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- Title
Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials.
- Authors
Leppin, Aaron L; Gionfriddo, Michael R; Kessler, Maya; Brito, Juan Pablo; Mair, Frances S; Gallacher, Katie; Wang, Zhen; Erwin, Patricia J; Sylvester, Tanya; Boehmer, Kasey; Ting, Henry H; Murad, M Hassan; Shippee, Nathan D; Montori, Victor M
- Abstract
<bold>Importance: </bold>Reducing early (<30 days) hospital readmissions is a policy priority aimed at improving health care quality. The cumulative complexity model conceptualizes patient context. It predicts that highly supportive discharge interventions will enhance patient capacity to enact burdensome self-care and avoid readmissions.<bold>Objective: </bold>To synthesize the evidence of the efficacy of interventions to reduce early hospital readmissions and identify intervention features--including their impact on treatment burden and on patients' capacity to enact postdischarge self-care--that might explain their varying effects.<bold>Data Sources: </bold>We searched PubMed, Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, and Scopus (1990 until April 1, 2013), contacted experts, and reviewed bibliographies.<bold>Study Selection: </bold>Randomized trials that assessed the effect of interventions on all-cause or unplanned readmissions within 30 days of discharge in adult patients hospitalized for a medical or surgical cause for more than 24 hours and discharged to home.<bold>Data Extraction and Synthesis: </bold>Reviewer pairs extracted trial characteristics and used an activity-based coding strategy to characterize the interventions; fidelity was confirmed with authors. Blinded to trial outcomes, reviewers noted the extent to which interventions placed additional work on patients after discharge or supported their capacity for self-care in accordance with the cumulative complexity model.<bold>Main Outcomes and Measures: </bold>Relative risk of all-cause or unplanned readmission with or without out-of-hospital deaths at 30 days postdischarge.<bold>Results: </bold>In 42 trials, the tested interventions prevented early readmissions (pooled random-effects relative risk, 0.82 [95% CI, 0.73-0.91]; P < .001; I² = 31%), a finding that was consistent across patient subgroups. Trials published before 2002 reported interventions that were 1.6 times more effective than those tested later (interaction P = .01). In exploratory subgroup analyses, interventions with many components (interaction P = .001), involving more individuals in care delivery (interaction P = .05), and supporting patient capacity for self-care (interaction P = .04) were 1.4, 1.3, and 1.3 times more effective than other interventions, respectively. A post hoc regression model showed incremental value in providing comprehensive, postdischarge support to patients and caregivers.<bold>Conclusions and Relevance: </bold>Tested interventions are effective at reducing readmissions, but more effective interventions are complex and support patient capacity for self-care. Interventions tested more recently are less effective.
- Publication
JAMA Internal Medicine, 2014, Vol 174, Issue 7, p1095
- ISSN
2168-6106
- Publication type
journal article
- DOI
10.1001/jamainternmed.2014.1608