In this study, we systematically review and meta-analyze the evidence for pediatric hospital discharge interventions that are associated with reduced health care use and/or improved patient and family satisfaction.
Abstract
CONTEXT:
Hospital-to-home transitions are critical opportunities to promote patient safety and high-quality care. However, such transitions are often fraught with difficulties associated with increased health care use and poor patient satisfaction.
OBJECTIVE:
In this review, we determine which pediatric hospital discharge interventions affect subsequent health care use or parental satisfaction compared with usual care.
DATA SOURCES:
We searched 7 bibliographic databases and 5 pediatric journals.
STUDY SELECTION:
Inclusion criteria were: (1) available in English, (2) focused on children <18 years of age, (3) pediatric data reported separately from adult data, (4) not focused on normal newborns or pregnancy, (5) discharge intervention implemented in the inpatient setting, and (6) outcomes of health care use or caregiver satisfaction. Reviews, case studies, and commentaries were excluded.
DATA EXTRACTION:
Two reviewers independently abstracted data using modified Cochrane data collection forms and assessed quality using modified Downs and Black checklists.
RESULTS:
Seventy one articles met inclusion criteria. Although most interventions improved satisfaction, interventions variably reduced use. Interventions focused on follow-up care, discharge planning, teach back–based parental education, and contingency planning were associated with reduced use across patient groups. Bundled care coordination and family engagement interventions were associated with lower use in patients with chronic illnesses and neonates.
LIMITATIONS:
Variability limited findings and reduced generalizability.
CONCLUSIONS:
In this review, we highlight the utility of a pediatric discharge bundle in reducing health care use. Coordinating follow-up, discharge planning, teach back–based parental education, and contingency planning are potential foci for future efforts to improve hospital-to-home transitions.
Patient transitions from hospital to home are increasingly recognized as critical opportunities to promote patient safety and high-quality care. Approximately 20% of children discharged from hospitals experience a caregiver-reported problem in the transition to home.1,2 Parents report difficulties with scheduling follow-ups, finding transportation, filling prescriptions, medication side effects, and patient deterioration.2,3
Although pediatric hospital discharge quality indicators remain under development, both postdischarge use rates and parental satisfaction scores have recently been identified as key quality measures. Difficulties in patient transitions are associated with increased postdischarge health care use (hereafter referred to simply as “use”), including prolonged hospitalization, return to the emergency department (ED) soon after discharge, and unplanned readmission.4 As such, 30-day pediatric readmission rates have been commissioned by the National Quality Forum as a pediatric quality measure.5 The Child Hospital Consumer Assessment of Hospital Providers and Systems survey was recently developed for use in the pediatric population and was also endorsed by the Agency for Healthcare Research and Quality as a quality measure.6,7 Parental or caregiver satisfaction with the hospital discharge process is one of the key composite measures assessed in the Child Hospital Consumer Assessment of Hospital Providers and Systems survey7 and has also been correlated with a decrease in postdischarge use.8–11 Use rates and parental satisfaction are therefore increasingly employed as key indicators of hospital discharge quality and serve as important outcomes for attempts to improve discharge processes.
As hospitals work to improve transitions from hospital to home, numerous discharge process improvements have been proposed. The adult transitions-of-care literature has revealed that both care coordination interventions (CCIs) and patient education interventions are key means of improving discharge outcomes, particularly for patients with chronic illnesses.12–15 The last systematic review of pediatric hospital discharge processes, published by Auger et al,16 was focused on discharge processes that affected subsequent hospital use, defined as readmissions and postdischarge ED visits. In a subsequent 2015 narrative review by the Seamless Transitions and (Re)admissions Network (STARNet), assembled with the support of the American Academy of Pediatrics Quality Improvement Innovation Networks and the Society of Hospital Medicine, 3 key focus areas for improved quality of pediatric care transitions were identified: communication between inpatient and outpatient health care providers, care coordination, and family engagement and education.17
Since these initial reviews, the body of literature regarding pediatric discharge process interventions that impact subsequent hospital use has continued to rapidly grow. Furthermore, postdischarge use, although important, occurs at much lower rates in children than in the adult population, making recruitment of adequate pediatric sample sizes to assess this outcome challenging. The rise of parental satisfaction as an important quality indicator provides the opportunity to evaluate interventions that may not have had a statistically significant impact on postdischarge use.6,7 Finally, a meta-analysis of the effect of pediatric discharge interventions on use has not previously been performed. We therefore undertook this updated systematic review and meta-analysis of the literature to determine which pediatric hospital discharge process interventions are associated with decreased use and/or improved patient and/or caregiver satisfaction compared with typical local discharge processes.
Methods
Search Strategy
Review methods were published to PROSPERO at initiation of the study (registration number: CRD42017053468), and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. We searched the following electronic bibliographic databases: Ovid Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, the Joanna Briggs Institute (JBI) Database, Scopus, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete. There were no date restrictions. See Supplemental Information for search terms and strategy. The authors reviewed all titles and abstracts published in 5 pediatric journals (Academic Pediatrics, Hospital Pediatrics, JAMA Pediatrics, Journal of Pediatrics, and Pediatrics) for relevant articles within the past 5 years. Both full articles and abstracts (eg, published meeting presentations) were considered in the search. Searches were re-run in July 2017 just before the final analyses, and further studies were retrieved.
Study Selection
A single author (M.Y.H.) reviewed all titles and abstracts to eliminate articles not meeting the following inclusion criteria: (1) available in English, (2) focused on children <18 years of age or pediatric results reported separately from adult data, (3) not focused on normal healthy newborns, (4) not focused on pregnancy, or (5) not review articles, case studies, or commentaries. Two of the listed authors (M.Y.H., U.S., S.T.L.) independently reviewed the abstracts remaining after this preliminary review. Additional inclusion criteria were (1) a hospital discharge process intervention that was implemented in the inpatient setting and (2) outcomes related to subsequent health care use or patient and family satisfaction with care received. Because several studies have revealed parental self-efficacy for home care management and parental assessment of readiness for discharge as key elements of satisfaction with and success in pediatric care transitions, we included outcomes of parental self-efficacy, confidence, and readiness as a subset of patient and family satisfaction.7,18,19 When it was unclear if an article met eligibility criteria or if there was disagreement between the 2 independent abstract reviewers, then the article was included in a full article review. Two coders (M.Y.H., R.L.S., P.D.V., A.R.B., L.N.R., B.P.T.) independently reviewed articles that met criteria for full review to confirm eligibility. We included abstracts to avoid publication bias, and further information was requested from the authors to perform additional review.
Data Abstraction
The authors initially piloted a modified Cochrane Collaboration data collection form for data abstraction from 2 articles to ensure uniformity of the review and allow for modification of the form as needed.20,21 Two coders (M.Y.H., R.L.S., P.D.V., A.R.B., L.N.R.) then independently abstracted data from each eligible article using the data collection form. Data abstraction included study design, inclusion and exclusion criteria, description of the intervention, number and age of study subjects, diagnoses studied, hospital location and type, presence of outcomes of interest, primary outcomes, and limitations. Any disagreements in data abstraction were resolved through consensus.
The inclusion criteria, exclusion criteria, and nature of interventions were highly variable across studies. We classified studies on the basis of intervention according to the following framework as defined by STARNet: (1) interventions involving communication between the inpatient and outpatient health care providers (provider communication interventions [PCIs]), (2) interventions involving care coordination (CCIs, defined as those that involved intentional organization of patient care activities), and (3) interventions involving family engagement (family engagement interventions [FEIs], which included family education and/or involvement in patient care).17 Studies fell into 1 to 3 of these categories on the basis of the interventions applied.
Within these 3 broad categories, we created subcategories consisting of common interventions that were evaluated in multiple studies, including those in which the hypotheses proposed by Auger et al16 in the previous systematic review were addressed. Specifically, Auger et al16 suggested that designating an individual or team to coordinate discharge planning and inpatient parental education incorporating task-based feedback learning would reduce subsequent use. Therefore, within the care coordination and family engagement categories, we separately reported the effectiveness of interventions involving focused discharge planning or inpatient parental education with or without teach-back learning. Other common categories of interventions were postdischarge follow-up care (within care coordination) and contingency planning (within family engagement).
Quality Assessment
Articles were independently scored for quality by using a modified Downs and Black22 checklist, which is used to consider recruitment, randomization, blinding, length of follow-up, statistical tests, intervention compliance, adjustment for confounders, and loss of patients to follow-up. Downs and Black22 item 27, which is used to attempt to provide an evaluation of sample size, was omitted in favor of the evaluation of confidence intervals (CIs) in the meta-analysis.
Meta-analysis
Because interventions were nearly uniformly effective in improving satisfaction, the analysis of effect sizes was focused on use, specifically on readmission and ED revisits. Numerators (the number of patients with a readmission or ED revisit) and denominators (the total number of patients in a group) were extracted from all articles, if provided, and used to calculate relative risks with 95% CIs. If only odds ratios with 95% CIs were given without the number of patients per group or the baseline risk, we used the rare disease assumption to convert to relative risk.23 The meta-analysis included both randomized and nonrandomized studies. Studies were excluded from the meta-analysis if risk ratios and/or CIs could not be calculated from the information provided. In cases in which multiple outcomes in a single patient population were evaluated in a study, we chose to include the outcome in which the longest follow-up time was evaluated. The relative risk and 95% CI for each of the studies was then plotted by using Excel version 16.13 (Microsoft Corporation, Redmond, WA). Pooled effect sizes were calculated by random effects models with weighting by inverse variance, and relative risks were plotted by using Meta-Essentials.24 The subgroup analysis was conducted by intervention type and patient population for subgroups containing a minimum of 2 studies. I2 was used to evaluate consistency.
Results
Search Results
There were 5539 studies identified through bibliographic database searches, and 90 articles were identified through the manual journal search. Thirty-eight of the articles identified through manual searching were not identified in the database searches but were subsequently eliminated because they did not meet inclusion criteria. The elimination of duplicates yielded 4971 unique publications. After inclusion and exclusion criteria were applied, 71 studies underwent a full systematic review (Fig 1). Compared with the Auger et al16 systematic review, we identified 62 additional studies, including 25 studies published within the Auger et al16 study time frame (15 in which use outcomes were addressed, 10 in which satisfaction outcomes were addressed, and 2 in which both use and satisfaction outcomes were addressed).
FIGURE 1.
PRISMA diagram showing article inclusion and exclusion.
Study Characteristics
Studies were highly variable in the patient population of focus. A majority of studies took place at academic centers, with only 14 studies involving community hospitals.25–38 Articles were focused on pediatric patients hospitalized in 3 broad categories: those with chronic conditions, neonates hospitalized in a NICU, and the general pediatric population. Health care use outcomes, most commonly readmission or ED revisits, were evaluated in 61 articles, whereas parental satisfaction was evaluated in 25 articles (Table 1).
TABLE 1.
Study Quality Score, Intervention, and Major Findings Separated by Patient Group
| Author, y | Study Design | Sample Size | Study Population | Intervention | Control | Outcome(s) | Quality Score | Key Limitations | Major Findings | Summary of Outcome | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Readmit | ED Revisit | Other Use | Parental Satisfaction | ||||||||||
| Care of patients with chronic illnesses | |||||||||||||
| Technology assisted | |||||||||||||
| Baker et al,39 2016 | Pre-post | 48 total patients (18 preintervention and 30 postintervention) | Children 0–25 y of age discharged from the hospital after first initiation of chronic ventilation; excluded: if weaned from ventilation before discharge or discharged on IV infusion | CCI: electronic tracking of discharge readiness, care coordination, and case management for home nursing; FEI: evidence-based education for caregivers | Usual care: different patient group in the preintervention time period | ED revisits within 6 mo; readmissions within 30 d and 12 mo | 14 | Did not discuss compliance with the study interventions; patients lost to follow-up were not described. May have been confounded by concurrent hospital-wide resource stewardship initiatives. | Readmissions and ED visits remained unchanged. Length of stay decreased by 42% (P = .002). Costs per hospitalization decreased by 43% (P = .01). | ∼ | ∼ | — | — |
| Schweitzer et al,40 2014 | Pre-post | 49 patient-caregiver pairs (23 preintervention and 26 postintervention) | Caregivers of children 0–17 y of age with a gastrostomy tube recommended by the primary care provider anticipated for minimum of 3 mo; children who were able to learn independent gastrostomy-tube cares were excluded | FEI: preprocedure education protocol | Usual care: different patient group in the preintervention time period | Unplanned phone calls within 3 mo postprocedure; unplanned clinic visits within 3 mo postprocedure; unplanned ED visits within 3 mo postprocedure; caregiver confidence | 14 | Specific P values were not reported. Distribution of potential confounders was not described. Patients lost to follow-up were not described. | Unplanned clinic visits remained unchanged. Unplanned ED visits decreased from 42% to 17%, but unplanned phone calls increased from 0% to 22% after procedure (P < .05). Caregiver confidence and mastery of information was improved after intervention. | — | + | ∼ | + |
| Statile et al,41 2016 | Pre-post | 385 hospitalizations (227 unique patients) | Children admitted to the study institution with medical complexity were defined as those with neurologic impairment and/or technology dependence. | PCI: collaboration with outpatient Complex Care Center; CCI: children with medical complexity grouped onto 1 inpatient team; proactive discharge planning; dedicated pharmacist, dietician, case manager, and social worker; weekly care coordination rounds; needs assessment tool; medication pathway | Usual care: different patient group in the preintervention time period | Readmissions at 30 d | 16 | Patients lost to follow-up were not described. | Readmission rates unchanged; improved discharges within 2 h of meeting discharge goals from 50% to 88%; length of stay unchanged. | ∼ | — | + | — |
| Multisystem disease | |||||||||||||
| Brittan et al,42 2015 | Retrospective cohort | 2415 total patients (521 with follow-up ≤3 d after discharge, 965 with follow-up 4–29 d after discharge, and 929 with no follow-up within <30 d) | Children 6 mo to 18 y of age with complex chronic conditions by ICD-9 code continuously enrolled in Medicaid fee-for-service for a 6 mo period before the index admission and 30 d after the index discharge date; excluded: pregnancy and childbirth-related diagnoses, chemotherapy admissions, and children readmitted within 3 d of discharge | CCI: children with follow-up appointments within ≤3 d of hospital discharge or within 4–29 d of hospital discharge | Children without a follow-up appointment within <30 d of hospital discharge | Readmission 4–30 d after discharge | 16 | May not have fully controlled for potential confounders (ie, technology dependence and illness severity). | Patients with follow-up ≤3 d after discharge had increased readmissions compared with controls (31.6% vs 20.9%; P = .002). Patients with follow-up 4–29 d after discharge had decreased odds of readmission compared with controls (aOR 0.5; 95% CI: 0.3–0.7). Patients with postdischarge follow-up had a lower hazard of readmissions compared with controls (HR: 0.5; 95% CI: 0.4–0.7). | + | — | — | — |
| Cohen et al,43 2010 | Prospective cohort | 28 patients (same group in pre- and postintervention) | Children 30 d to 14 y of age with chronic health problems expected to continue for ≥12 mo, affecting ≥2 organ systems and requiring multiple prescriptions and/or technologies and ongoing care by subspecialists and health professionals in multiple care settings; excluded: non–English-speaking parents | PCI: inpatient team communication with primary care provider; CCI: care coordination surrounding hospital management; nurse practitioner–run and/or hospitalist-run complex care clinic for hospital follow-up; FEI: written care plan | Usual care: same patient group in the preintervention time period | Outpatient visits within 1 y, ED visits within 1 y, and parental satisfaction | 16 | Did not adjust for differing lengths of follow-up | Outpatient visits increased from 2 to 8 from pre- to postintervention (P = .003). The ED visit rate did not change. The median length of stay decreased from 43 to 15 d (P = .04). Parental perception of care continuity, family centeredness, and comprehensiveness of care improved. | — | ∼ | ∼ | + |
| Dick et al,44 2004 | Pre-post | 10 in pilot and 57 in trial | Children hospitalized at the study institution with serious medical conditions requiring frequent case management contact and monitoring of respiratory, cardiac, hydration, and/or nutritional status; excluded: children with specific needs that could not be filled through the intervention and those at risk for a precipitous catastrophic event | CCI: telehome care for up to 6 wk postdischarge | Pre-post interviews in same patient and caregiver population | Patient and family satisfaction | 13 | No control group (steering committee dropped randomization because of low sample size and patient preference for telehome care); intervention not completely described; did not account for patients lost to follow-up | There was a strong satisfaction with telehome care, especially after participation in the intervention. | — | — | — | + |
| Congenital heart disease | |||||||||||||
| Kogon et al,45 2015 | Pre-post | 1320 total (685 preintervention and 635 postintervention) | Patients discharged from the study institution after congenital heart surgery | CCI: medications delivered to hospital before discharge and phone calls to families within 72 h of discharge; FEI: all discharges conducted with an interpreter | Usual care: different patient group in the preintervention time period | Readmission within 30 d | 14 | Characteristics of patients lost to follow-up were not identified or adjusted for. Compliance with the intervention was not evaluated. | No significant change in readmission rate (10% vs 12%; P = .27) | ∼ | — | — | — |
| Lushaj et al,46 2016 | Prospective cohort | 165 total (32 with problem identified and 133 without problem identified) | Children who had congenital heart surgery at the study institution and were discharged from the hospital | CCI: structured postdischarge phone follow-up 1–4 d after discharge | Children with a problem identified on postdischarge phone follow-up were compared with children for whom no problem was identified on phone follow-up | Early unplanned readmissions | 12 | Authors looked at differences between the group with identified problems on the phone follow-up and those without problems on the phone follow-up rather than at the effect of the phone follow-up itself and did not address patients lost to follow-up. There was not adequate adjustment for potential confounders. | Length of stay and readmissions were similar between patients with identified problems and those without identified problems on the phone follow-up. | ∼ | — | — | — |
| Uzark et al,47 1994 | Pre-post | 300 total (130 preintervention and 170 postintervention) | Children admitted to the study institution with need for cardiac catheterization; radiofrequency ablation; balloon angioplasty for aortic coarctation, pulmonary stenosis, or aortic stenosis; transcatheter closure of atrial septal defect; pulmonary artery stent; pacemaker; ligation of patent ductus arteriosus; surgical repair of atrial septal defect, aortic coarctation, ventricular septal defect, tetralogy of Fallot, or atrioventricular septal defect; aortic valvotomy or resection of subaortic membrane; arterial switch; or heart transplant | CCI: pediatric nurse practitioners to coordinate and track resource organization for diagnosis and treatment of children with heart disease | Usual care: different patient group in the preintervention time period | Readmissions | 13 | Borderline P value for the difference in patients discharged within expected length of stay; potential confounders not described or addressed; losses to follow-up not taken into account. | Unchanged readmission rates; percentage of patients discharged within the expected length of stay increased from 66% to 76% (P = .05). | ∼ | — | — | — |
| Wu et al,48 2015 | Non-RCT | 60 total (30 controls and 30 in intervention group) | Children 0–6 y of age hospitalized at the study institution with a medical diagnosis of ventricular septal defect with pulmonary arterial hypertension; mothers must be the primary caregiver of their child, capable of communicating in Chinese, and without cognitive disability; excluded: children with any other congenital defect or whose parent was a health care professional | CCI: discharge planning service and postdischarge follow-up phone calls at 1 wk and 1, 2, and 3 mo; FEI: one-on-one parental education while child was hospitalized | Usual care: different patient group assigned to control group | Readmissions within 1 mo; maternal readiness for discharge | 12 | Intervention and control patients were recruited during different time periods (to prevent cross contamination). Did not address all potential confounders; did not describe characteristics of patients lost to follow-up; unclear if accounted for differing lengths of follow-up. | Increased maternal discharge readiness (t = 3.35; P = .001); no significant difference in readmission rate. | ∼ | — | — | + |
| Yang et al,49 2004 | Non-RCT | 35 total (20 controls and 15 in the intervention group) | Mothers who were the main caregiver for their infant (0–6 mo of age) born with congenital heart disease (but not with other congenital conditions) who underwent CV surgery; capable of communicating in Chinese or Taiwanese; excluded: mothers who were “mentally retarded” or who were health professionals | CCI: systematic discharge nursing plan, in-home MD visit and assistance with problems, phone follow-up and consultation with MD; FEI: maternal participation in inpatient infant care with MD instruction | Usual care: different patient group in preintervention time period | Maternal confidence at 1 wk and 1 mo after discharge | 13 | Essentially a pre-post study, not randomized; potential confounders not fully described; patients lost to follow-up not described | Improved maternal confidence (P < .05) | — | — | — | + |
| Asthma | |||||||||||||
| Bergert et al,50 2014 | Pre-post | 763 total (231 controls and 532 in the intervention group) | Children 2–18 y of age hospitalized at the study institution with asthma in the problem list or nursing admission form; diagnosis confirmed by chart review | CCI: tracking of postdischarge follow-up; FEI: completion of action plan | Pre-post: different patient group in preintervention time period | ED visits within 180 d; readmissions within 180 d | 12 | Potential confounders not fully described or addressed; patients lost to follow-up not noted or accounted for; unclear sustainability of the intervention | CAC compliance improved, and postdischarge follow-up led to decreased readmission rates in the 91–180-d postdischarge period (OR 0.29; 95% CI: 0.11–0.78). There was no difference in 0–90-d postdischarge readmissions or in ED visits. | + | ∼ | — | — |
| Davis et al,51 2011 | Case-control | 698 cases matched to database controls | Children >12 mo of age admitted to the study institution with a primary or secondary diagnosis of asthma; children >12 mo of age with an adult caretaker present who was willing to participate | CCI: follow-up phone call 3 wk after discharge; FEI: bedside asthma education | Usual care: different patient group in the same time period | Asthma-related ED revisits within 365 d; No. asthma-related hospital days | 15 | Used a convenience sample of patients and parents; not blinded; not all potential confounders were addressed; patients lost to follow-up were not addressed | Increased risk of repeat ED visits (HR: 2.45; 95% CI: 1.82–3.31); no statistically significant difference in No. hospitalized d. | — | * | ∼ | — |
| Ebbinghaus and Bahrainwala,52 2003 | Retrospective cohort | Not specified | Children with asthma | CCI: referral to outpatient allergy and/or asthma clinic; FEI: standardized asthma education | Usual care: different patient group concurrently cared for by a separate inpatient service | Asthma-related readmissions within 2 wk; patient and family understanding | 9 | Low reporting quality; sample size not specified; does not employ appropriate statistical analysis; potential confounders are not described or addressed; patients lost to follow-up not addressed | Slight increase in readmission rate and decrease in cost, but statistical significance not addressed; trend toward decreased length of stay from 2.2 d pre- to 1.7 d postintervention; improved patient and family understanding and coordination of care. | ∼ | — | — | + |
| Ekim and Ocakci,53 2016 | Non-RCT | 120 total (60 controls and 60 in the intervention group) | Children 1–6 y of age hospitalized at the study institution with newly diagnosed asthma with parent present during the child’s inpatient admission | CCI: RN-led discharge planning program for childhood asthma management (including comprehensive discharge planning assessment and development of discharge plan) and coordination of follow-up, phone counseling, and home visit; FEI: asthma management education and designation of potential home triggers | Usual care: different patient group assigned to control group | Unscheduled outpatient visits within 3 mo; ED revisits within 3 mo; unplanned readmissions within 3 mo; parental asthma management self-efficacy | 12 | Not randomized; a consecutive sample used; confounders not adequately described or addressed; did not account for patients lost to follow-up; did not address differing lengths of follow-up; P values not reported for all outcomes | Reduced unscheduled outpatient visits (15.0% vs 21.6%) and ED revisits (11.6% vs 18.3%); no difference in readmission; improved parental self-efficacy. | ∼ | + | + | + |
| Evans et al,54 1999 | Pre-post | Parental satisfaction survey: 251 total (102 preintervention and 149 postintervention); use: 562 total (275 preintervention and 287 postintervention) | Children >18 mo of age admitted to the study institution for asthma care with at least 1 custodial parent; English-speaking family | CCI: restructured asthma care, including establishment of a pulmonary unit with increased bed capacity, standardized treatment protocols, ability for PCPs to directly admit patients with option to consult a specialist, and use of case managers to help patients and families overcome obstacles to care | Usual care: different patient group in preintervention time period | ED revisits within 2 wk; inpatient and observation readmission within 2 wk and 2 mo; parental satisfaction | 10 | Not blinded; patients lost to follow-up not described or accounted for; did not address differing lengths of follow-up; sample size not specified for use outcomes; does not employ appropriate statistical analysis for the study design | Decreased ED revisits (2 of 287 vs 11 of 275; P < .01); decreased 2-mo readmission rate (18 vs 27; P < .05), but unchanged 2-wk readmission rate; decreased length of stay reported (specific numbers not reported); parental satisfaction unchanged | + | + | — | ∼ |
| Fassl et al,55 2012 | Pre-post | 1865 total (754 preintervention, 438 during the intervention, and 673 postintervention) | Children 2–17 y of age hospitalized at the study institution with primary diagnosis code of asthma during the study period | FEI: education module and asthma home care plan | Pre-post: different patient group in preintervention time period | Asthma readmission in 6 mo | 18 | Patients lost to follow-up were not addressed. | Compliance with CAC-3 (asthma action plan for home) was associated with a decreased readmission rate from 17% to 12% (P = .01). Length of stay and cost remained unchanged. | + | — | — | — |
| Hatoun,56 2016 | Retrospective cohort | 124 admissions (47 controls and 77 in the intervention group) | Children 4 d to 22 y of age hospitalized at the study institution with a diagnosis of asthma | CCI: medications in hand on hospital discharge, and outpatient pharmacist delivered medications | Usual care: different patient group from same insurer did not have medications in hand at time of hospital discharge per insurance claims data | Outpatient follow-up visit within 10 d; ED use within 30 d; readmission within 30 d | 14 | Only analyzed a subset of patients who were part of the same Medicaid MCO (may not be generalizable); characteristics of patients lost to follow-up were not described. | Lower odds of ED revisits (OR: 0.22; 95% CI: 0.05–0.99); readmissions and outpatient follow-up visits were unchanged. | ∼ | + | ∼ | — |
| Izadi and Tam,57 2017 | Retrospective cohort | 182 total (104 controls and 78 in the intervention group) | Children 0–18 y of age hospitalized at the study institution with a discharge diagnosis of asthma who were referred for allergy and immunology follow-up | CCI: patients who were adherent to the recommendation for allergy and immunology follow-up | Patients who were nonadherent to the recommendation for allergy and immunology follow-up | No. visits and d in the ED within 1 y; No. visits and d in the hospital within 1 y; No. visits and d in the PICU within 1 y | 16 | Characteristics of patients lost to follow-up not described or accounted for; not blinded; did not account for differing lengths of follow-up; no adjustment for potential confounders | Decreased number of PICU visits (P = .0027) and days (P = .0076); Decreased No. hospital d (P = .0182) | ∼ | — | + | — |
| Kenyon and co-workers,16 2014 | Retrospective cohort | 31 658 children (17 363 β-agonist fills, 18 135 oral steroid fills, and 11 708 inhaled steroid fills) | Patients 2–18 y of age with claims for inpatient hospitalizations with primary diagnoses of asthma; excluded: children who died during the index hospitalization or who were not discharged from the hospital | CCI: filled prescriptions for β-agonists, oral steroids, and inhaled steroids | Children with unfilled prescriptions per claims data | Time to inpatient readmission for a principal or secondary diagnosis of asthma within 90 d of hospital discharge | 18 | Only analyzed patients who were part of the same Medicaid MCO (may not be generalizable); loss to follow-up was not accounted for. | Reduced readmissions within 14 d with β-agonist fills (HR: 0.67; 95% CI: 0.51–0.87) and inhaled steroid medication fills (HR: 0.59; 95% CI: 0.42–0.85); inhaled steroid medication fills were associated with decreased readmissions at 15–90 d (HR: 0.87; 95% CI: 0.77–0.98). | + | — | — | — |
| Madge et al,58 1997 | RCT | 201 total (105 controls and 96 in the intervention group) | Children 2–18 y of age admitted to the study institution with acute asthma | CCI: subsequent follow-up and telephone advice for families; FEI: nurse-led teaching program and written care information | Usual care: different patient group randomly assigned to the control group | ED revisits within the 14-mo study period; readmissions within the 14-mo study period | 16 | Not blinded; did not account for differing lengths to follow-up; did not give distribution of some potential confounders; did not address or account for patients lost to follow-up; did not address compliance with the intervention | No significant change in ED revisits or length of stay; decreased readmissions from 25% to 8% (P = .002) | + | ∼ | — | — |
| Morse et al,26 2011 | Cross-sectional | 45 499 admissions | Children 2–17 y of age hospitalized at institutions that participated in NACHRI’s Pediatric Quality Measurement System and the Pediatric Health Information System with a principal discharge diagnosis of asthma discharged from the hospital, length of stay ≤120 d, not enrolled in a clinical trial | FEI: compliance with asthma action plan for home | Noncompliance with Children’s Asthma Care measures per administrative data | ED revisits at 7 d; asthma-related readmissions at 7 d | 17 | Not all confounders of interest were described. Patients lost to follow-up were not described. | CAC-3 compliance is not associated with readmissions or ED revisits. There was insufficient variability between hospitals in CAC-1 and CAC-2 compliance to test difference in outcomes. | ∼ | ∼ | — | — |
| Ng et al,27 2006 | RCT | 100 total (45 controls and 55 in the intervention group) | Children 2–15 y of age admitted to the study institution with an acute asthma attack diagnosed by the attending pediatrician; excluded: children requiring ICU care or with non–Chinese-speaking parents | CCI: phone follow-up within 1 wk of discharge; FEI: intensive asthma education program, including video teaching, and written care instructions | Usual care: different patient group randomly assigned to the control group | No. ED revisits within 3 mo; readmissions within 3 mo | 20 | Relied on parental recall for outcomes (subject to recall bias); patients lost to follow-up not described or accounted for; not all potential confounders described or adjusted for | Decreased ED revisits (P = .004) and readmissions (P = .0037). | + | + | — | — |
| Nkoy et al,28 2015 | Pre-post | 3510 at tertiary care (1640 preintervention and 1870 postintervention); 1721 at community (1279 preintervention and 442 postintervention) | Children 2–17 y of age hospitalized with a primary diagnosis of asthma | CCI: standardized admission and discharge order sets (with criteria for discharge and checklist to facilitate transition to primary care provider) and controller algorithm; FEI: parental education and action plan | Usual care: different patient group in preintervention time period | Asthma-related readmissions at 6 mo | 18 | Patients lost to follow-up were not addressed. | Tertiary care: reduced asthma readmissions (OR: 0.81; P = .026) and length of stay (β = −.08; P < .001); no significant change in costs; community hospitals: Length of stay declined (β = −.24; P < .001), but readmissions remained unchanged. | + | — | — | — |
| Rice et al,59 2015 | RCT | 711 total (355 controls and 356 in the intervention group) | Children 2–17 y of age hospitalized with a primary admission diagnosis of asthma, asthma exacerbation, status asthmaticus, or reactive airways disease whose parents spoke English or Spanish; excluded: children admitted to the ICU or with significant chronic disease | FEI: asthma education by volunteer educators | Usual care: different patients randomly assigned to the control group | Attendance at follow-up visit 7–10 d after discharge; parent-reported asthma management self-efficacy | 21 | Not blinded; exact P values not reported if <.01 | Attendance at follow-up visit was unchanged. Parent-reported self-efficacy was higher (β = .47; P = .02). | — | — | ∼ | + |
| Sauers-Ford et al,29 2016 | Pre-post | 528 total (296 preintervention and 232 postintervention) | Children 2–18 y of age hospitalized with asthma who were discharged on the asthma care pathway. | CCI: medications in hand at time of hospital discharge | Usual care: different patient group in the preintervention time period | ED revisit within 90 d; readmissions within 90 d | 14 | Sample size was not reported. Not all potential confounders were discussed or accounted for. Patients lost to follow-up were not described. Precise P values were not reported. | Reduced percentage of patients who had a readmission or ED revisit (from 18% to 11%) | + | + | — | — |
| Stevens et al,60 2002 | RCT | 200 total (101 controls and 99 in the intervention group) | Children 18 mo to 5 y of age seen in the ED or admitted to the study institutions with primary diagnosis of acute severe asthma or wheezing | FEI: general asthma education booklet, 2 structured educational sessions with a specialized respiratory nurse, and written guided self-management plan | Usual care: different patient group randomly assigned to the control group | ED revisits at 12 mo; readmissions within 12 mo; parental confidence | 18 | No blinding; characteristics of patients lost to follow-up were not described or accounted for; did not account for potential differences in follow-up time | No statistically significant difference in ED revisits, readmission, or parental confidence | ∼ | ∼ | — | ∼ |
| Tolomeo et al,61 2010 | Retrospective cohort | 298 total (172 controls and 126 in the intervention group) | Children 2–15 y of age admitted with a primary diagnosis of asthma; excluded: children whose parents received complete formal asthma education by hospital staff before discharge but did not attend the intervention | FEI: parental group inpatient asthma self-management education program | Usual care | Asthma-related ED revisits within 12 mo; asthma-related readmissions within 12 mo | 17 | Patients lost to follow-up not taken into account | No effect on ED revisits and readmission rates | ∼ | ∼ | — | — |
| Warschburger et al,62 2003 | Non-RCT | 188 total (100 controls, 85 in the intervention group, and 3 missing) | Parents of children <8 y of age diagnosed with asthma who have not previously participated in a formal asthma education program recruited from 4 German inpatient rehab clinics | FEI: cognitive behavioral training program for parents | Information-centered standard program | Parental self-efficacy and quality of life | 16 | Unclear if this study was randomized or if allocation was concealed; not all potential confounders were discussed; exact probability values were not communicated; 22% drop-out rate. | Parents in both groups improved in asthma self-efficacy and quality of life. | — | — | — | + |
| Wesseldine et al,63 1999 | RCT | 160 total (80 controls and 80 in the intervention group) | Children 2–16 y of age admitted with a diagnosis of acute asthma | FEI: asthma education for the patient and family regarding self-management and individual home management plan and information booklet to take home | Usual care: different patients randomly assigned to the control group | Primary care provider consultations; ED revisits at 6 mo; asthma-related readmissions at 6 mo | 18 | Not blinded; patients lost to follow-up were not described. P values were not always precisely reported. | Reduced primary care provider consultations (39% vs 90%; P < .0001), ED revisits (8% vs 38%; P < .001), and readmissions (15% vs 37%; P = .001). | + | + | * | — |
| Other chronic conditions | |||||||||||||
| Caliskan Yilmaz and Ozsoy,64 2010 | Non-RCT | 49 total (25 controls and 24 in the intervention group) | Children 0–18 y of age admitted to the pediatric oncology unit newly diagnosed with cancer; excluded: children who previously received chemotherapy or who were in the terminal stage of illness | CCI: discharge planning, home visits, and phone consultation; FEI: discharge teaching for parents | Children meeting study criteria who lived outside of the study province | Unplanned readmissions; caregiver satisfaction | 15 | Not randomized or blinded; relied on parental recall for outcomes data. Not all P values are reported. Confounders were not discussed. Did not account for differing lengths of follow-up or adjust for patients who were lost to follow-up; did not adequately report assessment of caregiver satisfaction | Reduced unplanned readmissions (P = .08 for first admission, P = .13 for second admission, and P = .001 for third admission); improved caregiver satisfaction reported but not detailed | + | — | — | + |
| Carlisle et al,30 2012 | Retrospective cohort | 3004 total (1502 controls and 1502 in the intervention group) | Adolescents 15–19 y of age in Ontario discharged with a primary diagnosis of psychiatric disorder or self-inflicted trauma or poisoning; excluded: adolescents with a psychiatric hospitalization in the preceding 10 y and those who were readmitted or had an ED visit within 30 d postdischarge | CCI: postdischarge patient contact with a PCP or psychiatrist within 30 d | Adolescents without contact with a PCP or psychiatrist within 30 d postdischarge | Likelihood of psychiatric ED visit or readmission in 1 y; time to first psychiatric ED visit; time to first readmission | 19 | Characteristics of patients lost to follow-up were not discussed. | Increased likelihood of ED visit or readmission (HR: 1.22; 95% CI: 1.05–1.42; P = .0079); shorter mean time to first readmission (347.68 vs 357.37 d; P = .0026); no significant difference in time to first ED visit | * | * | — | — |
| Fontanella et al,65 2010 | Prospective cohort | 517 total (378 controls and 139 in the intervention group) | Adolescents 11–18 y of age consecutively admitted to 3 free-standing private psychiatric hospitals who are covered by Medicaid and are residents of Maryland; excluded: those discharged against medical advice, those who eloped, those for whom case records were missing, and those for whom psychotropic medications were not prescribed because of pregnancy | CCI: medication management and discharge planning | Usual care: different patient group from the same insurer did not receive the intervention | Time to readmission within 30 d of discharge | 14 | Patients lost to follow-up were not described or accounted for. | Reduced early readmissions with discharge planning identification of alternate living arrangements (HR: 0.18; 95% CI: 0.06–0.55) | + | — | — | — |
| Foster,66 1999 | Retrospective cohort | 204 total (unclear No. per group) | Children and adolescents discharged from inpatient psychiatric facilities within 1 y of entering the Fort Bragg evaluation | CCI: receipt of aftercare postdischarge | Children and adolescents who did not receive aftercare postdischarge | Readmission | 14 | Main outcomes not clearly described; intervention not clearly described; P values not precisely reported; characteristics of patients lost to follow-up were not described or accounted for | No statistically significant difference in readmission | ∼ | — | — | — |
| Frei-Jones et al,67 2009 | Pre-post | 174 total admissions (85 control admissions and 89 intervention admissions) | Children 1–6 y of age hospitalized with any diagnosis of sickle cell disease confirmed by hemoglobin analysis and admitted for further pain management; excluded: those not requiring IV opioids or those with ≥12 hospitalizations for sickle cell–related morbidity in the previous 12 mo | FEI: patient and caregiver education | Pre-post: different patient group in preintervention time period | Readmissions at 30 d | 17 | Patients lost to follow-up were not described or accounted for. Differing lengths of follow-up were not accounted for. | Readmissions decreased from 28% to 11% (P = .007). Length of stay increased by <1 d (P = .03; clinical relevance?). | + | — | — | — |
| Habich,68 2006 | Pre-post | 87 total (24 preintervention and 63 postintervention) | Children with diabetes | FEI: patient’s RN as primary patient-family diabetes educator and patient-family guidebook for home care | Usual care: different patient group in preintervention time period | Readmissions with primary diagnosis of diabetes in 60 d | 10 | Low-quality reporting; hypothesis, outcomes, and patient population not clearly described; potential confounders inadequately discussed; insufficient power to detect statistically significant change in outcomes. Patients lost to follow-up were not addressed. | No effect on readmissions or length of stay | ∼ | — | — | — |
| Roundy et al,69 2016 | Pre-post | 120 total (60 historical controls and 60 in the postintervention group) | Children 0–18 y of age hospitalized with a seizure in the study time period and with a discharge diagnosis of seizure or epilepsy; excluded: children with febrile seizures, provoked seizures (by illness or trauma), nonepileptogenic seizures, elective admissions for video EEG or diagnostic evaluation, and those who underwent epilepsy surgery during the study period | FEI: seizure action plan | Usual care: different patient group in preintervention time period | Telephone calls in 18 mo; clinic visits in 18 mo; ED revisits in 18 mo; hospitalization in 18 mo | 16 | Insufficient power to detect statistically significant change in outcomes; characteristics of patients lost to follow-up are not described or accounted for. | No statistically significant difference in ED revisits, hospitalizations, clinic visits, or phone calls | ∼ | ∼ | ∼ | — |
| Neonatal care | |||||||||||||
| Anand et al,70 2017 | Pre-post | 863 total (72 preintervention and 791 postintervention) | Infants with low birth wt of at least 35 wk corrected gestational age born from September 2009 to December 2014 (no significant medical concerns) | CCI: early discharge when infant reached 1900 g and met discharge criteria (bottling well, maintaining body temperature, steady wt gain, apnea free without caffeine), infant and family attended to by a dedicated nurse team for discharge planning and coordination, and reassessment 1 wk post-discharge by nurse clinician; FEI: dedicated nurse team to perform discharge teaching | Usual care: different patient group in preintervention time period | Readmissions | 10 | Did not fully address potential confounders; not blinded. Patients lost to follow-up were not addressed. P values were not precisely reported. | The readmission rate was unchanged. The mean length of stay declined by 5.5 d. | ∼ | — | — | — |
| Brooten et al,71 1986 | RCT | 79 total (40 controls and 39 in the intervention group) | Infants hospitalized with birth wt of ≤1500 g; excluded: infants with life-threatening congenital anomalies, grade 4 intraventricular hemorrhage, extensive surgical intervention, and/or oxygen dependence for >10 wk | CCI: early hospital discharge of infants with a very low birth wt of 2200 g if meeting discharge criteria (clinically well, nippling every 4 h, maintaining body temperature, no apnea or bradycardia, caretaker with satisfactory care-taking skills, home environment adequate), home follow-up care with a nurse, and frequent postdischarge nurse contact weekly | Usual care: different patient group randomly assigned to the control group | Acute care visits; readmissions within 14 d and 18 mo | 14 | P values were not precisely reported. Did not fully address potential confounders; not blinded; patients lost to follow-up were not addressed | No difference in acute care visits or readmissions; mean length of stay declined by 11.2 d (P < .05) | ∼ | — | ∼ | — |
| Broyles et al,35 2000 | RCT | 887 total (441 controls and 446 in the intervention group) | Infants born at the study institution who were born to a Dallas County resident and either weighed <1000 g or weighed 1001–1500 g and required mechanical ventilation in the first 48 h of life | CCI: comprehensive follow-up care (including access to a nurse practitioner or physician’s assistant at any time), transportation by taxi to the ED if needed, and postdischarge home visit; FEI: trained foster grandmother assigned to families with need for more education and/or support | Usual care: different patient group randomly assigned to the control group | Clinic visits within 1 y; ED visits within 1 y; total hospital admissions in 1 y; ICU admissions in 1 y | 22 | Did not account for differing periods of follow-up; did not account for nonconsenting patients | Increased visits to hospital clinics (3.1 more visits on average) and fewer total ED visits (597 vs 730; P = .03); similar total hospital admissions; 57% fewer PICU admissions (23 vs 53; P = .03). | ∼ | + | + | — |
| Casiro et al,36 1993 | RCT | 100 total (50 controls and 50 in the intervention group) | Infants with birth wt of ≤2000 g whose families resided in Winnipeg, Manitoba; excluded: infants with congenital anomalies likely to have deleterious effect on neurodevelopment, those placed into foster care, and infants requiring hospitalization past their expected date of birth | CCI: community-based follow-up without use of home apnea monitors and home nursing for 8 wk postdischarge | Usual care: different patient group randomly assigned to the control group | Use of ambulatory services within 1 y; readmissions within 1 y | 17 | Did not fully address potential confounders; not blinded; patients lost to follow-up were not addressed; did not adjust for differing lengths of follow-up; P values were not precisely reported | No significant difference in use of ambulatory services, readmissions, or length of stay | ∼ | — | ∼ | — |
| Chen et al,72 2016 | RCT | 126 total (63 controls and 63 in the intervention group) | Parents (age ≥18 y) of premature infants who were the primary caregivers for the infant after discharge, received grade 8 education or higher, and had an infant discharged from the hospital; excluded: parents of infants who received surgery, had a congenital malformation, or were abandoned, readmitted, or deceased | FEI: two 60-min discharge education sessions for parents of premature infants | Usual care: different patient group randomly assigned to the control group | Parental readiness for discharge | 16 | No description of randomization process, blinding, or allocation concealment; no description of potential confounders; did not address characteristics of patients lost to follow-up or adjust for loss to follow-up in the analysis | Improved parental readiness for discharge | — | — | — | + |
| Gibson et al,73 1998 | RCT | 100 total (49 controls and 51 in the intervention group) | Infants born at the study institutions with birth wt of ≤1800 g and gestational age of <36 wk; excluded: infants with congenital anomalies, severe apnea, central venous hyperalimentation, unresolved sepsis, neurologic impairment, or feeding intolerance; infants with no willing or capable caregiver, an unsafe home environment, or inaccessibility to home care services; and infants who died during the study | CCI: early discharge at ∼1800 g if caregiver was willing and able to care for the infant, if there was a safe and adequate home environment, if tolerating full gavage or nipple feeds, and if thermostable; daily home care follow-up by a NICU nurse; nurse availability by phone at any time; daily telephone rounds with the neonatologist | Usual care: different patient group randomly assigned to the control group | ED revisits within 6 mo; readmissions within 14 d and 6 mo | 15 | Of families, 43% declined to participate in the study. Outcomes not well described in the introduction or methods sections; does not precisely list all P values; not blinded; did not describe or account for losses to follow-up. | No significant difference in ED revisits or readmissions; decreased length of stay (27.6 vs 36.6 d; P = .005). | ∼ | ∼ | — | — |
| Gonya et al,74 2014 | Pre-post | 303 total (135 controls and 168 in the intervention group) | Children hospitalized in the study institution NICU during the study period | FEI: Creating Opportunities for Parent Empowerment program recognizes critical role of parents in neonatal development and encourages parents to take an active role and become educated in the neonate’s care. | Usual care: different patient group in preintervention time period | Annual readmission rate | 17 | Patients lost to follow-up were not described. | Reduced readmission rates (13.2% vs 23.9%; P = .05) and length of stay (127.1 vs 139.6 d; P < .05) | + | — | — | — |
| Gray et al,75 2000 | RCT | 56 total (30 controls and 26 in the intervention group) | Infants with very low birth wt hospitalized at the study institution and cared for in the NICU; excluded: if no Internet access at home, expected length of stay <14 d, no permanent residence, did not speak English, infant not being discharged to biological family, or at attending doctor’s discretion | FEI: Internet-based telemedicine program, including daily clinical report, message center, infant viewing, family room, clinical information, and discharge preparation | Usual care: different patient group randomly assigned to the control group | Parental satisfaction with quality of care | 16 | Not blinded; potential confounders not fully addressed; did not address patients lost to follow-up; enrolled families were given a computer, which may have led to bias in reported satisfaction; lack of generalizability given extensive exclusion criteria; sample size insufficient to detect changes in length of stay. | Unchanged length of stay (although tendency toward shorter length of stay, difference was not significant); improved parental satisfaction with care quality | — | — | — | + |
| Hüning et al,76 2012 | Pre-post | 1725 total (243 preintervention and 1482 postintervention) | Families with preterm infants <32 wk gestation, multiple preterm neonates, and neonates with congenital malformations or severe illness | CCI: discharge planning and follow-up visits established; FEI: family-centered care program involving prenatal support and counseling after the birth until discharge | Usual care: different patient group in preintervention time period | Readmissions within 28 d | 12 | Specific P values not reported; did not adequately describe statistical analysis; patients lost to follow-up were not described or accounted for; patient characteristics and confounders inadequately described | Unplanned readmissions declined (2.7%–6.4% annually postintervention vs 9.7% preintervention in infants >1500 g; 7.1%–8.3% annually in years 3 and 4 of the intervention vs 24.6% preintervention in infants <1500 g). No. patients who had longer than average lengths of stay declined (by 64%). | + | — | — | — |
| Ingram et al,37 2016 | Pre-post | 245 total (128 preintervention and 117 postintervention) | Parents of infants born between 27 + 0/7 and 33 + 6/7 wk gestation at the study institutions; excluded: parents of infants with major congenital anomalies or mothers <16 y of age | CCI: improved estimate of anticipated discharge date; FEI: family-centered discharge package to increase parental involvement and education | Usual care: different patient group in preintervention time period | ED revisits within 8 wk; readmission days within 8 wk; perceived maternal parenting self-efficacy scores | 16 | Does not describe or account for patients lost to follow-up; does not describe all potential confounders | ED revisits declined (20 vs 31; P < .05); no significant difference in readmission rate, length of stay, or parental self-efficacy scores | ∼ | + | — | ∼ |
| Kotagal et al,77 1995 | Pre-post | 734 total (477 preintervention and 257 postintervention) | All patients discharged from the NICU at the study institution | CCI: early discharge eliminating wt requirement when infant was clinically stable, free of apnea and bradycardia, normothermic, gaining wt with nipple feeds, and considered to have a safe home environment; dedicated staff nurse to ensure families had resources for discharge; and home nursing visits as needed after discharge; FEI: use of hospital funds to encourage family visitation during hospitalization | Usual care: different patient group in preintervention time period | ED revisits within 14 d; readmissions within 14 d | 13 | Does not describe or account for patients lost to follow-up; does not adjust for differing lengths of follow-up; does not describe all potential confounders | Decreased ED revisits (2.7% vs 8%; P < .01); no statistically significant change in readmissions; decreased length of stay (P < .0001) | ∼ | + | — | — |
| Langley et al,38 2002 | Retrospective cohort | 2181 total (1077 controls and 1104 in the intervention group) | Infants >12 mo of age with birth wt of ≤1500 g or who received level I intensive care for ≥48 h; excluded: multiple births and infants who died or had severe congenital anomalies | CCI: community nursing service (which provides home visits and a named nurse) to link primary and secondary health care services | Neonates not hospitalized on units that had a community nursing service | Readmissions within the first y of life | 13 | Does not account for differing lengths of follow-up or patients lost to follow-up; relied on parental recall for outcomes data; intervention and control groups were hospitalized at different hospitals, which was not controlled for; did not account for some potentially relevant confounders | No statistically significant difference in readmissions; length of stay decreased by 12.6% (95% CI: 5.3%–19.3%; P = .001). | ∼ | — | — | — |
| Moyer et al,78 2014 | Prospective cohort | 229 total (104 controls and 125 in the intervention group) | Infants hospitalized in the intensive care nursery at the study institution who were expected on the basis of birth wt, gestational age, or illness severity to be hospitalized for at least 2 wk and those with an identified primary care provider in the institution | CCI: care transitions coach (RN or health educator); FEI: education, personal health record given to families, and explaining relevant diagnoses, procedures, medications, etc | Usual care: different patient group admitted to a separate pod | Sick visits within 30 d; missed appointments within 30 d; unplanned readmissions within 30 d; secondary: caregiver satisfaction with the care transition | 22 | — | No statistically significant difference in sick visits, missed appointments, or readmissions; improved caregiver satisfaction with the care transition at 24–48 h postdischarge (P < .0001) but not at 30 d postdischarge. | ∼ | — | — | + |
| Shapiro,79 1995 | RCT | Not specified | Newborns with a birth wt of <2000 g whose families lived within Winnipeg city limits | CCI: early discharge of neonates who were clinically well, apnea and bradycardia free, normothermic, nippling well, and with a safe home environment; hospital-based nurse coordinator to help with discharge planning; family support for 2 mo after discharge; and “homemaker” to assist families in home care, provide light housekeeping, care for other children in the home, and provide respite to the parents; FEI: nurse coordinator and “homemaker” to provide parental education and facilitate communication | Usual care: different patient group randomly assigned to the control group | Readmissions within 1 y; use of ambulatory services within 1 y | 10 | Patients lost to follow-up were not described or accounted for; not blinded; the main outcomes were not clearly described; statistical analysis was not described, and no P value was given; did not appear to adjust for differing lengths of follow-up; unclear if compliance with the intervention was reliable; did not describe or adjust for potential confounders; at times, parental knowledge of the study changed patient care in the control group | No significant difference in use of ambulatory services or readmission rates; decreased length of stay (23 vs 31.5 d; no P value given) | ∼ | — | ∼ | — |
| Spinner et al,80 1998 | Prospective cohort | 43 infants all received intervention | Infants hospitalized in the intensive care nursery at the study institution under Keystone Health Plan East insurance | CCI: case management and early discharge with home oxygen, monitoring, IV antibiotics, gavage feeds, phototherapy, or nutrition | — | Parental satisfaction | 9 | Not blinded; no control group; insufficient power to detect true change in outcomes; appropriate statistical analysis not applied; confounders not described or accounted for | Reduced length of stay; high level of parent satisfaction. | — | — | — | + |
| Vohr et al,81 2017 | Prospective cohort | 954 total received the intervention (although unclear No. in year 1 vs year 3) | Early, moderate, and late preterm infants hospitalized for >5 d in the study institution NICU whose families were Rhode Island residents | CCI: transition home program team composed of physicians, nurse practitioners, social workers, and family resource specialists who made daily rounds and helped families overcome socioeconomic barriers to discharge; postdischarge phone call and home visit; and physician availability to take phone calls at any time FEI: team-provided parental education | No true control group; compared outcomes from year 1 of the transition home program with outcomes from year 3 | Unplanned readmissions within 90 d | 14 | Patients lost to follow-up were not described or accounted for; unclear if differing lengths to follow-up were accounted for | Lower readmission risk in year 3 of the intervention compared with year 1 (OR: 0.57; 95% CI: 0.36–0.93; P = .03) | + | — | — | — |
| General inpatient care | |||||||||||||
| Children with general hospitalization | |||||||||||||
| Beck and Gosik,82 2015 | Prospective cohort | 2536 controls (1390 preintervention and 1146 postintervention); 973 in the intervention group (421 preintervention and 552 postintervention) | Children discharged on weekdays from the pediatric hospitalist service | CCI: attending physician reallocation, standardized rounding workflow, multidisciplinary discharge planning, and discharge checklist | Usual care: nonhospitalist-services pediatric patients who did not undergo the intervention | Readmissions at 7, 14, and 30 d | 14 | Patient characteristics and potential confounders not clearly described; did not address patients lost to follow-up | Readmissions were unchanged. Length of stay was unchanged. The median discharge order entry moved from 14:05 to 10:45. The median time of discharge moved from 15:48 to 14:15. | ∼ | — | + | — |
| Christensen and Payne,31 2016 | Retrospective cohort | 28 794 total patients | Children 0–20 y of age in Minnesota attributed to the Medicaid Accountable Care Organization | CCI: ≥16 mo of assignment to a consistent primary care provider | 0–9 mo of assignment to a consistent primary care provider | Readmissions at 30 d | 11 | Did not fully describe potential confounders; patients lost to follow-up not addressed | Reduction in readmissions from 8.9% to 6.2% (P = .010) | + | — | — | — |
| Coller et al,83 2013 | Retrospective cohort | 172 discharges (146 controls and 26 in the intervention group) | Pediatric patients 0–18 y of age discharged from the study institution; excluded: deaths, transfers, NICU infants, and hospitalizations of <24 h | CCI: documented primary care provider follow-up plan | No documented follow-up plan | Readmissions at 30 d | 18 | Did not fully control for potential confounders | Increased odds of readmission (aOR: 4.52; 95% CI: 1.01–20.31; P = .049) | * | — | — | — |
| Coller et al,84 2017 | Prospective cohort | 701 total patients | Randomly selected pediatric patients 0–18 y of age enrolled from any medical or surgical service during an acute hospitalization lasting >24 h; excluded: patients who transferred to another facility, died, or were in neonatal care | PCI: various handoff communication practices, including PCP notification of admission, PCP update during admission, PCP notification of discharge, written or verbal inpatient-to-outpatient handoff, or discharge summary completed within 48 h; CCI: follow-up dates written in discharge summary, PCP follow-up recommended within 30 d, PCP follow-up scheduled within 30 d, verification of PCP identity during inpatient hospitalization, and subspecialist follow-up dates at discharge | Usual care: children within the study cohort who did not receive the listed intervention | Unplanned readmissions within 30 d per caregiver report | 15 | Relied in part on parent report for outcomes data (may be subject to recall bias); losses of patients to follow-up not addressed; confounders not fully discussed | Children with a follow-up appointment scheduled before discharge were more likely to be readmitted (75% vs 48.9%; P < .001; OR: 2.20; 95% CI: 1.08–4.46). | * | — | — | — |
| Flippo et al,85 2015 | Pre-post | 30 patients received intervention; 15 charts analyzed and compared with baseline | Children 0–18 y of age hospitalized on the general pediatric ward with diagnoses of nephritis, glomerulonephritis, minimal change disease, nephrotic syndrome, acute renal failure, asthma or asthma exacerbation, or urinary tract infection who are discharged from the hospital; excluded: children with a primary diagnosis of end-stage or chronic renal disease and children classified as “bedded” outpatients | CCI: postdischarge phone calls within 48–72 h of discharge | Usual care: different patient group in the preintervention time period | Preventable readmissions at 30 d | 12 | Patient characteristics and potential confounders not described or accounted for; poor compliance with the intervention (only 10 of 53 RNs attended training); patients lost to follow-up not addressed | No statistically significant change in readmission rate from baseline rates | ∼ | — | — | — |
| Gay et al,32 2016 | Retrospective cohort | 10 144 total patients (7361 controls and 2783 in the intervention group) | Children <18 y of age discharged from hospitals within the Case Mix inpatient administrative database | CCI: children discharged with home health | Children discharged from the same hospital but without home health were case matched for age, number and type of chronic complex conditions, reason for and severity of hospitalization, and race and/or ethnicity. | Readmission at 30 d and 1 y; total hospital admissions within 1 y; hospital d within 1 y | 17 | Did not adjust for differing lengths of follow-up; patients lost to follow-up not described or accounted for | Lower readmission rate at 30 d (18.3% vs 21.5%; P = .001); fewer admissions (0.83 vs 1.00; P < .001); fewer hospital days (6.4 vs 6.6 d; P < .001) | + | — | + | — |
| Heath et al,2 2015 | Pre-post | 1121 total discharges (538 controls and 583 in the intervention group) | Children hospitalized at the study institution on the attending-only wards and neurology comanaged service | CCI: follow-up phone calls made 72 h after pediatric hospital discharge | Usual care: different patient group in the preintervention time period | ED revisits within 14 d; readmissions at 14 and 30 d; Press Ganey patient satisfaction | 15 | "Quasi-experimental" but essentially a pre-post study (not randomized or blinded); patients lost to follow-up not described or accounted for | No statistically significant change in ED revisits, readmissions, or patient satisfaction scores | ∼ | ∼ | — | ∼ |
| Mallory et al,86 2017 | Pre-post | 2601 total patients in the postintervention period (patients in the preintervention period not specified) | Pediatric patients 0–18 y of age admitted to the study institutions (specific criteria varied by institution); excluded: patients with a primary oncologic diagnosis or discharged from the newborn nursery or critical care units | PCI: timely written handoff to the PCP; CCI: patient-centered transition bundle (including a transition readiness checklist), and postdischarge phone call; FEI: predischarge teach-back education | Usual care: different patient group in preintervention time period | Readmission within 30 d; caregiver performance of teach back during the postdischarge phone call | 14 | Did not describe all potential confounders, but did use statistical process control; patients lost to follow-up not accounted for | Improved caregiver performance of teach back from 17.7% to 81.8%; no significant change in readmission rates | ∼ | — | — | + |
| Petitgout,87 2015 | Pre-post | Not reported | Pediatric patients 0–21 y of age hospitalized in the general pediatric inpatient unit for medical reasons or transferred from intensive care to the general unit before discharge | CCI: initiation of a discharge coordinator position at the study institution | Usual care: different patient group in preintervention time period | Parental discharge satisfaction scores (Press Ganey) | 10 | Did not use appropriate statistical analysis; did not address potential confounders; did not address or account for patients lost to follow-up | The mean length of stay index decreased to <1.0 d. Press Ganey discharge satisfaction scores improved from the second percentile to the sixth percentile. | — | — | — | + |
| Shermont et al,88 2016 | Pre-post | 3044 total patients (1701 preintervention and 1343 postintervention) | Children admitted to the study institution | FEI: discharge bundle to teach home care with teach-back methodology and contingency planning taught to parents | Usual care: different patient group in the preintervention time period | Unplanned readmissions at 7 and 30 d | 14 | Did not report precise P values; the intervention and potential confounders were not fully described; patients lost to follow-up were not addressed | Decreased 7-d readmissions (from 4.18% to 3.81%; P < .05) and 30-d readmissions (from 9.85% to 8.78%; P < .05); length of stay was unchanged | + | — | — | — |
| Snowdon and Kane,89 1995 | Exploratory | 16 patients in the intervention group; no control group | Children 0–12 y of age admitted for unexpected acute illness for a minimum of 2 d with potential to recur; English-speaking parents. | CCI: discharge follow-up program | — | Parental perception of effectiveness of discharge follow-up program | 8 | No control group for comparison; participants were selected for the program by faculty; no statistical analysis was used to analyze results; potential confounders not described | Parents were highly satisfied with the discharge follow-up program and recommended continuing the program. | — | — | — | + |
| Weiss et al,90 2008 | Prospective cohort | 135 parents of children in the hospital | Parents at least 18 y of age; children 0–18 y of age hospitalized at the study institution with home as the discharge destination, sufficient English language skills, and telephone access for postdischarge survey; excluded: children discharged on hospice care | FEI: quality of discharge teaching | — | Parental readiness for discharge and coping difficulty | 15 | No real intervention applied (explores correlation between teaching quality and parental readiness for discharge); potential confounders not fully described or addressed; P values not precisely reported | Parental readiness for discharge was correlated with nursing discharge teaching quality. | — | — | — | + |
| White et al,33 2014 | Pre-post | 6049 total patients (3677 preintervention and 2372 postintervention) | Children admitted to the study institution general inpatient pediatric ward | CCI: development of discharge criteria for common diagnoses, time stamp when discharge goals were met, and emphasis on timely completion of discharge tasks before meeting medical criteria | Usual care: different patient group in the preintervention time period | Readmissions within 30 d | 18 | Patients lost to follow-up were not described or accounted for. | Unchanged readmission rate; improved percentage of patients discharged within 2 h of meeting discharge goals (80% vs 42%); decreased median length of stay (1.44 vs 1.56 d; P = .01) | ∼ | — | + | — |
| Yang and Chen,91 2012 | Prospective cohort with retrospective controls | 1285 total patients (642 preintervention and 643 postintervention) | Children 0–18 y of age admitted to the pediatric inpatient ward; excluded: children discharged from the nursery | CCI: postdischarge phone calls | Usual care: different patient group in the preintervention time period | Rate of ED visits within 3 d of hospitalization | 17 | Essentially a pre-post study design (not randomized or blinded) | Decreased ED visits (0.47% vs 1.71%; P = .034) | — | + | — | — |
| Specific acute illnesses | |||||||||||||
| Cheney et al,34 2005 | Prospective cohort with retrospective controls | 229 total (207 controls and 229 in the intervention group) | Children <12 mo of age admitted with bronchiolitis with their first wheezing episode requiring admission; excluded: infants with heart disease or significant respiratory problems or those who had received corticosteroids within 24 h of presentation or bronchodilators within 4 h of presentation | PCI: letter for patient’s PCP; CCI: bronchiolitis clinical pathway that included clinical management and prespecified discharge criteria; FEI: discharge plan for the parents | Usual care: different patient group in preintervention time period | Readmission within 2 wk | 16 | Characteristics of patients lost to follow-up were not discussed or accounted for. Cases and controls were not recruited over the same time period. | Decreased readmissions (0.9% vs 7.2%; P = .001); no significant difference in length of stay. | + | — | — | — |
| Jenkins et al,92 1996 | RCT | 123 total (61 controls and 62 in the intervention group) | Children <17 y of age admitted to the pediatric burn unit who sustained an acute thermal injury; excluded: children readmitted for the same burn injury or procedures related to a previous burn, skin loss from mechanical means, injury to tendons and/or bones, low-voltage burns to the mouth, burns not requiring burn unit level of care, nonconsenting caregivers, and those who failed to appear for follow-up appointments | FEI: multidisciplinary pediatric burn discharge book | Usual care: different patient group randomly assigned to the control group | Burn care knowledge; caregiver satisfaction | 18 | Unclear if treatment allocation was irrevocable at time of informed consent; P values were not precisely reported; study subjects were not blinded; did not adjust for potential confounders; did not give sufficient information regarding evaluation of parental satisfaction | Improved caregiver satisfaction | — | — | — | + |
| Kirsch et al,93 2015 | Pre-post | 180 received intervention (No. patients in preintervention period not reported) | Children discharged from the hospital on the bronchiolitis clinical pathway | CCI: using call center RNs to conduct postdischarge phone calls 24–48 h after discharge | Usual care: different patient group in preintervention time period | Readmissions within 24 h | 12 | Insufficient power to detect statistically significant difference in readmission rate; characteristics of patients lost to follow-up were not described or accounted for; no appropriate statistical analysis was used to analyze the difference in length of stay | No statistically significant change in readmission rate (although there was a trend toward decreased readmissions); length of stay declined from 3.08 to 2.47 d (no P value given) | ∼ | — | — | — |
| Wu et al94 2016 | Pre-post | Not reported | Variable per study institution | CCI: discharge planning, discharge checklists, and postdischarge phone call; FEI: family education and quality of discharge instructions | Usual care: different patient group in preintervention time period | Unplanned readmission at 72 h and 30 d; family readiness for discharge | 12 | Highly variable patient population at each site; characteristics of included patients were not fully described; potential confounders not addressed | Unchanged 72-h readmission rate; slightly increased 30-d readmission rate (6.3% vs 4.5%, P = .05); improved family readiness for discharge (P < .05) | ∼ | — | — | + |
Interventions were grouped by PCI, CCI, and FEI. Health care reuse measures included readmission, ED revisits, and other measures of reuse, such as PICU admissions, use of ambulatory care services, or phone calls. The satisfaction outcome was measured by parental satisfaction, readiness for discharge, self-efficacy, or confidence. Outcomes are summarized as + (if decreased reuse rates or improved satisfaction scores were statistically significant), * (if increased reuse rates or decreased satisfaction scores were statistically significant), and ∼ (if there was no association). aOR, adjusted odds ratio; CAC, Children’s Asthma Care; HR, hazard ratio; ICD-9, International Classification of Diseases, Ninth Revision; IV, intravenous; MOC, managed care organization; MD, medical doctor; NACHRI, National Association of Children’s Hospitals and Related Institutions; RN, registered nurse; OR, odds ratio; PCP, primary care provider; —, not applicable.
All study interventions were classified by using the STARNet framework into PCIs, CCIs, and FEIs (Table 1). The impact of PCIs was evaluated in only 5 studies.34,41,43,84,86 Out of 59 studies in which CCIs were evaluated, postdischarge follow-up (via clinic, home visit, or telephone) was incorporated in 38,* and the impact of intensive discharge planning services was evaluated in 26.† Of 39 studies providing FEIs,‡ inpatient parental education was incorporated in 29 studies (task-based or teach-back learning was specifically noted in 2 of these studies), and 14 studies involved contingency planning in parental education.
Quality Assessment
The quality of the included studies was variable. Downs and Black22 quality assessment scores ranged from 8 to 22 out of 28 possible points (Table 1). A prepost study design was used in 25 studies, which limited the quality score because such studies could not be randomized or fully blinded.§ Although 13 studies were randomized controlled studies,72,92 the quality of the trials varied, with allocation concealment being reported in only 11 studies.‖ Given the nature of the interventions, the authors of most studies were unable to blind participants, and the authors of only 3 studies noted any attempt to blind outcome assessors.27,35,92 Many studies had other technical problems, such as failure to account for potential confounders or patients lost to follow-up. Varying follow-up periods between patients within the study were not addressed or accounted for in several studies.
Effects of Provider Communication on Use
The effect of PCIs on subsequent hospital use was evaluated in only 5 studies; in all of these studies, PCIs were pooled with other intervention types.34,41,43,84,86 Only 2 of these studies revealed a significant effect on use. In their prospective cohort study, Cheney et al34 found that combining a letter to the patient’s primary care provider with CCIs and FEIs reduced readmissions (Table 2). On the other hand, the prospective cohort study by Coller et al84 (which was used to evaluate handoff communication practices in the general hospitalized population) revealed increased use.
TABLE 2.
Effective Interventions in Reducing Use
| Intervention Type | Patient Population(s) | ||
|---|---|---|---|
| Chronic | Neonatal | General | |
| PCIs | |||
| Letter to patient’s primary care provider | — | — | ✓ |
| CCIs | |||
| Ensuring postdischarge follow-up care | ✓ | ✓ | ✓ |
| Telephone follow-up after discharge | ✓ | ✓ | ✓ |
| Hiring or appointing a specific discharge planner | ✓ | ✓ | — |
| Intensive discharge planning | ✓ | ✓ | — |
| Postdischarge home visits | ✓ | ✓ | — |
| Prespecified discharge criteria | ✓ | — | ✓ |
| Ensuring that discharge medications are obtained | ✓ | — | — |
| Assigned primary care provider | — | — | ✓ |
| Home health | — | — | ✓ |
| FEIs | |||
| Inpatient education for caregivers | ✓ | ✓ | ✓ |
| Written care plan for home | ✓ | ✓ | ✓ |
| Contingency planning | ✓ | — | ✓ |
| Trained support person for families | — | ✓ | — |
| Active caregiver involvement in cares during hospitalization | — | ✓ | — |
| Dedicated hospital funds for caregiver visitation | — | ✓ | — |
Effective interventions in various patient populations. Interventions were marked as effective (✓) if found to be effective in reducing use in at least 50% of studies in the indicated patient group. ✓, effective; —, not studied in that patient population.
Effects of Care Coordination on Readmission
The effect of a CCI on use was evaluated in 52 articles. Overall, CCIs were associated with reduced readmission in 30% of studies (14 of 47). Effective CCIs in each patient population are shown in Table 2. Ensuring postdischarge follow-up care and telephone follow-up after discharge were effective in each of the 3 patient populations. Of those articles in which the effect of postdischarge follow-up care on readmission was evaluated, 9 studies (including 2 randomized controlled trials [RCTs]) revealed reduced readmissions,¶ but 3 studies (all observational cohort studies) revealed an increased readmission rate.30,83,84 In studies with increased use rates, authors often failed to account for potentially important confounders, such as illness severity or technology dependence. Discharge planning was also effective in both neonates and patients with chronic illnesses. Of those studies in which a new person was hired to take responsibility for discharge planning or the existing care team was restructured to designate a responsible party, 2 studies (including 1 prepost and 1 prospective cohort study) revealed decreased readmissions.54,81 Notably, in the neonatal population, all care coordination studies with reduced hospital use also encompassed at least 1 FEI. The overall risk ratio of readmissions for studies in which a CCI alone was conducted was 0.90 (95% CI: 0.75–1.08; I2 = 77%; Supplemental Fig 3, Table 3).
TABLE 3.
Summary of Effect Sizes by Intervention Type and Patient Population
| Intervention Type and Patient Group | Outcome: Readmissions | Outcome: ED Revisits | ||||
|---|---|---|---|---|---|---|
| N | Heterogeneity Test, I2, % | Risk Ratio (95% CI) | N | Heterogeneity Test, I2, % | Risk Ratio (95% CI) | |
| PCI alone | ||||||
| Total | 0 | — | — | 0 | — | — |
| Chronic | 0 | — | — | 0 | — | — |
| Neonatal | 0 | — | — | 0 | — | — |
| General | 0 | — | — | 0 | — | — |
| CCI alone | ||||||
| Total | 21 | 76.97 | 0.90 (0.75–1.08) | 7 | 70.49 | 0.70 (0.36–1.35) |
| Chronic | 11 | 84.76 | 0.78 (0.54–1.11) | 4 | 80.88 | 0.53 (0.14–2.05) |
| Neonatal | 4 | 0.00 | 1.03 (1.01–1.06) | 1 | — | — |
| General | 6 | 21.62 | 0.88 (0.72–1.07) | 2 | 78.44 | 0.64 (0.00–7378.66) |
| FEI alone | ||||||
| Total | 11 | 65.64 | 0.78 (0.63–0.97) | 5 | 79.20 | 0.57 (0.19–1.66) |
| Chronic | 9 | 68.73 | 0.79 (0.60–1.02) | 5 | 79.20 | 0.57 (0.19–1.66) |
| Neonatal | 1 | — | — | 0 | — | — |
| General | 1 | — | — | 0 | — | — |
| PCI and CCI | ||||||
| Total | 1 | — | — | 0 | — | — |
| Chronic | 0 | — | — | 0 | — | — |
| Neonatal | 0 | — | — | 0 | — | — |
| General | 1 | — | — | 0 | — | — |
| PCI and FEI | ||||||
| Total | 0 | — | — | 0 | — | — |
| Chronic | 0 | — | — | 0 | — | — |
| Neonatal | 0 | — | — | 0 | — | — |
| General | 0 | — | — | 0 | — | — |
| CCI and FEI | ||||||
| Total | 11 | 59.64 | 0.66 (0.46–0.94) | 7 | 86.67 | 0.65 (0.34–1.26) |
| Chronic | 7 | 31.55 | 0.48 (0.28–0.82) | 5 | 26.23 | 0.76 (0.28–2.01) |
| Neonatal | 4 | 0.00 | 0.95 (0.91–0.99) | 2 | 27.85 | 0.48 (0.01–36.75) |
| General | 0 | — | — | 0 | — | — |
| PCI, CCI, and FEI | ||||||
| Total | 1 | — | — | 1 | — | — |
| Chronic | 0 | — | — | 1 | — | — |
| Neonatal | 0 | — | — | 0 | — | — |
| General | 1 | — | — | 0 | — | — |
Summary of effect sizes for readmissions and ED revisits by intervention type and patient population. Per group N, I2, risk ratio, and 95% CI are given. —, not applicable.
Effects of Care Coordination on ED Revisits
Overall, CCIs were associated with reduced ED revisits in 52% of studies (9 of 17). Postdischarge follow-up care was associated with reduced ED revisits in 5 studies27,35,53,77,91 (including 2 RCTs and 1 quasi-experimental study) but with increased ED revisits in 2 studies (including 1 case-control and 1 retrospective cohort study).42,51 In regard to discharge planning, 3 studies in which a new person was hired to take responsibility for discharge planning or the existing care team was restructured to designate a responsible party for discharge planning revealed decreased ED revisits.53,54,77 This included 2 prepost studies54,77 and 1 quasi-experimental study.53 The overall risk ratio of ED revisits for studies in which a CCI alone was conducted was 0.70 (95% CI: 0.36–1.35; I2 = 70%; Supplemental Fig 4, Table 3).
Effects of Family Engagement on Readmission
The effect of an FEI on use was evaluated in 35 studies. Overall, 43% of FEI studies (13 of 30) were associated with reduced readmissions. Effective FEIs in each patient population are shown in Table 2. Inpatient caregiver education and written care plans with contingency planning were widely effective in FEIs across patient populations. Ten studies in which the effect of an inpatient parental education component was evaluated revealed reduced readmission.# Task-based or teach-back learning (which was effective) was specifically noted in only 1 of these studies.88 Similarly, 8 contingency planning studies revealed a reduced readmission rate.27,28,34,50,55,58,63,88 These included several RCTs and prepost studies that provided interventions such as completion of a written care plan for home27,28,50,55,58,63 or inpatient parental education focused specifically on contingency planning.88 The overall risk ratio of readmissions for studies in which an FEI alone was conducted was 0.78 (95% CI: 0.63–0.97; I2 = 66%; Supplemental Fig 3, Table 3).
Effects of Family Engagement on ED Revisits
Overall, 41% of FEI studies (7 of 17) were associated with reduced ED revisits. Four studies in which the effect of an inpatient parental education component on use was evaluated revealed reduced ED revisits.27,37,53,63 Only 1 study (case-control) revealed that ED revisits increased with an educational intervention.51 A reduction in ED revisits was revealed in both studies (RCTs) with contingency planning in the form of written care plans for home incorporated.27,63 The overall risk ratio of ED revisits for studies in which an FEI alone was conducted was 0.57 (95% CI: 0.19–1.66; I2 = 79%; Supplemental Fig 4, Table 3).
Further Subgroup Analysis of Readmission Risk by Intervention and Patient Population
Pooled risks for each intervention type by patient population are shown in Fig 2. A meta-analysis was performed for all subgroups containing at least 2 studies for which risk ratios and 95% CIs could be calculated. In patients with chronic illnesses, the risk ratio for readmissions if CCIs were enacted alone was 0.78 (95% CI: 0.54–1.11; I2 = 85%), whereas the risk ratio for readmission if FEIs were enacted alone was 0.79 (95% CI: 0.60–1.02; I2 = 69%). Notably, the risk ratio for readmissions in the subgroup in which both CCIs and FEIs were implemented was 0.48 (95% CI: 0.28–0.82; I2 = 32%). In neonatal patients, the risk ratio for readmissions if CCIs were enacted alone was 1.03 (95% CI: 1.01–1.06; I2 = 0.00%). Notably, if a CCI and an FEI were implemented together in the neonatal population, the risk ratio was 0.95 (95% CI: 0.91–0.99; I2 = 0.00%). In the general hospitalized patient population, the risk ratio for readmissions if CCIs were implemented alone was not significant at 0.88 (95% CI: 0.79–1.05; I2 = 22%). A summary table of the comparison between risk ratios for readmission and ED revisit by intervention type and patient group is provided in Table 3.
FIGURE 2.
Risk ratios for readmission by patient population and intervention type and forest plot for readmission by intervention type and patient group: RCT versus non-RCT, risk ratios, 95% CIs, and weight by patient population and intervention type for studies in which readmission is addressed. Risk ratios are indicated by the forest plots above, with risk ratios <1 favoring the intervention. Effect sizes were only calculated for those studies that provided sufficient information to calculate both the risk ratio and 95% CI. Nkoy et al28 performed separate analyses in 2 different patient populations (from a tertiary-care academic children’s hospital and a community hospital), and their study is therefore included twice. Similarly, because Brittan et al42 compared 2 groups of patients receiving follow-up in 2 different periods with those who did not receive follow-up, their study is also included twice (A and B). Pooled effect sizes are shown for each patient group (including patients with chronic illnesses, the neonatal population, and general patients who were hospitalized) by intervention type if effect sizes could be calculated for a minimum of 2 studies per group. a Studies that did not significantly impact readmission by this analysis but were reported as statistically significant by other statistical analysis methods not conducive to this meta-analysis.
Results of Individual Studies Regarding Patient and/or Caregiver Satisfaction
Of 25 studies in which a patient and/or caregiver satisfaction outcome was evaluated, 84% (21 of 25) revealed a positive effect on satisfaction.** Both studies in which PCIs were evaluated (1 prepost study that was focused on children with multisystem complex illnesses and 1 prospective cohort study that was focused on the general population of children hospitalized) revealed an association with improved satisfaction.43,86 CCIs were also associated with improved satisfaction across patient populations, including effective studies in children with chronic illnesses (n = 7),43,44,48,49,52,53,64 patients in the NICU (n = 2),78,80 and the general hospitalized population (n = 4).86,87,89,94 CCIs that were associated with improved satisfaction included assistance with scheduling follow-up care,43,53,89 in-home visits or follow-up telephone calls,44,48,49,53,64,86,94 and intensive discharge planning.43,48,53,64,78,80,87,94 Similarly, FEIs were associated with improved satisfaction in children with chronic illnesses (n = 9),†† neonates (n = 3),72,75,78 and general pediatric patients in the hospital (n = 4).86,90,92,94 Effective FEIs included parental education (n = 13),‡‡ written care plans for home (n = 1),43 and cognitive behavioral therapy for parents (n = 1).62
Discussion
This systematic review and meta-analysis revealed that the effectiveness of interventions to decrease subsequent use varied by population, whereas almost all interventions were associated with improved parental satisfaction. In patients with chronic illnesses and neonatal patients, bundled CCIs with FEIs were associated with decreased use.
Our results provide strong evidence for pooling of discharge interventions to improve discharge outcomes. Specifically, the meta-analysis revealed that pooling of CCIs and FEIs in both chronically ill and neonatal patient populations was associated with a decrease in readmissions, whereas single-category interventions alone did not decrease readmissions. Given these findings, an optimal discharge bundle would at least include both CCIs and FEIs. Although the pooled risk ratio for readmissions and ED revisits with CCIs overall crossed 1 (Supplemental Fig 3, Table 3), we found that the specific CCI of appointing a designated individual or team to coordinate discharge planning was consistently associated with decreased use across pediatric populations. Similarly, assisting with scheduling of postdischarge follow-up care was associated with lower use in a majority of studies (including RCTs), whereas studies that revealed higher use were typically weaker study designs (only observational cohort studies). This suggests that specific interventions within the CCI category, such as focused discharge planning and scheduling of follow-up, may be more effective than the broader group of CCIs. The effectiveness of focused discharge planning is supported by several previous studies in adult populations that revealed that a dedicated discharge planner improved patient satisfaction, use rates, and overall quality of hospital discharge.12,95,96 Although not as thoroughly studied in pediatrics, dedicated discharge planners are commonly used in many children’s hospitals as a means to improve efficacy and efficiency of care transitions.17,97 Thus, the CCIs of hiring or appointing a dedicated discharge planner and scheduling postdischarge follow-up care should be included in an ideal discharge bundle because these interventions were widely effective across populations. Such a bundle may help to maximize the effectiveness of the included interventions, similar to the bundles used for the prevention of central line–associated bloodstream infection and nosocomial pneumonia.98–100
Our results also reveal the importance of incorporating FEIs to improve discharge outcomes. The overall risk ratio for readmissions when FEIs were implemented was favorable, and an FEI was incorporated in all effective discharge interventions in the neonatal population. Family engagement has been recognized as especially important in NICU populations to promote the parent-infant bond and help facilitate the lifelong relationships within families that support a child’s ongoing development and growth.101 Within family engagement, the specific interventions of inpatient parental education incorporating teach back as well as written contingency planning were consistently effective in reducing readmissions across populations. Although the overall risk ratio did not support an effect of FEIs on reducing ED revisits, specific interventions of inpatient parental education and contingency planning were effective in a majority of studies, likely reflecting the effectiveness of these particular interventions within the broader FEI category. Our findings are supported by other studies that revealed that teach-back strategies improved understanding and adherence in patients with varying diagnoses across the health literacy spectrum.15,102,103 Meanwhile, written contingency planning has primarily been studied through the initiation of “asthma action plans,” which improve outcomes for adults and children with asthma.104–107 Thus, the FEIs of providing inpatient parental teach-back education and written contingency planning are also prime interventions to be included in an ideal discharge bundle.
Unlike studies in which use was evaluated, studies in which parental satisfaction was addressed were nearly uniformly effective. The studies that did not reveal a significant effect were largely focused on interventions that might not have been expected to have much impact on satisfaction with the hospitalization itself, such as postdischarge follow-up phone calls.2 Notably, because families were not blinded to the intervention in most studies, improvements in parental satisfaction might have reflected appreciation for attempts to improve discharge processes rather than acting as an indicator of improving care quality. Caution should therefore be used in using such a subjective quality measure in cases in which the parents are not blinded to the intervention.
Limitations of this study include heterogeneity in patient populations, interventions, control groups, and specific outcomes between the included studies. Given the high degree of heterogeneity within subgroups, pooled effect sizes should be interpreted cautiously in the meta-analysis. Many studies had wide CIs, in some cases suggesting an inadequate sample size. Between-study variability in patient populations also limits generalizability, whereas heterogeneous combinations of interventions hinder the ability to evaluate the impact of any single intervention. To avoid publication bias, we attempted to incorporate abstracts when appropriate, although their inclusion in the full review was limited by insufficient information to determine if studies met inclusion criteria. There is also potential for reporting bias because many studies were reliant on administrative data or parental report to assess outcomes (methods of data collection that are prone to underreporting of postdischarge use [for administrative data] or to recall bias [with parental report]). However, because many patients use multiple providers in various health systems, an accurate assessment of postdischarge use is often challenging.
Although we found many studies associated with improved use rates or parental satisfaction, this review reveals the need for further work in this area. Although nearly any intervention improved parental satisfaction scores, studies in which use was assessed often had wide CIs because of small sample size and low baseline pediatric postdischarge use rates. This suggests that larger multicenter trials in which sensitive quality metrics are appropriately used will be helpful for future evaluation of discharge interventions. Although such metrics could be related to either use or parent satisfaction, such work should also encompass other factors, such as well-being or quality of life, functional status, missed school and work days, school readiness and performance, or adverse events. The Agency for Healthcare Research and Quality’s Pediatric Quality Measures Program has funded 6 Centers of Excellence for ongoing work in this area.6,7,108,109
Future work should also be focused on understanding variability in outcomes. Much of this variability may be due to differences in the interventions themselves. However, there was also variation in the observed outcomes with similar interventions, such as establishing follow-up and providing parental education. Such findings suggest that differences in implementation could significantly impact an intervention’s effectiveness, although most of the included studies were not detailed enough to provide an in-depth analysis of implementation practices in the current review. Future studies should therefore be focused on developing guidelines for best implementation practices, which may be incorporated into the implementation of a standardized pediatric hospital discharge bundle.
Conclusions
In this study, we provide a meta-analysis of pediatric discharge interventions that impact health care use and parental satisfaction. Although the majority of interventions were effective in improving parental satisfaction, effectiveness in reducing use was variable. In this review, we provide evidence for CCIs and FEIs in association with reduced readmission rates, particularly in chronically ill and neonatal populations. In addition, bundling of FEIs with CCIs may aid in reducing readmission. With this review, we affirm the importance of several specific interventions, including ensuring follow-up care, focused discharge planning, inpatient-based teach-back education, and contingency planning, in promoting effective discharges. These interventions should be incorporated into discharge improvement bundles whenever possible.
Acknowledgments
We thank Bruce Abbott, medical librarian, for assistance in the literature search and Joy Melnikow, MD, MPH, for advising in the study design.
Glossary
- CCI
care coordination intervention
- CI
confidence interval
- CINAHL
Cumulative Index to Nursing and Allied Health Literature
- ED
emergency department
- FEI
family engagement intervention
- JBI
Joanna Briggs Institute
- MeSH
Medical Subject Heading
- PCI
provider communication intervention
- PRISMA
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- RCT
randomized controlled trial
- STARNet
Seamless Transitions and (Re)admissions Network
Footnotes
Dr Hamline conceptualized and designed the study, performed the literature search, reviewed articles for inclusion, coordinated and participated in data abstraction and the meta-analysis, drafted the manuscript, and reviewed and revised the manuscript; Drs Speier, Vu, Broman, Rasmussen, and Tullius reviewed articles for inclusion, abstracted data, and reviewed the manuscript; Dr Tancredi assisted with the meta-analysis and reviewed the manuscript; Dr Shaikh reviewed abstracts for inclusion and reviewed the manuscript; Dr Li reviewed abstracts for inclusion and critically reviewed the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
This trial has been registered with PROSPERO (https://www.crd.york.ac.uk/prospero/) (identifier CRD42017053468).
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by National Center for Advancing Translational Sciences, National Institutes of Health (grant UL1TR001860) and by the Health Resources and Services Administration through the Quality, Safety, and Comparative Effectiveness Research Training in Primary Care program (grant T32HP30037). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Health Resources and Services Administration. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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