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Transition of Care for Acute Stroke and Myocardial Infarction Patients
Evidence Reports/Technology Assessments, No. 202
DaiWai M Olson, PhD, RN, Lead Investigator, Janet Prvu Bettger, ScD, Clinical Investigator, Karen P Alexander, MD, Clinical Investigator, Amy S Kendrick, RN, MSN, EPC Project Manager, Julian R Irvine, MCM, EPC Project Coordinator, Liz Wing, MA, EPC Editor, Remy R Coeytaux, MD, PhD, EPC Investigator, Rowena J Dolor, MD, MHS, EPC Associate Director, Pamela W Duncan, PhD, Principal Investigator, and Carmelo Graffagnino, MD, Principal Investigator.
Author Information and AffiliationsStructured Abstract
Objectives:
To review the available published literature to assess whether evidence supports a beneficial role for coordinated transition of care services for the postacute care of patients hospitalized with first or recurrent stroke or myocardial infarction (MI). This review was framed around five areas of investigation: (1) key components of transition of care services, (2) evidence for improvement in functional outcomes, morbidity, mortality, and quality of life, (3) associated risks or potential harms, (4) evidence for improvement in systems of care, and (5) evidence that benefits and harms vary by patient-based or system-based characteristics.
Data Sources:
MEDLINE®, CINAHL®, Cochrane Database of Systematic Reviews, and Embase®.
Review Methods:
We included studies published in English from 2000 to 2011 that specified postacute hospitalization transition of care services as well as prevention of recurrent stroke or MI.
Results:
A total of 62 articles representing 44 studies were included for data abstraction. Transition of care interventions were grouped into four categories: (1) hospital -initiated support for discharge was the initial stage in the transition of care process, (2) patient and family education interventions were started during hospitalization but were continued at the community level, (3) community-based models of support followed hospital discharge, and (4) chronic disease management models of care assumed the responsibility for long-term care. Early supported discharge after stroke was associated with reduced total hospital length of stay without adverse effects on functional recovery, and specialty care after MI was associated with reduced mortality. Because of several methodological shortcomings, most studies did not consistently demonstrate that any specific intervention resulted in improved patient-or system -based outcomes. Some studies included more than one intervention, which made it difficult to determine the effect of individual components on clinical outcomes. There was inconsistency in the definition of what constituted a component of transition of care compared to “standard care.” Standard care was poorly defined, and nearly all studies were underpowered to demonstrate a statistical benefit. The endpoints varied greatly from study to study. Nearly all the studies were single-site based, and most (26 of 44) were conducted in countries with national health care systems quite different from that of the U.S., therefore limiting their generalizability.
Conclusions:
Although a basis for the definition of transition of care exists, more consensus is needed on the definition of the interventions and the outcomes appropriate to those interventions. There was limited evidence that two components of hospital-initiated support for discharge (early supported discharge after stroke and specialty care followup after MI)were associated with beneficial effects. No other interventions had sufficient evidence of benefit based on the findings of this systematic review. The adoption of a standard set of definitions, a refinement in the methodology used to study transition of care, and appropriate selection of patient-centered and policy-relevant outcomes should be employed to draw valid conclusions pertaining to specific components of transition of care.
Contents
- Preface
- Acknowledgments
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Literature Search and Screening
- Key Question 1 For patients hospitalized with first or recurrent stroke or myocardial infarction (MI), what are the key components of transition of care services? Can these components be grouped in a taxonomy, and are they based on a particular theory?
- Key Question 2 For patients hospitalized with first or recurrent stroke or MI, do transition of care services improve functional status and quality of life and reduce hospital readmission, morbidity, and mortality (up to 1 year postevent)?
- Key Question 3 For patients hospitalized with first or recurrent stroke or MI, what are the associated risks, adverse events, or potential harms—both system-based and patient-based—of transition of care services?
- Key Question 4 Do transition of care services improve aspects of systems of care for patients with stroke or MI (e.g., more efficient referrals, more timely appointments, better provider communication, reduced use of urgent care, or fewer emergency room visits as a result of transition of care services)? Is there improved coordination among multiple subspecialty care providers, and are new providers added to the care plan as a result of transition of care services?
- Key Question 5 For patients hospitalized with first or recurrent stroke or MI, do benefits and harms of transition of care services vary by characteristics—both patient-based and system-based—such as disease etiology and severity, comorbidities, sociodemographic factors, training of the health care providers, participants (patients, caregivers), geography (rural/urban, regional variations), and insurance status?
- Summary and Discussion
- Future Research
- References
- Abbreviations
- Appendixes
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10066-I, Prepared by: Duke Evidence-based Practice Center, Durham, North Carolina
Suggested citation:
Olson DM, Prvu Bettger J, Alexander KP, Kendrick AS, Irvine JR, Wing L, Coeytaux RR, Dolor RJ, Duncan PW, Graffagnino C. Transition of Care for Acute Stroke and Myocardial Infarction Patients: From Hospitalization to Rehabilitation, Recovery, and Secondary Prevention. Evidence Report No. 202. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-2007-10066-I.) AHRQ Publication No. 11(12)-E011. Rockville, MD. Agency for Healthcare Research and Quality. October 2011.
This report is based on research conducted by the Duke Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10066-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report.
- 1
540 Gaither Road, Rockville, MD 20850; www
.ahrq.gov
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