Effectiveness of discharge interventions from hospital to home on hospital readmissions: a systematic review.

BACKGROUND: Many discharge interventions are developed to reduce unplanned hospital readmissions, but it is unclear which interventions are more effective.

OBJECTIVES: The objective of this review was to identify discharge interventions from hospital to home that reduce hospital readmissions within three months and to understand their effect on secondary outcome measures.

INCLUSION CRITERIA: Participants were adults (18 years or older) discharged from a medical or surgical ward.The included interventions had to be designed to ease the care transition from hospital to home or to prevent problems after hospital discharge.This review considered only randomized controlled trials.The primary outcome measure was hospital readmission within three months after discharge. Secondary outcomes included patient satisfaction, return to emergency departments and mortality.

SEARCH STRATEGY: Studies in English between January 1990 and July 2014 were considered for inclusion. The databases searched were PubMed, Web of Science, Embase and CINAHL.

METHODOLOGICAL QUALITY: Methodological validity was assessed by two reviewers prior to inclusion using the standardized critical appraisal instruments from the Joanna Briggs Institute.

DATA EXTRACTION: Quantitative data were independently extracted by the two reviewers using the standardized data extraction tool from the Joanna Briggs Institute.

DATA SYNTHESIS: Meta-analysis was performed by using a random effect model; data were pooled using Mantel-Haenszel methods. For subgroups analysis only papers with critical appraisal score of seven or more were selected.

RESULTS: Meta-analysis was performed on 47 studies. The overall relative risk for hospital readmission was 0.77 [95% CI, 0.70-0.84] (p<0.00001). The relative risk for return to the emergency department was 0.75 [95% CI, 0.55-1.01] (p=0.06) and for mortality 0.70 [95% CI, 0.48-1.01] (p=0.06). Patient satisfaction improved in favor of the intervention group in five out of the six studies evaluating patient satisfaction.Exploratory subgroup analysis found that interventions starting during hospital stay and continuing after discharge were more effective in reducing readmissions compared to interventions starting after discharge (between subgroup difference p=0.01). Multicomponent interventions were not more effective compared to single component interventions (between subgroup difference p=0.54). Interventions oriented towards patient empowerment were more effective compared to all other interventions (between subgroup difference p=0.02).

CONCLUSIONS: Interventions designed to improve the care transition from hospital to home are effective in reducing hospital readmission. These interventions preferably start in the hospital and continue after discharge rather than starting after discharge. Enhancing patient empowerment is a key factor in reducing hospital readmissions.Interventions to reduce hospital readmissions should start during hospital stay and continue in the community (grade A recommendation). This requires financial systems to support and facilitate collaboration between hospitals and home care.Interventions that support patient empowerment are more effective in reducing hospital readmissions (grade B recommendation). To promote patient empowerment caregivers must be trained to increase patients' capacity to self-care.Future research should focus on interventions that improve patient empowerment and the effects of discharge interventions after more than three months.