The effect of clinical interventions on hospital readmissions: a meta-review of published meta-analyses

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Abstract

Background

The economic impact and ease of measurement of all-cause hospital readmission rates (HRR) have led to the current debate as to whether they are reducible, and whether they should be used as a publicly reported quality indicators of medical care.

Objective

To assess the efficacy of broad clinical interventions in preventing HRR of patients with chronic diseases

Method

A meta-review of published systematic reviews of randomized controlled trials (RCTs) of clinical interventions that have included HRR among the patients' outcomes of interest.

Main findings

Meta-analyses of RCTs have consistently found that, in the community, disease management programs significantly reduced HRR in patients with heart failure, coronary heart disease and bronchial asthma, but not in patients with stroke and in unselected patients with chronic disorders. Inhospital interventions, such as discharge planning, pharmacological consultations and multidisciplinary care, and community interventions in patients with chronic obstructive pulmonary diseases had an inconsistent effect on HRR.

Main study limitation

Despite their economic impact and ease of measurement, HRR are not the most important outcome of patient care, and efforts aimed at their reduction may compromise patients' health by reducing also justified re-admissions.

Conclusions

The efficacy of inhospital interventions in reducing HRR is in need of further study. In patients with heart diseases and bronchial asthma, HRR may be considered as a publicly reported quality indicator of community care, provided that future research confirms that efforts to reduce HRR do not adversely affect other patients’ outcomes, such as mortality, functional capacity and quality of life. Future research should also focus on the reasons for the higher efficacy of community interventions in patients with heart diseases and bronchial asthma than in those with other chronic diseases.

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Most cited references 84

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Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials

Graham Ellis, Martin A Whitehead, David Robinson … (2011)

Objective To evaluate the effectiveness of comprehensive geriatric assessment in hospital for older adults admitted as an emergency. Search strategy We searched the EPOC Register, Cochrane’s Controlled Trials Register, the Database of Abstracts of Reviews of Effects (DARE), Medline, Embase, CINAHL, AARP Ageline, and handsearched high yield journals. Selection criteria Randomised controlled trials of comprehensive geriatric assessment (whether by mobile teams or in designated wards) compared with usual care. Comprehensive geriatric assessment is a multidimensional interdisciplinary diagnostic process used to determine the medical, psychological, and functional capabilities of a frail elderly person to develop a coordinated and integrated plan for treatment and long term follow-up. Data collection and analysis Three independent reviewers assessed eligibility and trial quality and extracted published data. Two additional reviewers moderated. Results Twenty two trials evaluating 10 315 participants in six countries were identified. For the primary outcome “living at home,” patients who underwent comprehensive geriatric assessment were more likely to be alive and in their own homes at the end of scheduled follow-up (odds ratio 1.16 (95% confidence interval 1.05 to 1.28; P=0.003; number needed to treat 33) at a median follow-up of 12 months versus 1.25 (1.11 to 1.42; P<0.001; number needed to treat 17) at a median follow-up of six months) compared with patients who received general medical care. In addition, patients were less likely to be living in residential care (0.78, 0.69 to 0.88; P<0.001). Subgroup interaction suggested differences between the subgroups “wards” and “teams” in favour of wards. Patients were also less likely to die or experience deterioration (0.76, 0.64 to 0.90; P=0.001) and were more likely to experience improved cognition (standardised mean difference 0.08, 0.01 to 0.15; P=0.02) in the comprehensive geriatric assessment group. Conclusions Comprehensive geriatric assessment increases patients’ likelihood of being alive and in their own homes after an emergency admission to hospital. This seems to be especially true for trials of wards designated for comprehensive geriatric assessment and is associated with a potential cost reduction compared with general medical care.

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Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials.

Finlay McAlister, Simon Stewart, Stefania Ferrua … (2004)

The aim of this study was to determine whether multidisciplinary strategies improve outcomes for heart failure (HF) patients. Because the prognosis of HF remains poor despite pharmacotherapy, there is increasing interest in alternative models of care delivery for these patients. Randomized trials of multidisciplinary management programs in HF were identified by searching electronic databases and bibliographies and via contact with experts. Twenty-nine trials (5,039 patients) were identified but were not pooled, because of considerable heterogeneity. A priori, we divided the interventions into homogeneous groups that were suitable for pooling. Strategies that incorporated follow-up by a specialized multidisciplinary team (either in a clinic or a non-clinic setting) reduced mortality (risk ratio [RR] 0.75, 95% confidence interval [CI] 0.59 to 0.96), HF hospitalizations (RR 0.74, 95% CI 0.63 to 0.87), and all-cause hospitalizations (RR 0.81, 95% CI 0.71 to 0.92). Programs that focused on enhancing patient self-care activities reduced HF hospitalizations (RR 0.66, 95% CI 0.52 to 0.83) and all-cause hospitalizations (RR 0.73, 95% CI 0.57 to 0.93) but had no effect on mortality (RR 1.14, 95% CI 0.67 to 1.94). Strategies that employed telephone contact and advised patients to attend their primary care physician in the event of deterioration reduced HF hospitalizations (RR 0.75, 95% CI 0.57 to 0.99) but not mortality (RR 0.91, 95% CI 0.67 to 1.29) or all-cause hospitalizations (RR 0.98, 95% CI 0.80 to 1.20). In 15 of 18 trials that evaluated cost, multidisciplinary strategies were cost-saving. Multidisciplinary strategies for the management of patients with HF reduce HF hospitalizations. Those programs that involve specialized follow-up by a multidisciplinary team also reduce mortality and all-cause hospitalizations.

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Integrated care programmes for chronically ill patients: a review of systematic reviews.

Marielle MTJ Ouwens, Hub Wollersheim, Rosella Hermens … (2005)

To investigate effectiveness, definitions, and components of integrated care programmes for chronically ill patients on the basis of systematic reviews. Literature review from January 1996 to May 2004. Definitions and components of integrated care programmes and all effects reported on the quality of care. Searches in the Medline and Cochrane databases identified 13 systematic reviews of integrated care programmes for chronically ill patients. Despite considerable heterogeneity in interventions, patient populations, and processes and outcomes of care, integrated care programmes seemed to have positive effects on the quality of patient care. No consistent definitions were present for the management of patients with chronic illnesses. In all the reviews the aims of integrated care programmes were very similar, namely reducing fragmentation and improving continuity and coordination of care, but the focus and content of the programmes differed widely. The most common components of integrated care programmes were self-management support and patient education, often combined with structured clinical follow-up and case management; a multidisciplinary patient care team; multidisciplinary clinical pathways and feedback, reminders, and education for professionals. Integrated care programmes seemed to have positive effects on the quality of care. However, integrated care programmes have widely varying definitions and components and failure to recognize these variations leads to inappropriate conclusions about the effectiveness of these programmes and to inappropriate application of research results. To compare programmes and better understand the (cost) effectiveness of the programmes, consistent definitions must be used and component interventions must be well described.

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Author and article information

Journal

Journal ID (nlm-ta): Isr J Health Policy Res

Journal ID (iso-abbrev): Isr J Health Policy Res

Title: Israel Journal of Health Policy Research

Publisher: BioMed Central

ISSN (Electronic): 2045-4015

Publication date Collection: 2013

Publication date (Electronic): 23 January 2013

Volume: 2

Page: 1

Affiliations

[1 ]JDC Brookdale Institute, Health Policy Research Program, PO Box 3886, Jerusalem, 91037, Israel

[2 ]National Insurance Institute, Jerusalem, Israel

Article

Publisher ID: 2045-4015-2-1

DOI: 10.1186/2045-4015-2-1

PMC ID: 3557155

PubMed ID: 23343012

SO-VID: 06df7e7b-0d56-4bc8-b95b-4295afbd8cd8

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 25 July 2012

Date accepted : 13 November 2012

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The effect of clinical interventions on hospital readmissions: a meta-review of published meta-analyses

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Abstract

Background

Objective

Method

Main findings

Main study limitation

Conclusions

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Most cited references 84

Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials

Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials.

Integrated care programmes for chronically ill patients: a review of systematic reviews.

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