Hospitalists are charged with addressing the gaps in transitional care, which manifest as adverse events (AEs) and readmissions after discharge. The Centers for Medicare & Medicaid Services plan to lower reimbursement to hospitals with excessive 30–day readmission rates. However, there is a lack of evidence–based strategies for improving transitional care. We conducted a systematic review of interventions to improve safety after hospital discharge, focusing on studies with a hospital–based intervention component.
We searched CINAHL, MEDLINE, the Cochrane Database of Systematic Reviews, and EMBASE from 1991 to 2011. We included randomized controlled trials (RCTs) and nonrandomized controlled trials (CCTs) that evaluated interventions to prevent AEs or readmissions in general medical patient populations, utilized at least one intervention prior to discharge, and reported rates of emergency department visits, readmissions, or AEs after discharge. Titles and abstracts were screened and potentially relevant articles underwent full–text evaluation by two independent reviewers who extracted data on intervention characteristics, study methodological quality, and outcomes. We devised a taxonomy of interventions (Table); studies were further classified as using a “bridging” intervention (predischarge and postdischarge components) or a predischarge intervention only.
We identified 15,905 citations, of which 454 underwent full–text review. Forty–six studies met all inclusion criteria, including 25 RCTs, 18 CCTs, and 3 implementation studies. Studies used a median of four interventions (range 1–8); a bridging intervention was used in 31 studies (21 RCTs) and 12 used a predischarge only intervention (three RCTs). All but one study reported readmission or ED visit rates, including 16 studies (11 RCTs) that reported these outcomes at 30 days after discharge. Only 10 studies reported AE rates after discharge (five of which measured postdischarge adverse drug events). We identified five studies (four RCTs) that reported significant reductions in 30–day ED visit or readmission rates; all of these studies used a bridging strategy with >=5 separate interventions. Only one study achieved a significant reduction in adverse drug events.
Despite pressure to improve transitional care, only a small number of resource–intensive interventions involving both predischarge and postdischarge components have successfully reduced 30–day readmissions. There is a notable lack of studies targeting and documenting improvement in specific AEs after discharge.
Taxonomy of Interventions to Prevent Adverse Events and Readmissions After Hospital Discharge