TY - JOUR
T1 - Preventing 30-day hospital readmissions
T2 - A systematic review and meta-analysis of randomized trials
AU - Leppin, Aaron L.
AU - Gionfriddo, Michael R.
AU - Kessler, Maya
AU - Brito, Juan Pablo
AU - Mair, Frances S.
AU - Gallacher, Katie
AU - Wang, Zhen
AU - Erwin, Patricia J.
AU - Sylvester, Tanya
AU - Boehmer, Kasey
AU - Ting, Henry H.
AU - Murad, M. Hassan
AU - Shippee, Nathan D.
AU - Montori, Victor M.
PY - 2014/7
Y1 - 2014/7
N2 - 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; I2 = 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.
AB - 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; I2 = 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.
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U2 - 10.1001/jamainternmed.2014.1608
DO - 10.1001/jamainternmed.2014.1608
M3 - Review article
C2 - 24820131
AN - SCOPUS:84904128037
SN - 2168-6106
VL - 174
SP - 1095
EP - 1107
JO - JAMA internal medicine
JF - JAMA internal medicine
IS - 7
ER -