Preventing 30-Day Hospital Readmissions A Systematic Review and Meta-analysis of Randomized Trials

被引:613
作者
Leppin, Aaron L. [1 ]
Gionfriddo, Michael R. [1 ,2 ]
Kessler, Maya [1 ,3 ]
Brito, Juan Pablo [1 ,3 ,4 ]
Mair, Frances S. [5 ]
Gallacher, Katie [5 ]
Wang, Zhen [1 ,4 ]
Erwin, Patricia J. [6 ]
Sylvester, Tanya [7 ]
Boehmer, Kasey [1 ,8 ]
Ting, Henry H. [1 ]
Murad, M. Hassan [1 ,4 ]
Shippee, Nathan D. [9 ]
Montori, Victor M. [1 ,3 ,4 ]
机构
[1] Mayo Clin, Knowledge & Evaluat Res Unit, Rochester, MN 55905 USA
[2] Mayo Clin, Mayo Grad Sch, Rochester, MN 55905 USA
[3] Mayo Clin, Dept Med, Rochester, MN 55905 USA
[4] Mayo Clin, Ctr Sci Healthcare Delivery, Rochester, MN 55905 USA
[5] Univ Glasgow, Inst Hlth & Wellbeing, Glasgow, Lanark, Scotland
[6] Mayo Clin, Mayo Clin Lib, Rochester, MN 55905 USA
[7] St Louis Univ, Sch Med, St Louis, MO USA
[8] Univ Minnesota, Sch Publ Hlth, Minneapolis, MN USA
[9] Univ Minnesota, Sch Publ Hlth, Div Hlth Policy & Management, Minneapolis, MN USA
基金
美国国家卫生研究院;
关键词
CARE TRANSITIONS INTERVENTION; HEART-FAILURE MANAGEMENT; FOLLOW-UP; OLDER-ADULTS; SELF-CARE; DISCHARGE PROGRAM; ELDERLY-PATIENTS; TREATMENT BURDEN; HOME VISITS; OUTCOMES;
D O I
10.1001/jamainternmed.2014.1608
中图分类号
R5 [内科学];
学科分类号
100201 [内科学];
摘要
IMPORTANCE Reducing early (< 30 days) hospital readmissions is a policy priority aimed at improving health care quality. The cumulative complexity model conceptualizes patient context. It predicts that highly supportive discharge interventions will enhance patient capacity to enact burdensome self-care and avoid readmissions. OBJECTIVE To synthesize the evidence of the efficacy of interventions to reduce early hospital readmissions and identify intervention features-including their impact on treatment burden and on patients' capacity to enact postdischarge self-care-that might explain their varying effects. DATA SOURCES We searched PubMed, Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, and Scopus (1990 until April 1, 2013), contacted experts, and reviewed bibliographies. STUDY SELECTION Randomized trials that assessed the effect of interventions on all-cause or unplanned readmissions within 30 days of discharge in adult patients hospitalized for a medical or surgical cause for more than 24 hours and discharged to home. DATA EXTRACTION AND SYNTHESIS Reviewer pairs extracted trial characteristics and used an activity-based coding strategy to characterize the interventions; fidelity was confirmed with authors. Blinded to trial outcomes, reviewers noted the extent to which interventions placed additional work on patients after discharge or supported their capacity for self-care in accordance with the cumulative complexity model. MAIN OUTCOMES AND MEASURES Relative risk of all-cause or unplanned readmission with or without out-of-hospital deaths at 30 days postdischarge. RESULTS In 42 trials, the tested interventions prevented early readmissions (pooled random-effects relative risk, 0.82 [95% CI, 0.73-0.91]; P < .001; I-2 = 31%), a finding that was consistent across patient subgroups. Trials published before 2002 reported interventions that were 1.6 times more effective than those tested later (interaction P = .01). In exploratory subgroup analyses, interventions with many components (interaction P = .001), involving more individuals in care delivery (interaction P = .05), and supporting patient capacity for self-care (interaction P = .04) were 1.4, 1.3, and 1.3 times more effective than other interventions, respectively. A post hoc regression model showed incremental value in providing comprehensive, postdischarge support to patients and caregivers. CONCLUSIONS AND RELEVANCE Tested interventions are effective at reducing readmissions, but more effective interventions are complex and support patient capacity for self-care. Interventions tested more recently are less effective.
引用
收藏
页码:1095 / 1107
页数:13
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