Table A7: GRADE Evidence Profile for Comparison of Predischarge Planning Plus Postdischarge Support and Usual Care.
| No. of Studies (Design) | Risk of Bias | Inconsistency | Indirectness | Imprecision | Publication Bias | Upgrade Considerations | Quality |
|---|---|---|---|---|---|---|---|
| Readmissions | |||||||
| 2 systematic reviews of RCTs 4 recent RCTs |
Some serious limitations (-1)a |
Some serious limitations (-1)b |
No serious limitations | No serious limitations | Undetected | None | ⊕⊕ Low |
| Length of Stay | |||||||
| 1 systematic review of RCTs | Some serious limitations (-1)c |
Some serious limitations (-1)d |
No serious limitations | No serious limitations | Undetected | None | ⊕⊕ Low |
| Mortality/Survival | |||||||
| 1 Systematic Review of RCTs 1 recent RCT |
Some serious limitations (-1)e |
Some serious limitations (-1)f |
No serious limitations | No serious limitations | Undetected | None | ⊕⊕ Low |
| HRQOL | |||||||
| 1 systematic review of RCTs 2 recent RCTs |
Very serious limitations (-2)g |
Some serious limitations (-1)h |
No serious limitations | No serious limitations | Undetected | None | ⊕ Very Low |
| Patient Satisfaction | |||||||
| 1 recent RCT | Very serious limitations (-2)i |
Some serious limitations (-1)j |
No serious limitations | No serious limitations | Undetected | None | ⊕ Very Low |
Abbreviations: EPOC, Effective Practice and Organization of Care Group; HF, heart failure; No., number; RCT, randomized controlled trial
Average EPOC Risk of Bias score in studies included in systematic review by Hansen et al was 5 out of 9.
The systematic review by Phillips et al (11) reported that 16/18 RCTs were assigned a Jadad score of 4 out of 5 and 2 studies reported a score of 3 out of 5. The overall summary estimate was significantly heterogeneous (P < 0.001). When a large study was removed from meta-analysis, heterogeneity was reduced but was still significant (P = 0.04)
Some significant differences in baseline characteristics between treatment arms in recent RCTs.
Phillips et al (11) found a significant difference in readmissions favouring comprehensive discharge planning with postdischarge support, however, there was significant statistical heterogeneity. Hansen et al did not conduct a meta-analysis due to heterogeneity among the included studies and could not make a conclusion as to which comprehensive discharge bundle/package was most effective compared with usual care. Of the 4 recent RCTs that were not included in the previous systematic reviews, 1 found a significant difference in readmissions favouring comprehensive pre- and postdischarge care.
The systematic review by Phillips et al (11) reported that 16/18 RCTs were assigned a Jadad score of 4 out of 5 and 2 studies reported a score of 3 out of 5. Hospital LOS was not reported in all studies included in the systematic reviews and of those that did, it was reported as a secondary outcome.
Phillips et al (11) did not find a significant difference in hospital LOS between the comprehensive discharge planning and postdischarge follow-up and usual care. Not all studies in the systematic reviews reported on hospital LOS. None of the 4 recent RCTs reported on hospital LOS.
The systematic review by Phillips et al (11) reported that 16/18 RCTs were assigned a Jadad score of 4 out of 5 and 2 studies reported a score of 3 out of 5. Mortality/survival was not reported in all studies included in the systematic reviews and of those that did, it was reported as a secondary outcome. One of the 4 recent RCTs reported a significant reduction in mortality for patients in the intervention group. (RCT incorporated an additional component to postdischarge follow-up [HF clinics]).
Phillips et al (11) did not find a significant difference in mortality between study arms. One of the 4 recent RCTs reported mortality and found a significant difference favouring comprehensive discharge planning and follow-up (Unlike the studies included in Phillips et al, this RCT also incorporated HF clinic visits as part of the intervention.)
The systematic review by Phillips et al reported that 16/18 RCTs were assigned a Jadad score of 4 out of 5 and 2 studies reported a score of 3 out of 5. HRQOL was not reported in all studies included in the systematic reviews and of those that did, it was assessed using different measurement tools and reported as a secondary outcome.
Two of the 4 recent RCTs reported HRQOL. One study had significant differences in baseline characteristics between study arms and the other RCT incorporated an additional component to postdischarge follow-up (HF clinics).
Phillips et al (11) meta-analyzed data for this outcome and reported that HRQOL scores of intervention patients improved significantly more than usual care patients. (Statistical heterogeneity was not reported.) One of the 4 recent RCTs reported a significant improvement in HRQOL for patients receiving comprehensive discharge planning (this study also incorporated HF clinic visits in the postdischarge follow-up). One RCT reported a significant improvement in HRQOL at one time point during follow-up (12 weeks). No significant difference was found at any other time point (2, 6, 26, and 52 weeks).
Significantly more patients with hypertension in the control group than the treatment group at baseline. This endpoint was a secondary outcome and performed on a subgroup of patients.
Satisfaction with care was greater in intervention patients at 2 and 6 weeks, however, no other time points were reported in a study that lasted 12 weeks.