed and a 3-month period of implemen tation was undertaken to exclude bias caused by a placebo effect of undertaking the tria l. Groups received comparable amounts of physiotherapy and occupational therapy Outcomes Hospital length of stay, discharge destination, mortality a t 26 weeks, mortality or insti- tutionalisation, activities of daily living index, anxiety and depression, quality of life Notes - Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Computer-generated list of randomised numbers Allocation concealment (selection bias) Low risk Randomisation of ce allocated patients to intervention or con - trol Blinding (performance bias and detection bias) All outcomes Low risk Participants and health professionals aware of allocation gr oup; low risk for objective outcomes (readmission, mortality and length of stay) Incomplete outcome data (attrition bias) All outcomes Low risk All patients randomised accounted for at follow-up Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data reported 58 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Weinberger 1996 Methods RCT Participants Patients with diabetes mellitus, HF, COPD; patients were excluded if already receiving care at a primary care clinic, residing or being discharged to nurs ing home, admitted for surgical procedure or cancer diagnosis, if cognitively impaired and had no care giver, and if had no access to a telephone Number of patients recruited: T = 695, C = 701 Mean age (SD): T = 63.0 years (11.1), C = 62.6 years (10.9) Sex (female): T = 7/695 (1%), 14/701 (2%) Interventions Setting : 9 Veterans Affairs hospitals, USA Pre-admission assessment : no Case nding on admission : no Inpatient assessment and preparation of a discharge plan ba sed on individual pa- tient needs : 3 d before discharge a primary nurse assessed the patient’s p ostdischarge needs. 2 d before discharge the primary care physician visited t he patient and discussed patient’s discharge plan with the hospital physician and revi ewed the patient. Primary nurse made an appointment for the patient to visit the primar y care clinic within 1 week of discharge Implementation of the discharge plan : patient provided with education materials and given a card with the names and beeper numbers of the primary car e nurse and physician.
Primary care nurse telephoned the patient within 2 working da ys after discharge. Primary care physician and primary nurse reviewed and updated the trea tment plan at the 1st postdischarge appointment Monitoring : not reported Control : did not have access to the primary care nurse and received no supp lementary education or assessment of needs beyond usual care Outcomes Readmission to hospital, health status, patient satisfacti on, intensity of primary care Notes Discharge planning within 3 d of discharge 9 VA hospitals participated in the trial Risk of bias Bias Authors’ judgement Support for judgement Random sequence generation (selection bias) Low risk Produced by statistical coordinating centre Allocation concealment (selection bias) Low risk Allocation made by telephoning the statistical coordinating ce n- tre Blinding (performance bias and detection bias) All outcomes Low risk Objective measures of outcome and telephone interviews Incomplete outcome data (attrition bias)All outcomes Low risk All patients randomised accounted for at follow-up 59 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Weinberger 1996(Continued) Selective reporting (reporting bias) Unclear risk Not able to judge from available information Baseline data Low risk Baseline data reported ADE : adverse drug event; ADL: activities of daily living; AGU: acute geriatric unit; AHCP: after-hospital care plan; AHCPR: Agency for Health Care Policy and Research; C: control; CHF: congestive heart failure; CM: case manager; COPD: chronic obstructive pul- monary disease; DA: discharge advocate; DC: discharge coordinator; DSM: Diagnostic and Statistical Manual of Mental Disorders; ED : emergency department; GEM: geriatric evaluation and management team; GP: general practitioner; HF: heart failure; IADL:
instrumental activities of daily living; ICP: integrated care pathway; MDT: Multidisciplinary team; MI: myocardial infarction; MM : mini-mental assessment; NCM: nurse care manager; NP: Nurse practitioner; OT: occupational therapist; PCP: primary care provider; PO: Primary outcome; PT: physiotherapist; RA: research assistant; RCT: randomised controlled trial; RED: re-engineered discharge; RN: registered nurse; SD: standard deviation; T: treatment; TIA: transient Ischaemic attack.
Characteristics of excluded studies [ordered by study ID] Study Reason for exclusion Applegate 1990 RCT: discharge planning plus geriatric assessment unit Brooten 1987 Discharge planning plus home care package Brooten 1994 Discharge planning plus home care package plus counselling Carty 1990 Early postpartum hospital discharge Casiro 1993 Intervention: discharge planning plus home care package Choong 2000 Intervention: clinical pathway for patients with a fractured n eck of femur, discharge planning is not described Cossette 2015 Intervention is focused on decreasing the number of emergency r oom visits, not discharge planning Donahue 1994 Intervention discharge planning plus postdischarge care package Dudas 2001 Intervention is focused on telephone follow-up, not discharge planning. Randomised to groups after discharge from hospital Englander 2014 Transitional care intervention; the only element of discharg e planning was primary care-medical home linkage Epstein 1990 RCT: consultative geriatric assessment and limited follow-u p Fretwell 1990 RCT: consultative inpatient multidisciplinary team care 60 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. (Continued) Gayton 1987 Controlled trial: inpatient geriatric consultation team Germain 1995 Geriatric assessment and intervention team Gillette 1991 Hospital-based case management team for neonatal intensive ca re González-Guerrero 2014 Control group given the same manual as intervention group atdischarge Haggmark 1997 Study design not clear Hansen 1992 RCT: follow-up home visits Hickey 2000 Patients in the intervention group received discharge planning from a nurse case manager, patients in the control group received discharge planning on request Hogan 1990 Controlled trial of geriatric consultation team and follow-u p after discharge Jenkins 1996 RCT: discharge teaching book Karppi 1995 Discharge planning plus geriatric assessment unit Kleinpell 2004 Intervention and control groups received discharge planning, the intervention group also received a discharge planning questionnaire Kravitz 1994 Nested cohort study of postdischarge follow-up Lande eld 1995 Special unit plus rehabilitation Linden 2014 1. Multidimensional intervention, based on the transition al care model 2. Control group also received discharge planning Lof er 2014 Medication review only, not discharge planning Martin 1994 RCT of discharge planning plus hospital at home Marusic 2013 Intervention was standardised to all patients; no individu al assessment done McGrory 1994 Assessed primary nursing and discharge teaching McInnes 1999 Both groups received discharge planning, intervention group also received GP input to discharge planning process Melin 1993 Postdischarge care Melin 1995a RCT (secondary analysis); in-home primary care Melin 1995b Postdischarge care 61 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. (Continued) Murray 1995 Controlled trial; communication between hospital and home Naylor 1999 RCT. Discharge planning and home follow-up. Naylor 2004 Complex package of care; main emphasis was not on discharge plan ning Nickerson 2005 No results reported for the control group Nikolaus 1995 Pilot study for comprehensive geriatric assessment Reuben 1995 RCT of comprehensive geriatric assessment in HMO setting Rich 1993b Pilot study of discharge planning plus home care package Rich 1995b Discharge planning plus home care package Rubenstein 1984 Discharge planning plus geriatric assessment unit Saleh 2012 Postdischarge care Saltz 1988 RCT: effect of geriatric consultation team on discharge placement Shah 2013 Intervention was standardised to all patients; no individual assessment done Sharif 2014 Intervention solely focused on providing education and infor mation Shyu 2010 Multifaceted intervention which included a home care component Siu 1996 Geriatric assessment started at hospital and continued at home Smith 1988 RCT: postdischarge intervention to reduce non-elective readmi ssion Thomas 1993 RCT: comprehensive geriatric consultation team Townsend 1988 Postdischarge care Tseng 2012 Intervention included a large component of rehabilitation that was not available to the control group Victor 1988 Augmented home help scheme Voirol 2004 Intervention was standardised to all patients; no individual assessment done Winograd 1993 RCT: inpatient interdisciplinary geriatric assessment team Yeung 2012 Multidimensional intervention, based on the transitional care model 62 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. HMO: health maintenance organisation; RCT: randomised controlled trial.
Characteristics of ongoing studies [ordered by study ID] NCT02112227 Trial name or title Patient-centered Care Transitions in Heart Failure (PACT-HF) Methods Single blind parallel randomised control trial Participants Setting: Canada Inclusion criteria: aged ≥16 years and hospitalised with HF Main exclusion criterion: transferred to another hospital Interventions Intervention: pre-discharge needs assessment; self-care educa tion; comprehensive discharge summary; referral to HF clinic and nurse-led home care Control: care as usual Outcomes Main outcomes: all-cause readmission rate at 30d; 6m composite a ll-cause death, readmission, or emergency room visit Starting date July 2014 Contact information - Notes Estimated completion date December 2017 ClinicalTrials.gov Identi er: NCT02112227 NCT02202096 Trial name or title Comprehensive Transitional Care Program for Colorectal Can cer Patients Methods Parallel randomised control trial (pilot) Participants Setting: safety-net hospital, USA Inclusion criteria: aged≥18 years, diagnosis of colorectal cancer and undergoing surgery for either palliative cure or palliation Main exclusion criteria: patients not expected to survive Interventions Intervention: pre-discharge needs assessment; medication re conciliation; visit before discharge; comprehensive discharge summary; direct communication with primary care team; co-ordination of follow-up visits; phone call within 24h of discharge Control: care as usual Outcomes Main outcome: readmission and emergency room visits rate at 30 d Starting date February 2015 Contact information - 63 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. NCT02202096(Continued) Notes Estimated completion date February 2016 ClinicalTrials.gov Identi er: NCT02202096 NCT02295319 Trial name or title The Impact of Individual-based Discharges From Acute Admission Units to Home Methods Open label parallel randomised control trial Participants Setting: acute admission unit, Denmark Inclusion criteria: aged≥18 years, medicine diagnosis, discharged home, ≥admission last year, planned follow-up after discharge (GP, home care, outpatient clinic) Main exclusion criterion: cognitively impaired, not local Interventions Intervention: provision of information and establishment of a discharge plan with the patient; phone interview within 48 h of discharge Control: care as usual Outcomes Main outcome: readmission rate at 30 d Starting date November 2014 Contact information - Notes Estimated completion date December 2015 ClinicalTrials.gov Identi er: NCT02295319 NCT02351648 Trial name or title Randomised Control Trial of a Transitional Care Model Methods Single blind parallel randomised control trial Participants Setting: general hospital, Singapore Inclusion criteria: aged ≥21 years and > 1 admission last 90 d Main exclusion criteria: not local or discharged to long-term care facility; not able to provide informed consent; requires acute treatment or waiting for surgery; primary tea m consultant not participating in research Interventions Intervention: pre-discharge needs assessment; comprehensiv e discharge summary; home/phone visit within 48 h of discharge; subsequent contact as needed; research team av ailable for phone inquiries Control: care as usual Outcomes Main outcome: readmission rate at 30 d Starting date October 2012 Contact information - 64 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. NCT02351648(Continued) Notes Completed December 2014 ClinicalTrials.gov Identi er: NCT02351648 NCT02388711 Trial name or title Comprehensive Transitional Care Program for Colorectal Can cer Patients Methods Single blinded parallel randomised control trial Participants Setting: US Inclusion criteria: aged≥65 years, diagnosis of dementia, informal care giver availab le for regular contact, English-speaking, access to telephone Main exclusion criteria: discharged to institutional setting , moderate-high alcohol intake, other complex health issues Interventions Intervention: nurse case manager; inpatient meeting before discharge; 1-4 postdischarge phone calls Control: care as usual Outcomes Change from baseline in rehospitalisation at 14, 30 and 90 d Starting date March 2015 Contact information - Notes Estimated completion date March 2019 ClinicalTrials.gov Identi er: NCT02388711 NCT02421133 Trial name or title Transitional Care Program on 30-Day Hospital Readmissions f or Elderly Patients Discharged From a Short Stay Geriatric Ward (PROUST) Methods Open label parallel stepped wedge randomised control trial Participants Setting: acute geriatric service, France Inclusion criteria: aged ≥75 years, admitted for > 48 h, discharged home, at risk of readm ission/ER visit Main exclusion criteria: hospital at home, not local Interventions Intervention: pre-discharge needs assessment; medication re conciliation; comprehensive discharge summary with medication review; direct communication with primary care t eam and scheduling of follow-up appoint- ment within 30 d of discharge; phone call and home visits for 4 we eks postdischarge Control: care as usual Outcomes Main outcome: unscheduled readmission and emergency room visi ts rate at 30 d Starting date May 2015 65 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. NCT02421133(Continued) Contact information - Notes Estimated completion date August 2018 ClinicalTrials.gov Identi er: NCT02421133 ER : emergency room; HF: heart failure. 66 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. D A T A A N D A N A L Y S E S Comparison 1. Effect of discharge planning on hospital length of stay Outcome or subgroup titleNo. of studies No. of participants Statistical method Effect size 1 Hospital length of stay - older patients with a medical condition 12 2193 Mean Difference (IV, Fixed, 95% CI) -0.73 [-1.33, -0.12] 2 Sensitivity analysis imputingmissing SD for Kennedy trial 11 1825 Mean Difference (IV, Fixed, 95% CI) -0.98 [-1.57, -0.38] 3 Hospital length of stay - oldersurgical patients 2 184 Mean Difference (IV, Fixed, 95% CI) -0.06 [-1.23, 1.11] 4 Hospital length of stay - oldermedical and surgical patients 2 1108 Mean Difference (IV, Fixed, 95% CI) -0.60 [-2.38, 1.18] Comparison 2. Effect of discharge planning on unscheduled readmissi on rates Outcome or subgroup titleNo. of studies No. of participants Statistical method Effect size 1 Within 3 months of discharge from hospital 17 4853 Risk Ratio (M-H, Fixed, 95% CI) 0.88 [0.79, 0.97] 1.1 Unscheduled readmission for those with a medical condition 15 4743 Risk Ratio (M-H, Fixed, 95% CI) 0.87 [0.79, 0.97] 1.2 Older people admitted to hospital following a fall 2 110 Risk Ratio (M-H, Fixed, 95% CI) 1.36 [0.46, 4.01] 2 Patients with medical or surgical condition Other data No numeric data 3 Patients with a medical condition Other data No numeric data 4 Patients who have had surgery Other data No numeric data 5 Patients with a mental healthdiagnosis Other data No numeric data 67 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Comparison 3. Effect of discharge planning on days in hospital due to unscheduled readmission Outcome or subgroup titleNo. of studies No. of participants Statistical method Effect size 1 Patients with a medical condition Other data No numeric data 2 Patients with a medical or surgical condition Other data No numeric data 3 Patients with a surgical condition Other data No numeric data Comparison 4. Effect of discharge planning on patients’ place of dis charge Outcome or subgroup titleNo. of studies No. of participants Statistical method Effect size 1 Patients discharged from hospital to home 2 419 Risk Ratio (M-H, Fixed, 95% CI) 1.03 [0.93, 1.14] 2 Patients with a medical condition Other data No numeric data 3 Patients with a medical orsurgical condition Other data No numeric data 4 Older patients admitted tohospital following a fall in residential care at 1 year 1 60 Odds Ratio (M-H, Fixed, 95% CI) 0.46 [0.15, 1.40] Comparison 5. Effect of discharge planning on mortality Outcome or subgroup title No. of studies No. of participants Statistical method Effect size 1 Mortality at 6 to 9 months 8 2654 Risk Ratio (M-H, Fixed, 95% CI) 1.02 [0.83, 1.27] 1.1 Older people with a medical condition 7 2594 Risk Ratio (M-H, Fixed, 95% CI) 1.02 [0.82, 1.27] 1.2 Older people admitted to hospital following a fall 1 60 Risk Ratio (M-H, Fixed, 95% CI) 1.33 [0.33, 5.45] 2 Mortality for trials recruiting both patients with a medical condition and those recovering from surgery Other data No numeric data 3 Mortality at 12 months Other data No numeric data 68 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Comparison 6. Effect of discharge planning on patient health outcomes Outcome or subgroup titleNo. of studies No. of participants Statistical method Effect size 1 Patient-reported outcomes:
Patients with a medical condition Other data No numeric data 2 Patient-reported outcomes:Patients with a surgical condition Other data No numeric data 3 Patient-reported outcomes:Patients with a medical or surgical condition Other data No numeric data 4 Falls at follow-up: patientsadmitted to hospital following a fall 1 60 Risk Ratio (M-H, Fixed, 95% CI) 0.87 [0.50, 1.49] 5 Patient-reported outcomes:
Patients with a mental health diagnosis Other data No numeric data Comparison 7. Effect of discharge planning on satisfaction with ca re process Outcome or subgroup titleNo. of studies No. of participants Statistical method Effect size 1 Satisfaction Other data No numeric data 1.1 Patient and care givers’ satisfaction Other data No numeric data 1.2 Professional’s satisfaction Other data No numeric data Comparison 8. Effect of discharge planning on hospital care costs Outcome or subgroup title No. of studies No. of participants Statistical method Effect size 1 Patients with a medical condition Other data No numeric data 2 Patients with a surgical condition Other data No numeric data 3 Patients with a mental health diagnosis Other data No numeric data 4 Patients admitted to a generalmedical service Other data No numeric data 5 Hospital outpatient departmentattendance 1 288 Risk Ratio (M-H, Fixed, 95% CI) 1.07 [0.74, 1.56] 69 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. 6 First visits to the emergencyroom 2 740 Risk Ratio (M-H, Fixed, 95% CI) 0.80 [0.61, 1.07] Comparison 9. Effect of discharge planning on primary and communit y care costs Outcome or subgroup titleNo. of studies No. of participants Statistical method Effect size 1 Patients with a medical condition Other data No numeric data Comparison 10. Effect of discharge planning on medication use Outcome or subgroup title No. of studies No. of participants Statistical method Effect size 1 Medication problems after being discharged from hospital Other data No numeric data 2 Adherence to medicines Other data No numeric data 3 Knowledge about medicines Other data No numeric data 4 Hoarding of medicines Other data No numeric data 5 Prescription errors Other data No numeric data 6 Medication appropriateness Other data No numeric data 70 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Analysis 1.1. Comparison 1 Effect of discharge planning on hospital length of stay, Outcome 1 Hospital length of stay - older patients with a medical condition.
Review: Discharge planning from hospital Comparison: 1 Effect of discharge planning on hospital lengt h of stay Outcome: 1 Hospital length of stay - older patients with a med ical condition Study or subgroup Discharge planning Control Mean Difference Weight Mean Difference N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI Kennedy 1987 39 7.8 (0) 41 9.7 (0) Not estimable Moher 1992 136 7.43 (6.33) 131 9.4 (8.97) 10.5 % -1.97 [ -3.84, -0.10 ] Naughton 1994 51 5.4 (5.5) 60 7 (7) 6.8 % -1.60 [ -3.93, 0.73 ] Naylor 1994 72 7.4 (3.8) 66 7.5 (5.2) 15.6 % -0.10 [ -1.63, 1.43 ] Harrison 2002 92 7.59 (8.36) 100 7.67 (7.99) 6.8 % -0.08 [ -2.40, 2.24 ] Rich 1993a 63 4.3 (8.8) 35 5.7 (12) 1.8 % -1.40 [ -5.93, 3.13 ] Rich 1995a 142 3.9 (10) 140 6.2 (11.4) 5.8 % -2.30 [ -4.80, 0.20 ] Preen 2005 91 11.6 (5.7) 98 12.4 (7.4) 10.4 % -0.80 [ -2.68, 1.08 ] Sulch 2000 76 50 (19) 76 45 (23) 0.8 % 5.00 [ -1.71, 11.71 ] Laramee 2003 131 5.5 (3.5) 125 6.4 (5.2) 30.8 % -0.90 [ -1.99, 0.19 ] Lindpaintner 2013 30 12.2 (6.7) 30 12.4 (5.7) 3.7 % -0.20 [ -3.35, 2.95 ] Gillespie 2009 182 11.9 (13) 186 10.5 (9.3) 6.9 % 1.40 [ -0.91, 3.71 ] Total (95% CI) 1105 1088 100.0 % -0.73 [ -1.33, -0.12 ] Heterogeneity: Chi 2 = 11.04, df = 10 (P = 0.35); I 2 =9% Test for overall effect: Z = 2.35 (P = 0.019) Test for subgroup differences: Not applicable -10 -5 0 5 10 Favours treatment Favours control 71 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Analysis 1.2. Comparison 1 Effect of discharge planning on hospital length of stay, Outcome 2 Sensitivity analysis imputing missing SD for Kennedy trial.
Review: Discharge planning from hospital Comparison: 1 Effect of discharge planning on hospital lengt h of stay Outcome: 2 Sensitivity analysis imputing missing SD for Ken nedy trial Study or subgroup Discharge planning Control Mean Difference Weight Mean Difference N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI Harrison 2002 92 7.59 (8.36) 100 7.67 (7.99) 6.7 % -0.08 [ -2.40, 2.24 ] Kennedy 1987 39 7.8 (3.8) 41 9.7 (5.2) 9.1 % -1.90 [ -3.89, 0.09 ] Laramee 2003 131 5.5 (3.5) 125 6.4 (5.2) 30.1 % -0.90 [ -1.99, 0.19 ] Lindpaintner 2013 30 12.2 (6.7) 30 12.4 (5.7) 3.6 % -0.20 [ -3.35, 2.95 ] Moher 1992 136 7.43 (6.33) 131 9.4 (8.97) 10.3 % -1.97 [ -3.84, -0.10 ] Naughton 1994 51 5.4 (5.5) 60 7 (7) 6.6 % -1.60 [ -3.93, 0.73 ] Naylor 1994 72 7.4 (3.8) 66 7.5 (5.2) 15.3 % -0.10 [ -1.63, 1.43 ] Preen 2005 91 11.6 (5.7) 98 12.4 (7.4) 10.2 % -0.80 [ -2.68, 1.08 ] Rich 1993a 63 4.3 (8.8) 35 5.7 (12) 1.7 % -1.40 [ -5.93, 3.13 ] Rich 1995a 142 3.9 (10) 140 6.2 (11.4) 5.7 % -2.30 [ -4.80, 0.20 ] Sulch 2000 76 50 (19) 76 45 (23) 0.8 % 5.00 [ -1.71, 11.71 ] Total (95% CI) 923 902 100.0 % -0.98 [ -1.57, -0.38 ] Heterogeneity: Chi 2 = 8.47, df = 10 (P = 0.58); I 2 =0.0% Test for overall effect: Z = 3.20 (P = 0.0014) Test for subgroup differences: Not applicable -10 -5 0 5 10 Favours experimental Favours control 72 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Analysis 1.3. Comparison 1 Effect of discharge planning on hospital length of stay, Outcome 3 Hospital length of stay - older surgical patients.
Review: Discharge planning from hospital Comparison: 1 Effect of discharge planning on hospital lengt h of stay Outcome: 3 Hospital length of stay - older surgical patients Study or subgroup Discharge planning Control Mean Difference Weight Mean Difference N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI Naylor 1994 68 15.8 (9.4) 66 14.8 (8.3) 15.2 % 1.00 [ -2.00, 4.00 ] Lin 2009 26 6.04 (2.41) 24 6.29 (2.17) 84.8 % -0.25 [ -1.52, 1.02 ] Total (95% CI) 94 90 100.0 % -0.06 [ -1.23, 1.11 ] Heterogeneity: Chi 2 = 0.57, df = 1 (P = 0.45); I 2 =0.0% Test for overall effect: Z = 0.10 (P = 0.92) Test for subgroup differences: Not applicable -10 -5 0 5 10 Favours treatment Favours control Analysis 1.4. Comparison 1 Effect of discharge planning on h ospital length of stay, Outcome 4 Hospital length of stay - older medical and surgical patients.
Review: Discharge planning from hospital Comparison: 1 Effect of discharge planning on hospital lengt h of stay Outcome: 4 Hospital length of stay - older medical and surgic al patients Study or subgroup Discharge planning Control Mean Difference Weight Mean Difference N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI Hendriksen 1990 135 11 (0) 138 14.3 (0) Not estimable Evans 1993 417 11.9 (12.7) 418 12.5 (13.5) 100.0 % -0.60 [ -2.38, 1.18 ] Total (95% CI) 552 556 100.0 % -0.60 [ -2.38, 1.18 ] Heterogeneity: not applicable Test for overall effect: Z = 0.66 (P = 0.51) Test for subgroup differences: Not applicable -10 -5 0 5 10 Favours treatment Favours control 73 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Analysis 2.1. Comparison 2 Effect of discharge planning on unscheduled readmission rates, Outcome 1 Within 3 months of discharge from hospital.
Review: Discharge planning from hospital Comparison: 2 Effect of discharge planning on unscheduled re admission rates Outcome: 1 Within 3 months of discharge from hospital Study or subgroup Treatment Control Risk Ratio Weight Risk R atio n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI 1 Unscheduled readmission for those with a medical condition Balaban 2008 4/47 4/49 0.6 % 1.04 [ 0.28, 3.93 ] Farris 2014 49/281 47/294 7.6 % 1.09 [ 0.76, 1.57 ] Goldman 2014 89/347 77/351 12.6 % 1.17 [ 0.90, 1.53 ] Harrison 2002 23/80 31/77 5.2 % 0.71 [ 0.46, 1.11 ] Jack 2009 47/370 59/368 9.8 % 0.79 [ 0.56, 1.13 ] Kennedy 1987 11/39 14/40 2.3 % 0.81 [ 0.42, 1.55 ] Lainscak 2013 25/118 43/135 6.6 % 0.67 [ 0.43, 1.02 ] Laramee 2003 49/131 46/125 7.8 % 1.02 [ 0.74, 1.40 ] Legrain 2011 64/317 99/348 15.6 % 0.71 [ 0.54, 0.93 ] Moher 1992 22/136 18/131 3.0 % 1.18 [ 0.66, 2.09 ] Naylor 1994 11/72 11/70 1.8 % 0.97 [ 0.45, 2.10 ] Nazareth 2001 64/164 69/176 11.0 % 1.00 [ 0.76, 1.30 ] Rich 1993a 21/63 16/35 3.4 % 0.73 [ 0.44, 1.20 ] Rich 1995a 41/142 59/140 9.8 % 0.69 [ 0.50, 0.95 ] Shaw 2000 5/51 12/46 2.1 % 0.38 [ 0.14, 0.99 ] Subtotal (95% CI) 2358 2385 99.2 % 0.87 [ 0.79, 0.97 ] Total events: 525 (Treatment), 605 (Control) Heterogeneity: Chi 2 = 19.52, df = 14 (P = 0.15); I 2 =28% Test for overall effect: Z = 2.65 (P = 0.0080) 2 Older people admitted to hospital following a fall Lin 2009 2/26 2/24 0.3 % 0.92 [ 0.14, 6.05 ] Pardessus 2002 5/30 3/30 0.5 % 1.67 [ 0.44, 6.36 ] 0.1 0.2 0.5 1 2 5 10 Favours treatment Favours control (Continued . . .) 74 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. (. . . Continued ) Study or subgroup Treatment Control Risk Ratio Weight Risk R atio n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI Subtotal (95% CI) 56 54 0.8 % 1.36 [ 0.46, 4.01 ] Total events: 7 (Treatment), 5 (Control) Heterogeneity: Chi 2 = 0.25, df = 1 (P = 0.62); I 2 =0.0% Test for overall effect: Z = 0.56 (P = 0.57) Total (95% CI) 2414 2439 100.0 % 0.88 [ 0.79, 0.97 ] Total events: 532 (Treatment), 610 (Control) Heterogeneity: Chi 2 = 20.40, df = 16 (P = 0.20); I 2 =22% Test for overall effect: Z = 2.57 (P = 0.010) Test for subgroup differences: Chi 2 = 0.65, df = 1 (P = 0.42), I 2 =0.0% 0.1 0.2 0.5 1 2 5 10 Favours treatment Favours control Analysis 2.2. Comparison 2 Effect of discharge planning on u nscheduled readmission rates, Outcome 2 Patients with medical or surgical condition.
Patients with medical or surgical condition Study Readmission rates Notes Evans 1993 At 4 weeks: T = 103/417 (24%), C = 147/418 (35%) Difference −10.5%; 95% CI −16.6% to −4.3%, P < 0.001 At 9 months: T = 229/417 (55%), C = 254/418 (61%) Difference −5.8%; 95% CI −12.5% to 0.84%, P = 0.08 - Analysis 2.3. Comparison 2 Effect of discharge planning on u nscheduled readmission rates, Outcome 3 Patients with a medical condition.
Patients with a medical condition Study Readmission rates Notes Farris 2014 At 30 d:
I = 47/281 (17%), C = 43/294 (15%) Difference 2%; 95% CI −0.04% to 0.08% At 90 d:
ET = 49/281 (17%), C = 47/294 (16%) Difference 1%; 95% CI −5% to 8% - Gillespie 2009 At 12 months:
I = 106/182 (58.2%), C = 110/186 (59.1%) - 75 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Patients with a medical condition(Continued) Difference −0.9%, 95% CI −10.9% to 9.1% Goldman 2014 At 30 d:
I = 50/347 (14%), C = 47/351 (13%) Difference 1%; 95% CI −4% to 6% At 90 d:
I = 89/347 (26%), C = 77/351 (22%) Difference 3.7%; 95% CI −2.6% to 10% Data provided by the trialists Kennedy 1987 At 1 week:
I = 2/38 (5%), C = 8/40 (20%) Difference −15%; 95% CI −29% to −0.4% At 8 weeks: I = 11/39 (28%), C = 14/40 (35%) Difference −7%; 95% CI −27.2% to 13.6% - Lainscak 2013 At 90 d:
COPD −related I = 14/118 (12%), C = 33/135 (24%) Difference 12%; 95% CI 3% to 22% All-cause readmission T = 25/118 (21%), C = 43/135 (32%) Difference 11%; 95% CI −0.3% to 21% Data provided by the trialists; data also available for 30− and 180 −d Laramee 2003 At 90 d:
T = 49/131 (37%), C = 46/125 (37%), P > 0.99 Readmission days: T= 6.9 (SD 6.5), C = 9.5 (SD 9.8) - Moher 1992 At 2 weeks:T = 22/136 (16%), C = 18/131 (14%) Difference 2%; 95% CI −6% to 11%, P = 0.58 - Naylor 1994 Within 45-90 d:
T = 11/72 (15%), C = 11/70 (16%) Difference 1%; 95% CI −8% to 12% Authors also report readmission data for 2-6 weeks fol- low up Nazareth 2001 At 90 d:
T = 64/164 (39%), C = 69/176 (39.2%) Difference 0.18; 95% CI −10.6% to 10.2% At 180 d: T = 38/136 (27.9%), C = 43/151 (28.4%) Difference 0.54; 95% CI −11 to 9.9% - Shaw 2000 At 90 d:
T = 5/51 (10%), C = 12/46 (26%) OR 3.25; 95% CI 0.94 to 12.76, P = 0.06 Authors also report data for readmission due to non- compliance with medication At 3 months: T = 4/51 (8%), C = 7/46 (15%) Difference −7%; 95% CI −0.2 to 0.05 76 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Patients with a medical condition(Continued) Weinberger 1996 Number of readmissions per month T = 0.19 (+ 0.4) (n = 695), C = 0.14 (+ 0.2), P = 0.005 (n = 701) At 6 months:
T = 49%, C = 44%, P = 0.06 Treatment group readmitted ’sooner’ (P = 0.07) Non-parametric test used to calculate P values for monthly readmissions Analysis 2.4. Comparison 2 Effect of discharge planning on u nscheduled readmission rates, Outcome 4 Patients who have had surgery.
Patients who have had surgery Study Readmission rates Notes Naylor 1994 Within 6 to 12 weeks: T = 7/68 (10%), C = 5/66 (7%) Difference 3%; 95% CI 7% to 13% - Analysis 2.5. Comparison 2 Effect of discharge planning on u nscheduled readmission rates, Outcome 5 Patients with a mental health diagnosis.
Patients with a mental health diagnosis Study Readmissions Mean time to readmission Naji 1999 At 6 months: T = 33/168 (19.6%), C = 48/175 (27%) Difference 7.4%; 95% CI −1.1% to 16.7% Mean time to readmission T = 161 d, C = 153 d Analysis 3.1. Comparison 3 Effect of discharge planning on d ays in hospital due to unscheduled readmission, Outcome 1 Patients with a medical condition.
Patients with a medical condition Study Days in hospital Notes Naylor 1994 Medical readmission days 2 weeks: T = 21 d (n = 72), C = 73 d (n = 70) Difference −52 d; 95% CI −78 to −26 2 to 6 weeks: T = 16 d (n = 72), C = 49 d (n = 70) Difference −33 d; 95% CI −53 to −13 6 to 12 weeks: T = 94 d (n = 72), C = 100 d (n = 70) Difference −6 d; 95% CI −83 to 71 Weinberger 1996 Medical readmission days at 6 months follow up: T = 10.2 (19.8), C = 8.8 (19.7) difference 1.4 d, P = 0.04 - 77 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Analysis 3.2. Comparison 3 Effect of discharge planning on days in hospital due to unscheduled readmission, Outcome 2 Patients with a medical or surgical condition.
Patients with a medical or surgical condition Study Days in hospital Notes Evans 1993 Readmission days at 9 months: T = 10.1 ± 8.3, C = 12.1 ± 9.1, P = 0.001; 95% CI − 3.18 to −0.82 - Hendriksen 1990 T = 15.5 d per readmission C = 13.5 d per readmission P > 0.05 Not possible to calculate exact P Rich 1993a Days to rst readmission Overall: T = 31.8 (5.1) (n = 63), C = 42.1 (7.3) (n = 35)Moderate-risk group: T = 35.1 (9.0) (n = 40), C = 28.
6 (7.2) (n = 21) High-risk group: T = 27.8 (3.5) (n = 23), C = 50.2 (10.
5) (n = 14) - Analysis 3.3. Comparison 3 Effect of discharge planning on d ays in hospital due to unscheduled readmission, Outcome 3 Patients with a surgical condition.
Patients with a surgical condition Study Days in hospital Notes Naylor 1994 Surgical readmission days 2 weeks: T = 34 d (n = 68), C = 32 d (n = 66) Difference 2 d; 95% CI −13 to 17 2 to 6 weeks: T = 63 (n = 68), C = 52 (n = 66) Difference 11 d; 95% CI −20 to 52 6 to 12 weeks: T = 52 (n = 68), C = 26 (n = 66) Difference 26 d; 95% CI −8 to 60 - 78 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Analysis 4.1. Comparison 4 Effect of discharge planning on patients’ place of discharge, Outcome 1 Patients discharged from hospital to home.
Review: Discharge planning from hospital Comparison: 4 Effect of discharge planning on patients’ plac e of discharge Outcome: 1 Patients discharged from hospital to home Study or subgroup Inter vention Control group Risk Ratio Wei ght Risk Ratio n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI Moher 1992 111/136 104/131 66.2 % 1.03 [ 0.91, 1.16 ] Sulch 2000 56/76 54/76 33.8 % 1.04 [ 0.85, 1.26 ] Total (95% CI) 212 207 100.0 % 1.03 [ 0.93, 1.14 ] Total events: 167 (Inter vention), 158 (Control group) Heterogeneity: Chi 2 = 0.01, df = 1 (P = 0.94); I 2 =0.0% Test for overall effect: Z = 0.58 (P = 0.56) Test for subgroup differences: Not applicable 0.1 0.2 0.5 1 2 5 10 Favours treatment Favours control Analysis 4.2. Comparison 4 Effect of discharge planning on p atients’ place of discharge, Outcome 2 Patients with a medical condition.
Patients with a medical condition Study Place of discharge Notes Goldman 2014 Discharged to an institutional setting:
T = 19/347 (5.5%), C = 9/352 (2.6%) Difference 2.9%; 95% CI −0.04% to 6% - Kennedy 1987 At 2 weeks:
87% no change in placement from time of discharge to 2-week follow-up time (both groups) At 4 weeks: majority no change (both groups) No data shown Legrain 2011 Discharged home or to a nursing home:
T = 183/317 C = 191/348 - Lindpaintner 2013 Discharged home T = 25/30 (83%), C = 30/30 (100%) Difference 17%, 95% CI 2 to 34% - Moher 1992 Discharged home:T = 111/136 (82%), C = 104/131 (79%) Difference 2.2%; 95% CI −7.3% to 11.7% - 79 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Patients with a medical condition(Continued) Naughton 1994 Discharged to nursing home:
T = 3/51 (5.9%) C = 2/60 (3.3%) Difference 2.5%; 95% CI −5.3% to 10.4% - Sulch 2000 Discharged home:
T = 56/76 (74%), C = 54/76 (71%) Discharged to an institution: T = 10/76 (13%), C = 16/76 (21%) OR 1.5; 95% CI 0.5 to 2.8 - Analysis 4.3. Comparison 4 Effect of discharge planning on p atients’ place of discharge, Outcome 3 Patients with a medical or surgical condition.
Patients with a medical or surgical condition Study Place of discharge Notes Evans 1993 Discharged to home: T = 330/417 (79%), C = 305/418 (73%) P = 0.04 difference 6%; 95% CI 0.39% to 12% Home at 9 months: T = 259/417 (62%), C = 225/418 (54%) P = 0.01 difference 8.3%; 95% CI 1.6% to 15% - Hendriksen 1990 Discharged to nursing home:T = 0/135 (0%), C = 3/138 (2%) Difference −2%; 95% CI −4.6% to 0.26% At 6 months: admitted to another institution T = 3/135 (2%), C = 14/138 (10%) Difference -8%; 95% CI −13.5% to −2.3% - 80 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Analysis 4.4. Comparison 4 Effect of discharge planning on patients’ place of discharge, Outcome 4 Older patients admitted to hospital following a fall in residenti al care at 1 year.
Review: Discharge planning from hospital Comparison: 4 Effect of discharge planning on patients’ plac e of discharge Outcome: 4 Older patients admitted to hospital following a fa ll in residential care at 1 year Study or subgroup Discharge planning Control group Odds Rat io Weight Odds Ratio n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI Pardessus 2002 7/30 12/30 100.0 % 0.46 [ 0.15, 1.40 ] Total (95% CI) 30 30 100.0 % 0.46 [ 0.15, 1.40 ] Total events: 7 (Discharge planning), 12 (Control group) Heterogeneity: not applicable Test for overall effect: Z = 1.37 (P = 0.17) Test for subgroup differences: Not applicable 0.01 0.1 1 10 100 Favours experimental Favours control Analysis 5.1. Comparison 5 Effect of discharge planning on m ortality, Outcome 1 Mortality at 6 to 9 months.
Review: Discharge planning from hospital Comparison: 5 Effect of discharge planning on mor tality Outcome: 1 Mor tality at 6 to 9 months Study or subgroup Treatment Control Risk Ratio Weight Risk R atio n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI 1 Older people with a medical condition Goldman 2014 10/347 6/351 4.3 % 1.69 [ 0.62, 4.59 ] Lainscak 2013 11/118 13/135 8.7 % 0.97 [ 0.45, 2.08 ] Laramee 2003 13/131 15/125 11.0 % 0.83 [ 0.41, 1.67 ] Legrain 2011 56/317 65/348 44.4 % 0.95 [ 0.68, 1.31 ] Nazareth 2001 22/137 19/151 12.9 % 1.28 [ 0.72, 2.25 ] Rich 1995a 13/142 17/140 12.3 % 0.75 [ 0.38, 1.49 ] Sulch 2000 10/76 6/76 4.3 % 1.67 [ 0.64, 4.36 ] Subtotal (95% CI) 1268 1326 97.9 % 1.02 [ 0.82, 1.27 ] 0.1 0.2 0.5 1 2 5 10 Favours treatment Favours control (Continued . . .) 81 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. (. . . Continued ) Study or subgroup Treatment Control Risk Ratio Weight Risk R atio n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI Total events: 135 (Treatment), 141 (Control) Heterogeneity: Chi2 = 3.89, df = 6 (P = 0.69); I 2 =0.0% Test for overall effect: Z = 0.16 (P = 0.87) 2 Older people admitted to hospital following a fall Pardessus 2002 4/30 3/30 2.1 % 1.33 [ 0.33, 5.45 ] Subtotal (95% CI) 30 30 2.1 % 1.33 [ 0.33, 5.45 ] Total events: 4 (Treatment), 3 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.40 (P = 0.69) Total (95% CI) 1298 1356 100.0 % 1.02 [ 0.83, 1.27 ] Total events: 139 (Treatment), 144 (Control) Heterogeneity: Chi 2 = 4.03, df = 7 (P = 0.78); I 2 =0.0% Test for overall effect: Z = 0.22 (P = 0.82) Test for subgroup differences: Chi 2 = 0.14, df = 1 (P = 0.71), I 2 =0.0% 0.1 0.2 0.5 1 2 5 10 Favours treatment Favours control Analysis 5.2. Comparison 5 Effect of discharge planning on m ortality, Outcome 2 Mortality for trials recruiting both patients with a medical condition and those recovering from surgery.
Mortality for trials recruiting both patients with a medica l condition and those recovering from surgery Study Mortality at 9 months Notes Evans 1993 T = 66/417 (16%) C = 67/418 (16%) - Analysis 5.3. Comparison 5 Effect of discharge planning on m ortality, Outcome 3 Mortality at 12 months.
Mortality at 12 months Study Mortality at 12 months Notes Gillespie 2009 T: 57/182 (31%); C: 61/186 (33%) Difference −2%, 95% CI −11% to 8% 82 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Analysis 6.1. Comparison 6 Effect of discharge planning on patient health outcomes, Outcome 1 Patient- reported outcomes: Patients with a medical condition.
Patient-reported outcomes: Patients with a medical condit ion Study Patient health outcomes Notes Harrison 2002 SF-36 Baseline Physical component T = 28.63 (SD 9.46) N = 78 C = 28.35 (SD 9.11) N = 78 Mental component T = 50.49 (SD 12.45) N = 78 C = 49.81 (SD 11.36) N = 78 At 12 weeks Physical component T = 32.05 (SD 11.81) N = 77 C = 28.31 (SD 10.0) N = 74 Mental component T = 53.94 (SD 12.32) N = 78 C = 51.03 (SD 11.51) N = 78 Minnesota Living with Heart Failure Questionnaire (MLHFQ) At 12 week follow-up (See table 4) n, % Worse: T = 6/79 (8), C = 22/76 (29) Same: T = 7/79 (9), C = 10/76 (13) Better: T = 65/79 (83), C = 44/76 (58) SF-36 a higher score indicates better health status MLHFQ a lower score indicates less disability from symptoms Kennedy 1987 Long Term Care Information System (LTCIS) Health and functional status (also measures services re- quired) No data reported Lainscak 2013 St. George’s Respiratory Questionnaire (SGRQ) Change from 7 to 180 d after discharge T = 1.06 (95% CI 9.50 to 8.43), C = −0.11 (95% CI − 11.34 to 8.12) Complete data available for only approximately half of the patients For the SGRQ, higher scores indicate more limitations; minimal clinically important difference estimated as 4 points Naylor 1994 Data aggregated for both groups. Mean Enforced Social Dependency Scale increased from 19.6 to 26.3 P < 0.
01 No data reported for each group. Decline in functional status reported for all patients Functional status. Scale measured:
•Mental status • Perception of health • Self-esteem • Affect Not possible to calculate exact P value 83 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Patient-reported outcomes: Patients with a medical condition(Continued) Nazareth 2001 General well-being questionnaire : 1 = ill health, 5 = good health At 3 months:
T = 76, mean 2.4 (SD 0.7) C = 73, mean 2.4 (SD 0.6) At 6 months: T = 62, mean 2.5 (SD 0.6) C = 61, mean 2.4 (SD 0.7) Mean difference 0.10; 95% CI −0.14 to 0.34 - Preen 2005 SF-12 (N not reported for follow-up) Mental component score Predischarge score:
T = 37.4 SD 5.4 C = 39.8 SD 6.1 7 d postdischarge:
T = 42.4 SD 5.6 C = 40.9 SD 5.7 Physical component score Predischarge score:
T = 27.8 SD 4.8 C = 28.3 SD 4.7 7 d postdischarge:
T = 27.2 SD 4.5 C = 27.2 SD 4.1 - Rich 1995a Chronic Heart Failure Questionnaire Treatment N = 67, Control N = 59 Total score At baseline:
T = 72.1 (15.6), C = 74.4 (16.3) At 90 d:
T = 94.3 (21.3), C = 85.7 (19.0) Change score = 22.1 (20.8), P = 0.001 Dyspnoea At baseline:
T = 9.0 (7.9), C = 8.1 (7.7) At 90 d:
T = 15.8 (12.8), C = 11.9 (10.0) Change score 6.8 (7.9) Fatigue At baseline:
T = 12.9 (5.3), C = 14.1 (5.6) At 90 d:
T = 18.3 (6.3), C = 16.8 (5.5) Change score 5.4 (5.5) Emotional function At baseline: Chronic Heart Failure Questionnaire contains 20 ques- tions that the patient is asked to rate on a scale 1 to 7 with a low score indicating poor quality of life 84 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Patient-reported outcomes: Patients with a medical condition(Continued) T = 31.9 (8.5), C = 33.3 (8.1) At 90 d:
T = 37.4 (7.8), C = 35.2 (8.4) Change score 5.6 (7.1) Environmental mastery At baseline:
T = 18.3 (5.8), C = 18.9 (4.8) At 90 d:
T = 22.7 (4.9), C = 21.7 (4.6) Change score 4.4 (5.3) Sulch 2000 Barthel activities of daily living Median scores At 4 weeks:
T = 13, C = 11 At 12 weeks: T = 15, C = 17 At 26 weeks: T = 17, C = 17 Median change from 4 to 12 weeks: P < 0.01 Rankin score Median score At 4 weeks:
T = 1, C = 1 At 12 weeks:
T = 3, C = 3 At 26 weeks: T = 3, C = 3 Hospital anxiety and depression scale Anxiety Median scores At 4 weeks: T = 5, C = 5 At 12 weeks: T = 4, C = 4 At 26 weeks T = 4, C = 4 Depression Median scores At 4 weeks: T = 6, C = 5 At 12 weeks: T = 5, C = 5 At 26 weeks:
T = 5, C = 5 EuroQol At 4 weeks:
T = 41, C = 44 Median scores The Barthel ADL Index covers activities of daily living; scores range from 0 to 20, with higher scores indicating better functioning The Rankin scale assesses activities of daily living in people who have had a stroke; it contains 7 items with scores ranging from 0 to 6. Higher scores indicating more disability The Hospital Anxiety and Depression Scale is a 14-item Likert scale (0-3); scores range from 0 to 21 for each subscale (anxiety and depression), with higher scores indicating more burden from symptoms The EuroQol contains 5 items; higher scores indicate better self-perceived health status Not possible to calculate exact P value 85 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Patient-reported outcomes: Patients with a medical condition(Continued) At 4 weeks:
T = 41, C = 44 P = 0.10 At 12 weeks: T = 59, C = 65 P = 0.07 At 26 weeks:
T = 63, C = 72 P < 0.005 Weinberger 1996 At 1 month: no signi cant differencesP = 0.99 At 3 months: no signi cant differences P = 0.53 SF-36 No data shown Analysis 6.2. Comparison 6 Effect of discharge planning on p atient health outcomes, Outcome 2 Patient- reported outcomes: Patients with a surgical condition.
Patient-reported outcomes: Patients with a surgical condi tion Study Patient health outcomes Notes Lin 2009 OARS Multidimensional Functional Assessment Questionnaire(Chinese version) at 3 months follow-up Mean (SD) T = 16.92 (1.41) C = 16.83 (1.71) 9 components, each component scored 0 to 2 with a total score range 0-18 Lin 2009 SF 36 Mean (SD) Physical aspects Pre-test T: 74.09 (21.05), C: 68.15 (21.62) Post-test T: 49.05 (16.27), C: 39.56 (16.76) Between group difference P = 0.09 Physical functioning Pre-test T: 74.80 (25.15), C: 73.33 (18.04) Post-test T: 55.77 (22.56), C: 51.46 (24.82) Between group difference P = 0.60 Role physical Pre-test T: 66.34 (47.40), C: 65.63 (44.12) Post-test T:16.34 (34.60), C: 12.50 (33.78) Between group difference P = 0.78 Bodily pain Pre-test T: 88.15 (18.48), C: 77.08 (22.44) Post-test T: 55.16 (23.20), C: 38.58 (27.68) Between group difference p=0.009 General health perceptions Pre-test T: 67.03 (15.31), C: 56.54 (19.96) Post-test T: 68.46 (16.55), C: 55.70 (22.23) Between group differences p=0.03 - 86 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Patient-reported outcomes: Patients with a surgical condition(Continued) Mental aspects Pre-test T: 74.49 (16.66), C: 68.24 (15.09) Post-test T: 50.57 (18.72), C: 43.43 (17.28) Between group difference P = 0.09 Mental health Pre-test T: 71.23 (12.18), C: 67.83 (12.28) Post-test T: 22.30 (10.31), C: 20.00 (11.62) Between group difference P = 0.27 Role emotion Pre-test T: 76.92 (40.84), C: 68.05 (41.10) Post-test T: 52.56 (44.39), C: 54.16 (41.49) Between group difference P = 0.71 Social functioning Pre-test T: 80.76 (15.09), C: 77.08 (15.93) Post test T: 61.01 (24.32), C: 45.83 (20.41) Between group difference P = 0.03 Vitality Pre-test T: 69.03 (12.88), C: 60.00 (11.70) Post-test T: 66.34 (16.94), C: 53.75 (21.93) Between group difference P = 0.004 Naylor 1994 No differences between groups reported No data reported Naylor 1994 - - Analysis 6.3. Comparison 6 Effect of discharge planning on p atient health outcomes, Outcome 3 Patient- reported outcomes: Patients with a medical or surgical cond ition.
Patient-reported outcomes: Patients with a medical or surg ical condition Study Patient health outcomes Notes Evans 1993 At 1 month: mean (SD) T = 85.3 (21.0) n = 417 C = 86.5 (21.0) n = 418 Difference −1.2; 95% CI −4.05 to 1.65 Barthel score (scale 1 to 100) Pardessus 2002 Functional Autonomy Measurement System (SMAF) At 6 months:Mean scores T = 29.55 ± 2.64, C = 37.73 ± 2.40 At 12 months: T = 31.76 ± 3.53, C = 39.25 ± 2.3 Katz ADL At 6 months: Mean scores T = 3.79 ± 0.32, C = 3.11 ± 0.27 At 12 months: Means scores T = 3.84 ± 0.33, C = 2.76 ± 0.29 IADL The SMAF scale assesses seven elds of activities of daily living. It has 22 items with scores ranging from 0 (total independence) to 87 (total dependence) The Katz ADL scale covers six ADLs, with scores ranging from 0 (totally dependent) to 6 (totally independent) 87 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Patient-reported outcomes: Patients with a medical or surgical condition(Continued) At 6 months:
Mean scores T = 2.41 ± 0.20, C = 2.96 ± 0.18 At 12 months: T = 2.24 ± 0.19, C = 3.14 ± 0.16 Analysis 6.4. Comparison 6 Effect of discharge planning on p atient health outcomes, Outcome 4 Falls at follow-up: patients admitted to hospital following a fall.
Review: Discharge planning from hospital Comparison: 6 Effect of discharge planning on patient health outcomes Outcome: 4 Falls at follow-up: patients admitted to hospita l following a fall Study or subgroup Discharge planning Control Risk Ratio Wei ght Risk Ratio n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI Pardessus 2002 13/30 15/30 100.0 % 0.87 [ 0.50, 1.49 ] Total (95% CI) 30 30 100.0 % 0.87 [ 0.50, 1.49 ] Total events: 13 (Discharge planning), 15 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.52 (P = 0.61) Test for subgroup differences: Not applicable 0.01 0.1 1 10 100 Favours experimental Favours control Analysis 6.5. Comparison 6 Effect of discharge planning on p atient health outcomes, Outcome 5 Patient- reported outcomes: Patients with a mental health diagnosis .
Patient-reported outcomes: Patients with a mental health d iagnosis Study Patient health outcomes Notes Naji 1999 Hospital Anxiety Depression Scale At 1 month after discharge, median (IQR) Anxiety T = 11.0 (6.0, 15.0), C = 10.0 (5.0, 14.0) Mann Whitney P = 0.413 Depression T = 9.5 (5.0, 13.3), C = 7.0 (3.0, 11.0) Mann Whitney P = 0.016 Behavioural and Symptom Identi cation Scale Relation to self/other - 88 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Patient-reported outcomes: Patients with a mental health diagnosis(Continued) T = 1.8 (1.2, 2.8), C = 1.7 (0.4, 2.7) Mann Whitney P = 0.10 Depression/anxiety T = 1.7 (0.8, 2.7), C = 1.5 (0.4, 2.4) Mann Whitney P = 0.46 Daily living/role functioning T = 2.0 (0.9, 2.8), C = 1.8 (0.8, 2.8) Mann Whitney P = 0.37 Impulsive/addictive behaviour T = 0.7 (0.3, 1.6), C = 0.7 (0.1, 1.5) Mann Whitney P = 0.89 Psychosis T = 0.5 (0.2, 0.8), C = 0.7 (0.2, 1.0) Mann Whitney P = 0.31 Total symptom score T = 1.4 (0.6, 2.1), C = 1.3 (0.5, 2.1) Mann Whitney P = 0.54 Analysis 7.1. Comparison 7 Effect of discharge planning on s atisfaction with care process, Outcome 1 Satisfaction.
Satisfaction Study Satisfaction Notes Patient and care givers’ satisfaction Laramee 2003 Mean hospital care: T = 4.2 (N = 120), C = 4.0 (N = 100), P = 0.003 Mean hospital discharge: T = 4.3 (N = 120), C = 4.0 (N = 100), P < 0.001 Mean care instructions: T = 4.0 (N = 120), C = 3.4 (N = 100), P < 0.001 Mean recovering at home: T = 4.4 (N = 120), C = 3.9 (N = 100), P < 0.001 Mean total score: T = 4.2 (N = 120), C = 3.8 (N = 100), P < 0.001 - Lindpaintner 2013 Satisfaction with discharge process At 5 d (median and IQR) Patients: T = 1 (0), C = 1 (1-2) Carers: T = 1 (0), C = 1 (1-2) At 30 d Patients: T = 1 (1-2), C = 1 (1-2) Carers: T = 1 (1-2), C = 2 (1-3) 4-point Likert-scale, lower scores indicate higher satis- faction Moher 1992 Satis ed with medical care: T = 89%, C = 62% Difference 27%; 95% CI 2% to 52%, P < 0.001 “Please rate how satis ed you were with the care you received…” Subgroup of 40 patients, responses from 18 in the treat- 89 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Satisfaction(Continued) ment group and 21 in the control group Nazareth 2001 Client satisfaction questionnaire score (1 = dissatis ed, 4 = satis ed) At 3 months:
T = 76, mean 3.3 (SD 0.6) C = 73, mean 3.3 (SD 0.6) At 6 months: T = 62, mean 3.4 (SD 0.6) C = 61, mean 3.2 (SD 0.6) Mean difference 0.20; 95% CI −0.56 to 0.96 Weinberger 1996 At 1 month:
Treatment group more satis ed, P < 0.001 At 6 months: Treatment group more satis ed, P < 0.001 Authors report differences were greatest for patients’ perceptions of continuity of care and non- nancial ac- cess to medical care Patient Satisfaction Questionnaire, 11 domains with a 5-point scale Professional’s satisfaction Bolas 2004 Standard of information at discharge improved GPs: 57% agreed Community pharmacists: 95% agreed Response rate of 55% (GPs) and 56% (community pharmacists) No information provided about the survey Lindpaintner 2013 Satisfaction with discharge process At 5 d (median and IQR) Primary care physician: T = 1 (1-2), C = 2 (1-3) Visiting nurse: T = 1 (1-2), C = 2 (1-4) At 30 d (median and IQR) Primary care physician: T = 2 (1-3), C = 1 (1-2) Number of respondents ranged between 15 (visiting nurse) and 30 (PCP) 4-point Likert scale, lower scores indicate higher satis- faction Analysis 8.1. Comparison 8 Effect of discharge planning on h ospital care costs, Outcome 1 Patients with a medical condition.
Patients with a medical condition Study Costs Notes Gillespie 2009 Total T: USD 12000; C: USD 12500 Mean difference: −USD 400 ( −USD 4000 to USD 3200) Visits to ED T: USD 160; C: USD 260 Mean difference: −USD 100 ( −USD 220 to −USD 10) Readmissions Costs calculated for 2008 90 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Patients with a medical condition(Continued) T: USD 12000; C: USD 12300 Mean difference: − USD 300 ( −USD 3900 to USD 3300) Laramee 2003 Total inpatient and outpatient median costs T = USD 15,979 C = USD 18,662 P = 0.14 The case manager (CM) kept a log during the rst, mid- dle and last 4 weeks of the recruitment period of how much time was spent with each patient during the 12- week study period. Thus, the average cost of the intervention was calculated based on an hourly wage (including bene ts) of USD 33.93 for the CM. The average intervention cost per patient was USD 228.52, and the average time spent with each intervention patient was 6.7 h per 12 weeks Naughton 1994 - Number: T = 51, C = 60 Total cost of hospital care including breakdown of costs for laboratory, diagnostic imaging, pharmacy and reha- bilitation services Naylor 1994 Initial stay mean charges (USD):
T = 24,352 ± 15,920 (n = 72) C = 23,810 ± 18,449 (n = 70) Difference 542 (CI −5121 to 6205) Medical readmission total charges in USD (CIs are in thousands):
At 2 weeks:
T = 68,754 C = 239,002 Difference = −170,247 (CI −253 to −87) 2-6 weeks: T = 52,384 C = 189,892 Difference = −137,508 (CI −210 to −67) 6-12 weeks: T = 471,456 C = 340,496 Difference = 130,960 (CI −205 to 467) Charge data were used to calculate the cost of the initial hospitalisation Readmission costs were calculated using the mean charge per day of the index hospitalisations times the actual number of days of subsequent hospitalisations, as pa- tients were readmitted to a variety of hospitals with a wide range of charges Total charges including readmission charges ( rst read- mission only if multiple readmissions) Rich 1995a Intervention cost USD 216 per patient Caregiver cost T = USD 1164, C = USD 828 Difference USD 336 Other medical care T = USD 1257, C = USD 1211 Difference USD 46 Readmission costs T = USD 2178, C = USD 3236 - 91 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Patients with a medical condition(Continued) Difference −USD 1058 All costs T = USD 4815, C = USD 5275 Difference −USD 460 Analysis 8.2. Comparison 8 Effect of discharge planning on h ospital care costs, Outcome 2 Patients with a surgical condition.
Patients with a surgical condition Study Costs Notes Naylor 1994 Surgical initial stay mean charges (USD): T = 105,936 ± 52,356 (n = 68) C = 98,640 ± 52,331 (n = 66) Difference 7296 (CI −5141 to 19,733) Surgical readmission total charges (USD):
At 2 weeks:
T = 111,316 C = 104,768 Difference = 6548 (CI −43 to 56) 2-6 weeks: T = 209,536 C = 170,248 Difference = 39,288 (CI −66 to 144) 6-12 weeks:
T = 170,248 C = 85,124 Difference = 85,124 (CI −28 to 198) Charge data were used to calculate the cost of the initial hospitalisation Total charges including readmission charges ( rst read- mission only if multiple readmissions) Readmission costs were calculated using the mean charge per day of the index hospitalisations times the actual num- ber of T of subsequent hospitalisations, as patients were readmitted to a variety of hospitals with a wide range of charges Analysis 8.3. Comparison 8 Effect of discharge planning on h ospital care costs, Outcome 3 Patients with a mental health diagnosis.
Patients with a mental health diagnosis Study Costs Notes Naji 1999 T = an additional GBP 1.14 per patient Intervention can avert 3 outpatient appointments for every 10 patients Telephone calls: T = 124/168 (86%), C = 19/175 (12%) 92 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Analysis 8.4. Comparison 8 Effect of discharge planning on hospital care costs, Outcome 4 Patients admitted to a general medical service.
Patients admitted to a general medical service Study Costs Notes Jack 2009 - Follow-up PCP appointments were given an estimated cost of USD 55, on the basis of costs from an average hospital follow-up visit at Boston Medical Center Legrain 2011 The cost savings balanced against the cost of the inter- vention reported to be EUR 519/patient - Legrain 2011 Total cost of adverse drug reactions-related admissions (180 days follow-up) T = USD 487/participant C = USD 1184/participant P = 0.13 - Analysis 8.5. Comparison 8 Effect of discharge planning on h ospital care costs, Outcome 5 Hospital outpatient department attendance.
Review: Discharge planning from hospital Comparison: 8 Effect of discharge planning on hospital care c osts Outcome: 5 Hospital outpatient depar tment attendance Study or subgroup Treatment Control Risk Ratio Weight Risk R atio n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI Nazareth 2001 39/137 40/151 100.0 % 1.07 [ 0.74, 1.56 ] Total (95% CI) 137 151 100.0 % 1.07 [ 0.74, 1.56 ] Total events: 39 (Treatment), 40 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.38 (P = 0.71) Test for subgroup differences: Not applicable 0.1 0.2 0.5 1 2 5 10 Favours treatment Favours control 93 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Analysis 8.6. Comparison 8 Effect of discharge planning on hospital care costs, Outcome 6 First visits to the emergency room.
Review: Discharge planning from hospital Comparison: 8 Effect of discharge planning on hospital care c osts Outcome: 6 First visits to the emergency room Study or subgroup Discharge planning Usual care Risk Ratio W eight Risk Ratio n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI Farris 2014 41/281 46/294 54.6 % 0.93 [ 0.63, 1.37 ] Harrison 2002 26/88 35/77 45.4 % 0.65 [ 0.43, 0.97 ] Total (95% CI) 369 371 100.0 % 0.80 [ 0.61, 1.07 ] Total events: 67 (Discharge planning), 81 (Usual care) Heterogeneity: Chi 2 = 1.62, df = 1 (P = 0.20); I 2 =38% Test for overall effect: Z = 1.51 (P = 0.13) Test for subgroup differences: Not applicable 0.01 0.1 1 10 100 Favours experimental Favours control Analysis 9.1. Comparison 9 Effect of discharge planning on p rimary and community care costs, Outcome 1 Patients with a medical condition.
Patients with a medical condition Study Use of services Notes Farris 2014 Unscheduled of ce visits At 30 d T = 31/281 (11%), C = 32/294 (11%) Difference 0%; 95% CI −5% to 5% At 90 d T = 42/281 (15%), C = 33/294 (11%) Difference 4%; 95% CI −2 to 9% Results for Enhanced vs Control intervention (results for minimal intervention not reported) Goldman 2014 Primary care visits at 30 d T = 189/301 (62.8%), C = 186/316 (58.9%) Difference 4%; 95% CI −3.7% to 11.5% - Laramee 2003 Visiting Nurse postdischarge:
T = 70/141(50%), Control: 64/146 (44%) - Nazareth 2001 General practice attendance:
At 3 months:T = 101/130 (77.7%) C = 108/144 (75%) Difference 2.7%; 95% CI −7.4 to 12.7% At 6 months: - 94 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Patients with a medical condition(Continued) T = 76/107 (71%) C = 82/116 (70.7%) Difference 0.3%; 95% CI −11.6 to 12.3% Weinberger 1996 Median time from hospital discharge to the rst visit:
Treatment 7 d Control 13 d P < 0.001 Visit at least one general medicine clinic in 6-month follow up:
Treatment 646/695 (93%) Control 540/701 (77%) Difference 16%; 95% CI 12.3% to 19.6%, P < 0.001 Mean number of visits to general medical clinic: Treatment 3.7 Control 2.2 P < 0.001 - Analysis 10.1. Comparison 10 Effect of discharge planning o n medication use, Outcome 1 Medication problems after being discharged from hospital.
Medication problems after being discharged from hospital Study Number of problems Notes Bolas 2004 Intervention group demonstrated a higher rate of reconcil- iation of patient’s own drugs with the discharge prescrip- tion; 90% compared to the 44% in the control group - Shaw 2000 Mean number of problems (SD) At 1 week: T = 2.0 (1.3), C = 2.5 (1.6) At 4 weeks:
T = 1.9 (1.5), C = 2.9 (1.8) At 12 weeks: T = 1.4 (1.2), C = 2.4 (1.6) Problems included dif culty obtaining a prescription from the GP; insuf cient knowledge about medication; non- compliance Analysis 10.2. Comparison 10 Effect of discharge planning o n medication use, Outcome 2 Adherence to medicines.
Adherence to medicines Study Adherence to medicines Notes Nazareth 2001 At 3 months: T = 79, mean 0.75 (SD 0.3), C = 72 mean 0.75 (SD 0.
28) At 6 months: 0 = none 1 = total/highest level 95 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Adherence to medicines(Continued) T = 60, mean 0.78 (SD 0.30), C = 58 mean 0.78 (SD 0.
30) Rich 1995a Taking 80% or more of prescribed pills at 30 d after discharge T = 117/142 (82.5%), C = 91/140 (64.9%) - Analysis 10.3. Comparison 10 Effect of discharge planning o n medication use, Outcome 3 Knowledge about medicines.
Knowledge about medicines Study Knowledge Notes Bolas 2004 Mean error rate in knowledge of drug therapy at 10-14 d follow up Drug name T = 15%, C = 43%, P < 0.001 Drug dose T = 14%, C = 39%, P < 0.001 Frequency T = 15%, C = 39%, P < 0.001 (n for each group not reported) - Nazareth 2001 At 3 months: T = 86, mean 0.69 (SD 0.33) C = 83, mean 0.62 (SD 0.34) At 6 months: T = 65, mean 0.69 (SD 0.35) C = 68, mean 0.68 (SD 0.30) Mean difference 0.01; 95% CI −0.12 to 0.13 0 = none 1 = total/highest level Shaw 2000 At 1 and 12 weeks post-discharge:
Signi cant improvement in knowledge medication for both groups (no differences between groups) - Analysis 10.4. Comparison 10 Effect of discharge planning o n medication use, Outcome 4 Hoarding of medicines.
Hoarding of medicines Study Hoarding Notes Bolas 2004 90% of people who brought drugs to the hospital were returned in the intervention group compared to 50% in the controls - Nazareth 2001 At 3 months: T = 87, mean 0.006 (SD 0.04) C = 82 mean 0.005 (SD 0.03) Mean difference 0.001; 95% CI −0.01 to 0.012 0 = none 1 = total/highest level 96 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. Hoarding of medicines(Continued) At 6 months T = 70, mean 0.02 (SD 0.13) C = 69 mean 0.013 (SD 0.06) Mean difference 0.007; 95% CI −0.013 to 0.27 Analysis 10.5. Comparison 10 Effect of discharge planning o n medication use, Outcome 5 Prescription errors.
Prescription errors Study Eggink 2010 Following a review of medication by a pharmacist, 68% in the cont rol group had at least one discrepancy or medication error compared to 39% in the intervention group (RR 0 .57; 95% CI 0.37 to 0.88). The percent of medications with a discrepancy or error in the intervention gro up was 6.1% in intervention group and 14.6% in the control group (RR = 0.42; 0.27 to 0.66) Kripalani 2012 Clinically important medication errors (total number of event s; could be more than one per patient) At 30 d T = 370/423, M = 0.87 (SD 1.18) C = 407/428, M = 0.95 (SD 1.36) Analysis 10.6. Comparison 10 Effect of discharge planning o n medication use, Outcome 6 Medication appropriateness.
Medication appropriateness Study Medication appropriateness Notes Farris 2014 Discharge T = 7.1 (SD 7.0), C = 6.1 (SD 6.6) 30 d post-discharge T = 10.1 (SD 8.9), C = 9.6 (SD 9.5) P = 0.78 90 d post-discharge T = 11.6 (SD 10.5), C = 11.1 (11.3) P = 0.94 As measured by the medication appropriateness index (MAI); summed MAI per participant Results for Enhanced v Control intervention (results for minimal intervention not reported) 97 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. A P P E N D I C E S Appendix 1. Search strategies 2015 CINAHL (EBSCOHost)[1982 - present] S24 S22 and S23 Limiters - Published Date from: 20121231-2015 1005 S23 ( (MH “Experimental Studies+”) OR (MH “Treatment Outcomes+ ”) ) OR TI random* OR AB random* S22 S3 or S21 S21 S11 and S20 S20 S12 or S13 or S14 or S15 or S16 or S17 or S18 or S19 S19 TI ( ((hospital or hospitali?ed or bed) n2 days) ) OR AB ( ((hosp ital or hospitali?ed or bed) n2 days) ) S18 TI length n2 hospital stay OR AB length n2 hospital stay S17 TI length n2 stay OR AB length n2 stay S16 TI ( rehospitali?ation* or re-hospitali?ation* or rehos pitali?ed or re-hospitali?ed ) OR AB ( rehospitali?ation* or re-hospitali?ation* or rehospitali?ed or re-hospitali?ed ) S15 TI ( readmission or readmitted or re-admission or re-admit ted ) OR AB ( readmission or readmitted or re-admission or re-ad mitted ) S14 (MH “Readmission”) S13 (MH “Length of Stay”) S12 (MM “Continuity of Patient Care”) S11 S4 or S5 or S6 or S7 or S8 or S9 or S10 S10 TI discharge procedure* OR AB discharge procedure* S9 TI discharge program* OR AB discharge program* S8 TI discharge service* OR AB discharge service* S7 TI discharge* n2 plan* OR AB discharge* n2 plan* S6 TI hospital n2 discharge* OR AB hospital n2 discharge* S5 TI patient* n2 discharge* OR AB patient* n2 discharge* S4 (MM “Patient Discharge Education”) OR (MM “Patient Discharge” ) OR (MM “Early Patient Discharge”) S3 S1 or S2 S2 (MH “Discharge Planning”) S1 TI (discharge and (plan* or service? or program* or interventi on?)) Cochrane Central Register of Controlled Trials vid Cochran e Library(Wiley)[Issue 10, 2014] Date searched: 05 October 2015 #1 (discharge and (plan* or service? or program* or intervention ?)):ti #2 MeSH descriptor Patient Discharge explode all trees #3 (patient* near2 discharge):ti,ab,kw #4 (hospital near2 discharge):ti,ab,kw #5 (discharge near2 plan*):ti,ab,kw #6 “discharge service*” OR “discharge program*” OR “discharge p rocedure*”:ti,ab,kw #7 (#2 OR #3 OR #4 OR #5 OR #6) #8 MeSH descriptor Patient Readmission explode all trees #9 MeSH descriptor Length of Stay explode all trees #10 MeSH descriptor Continuity of Patient Care, this term onl y #11 (readmission or readmitted or re-admission or re-admitted ):ti,ab,kw #12 (rehospitali?ation* or re-hospitali?ation* or rehospit ali?ed or re-hospitali?ed):ti,ab,kw #13 “length of stay”:ti,ab,kw #14 “length of hospital stay”:ti,ab,kw #15 ((hospital or hospitali?ed or bed) near2 days):ti,ab,kw #16 (#8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15) #17 (#2 AND #16) #18 (#1 OR #17), from 2012 to 2015 Embase (OvidSP)[1974 to present] Date Searched: 05 October 2015 98 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. 1 (discharge and (plan* or service? or program* or intervention?)).ti.
2 *Patient Discharge/ 3 (patient* adj2 discharge*).ti,ab.
4 (hospital adj2 discharge*).ti,ab.
5 (discharge adj2 plan*).ti,ab.
6 (discharge adj service*).ti,ab.
7 (discharge adj program*).ti,ab.
8 (discharge adj procedure*).ti,ab.
9 2 or 3 or 4 or 5 or 6 or 7 or 8 10 *“Continuity of Patient Care”/ 11 *“Length of Stay”/ 12 Patient Readmission/ 13 (readmission or readmitted or re-admission or re-admitted). ti,ab.
14 (rehospitali?ation* or re-hospitali?ation* or rehospita li?ed or re-hospitali?ed).ti,ab. (6918) 15 length of stay.ti,ab.
16 length of hospital stay.ti,ab.
17 ((hospital or hospitali?ed or bed) adj2 days).ti,ab.
18 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 19 9 and 18 20 1 or 19 21 (random* or factorial* or crossover* or cross over* or cross-ove r* or placebo* or (doubl* adj blind*) or (singl* adj blind*) or assign* or allocat* or volunteer*).ti,ab. (1404240) 22 crossover-procedure/ or double-blind procedure/ or randomiz ed controlled trial/ or single-blind procedure/ 23 21 or 22 24 nonhuman/ 25 23 not 24 26 20 and 25 27 (2012* or 2013* or 2014* or 2015* or 2016*).em,dp,yr.
28 26 and 27 MEDLINE(R) In-Process & Other Non-Indexed Citations and ME DLINE(R)(OvidSP) [1946 to Present] Date searched: 05 October November 2015 1 (discharge and (plan* or service? or program* or intervention? )).ti.
2 *Patient Discharge/ 3 (patient* adj2 discharge*).ti,ab.
4 (hospital adj2 discharge*).ti,ab.
5 (discharge adj2 plan*).ti,ab.
6 (discharge adj service?).ti,ab.
7 (discharge adj program*).ti,ab.
8 (discharge adj procedure*).ti,ab.
9 2 or 3 or 4 or 5 or 6 or 7 or 8 10 *“Continuity of Patient Care”/ 11 *“Length of Stay”/ 12 Patient Readmission/ 13 (readmission or readmitted or re-admission or re-admitted). ti,ab.
14 (rehospitali?ation* or re-hospitali?ation* or rehospita li?ed or re-hospitali?ed).ti,ab. (4530) 15 length of stay.ti,ab.
16 length of hospital stay.ti,ab.
17 ((hospital or hospitali?ed or bed) adj2 days).ti,ab.
18 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 19 9 and 18 20 1 or 19 21 randomized controlled trial.pt.
22 controlled clinical trial.pt. 99 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. 23 randomized.ab.
24 placebo.ab.
25 drug therapy.fs.
26 randomly.ab.
27 trial.ab.
28 groups.ab.
29 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 30 exp animals/ not humans.sh.
31 29 not 30 32 20 and 31 33 (2012* or 2013* or 2014* or 2015* or 2016*).ed,dp,yr.
34 32 and 33 Social Science Citation Index(Web of Knowledge) Date searched: 05 October 2015 # 7 #6 AND #5 # 6 TS=(random* or blind* or allocat* or assign* or trial* or pla cebo* or crossover* or cross-over*) # 5 #4 OR #1 # 4 #3 AND #2 # 3 TS=(“hospital discharge” OR “patient discharge”) # 2 TS=(“length of stay” OR “length of hospital stay”) OR TS=(“h ospital days” OR “bed days” OR “days hospitali?ed”) OR TS= (rehospitali?ation* or re-hospitali?ation* or rehospitali ?ed or re-hospitali?ed) OR TS=(readmission or readmitted or r e-admission or re- admitted) # 1 TS=(“discharge plan*” OR “discharge care” OR “discharge servi ce*” OR “discharge program*” OR “discharge procedure*”) PsycInfo (OvidSP) [1967 to Present] Date searched: 05 October 2015 1 (discharge and (plan* or service? or program* or intervention? )).ti.
2 Discharge Planning/ 3 1 or 2 4 *Hospital Discharge/ 5 (patient* adj2 discharge*).ti,ab.
6 (hospital adj2 discharge).ti,ab.
7 (discharge adj2 plan*).ti,ab.
8 (discharge adj service*).ti,ab.
9 (discharge adj program*).ti,ab.
10 (discharge adj procedure*).ti,ab.
11 4 or 5 or 6 or 7 or 8 or 9 or 10 12 Psychiatric Hospital Readmission/ 13 “Length of Stay”/ 14 (readmission or readmitted or re-admission or re-admitted). ti,ab.
15 (rehospitali?ation* or re-hospitali?ation* or rehospita li?ed or re-hospitali?ed).ti,ab.
16 length of stay.ti,ab.
17 length of hospital stay.ti,ab.
18 ((hospital or hospitali?ed or bed) adj2 days).ti,ab.
19 12 or 13 or 14 or 15 or 16 or 17 or 18 20 1 or 19 21 3 or 20 22 (placebo* or random*).tw. or exp treatment/ 23 22 and 22 24 (2012* or 2013* or 2014* or 2015*).up,dp,yr.
25 23 and 24 100 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. F E E D B A C K Cochrane Highly Sensitive Search Strategy Summary The Cochrane Highly Sensitive Search Strategy should BE REFERENCED ’Dickersin K, Scherer R, Lefebvre C. Identifying relevant studies for systematic reviews. BMJ 1994;309:1286-91’ inst ead of ’Anonymous. MEDLINE optimally sensitive search strat egy (OSS) for SilverPlatter. Workshop on Identifying and Registerin g Trials. UK Cochrane Centre, 1996’.
Reply This change has now been made.
Contributors Mike Clarke W H A T ’ S N E W Last assessed as up-to-date: 5 October 2015.
Date Event Description 23 October 2015 New search has been performed This is the third update of the original review. A new search was conducted (October 2015) and other con- tent updated, six new studies were added to the review 23 October 2015 New citation required but conclusions have not changed Six new studies were included in this update. The total number of studies included in the review is now 30 H I S T O R Y Protocol rst published: Issue 3, 1997 Review rst published: Issue 4, 2000 Date Event Description 12 December 2012 New search has been performed New search completed March 2012. Three new stud- ies. 101 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. (Continued) 7 December 2012 New citation required but conclusions have not changed New Search March 2012. Three new studies. 10 November 2009 New citation required and conclusions have changed Authors found 10 new studies, providing evidence about the effect of discharge planning 23 September 2003 New search has been performed Search identi ed additional trials for inclusion C O N T R I B U T I O N S O F A U T H O R S Daniela Gon alves-Bradley (DCGB) scanned the abstracts and extracted data fo r this update and took the lead in analysing the data and updating the text of the review. Natasha Lannin (NL), Lindy Clemson (LC) and Ian Cameron (IC) scanned the abstracts and extracted data. Sasha Shepperd (SS) co-authored the protocol for the review with Julie Parkes (no longer an author), extracted and analysed data for previous versions of this review, and led t he writing of the review.
D E C L A R A T I O N S O F I N T E R E S T DCGB: none known.
NL: none known.
LC: none known.
IC: none known.
SS: none known.
S O U R C E S O F S U P P O R T Internal sources • Anglia and Oxford Regional Research and Development Program me, UK.
External sources • NIHR Evidence Synthesis Award to SS and NHS Cochrane Collabora tion Programme Grant Scheme, UK.
• NIHR Evidence Synthesis Award; and an NIHR Cochrane Programme grant for the last two updates., UK. 102 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd. D I F F E R E N C E S B E T W E E N P R O T O C O L A N D R E V I E W We performed post hoc subgroup analyses for patients admitted to hospital following a fall and patients admitted to a mental health setting. We performed a post hoc sensitivity analysis by imp uting a missing standard deviation for one trial. We made a po st hoc decision to exclude studies that were considered to be methodol ogically weak. We added new analysis to the summary of ndings table by including results for the patients admitted to hospital fo llowing a fall, patients and healthcare professionals satisfaction, and costs.
We merged the outcome “Psychological health of patients” with t he outcome “Patient health status”.
I N D E X T E R M S Medical Subject Headings (MeSH) ∗ Patient Discharge; Aftercare [organization & administration ]; Controlled Clinical Trials as Topic; Health Care Costs; Inte ntion to Treat Analysis; Length of Stay [statistics & numerical data]; Ou tcome Assessment (Health Care); Patient Readmission [statistics & numerical data]; Randomized Controlled Trials as Topic MeSH check words Humans 103 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.
