Hospital-initiated transitional care can improve outcomes for stroke, MI
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Hospital-initiated transitional care can improve some outcomes in adults hospitalized for stroke or MI, according to a systematic review published Sept. 17 in the Annals of Internal Medicine.

Transitional care is a time-limited service to prevent discontinuous care and adverse outcomes, including rehospitalization. Focused implementation efforts and financial incentives have already begun in response to several components of the Patient Protection and Affordable Care Act that highlight transitional care as a cornerstone of improved continuity, according to the study authors.

“When done properly, transitional care should be based on a comprehensive care plan and the availability of healthcare providers who are well-trained in long-term care and are armed with information about the patient’s goals, preferences and clinical status,” Susan T. Bray-Hall, MD, from University of Colorado School of Medicine in Denver, wrote in the accompanying editorial. “Well-executed transitions should include logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition.”

However, the researchers of this study said it remains “unclear” which patient populations benefit from transitional care services.

Janet Prvu Bettger, ScD, of the Duke University School of Nursing in Durham, N.C., and colleagues reviewed 62 articles representing 44 studies of transitional care for either acute stroke (27 studies) or MI (17 studies). Four intervention types were studied: hospital-initiated support (14 patients), patient and family education (seven patients), community-based support (20 patients) and chronic disease management (three patients).

Acknowledging that “a challenge” in preparing this review was defining the concept of transitional care after hospitalization for stroke or MI, the authors focused on the process patients had as they left the acute care hospital and reintegrated into society. In doing so, they identified more studies of patients with acute stroke than with MI and more community-based interventions than any other type. “Focusing mostly on the intervention or service in the community may ignore some of the most challenging patient and provider issues during the transition from hospital to home,” they wrote.

Most studies (68 percent) were of fair quality, but the authors cautioned that few studies were high-quality or reported adverse events.

Overall, moderate-strength evidence showed that hospital-initiated support reduced length of stay for patients who had a stroke, and low-strength evidence showed that it reduced mortality for patients who had an MI.  

Bettger et al said finding additional transitional care interventions that improve functional outcomes and prevent rehospitalizations and adverse events is a “high priority” for the growing population of patients who have an MI or a stroke.

Bray-Hall questioned: What outcomes should we focus on, and which do patients care about the most? She stressed that patient-centered outcomes should be the “focus of our work and should include mortality, functional status, quality of life and caregiver burden. Other outcomes, including documentation of medication reconciliation or time for the community provider to receive a discharge summary, may be useful surrogates but may not directly link to improvements in patient-centered outcomes.”

While acknowledging that researchers do not yet know which interventions yield the most benefit, Bray-Hall wrote that reviews, such as this one by Bettger et al, help in the next important steps, including “identifying pertinent outcomes; clearly defining simple and reproducible interventions; assessing costs; choosing the appropriate target population for study; and, eventually, designing collaborative, multi-institutional studies to translate the most effective programs into wider practice.”

The Agency for Healthcare Research and Quality funded the study.