SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
March, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Rehospitalisation following discharge is a frequent event that affects patients’ quality of life and can be associated with poor health outcomes. Avoiding rehospitalization is a goal that may both improve quality of care and reduce healthcare costs.
Key messages
Hansen LO, Young RS, Hinami K et al. Interventions to reduce 30 day rehospitalization: a systematic review. Ann Intern Med 2011; 155:520-8.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Rehospitalization creates considerable burdens for both patients and health systems. Interventions to reduce avoidable hospitalization can be classified into three groups, based on the timing of the intervention:
| Review objectives:To estimate the effectiveness of interventions to reduce 30 day rehospitalisation | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials, cohort studies, or uncontrolled before after studies assessing interventions delivered around the time of discharge and applicable to general medical adult populations (rather than disease specific approaches) |
43 included studies: 16 randomised trials, 14 non randomised trials, and 13 uncontrolled before after studies. Most studies (56%) tested a single component intervention. |
| Participants | General medical adult acute inpatient populations. Studies of paediatric, obstetric, and psychiatric populations were excluded. |
Most studies focused on people admitted to general medicine wards or people with heart failure or chronic obstructive pulmonary disease. |
| Settings | Hospital, ambulatory care and patients’ homes. |
USA (28), UK (2), Canada (2), Hong Kong (2), and 1 study in each of the following countries: Australia, Belgium, Denmark, Ireland, Israel, Netherlands, New Zealand, Portugal, and Taiwan. |
| Outcomes | 30 day rehospitalisation |
30 day rehospitalisation |
| Date of most recent search: January 2011. | ||
| Limitations: This is well conducted systematic review with only minor limitations. | ||
Hansen LO, Young RS, Hinami K et al. Interventions to reduce 30 day rehospitalization: a systematic review. Ann Intern Med 2011; 155:520-8.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
The review included 43 studies. The effects of interventions are presented in three categories: pre discharge interventions, post discharge interventions and interventions that aim to bridge the transition between care settings. Several of the common discharge interventions were only assessed as part of multicomponent “discharge bundles”.
1) Pre discharge Interventions
Pre discharge patient education and discharge planning were the most commonly evaluated interventions (22 of 43 studies), but were evaluated mostly as ‘bundled’ interventions and so do not provide evidence on the effects of pre discharge interventions alone. Three studies assessed pre discharge interventions alone. One study that assessed a patient education intervention found a small decrease in rehospitalisation. The two studies assessing discharge planning had mixed results.
Predischarge interventions |
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| People: People admitted to hospital in Canada and the USA (2 studies). Settings: Hospitals. Intervention: Patient education or discharge planning. Comparison: No intervention. |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
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| Rehospitalisation |
The studies had mixed results: one study found an 11% reduction in rehospitalisation, one study found a 7.1% reduction, and one study found a 7.8% increase. |
Very low
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| GRADE: GRADE Working Group grades of evidence (see above and last page). |
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2) Postdischarge Interventions
Post discharge interventions included follow up telephone calls (17 studies), patient activated “hotlines” (5), home visits (9), timely outpatient follow up (5), and timely communication of patient information to an outpatient provider (5). Only three studies examined postdischarge interventions alone: one assessed home visits and two assessed follow up telephone calls. The other studies assessed post discharge interventions together with other interventions or did not use randomised designs and so do not provide evidence on the effects of post discharge interventions alone.
Post discharge interventions |
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| People: Outpatients in Israel, the United Kingdom, and the USA Settings: Home Intervention: Follow up telephone calls or home visits. Comparison: No intervention. |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
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| Rehospitalisation |
The studies had mixed results: one study found a 2% reduction in rehospitalisation, one study found a 0.5% increase, and one study found a 10% increase. |
Low |
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| GRADE: GRADE Working Group grades of evidence (see above and last page) |
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Twelve studies described strategies involving “bridging” interventions, with several studies assessing more than one intervention in ‘bundles’:
Interventions bridging the transition from hospital to home |
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| People: Inpatients and outpatients in Australia (1), Canada (1), the Netherlands (1), the United Kingdom (1), and the USA (8). Settings: Hospital and home. Intervention: Patient centred discharge instructions, as part of a bundle of interventions; inpatient outpatient provider continuity; interactions between patients and nurses, as part of a bundle of interventions. Comparison: No intervention. |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
Comments | |
| Rehospitalisation |
Eight studies assessed patient centred discharge instructions. The results ranged from a 10% reduction in rehospitalisation to a 2% increase. |
Very low
|
The certainty of the evidence was assessed as very low due to risk of bias and inconsistency of the results, which include both benefit and harm | |
| Improvements in inpatient outpatient provider continuity may slightly reduce rehospitalisation. The two studies found reductions of 0.7% and 4.4%. |
Low
|
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| Six studies assessed interactions between patients and nurses before and after discharge to support patient self care. The reductions in rehospitalisation ranged from 2-12%. |
Very low
|
The certainty of the evidence was assessed as very low due to risk of bias and inconsistency of the results. | ||
| GRADE: GRADE Working Group grades of evidence (see above and last page) |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
|
The certainty of the evidence is low or very low.
|
In addition to the evidence from high income countries being uncertain, the applicability of that evidence to low income countries is uncertain because the effects of interventions might depend on the capacity and type of health professionals available to deliver interventions before and after hospital discharge; the availability of community based care and support, to ensure continuity of care; other health systems resources needed to implement the interventions; and the resources available in the household to support patient care.
|
| EQUITY | |
| There was no information in the review regarding the differential effects of the interventions for disadvantaged populations. |
The impacts of these interventions on inequities is uncertain. Some of the interventions involve shifts in care from secondary to primary level and to the home. The effects of these interventions may depend on the potential of health systems to address the limited availability of community care, and the capacity of health professionals to provide care for disadvantaged populations.
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| ECONOMIC CONSIDERATIONS | |
| The systematic review did not address the costs or cost effectiveness of these interventions. |
Both costing studies and cost effectiveness studies (for effective interventions) are needed. Detailed information on the resources needed to implement these interventions would be helpful in assessing their applicability to other settings. |
| MONITORING & EVALUATION | |
| The available evidence on interventions to reduce rehospitalisation is of low or very low certainty, and no eligible studies from low income countries were identified. |
Rigorous studies of the effects and cost effectiveness of these interventions are needed in low income countries before scaling up their use.
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low income countries. For additional details about how these judgements were made see:www.supportsummaries.org/methods |
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Scott IA. Preventing the rebound: improving care transition in hospital discharge processes. Aust Health Rev 2010; 34:445-51.
Cain CH, Neuwirth E, Bellows J, et al. Patient experiences of transitioning from hospital to home: an ethnographic quality improvement project. J Hosp Med 2012; 7:382-87.
Long T, Genao I, Horwitz LI. Reasons for readmission in an underserved high risk population: a qualitative analysis of a series of inpatient interviews. BMJ Open 2013; 3(9):e003212.
Gonçalves Bradley DC, Lannin NA, Clemson LM, et al. Discharge planning from hospital. Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD000313.
Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by Richard Walker. We did not receive any comments from the review authors.
Hansen LO, Young RS, Hinami K et al. Interventions to reduce 30 day rehospitalization: a systematic review. Ann Intern Med 2011; 155:520-8.
The summary should be cited as
Ciapponi A. Are interventions to reduce rehospitalisation within thirty days of discharge effective? March 2017. www.supportsummaries.org
evidence informed health policy, evidence based, systematic review, health systems research, health care, low and middle income countries, developing countries, primary health care, hospitalization, readmission, patient discharge, continuity of patient care, transition.
