Background

Despite advances in the quality of acute-care management of stroke and myocardial infarction(MI), there are gaps in knowledge about effective interventions to better manage the transition of care for patients with these complex health conditions. Transition of careis defined as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location,”¹ and is often provided by interdisciplinary teams of professionals.² Indicators of potential transition problems include avoidable rehospitalizations and emergency room visits as well as poor functional status and quality of life. The Centers for Disease Control and Prevention (CDC) requested the Agency for Healthcare Research and Quality’s (AHRQ’s) Evidence-based Practice Center (EPC) Program to systematically review the evidence for transition of care services and programs that improve the posthospitalization quality of care for individuals who have experienced strokes or MIs. The results of this review will inform the CDC about the current strength of evidence as they develop future initiatives (e.g., research, clinical, public health and policy) to implement evidence-based recommendations for stroke and MI systems of care and postacute quality-of-care programs. State health departments are developing strategic and comprehensive plans for quality improvement programs for health systems, communities, and individuals to advance the transition of care. Their decisions should be informed by the current strength of evidence for transition of care models implemented during acute care, hospitalizations, and postacute settings of care (e.g., skilled nursing facilities, inpatient rehabilitation centers, community). Yet, the best practices for care transitions are not well established.

The mission of the Division for Heart Disease and Stroke Prevention (DHDSP) at the CDC is to provide public health leadership to improve cardiovascular health, reduce the burden, and eliminate disparities associated with heart disease and stroke. Cardiovascular disease and stroke account for 15 percent of the total health expenditures in 2007,³ and the total estimated costs for both are over $286 billion per year. Of the $286 billion, $40 billion is attributable to stroke.⁴ Advances in the management and quality of acute care have contributed to reduced mortality in both conditions.⁵ Yet some of the social and economic consequences of MI and stroke are their contribution to the burden of poor health, chronic disease, and disability rather than death. MIs and strokes contribute to, or become, chronic diseases due to the high risks of rehospitalization, functional decline, disability, and future cardiovascular events and second strokes.

The median risk-standardized 30-day readmission rate for acute MI is approximately 20 percent.⁶ Stroke patients are also at high risk for hospital readmissions, with 30 percent of acute stroke patients experiencing at least one readmission within 90 days after discharge.⁷ Acute -care hospitalization is a “point of influence” to improve outcomes and quality of care for recovery, risk-factor management, and better health. Better management of patients’ care will require management across multiple providers and settings. It will soon be expected that acute-care settings accept the responsibility to manage care transitions and avoid rehospitalizations. In 2012, the Patient Protection and Affordable Care Act will financially penalize hospitals for high readmission rates. In 2015, acute MI will be one of the conditions targeted for improved quality of care, and stroke may be a condition identified in the future. These policies will increase the incentives for acute-care hospitals to develop effective transition of care programs and support integrated care. It will be important for health systems to develop and implement sustainable transition of care models in collaboration with primary care, other postacute health care systems (e.g., home health, rehabilitations centers, skilled nursing facilities), community-based services, and patients and their families.

Most of the programs supporting transition of care have been developed for congestive heart failure^8,9 and older adults with multiple comorbidities.^1,10 Acute MI and stroke also are complex health conditions that require effective interventions to better manage transition of care. However, there are major gaps in knowledge about best practices for transition of care for MI and stroke. In 2007, an AHRQ technical review identified multiple quality gaps in the coordination of chronic disease care,¹¹ and there was only one study of stroke and none of MI included in that review.

There are some inconsistencies in the early literature on transition of care models, depending on the focus of the study and the disciplines leading the interventions (nursing, medicine, rehabilitation).¹² This suggests that a broad and multidisciplinary re view is required to adequately explore the key questions of transition of care for patients diagnosed with stroke or MI. With the advent of transition of care models and methods to integrate service delivery, it is imperative that we synthesize the evidence to find promising models of transition of care or to identify gaps in the evidence and needed research and program development to improve the quality of management of two of the most common health problems. These efforts are consistent with the Institute of Medicine’s priorities to (1) compare the effectiveness of diverse models of transition support services for adults with complex health care needs (e.g., the elderly, homeless, mentally challenged) after hospital discharge and (2) compare the effectiveness of different quality improvement strategies in disease prevention, acute care, chronic disease care, and rehabilitation services for diverse populations of children and adults.¹³

Scope and Key Questions

The first challenge of this systematic review was to consider the pathways for the transition of care. Transitions may include those that are direct to the outpatient environment as well as those to and from intermediate care environments. In addition, the components of transition of care may occur separately or in aggregate, which makes it important to know how the components are categorized and described within a clear taxonomy.

The second challenge was to dissect those data relevant to the disease states of interest. The incidence of stroke and MI increases with age, as does the presence of other chronic conditions that may be driving downstream outcomes. Also, stroke and MI are not exclusively diseases of the elderly, so it is fundamental to explore stroke and MI transitions within the population as a whole as well as in the older or chronically ill population.

While both stroke and MI result from disorders of the vascular system—and as such share many common risk factors—each medical condition presents unique challenges regarding transitions across care settings. Stroke patients more often transition from hospital to inpatient rehabilitation facilities, nursing homes for rehabilitation or palliative care, or home health services. Also, patients with stroke have more long-term physical disability and cognitive impairments that may require rehabilitative services or long-term institutional support. In contrast, patients with MI are more likely to be discharged directly home and receive outpatient transition of care services. Additionally, patients with stroke are more likely to be older, female, and African American than are patients with MI.¹⁴

As part of this systematic review, we explored features of transition of care that are common to both vascular disorders as well as features that are unique to disease-specific needs. The key questions considered in this review were:

• 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?

Purpose of This Report

The goal of this evidence report was to review the literature that explored the opportunities and limitations of existing transition of care models, such as patient resource management, that are available for patients as they navigate from acute hospital care to rehabilitation services and eventually to independent or dependent living. Each step in the transition process was evaluated on its own merits as well as how it integrated the care of patients as they were discharged from the hospital and sought care with other providers, through different health care systems or in community programs. We reviewed the available published literature to assess whether evidence existed to support a beneficial role for coordinated transition of care for the postacute management period of medical, rehabilitative, and nursing services. Metrics of successful application of transition of care services included hospital readmission rates, second events (stroke or MI), resource utilization (cardiac or stroke rehabilitation, medical followup), functional status, medication adherence, and compliance with health care programs aimed at secondary prevention.

Role of the Technical Expert Panel

We identified experts in the field of transitional care for patients with stroke and MI to serve as members of the project’s Technical Expert Panel (TEP). The TEP contributes to AHRQ’s broader goals of (1) creating and maintaining science partnerships and public–private partnerships and (2) meeting the needs of an array of potential customers and users of this report. To ensure accountability and scientifically relevant work, we asked the TEP for input at key stages of the project. More specifically, TEP members participated in conference calls and email exchanges to refine the analytic framework and key questions at the beginning of the project, refine the scope, discuss inclusion and exclusion criteria, and provide input on methodology.

Members of our TEP represented a broad range of experience relevant to our topic because of their extensive knowledge of the literature. They included experts in cardiology, vascular neurology, community-based medicine and rehabilitation, and geriatric medicine. Additionally, the TEP included representatives from the National Institutes of Health as well as Blue Cross and Blue Shield.