Table 2: Summary of Systematic Reviews.

Author, Year, Country	Purpose	Inclusion Criteria	Results	Conclusion	Limitations
Hansen et al, 2011 (7) United States Literature search up to January 2011	Describe interventions evaluated in studies aimed at reducing rehospitalization within 30 days of discharge	RCTs (the authors also included observational studies, but HQO did not examine them in this analysis) Adults Interventions did not require disease-specific approaches (e.g., measurement of brain natriuretic peptide before HF discharge)	43 studies (16 RCTs) identified and divided into: -predischarge interventions; -patient education, medication reconciliation, discharge planning, and scheduling of follow-up appointments before discharge; -postdischarge interventions; -follow-up telephone calls, patient-activated hotlines, timely communication with ambulatory providers, timely ambulatory provider follow-up, and postdischarge home visits; -bridging interventions; and -transition coaches, physician continuity across the inpatient and outpatient setting, and patient-centred discharge instruction. 5 of 16 RCTs documented statistically significant improvement in rehospitalization outcomes within 30 days. Of these 5 trials, 1 consisted of a single intervention in which high-risk patients received early discharge planning or usual care; the treatment group experienced an absolute 11 percentage point reduction in 30-day rehospitalization. The remaining 4 RCTs tested multicomponent discharge bundles. However, 1 RCT did not report results for 30-day readmission but for 2 weeks, and 1 RCT combined readmission and ED visits. The 2 remaining RCTs demonstrated absolute reductions in 30-day readmission of between 3.6 and 6.0 percentage points. The patient-centred discharge instructions and postdischarge telephone call were included in all 4 RCTs showing significantly effective discharge bundles.	No single intervention implemented alone was regularly associated with reduced risk for 30-day rehospitalization.	Inadequate description of individual studies’ interventions precluded meta-analysis of effects. Many studies were single-institution assessments of quality improvement activities rather than those with experimental designs. Several interventions have not been studied outside of multicomponent “discharge bundles.”
Naylor et al, 2011 (1) United States Literature search cut-off date not reported	To identify and synthesize available evidence regarding discharge planning for adult, chronically ill populations	RCTs conducted in the United States Adults	21 RCTs identified. Naylor et al focused on 9 studies (3 of which were by the lead author) demonstrating positive effects of discharge planning on readmissions. “Because a key aim of the Affordable Care Act is to reduce avoidable hospital readmissions, we were particularly interested in the 9 interventions that reported a statistically significant positive effect on at least one measure of readmissions…” All but 1 of the 9 studies reported reductions in all-cause readmissions through at least 30 days after discharge. Of the remaining 8 interventions, 3 found positive, long-term effects in all-cause readmissions through 6 or 12 months following the index hospital discharge. These included 2 comprehensive discharge planning and follow-up interventions with home visits that were conducted by the lead author of the systematic review. The third intervention was a telehealth-facilitated intervention in which HF patients received either a videophone or telephone postdischarge support program. The study reported reduced all-cause readmissions through 12 months only when the 2 interventions groups were combined. There were no differences between the intervention group and the control group at 3 or 6 months. Discharge planning was not examined in this study.	“Our evidence review reveals nearly a dozen interventions that have demonstrated some positive effect on hospital readmissions.”	No overall systematic assessment of the 21 RCTs. Authors focused solely on the 9 studies that demonstrated positive effects of discharge planning on readmissions. Seven of the 21 studies focused on discharge management plus follow-up. Meta-analysis was not conducted due to heterogeneity of study design. “The nature and practice of transitional care is evolving, and a standardized definition has not yet been established. The Affordable Care Act’s interpretation of transitional care is broad, so we chose to be inclusive in our search. Thus the interventions retained in our synthesis are diverse and in some cases could reasonably be categorized in other ways (for example, as telehealth and case management interventions).”
Shepperd et al, 2010 (4) United Kingdom Literature search up to March 2009	To determine the effectiveness of planning the discharge of patients moving from hospital	RCTs that compared an individualized discharge plan with routine discharge care that was not tailored to the individual patient	21 RCTs (7,234 patients). Follow-up ranged from 2 weeks to 9 months. Readmission to hospital was significantly reduced for patients allocated to discharge planning (readmission rates RR, 0.85; 95% CI, 0.74–0.97, 11 trials). For elderly patients with a medical condition (usually HF), there was insufficient evidence for a difference in mortality (RR, 1.04; 95% CI, 0.74–1.46, 4 trials). In 3 trials, patients allocated to discharge planning reported increased satisfaction.	A structured discharge plan tailored to the individual patient probably brings about small reductions in readmission rates for older people admitted to hospital with a medical condition. The impact of discharge planning on mortality and health outcomes remains uncertain.	Key issue in interpreting the evidence is the definition of the intervention and the subsequent understanding of the relative contribution of each element. It was not possible to assess how some components of the process compared between trials. Inclusion of the caregiver or family was mentioned by some of the trials, but the degree to which this was done was not always apparent or reported. Monitoring of patient discharge planning differed (e.g., telephone or visiting primary care clinics). Three trials examined the effectiveness of a pharmacy discharge plan. The context in which an intervention such as discharge planning is delivered may also play a role, not only in the way the intervention is delivered, but in the way services are configured for the control group. Orientation of primary care services differs between countries, which may affect communication between services. Different perceptions of care by professionals of alternative care settings and country-specific funding arrangements may also influence discharge. Two studies reported discharge planning commencing from the time a patient was admitted to hospital, and another reported that discharge planning was implemented 3 days prior to discharge. The timing of delivery of discharge planning, which depends on other services, will have some bearing on how quickly these services can begin providing care. The patient population may also impact outcome (e.g., patients experiencing major complications from their chronic disease combined with an intervention designed to increase the intensity of primary care services may explain the observed increase in readmission days for those receiving the intervention.) Shepperd et al excluded RCTs evaluating interventions where discharge planning was not the main focus of a multifaceted package of care.
Scott, 2010 (8) Australia Literature search up to March 2009	To determine the relative efficacy of peridischarge interventions categorized into 2 groups: -single component interventions (sole or predominant) implemented either before or after discharge -integrated multicomponent interventions that have pre- and postdischarge elements	Controlled trials or systematic reviews that reported data on interventions targeting hospitalized patients and measured readmission rates	7 systematic reviews were key sources of data for analysis. Studies (not all RCTs) summarized as a narrative review. Formal meta-analysis not applied due to considerable study heterogeneity in design and outcome measures. Single component interventions that reduced readmissions: -intense self-management -transition coaching of high-risk patients -nurse home visits Telephone support of patients with HF Multicomponent interventions that reduced readmissions: -early assessment of discharge needs -enhanced patient and caregiver education and counselling -early postdischarge follow-up of high-risk patients	Peridischarge interventions are highly heterogeneous and reported outcomes show considerable variation. Multicomponent interventions targeted at high-risk populations that include pre- and postdischarge elements seem to be more effective in reducing readmissions than most single component interventions that do not span the hospital-community interface.	No critical review of single studies within the systematic review was undertaken Non-RCTs included in some of the systematic reviews “It is not an exhaustive systematic review of all individual trials of clinical interventions that relate to discharge processes in some way.”
Kumar and Grimmer-Somers, 2007 (9) Australia Literature search cut-off dates not reported	To systematically evaluate the secondary literature on hospital avoidance and discharge programs using a framework of best practice principles in health care (safety, effectiveness, timeliness, equity, efficiency, and patient-centredness)	Systematic reviews and grey literature reflecting the descriptive reviews of published and unpublished literature Patients of any age and with any condition who had been discharged from hospital to home RCTs and observational studies	48 publications “Overall, the health outcome, hospital LOS, and readmission rates associated with community/home-based care were no worse than those derived from hospital-based care. However, patients and caregivers mostly preferred care provided out of hospital, and this was often reflected in positive functional change and improved satisfaction scores.”	“While there was evidence for improved patient-centred outcomes, the evidence for safety, effectiveness, and efficiency of hospital avoidance and discharge programs was equivocal.”	Lack of description in many of the publications of “standard hospital care” as a comparator
Mistiaen et al, 2007 (10) Netherlands Literature search up to November 2006	To systematically examine reviews of the effectiveness of interventions aimed at reducing postdischarge problems in adults discharged home from an acute general care hospital	Systematic reviews Adult patients hospitalized primarily for a physical problem. Outcomes measured include patient status at discharge, patient functioning within 3 months of discharge, or health care service use and costs after discharge	15 systematic reviews All reviews dealt with considerable heterogeneity in interventions, populations and outcomes making synthesizing and pooling difficult. Although a statistically significant effect was occasionally found, most review authors reached no firm conclusions about the effectiveness of the discharge interventions. Limited evidence that some interventions may improve patients’ knowledge, may help in keeping patients at home, or may reduce readmissions to hospital Interventions that combine discharge planning and discharge support tend to lead to the greatest effects. There is little evidence that discharge interventions have an impact on hospital LOS, discharge destination, or dependency at discharge. No evidence that discharge interventions have a positive impact on the physical status of patients after discharge or on health care use after discharge.	Based on 15 high quality systematic reviews, there is some evidence that some interventions, particularly those with educational components and those that combine predischarge and postdischarge interventions, may have a positive impact. However, on the whole there is limited summarized evidence that discharge planning and discharge support interventions have a positive impact on patient status at hospital discharge, on patient functioning after discharge, or on health care use after discharge and costs.	“The umbrella concept of ‘discharge interventions’ is too broad to endeavour synthesizing by means of a review of systematic reviews already dealing with vast heterogeneity.” Poor description of interventions and control conditions
Phillips et al, 2004 (11) United States Literature search up to October 2003.	To evaluate the effect of comprehensive discharge planning plus postdischarge support on the rate of readmission, all-cause mortality, hospital LOS, and HRQOL	RCTs that described interventions to modify hospital discharge for older patients with HF compared with usual care Studies with clearly defined inpatient and outpatient components Studies that reported readmission as the primary outcome	18 RCTs (3,304 patients) Mean follow-up 8 months (range 3–12 months) Intervention vs. usual care: Readmission 555/1590 vs. 741/1714 RR, 0.75; 95% CI, 0.64–0.88 All-cause mortality RR, 0.87; 95% CI, 0.73–1.03; n = 14 studies Percent improvement in HRQOL scores compared with baseline 25.7% (95% CI, 11.0%–40.4%) vs. 13.5% (95% CI, 5.1%–22.0%), n = 6, P = 0.01	Comprehensive discharge planning plus postdischarge support for older patients with HF significantly reduced readmission rates and may improve health outcomes such as survival and HRQOL.	For most studies, usual care was not explicitly described. No studies evaluated the efficacy of comprehensive discharge planning without components for postdischarge support for patients with HF. The duration of components for postdischarge support was not consistently reported and varied by study. Components for postdischarge support varied by study. Unable to ascertain whether events that occurred distant from the index discharge were related to the initial DRG or new problems for patients who were readmitted or those who died.

Abbreviations: CI, confidence interval; DRG, diagnosis related group; ED, emergency department; HF, heart failure; HQO, Health Quality Ontario; HRQOL, health-related quality of life; LOS, length of stay; RCT, randomized controlled trial; RR, relative risk.