Hospital Transition Care

A great deal of attention is focused on preventing hospital readmissions and ensuring better transitions of care between hospitals and other settings.  An Agency for Healthcare Research and Quality report looks at the evidence for which, if any, care transition programs for stroke and heart attack patients have shown results.   (AHRQ Report)  To compile the report, researchers formulated several key questions and then searched for studies which might have a bearing on those questions.  They analyze the quality of the studies as well as coming up with their ultimate findings.

In the end, only 62 articles from 44 studies were included in the report.  The researchers categorized interventions into four types:  beginning discharge care in the hospital; education; community-based support systems, including professional visits; and transition to chronic disease management.  In regard to outcomes, including utilization and cost ones, as well as quality of life and functional ones, there was moderate evidence for early supported discharge for stroke patients and referrals for specialty followup for heart attack patients.  No other intervention had any significant evidence in regard to outcomes.

There was not adequate evidence to identify if any of the interventions caused adverse events or if they improved care coordination or that characteristics of patients, providers, etc. affected the outcomes.  The overall quality of study design was not good, which hindered coming to conclusions.  The researchers made a number of recommendations for followup research that could provide useful guidance for those who are trying to improve care.   While improving care transitions is intuitively the right thing to do, as with all aspects of health services, it is best to have clear evidence of what works rather than just assuming that something is a good idea.