Table 1 Characteristics of included trials
Author [Ref. Number] | Design | Facility | Country | Number of subjects | Number of subjects in each group | Subject characteristics | Intervention group | Control group | Timing of Intervention | Number of intervening occupations1) | Number of classified interventions2) | Outcomes3) 4) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
Harrison et al. 2002 [26] | Single-center RCT | Two general medical units of a large urban teaching hospital | Canada | 157 | Intervention: 79 Control: 78 | Patients admitted to eligible facilities and diagnosed with congestive heart failure | Transitional Care (use of comprehensive protocols for counseling and education for heart failure self-management; collaboration with planned home care nurses to help patients take responsibility for their own care) | Usual care | On admission, within 24 hours and 2 weeks after discharge | 1 | 7 | ・Health-related quality of life: Minnesota Living with Heart Failure Questionnaire(MLHFQ) ・QOL: SF-36 ・ The number of all-cause emergency room visits and hospital readmissions. |
Latour et al. 2007 [27] | Single-center RCT | The VU University Medical Center in Amsterdam | Netherlands | 121 | Intervention: 69 Control: 52 | Patients 18 years of age or older who have been admitted to the Department of Internal Medicine, Gastroenterology, Respiratory Medicine, or Cardiology at least once in the past 5 years | A nurse-led, home-based case management intervention NHI (care plan development based on assessment of case and complexity of care, post-discharge home visits according to care plan, psychosocial support by telephone, mediation between patient and provider, guidance on medication, exercise, diet, promotion of self-management, etc.) | Usual care | Within 1–3 days after discharge, within 3–10 days, visits every 2 months, regular phone calls, up to 24 weeks after discharge | 1 | 7 | ・The number of emergency　readmissions ・QOL: SF-36 ・Psychological functioning: the Hospital Anxiety and Depression Scale (HADS) Other Multiple Outcomes |
Li et al. 2014 [28] | Multicenter RCT | The renal unit of two local regional hospitals | China | 135 | Intervention: 69 Control: 66 | Inpatient in renal ward receiving peritoneal dialysis | Pre-discharge comprehensive discharge planning protocols and standardized nurse-led post-discharge telephone support interventions | Routine discharge care | Before discharge, up to 72 hours after discharge, 6 weeks after discharge | 1 | 4 | ・QOL: The Kidney Disease Quality of Life Short Form (KDQOL-SF, version 1.3, RAND, Santa Monica, CA, USA) ・The observed complication control of participants ・The existence of complications ・Number of hospitalizations and attended outpatient clinics ・Days between index discharge and readmission |
Goldman et al. 2014 [29] | Single-center RCT | San Francisco General Hospital and Trauma Center | United States of America | 561 | Intervention: 275 Control: 286 | Eligible facility inpatients 55 years of age and older | Nurse-led individualized discharge planning and post-discharge telephone follow-up | Usual discharge care | Enrollment date and within 24 hours of discharge, days 1–3 and 6–10 post-discharge | 1 | 6 | ・ED visits or readmissions ・Non-ED ambulatory care visits |
Chow et al. 2014 [30] | Single-center RCT | Medical department of a 1700-bed acute, general regional hospital | Hong Kong | 281 | Home visit: 87 Call: 96 Control: 98 | Patients 65 years of age or older admitted to the internal medicine ward with a diagnosis of chronic respiratory disease, cardiac disease, type 2 diabetes mellitus, or renal disease | Two groups of home visits or telephone intervention with a nurse-led case management program (integrated pre-discharge and post-discharge multicomponent intervention, framed as a self-help program using a motivational and empowerment approach) | Two placebo calls (5 minutes each) within 4 weeks | Pre-discharge, up to 4 weeks after discharge | 1 | 6 | ・Unplanned hospital readmission rate ・Self-efficacy ・Self-rated health ・QOL: SF-36 |
Wong et al. 2015 [31] | Multicenter RCT | Three regional hospitals within the same cluster | Hong Kong | 108 | Intervention: 54 Control: 54 | Stroke patients admitted to eligible facilities and scheduled to be discharged home | Transitional care program (family interviews, home visits, and telephone follow-up by providing holistic care using the Omaha system) | Routine hospital-based physical training programme | Pre-discharge, 1, 2, 3, and 4 weeks post-discharge | 1 | 5 | ・QOL: SF-36 ・The World Health Organization– Quality of Life– Spirituality, Religion and Personal Beliefs (WHO-QOL-SRPB) ・The patient satisfaction questionnaire (PSQ-HK) ・Functional performance: the Modified Barthel Index (MBI) ・Depressive symptomatology in the general population: the Center for Epidemiological Studies for Depression Scale (CES-D) ・Hospital readmission and unscheduled Emergency Department attendance rates |
Chan et al. 2015 [32] | Single-center RCT | San Francisco General Hospital and Trauma Center | United States of America | 616 | Intervention: 301 Control: 315 | Eligible facility inpatients 55 years of age and older | Nurse-led individualized discharge planning and post-discharge telephone follow-up | Usual care | Enrollment date and within 24 hours of discharge, days 1–3 and 6–10 post-discharge | 1 | 10 | ・Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Domains of Patient Experience. ・Three-Item Care Transitions Measure (CTM-3) |
Zhang et al. 2017 [33] | Single-center RCT | The cardiovascular medical department of a 1,700-bed three-A hospital in the city | China | 199 | Intervention: 100 Control: 99 | Cardiology inpatients diagnosed with angina pectoris or myocardial infarction | Pre- and post-discharge nurse-led transitional care programs (pre-discharge: assessment and patient education; post-discharge: teaching and counseling, treatments and procedures, case management and monitoring) | Routine care Monthly placebo social calls | Approximately 1 week before discharge and 7 months after discharge | 1 | 5 | ・Hospital readmission rate ・Self-efficacy to implement health-promoting　behaviours: the Chinese version of Selfrated abilities for health practices scale (SRAHP) ・Functional status and quality of life: the Chinese version of Seattle Angina Questionnaire (SAQ) |
Liu L. 2018 [34] | Single-center RCT | Department of Neurology at a tertiary first-class hospital in Zhengzhou | China | 40 | Intervention: 20 Control: 20 | Patients admitted to an eligible facility with an initial diagnosis of stroke and scheduled for discharge | Nurse-led transitional care interventions (discharge assessment, individualized transitional care plans and health education, exercise programs, home visits and telephone tutoring) | Routine instructions at discharge | Prior to and one month after discharge | 3 | 6 | ・Functional exercise compliance: The functional exercise compliance questionnaire developed by Zhenxiang Zhang et al. ・Health status: SF-36 |
Spall et al. 2019 [35] | Step-wedge cluster　RCT | 11 tertiary or quaternary care urban hospitals across southern Ontario for Inclusion | Canada | 2494 | Intervention: 1104 Control: 1390 | Patients admitted to eligible facilities due to heart failure | Patient-Centered Transitional Care in Heart Failure (PACT-HF) service model (needs assessment, self-care education, discharge summary, arranging visits to family physician, home visits after discharge, etc.) | Transitional care at clinician discretion | Upon discharge from the hospital Once a week for 4 to 6 weeks until the cardiac function clinic visit | 1 | 7 | ・All-cause readmission, emergency department visit, or death at 3 months and all-cause readmission or emergency department visit at 30 days ・B-PREPARED score for discharge preparedness ・3-Item Care Transitions Measure (CTM-3) score ・Euro QOL-5D -5 level version (EQ-5D-5L) scores ・Quality-adjusted life-years (QALY) ・Post hoc exploratory clinical outcomes: components of the composite clinical outcomes, number of clinical events |
Cui et al. 2019 [36] | Single-center RCT | The Liaocheng People’s Hospital cardiology department | China | 96 | Intervention: 48 Control: 48 | Patients with coronary heart disease, 18 years of age or older, admitted to an eligible facility | Structured, nurse-led educational programs (e.g., educational sessions, exercise plans, telephone or face-to-face pre-visit interviews) | Standard medical care by physicians and nurses; recommendation to attend a heart failure clinic after discharge from the hospital | Before discharge, 4 weeks and up to 12 months after discharge | 1 | 6 | ・All-cause mortality ・Hospital readmission due to cardiac problems, such as shortness of breath, chest pain, arrhythmia, and syncope ・The self-management ability |
Lisby et al. 2019 [37] | Single-center RCT | An acute medical unit at a large Danish university hospital | Denmark | 200 | Intervention: 101 Control: 99 | Inpatients 18 years of age or older at high risk of readmission who are admitted to an acute care internal medicine unit and are scheduled to be discharged home | Nurse-led comprehensive discharge intervention (assessment of overall situation and intervention, interview regarding discharge recommendations, discharge letter, post-discharge follow-up phone call) | The usual nursing routines in the acute medical unit | Before and 2 days after discharge | 1 | 5 | ・The proportion of all-cause readmissions ・The total number of readmissions post-discharge ・Health-related outcomes: (1) number of emergency room visits that did not result in hospitalization, (2) number of visits to general practitioners, (3) number of after-hours visits ・Health-related quality of life: EuroQol-5D (EQ-5D) ・Patient experience: 10 questions selected from the Danish National Patient Experience Survey in the emergency department Other Multiple Outcomes |
Liu Z et al. 2020 [38] | Single-center RCT | A large-scale general hospital located in the northwestern part of mainland China | China | 88 | Intervention: 44 Control: 44 | Inpatients with rheumatoid arthritis in the Department of Rheumatology and Immunology | Omaha System Transitional Care Program (individual discharge plans, patient education, post-discharge follow-up calls, timely interventions, rehabilitation plans, etc.) | Routine care | Up to 3 days prior to discharge, within 72 hours and 4 weeks after discharge | 1 | 6 | ・Self-efficacy: the Chinese version of the Arthritis Self-Efficacy Scale-8 (ASES-8) ・Health status and physical function: The Health Assessment Questionnaire-Disability Index (HAQ-DI) ・Hospital readmission rates |
Gilbert et al. 2021 [39] | Step-wedge cluster　RCT | 10 geriatric acute care units, of which 3 were university hospitals and 7 were general hospitals. | France | 705 | Intervention: 336 Control: 369 | Patients over 75 years old admitted to an acute geriatric ward for more than 48 hours and returned home after admission | Nurse-led bridging program (discharge planning, community service coordination, assistance with needs projections, post-discharge follow-up home visits, phone calls, etc.) | Usual care plan | Pre-discharge, day of discharge, and 1 month post-discharge (48–72 hours and 3 week visit after discharge, 2 and 4 week phone call after discharge) | 1 | 5 | ・A composite of at least 1 unscheduled hospital readmission or ED visit within 30 days from discharge ・Thirty-day mortality ・Length of stay during index admission ・Patients’ quality of life: the French version of EuroQoL-5D questionnaire ・Patients’ satisfaction: the Care Transition Measuree15 (CTM-15) questionnaire Other Multiple Outcomes |
Coskun et al. 2022 [40] | Single-center RCT | One cardiovascular surgery clinic of a university hospital located in the Black Sea Region of Turkey | Turkey | 64 | Intervention: 32 Control: 32 | Patients over 60 years of age admitted for the first time for open heart surgery | Nurse-led transitional care model TCM (health status assessment, regular clinic visits, care process coordination, individualized care planning, post-discharge home visits, etc.) | Routine healthcare practices by cardiovascular doctors and nurses in cardiovascular clinic | From the date of admission to 9 weeks after discharge | 4 | 4 | ・The patients’ functional autonomy: The Functional Autonomy Measurement System (SMAF) ・QOL: SF-36 ・Their post-discharge recurrent referral rates to hospital and recurrent hospitalization rates |
Lin et al. 2022 [41] | Multicenter RCT | Four stroke wards from the First and the Third Affiliated Hospitals of Army Medical University | China | 140 | Intervention: 70 Control: 70 | Stroke patients 18 years of age or older with a first diagnosis of ischemic or hemorrhagic stroke who will be discharged home and family caregivers 18 years of age or older who are the primary caregivers of the patient | Nurse-led health coaching program (individual coaching sessions prior to discharge, follow-up intervention after discharge: telephone support and in-person coaching in outpatient settings) | Usual transitional discharge plan | Pre-discharge and 12 weeks post-discharge | 1 | 7 | ・Self-efficacy of stroke survivors: the Stroke Self-efficacy Questionnaire (SSEQ) ・QoL: the short version of the Stroke-Specific Quality of Life Scale (SSQoL-12) ・Stroke-related health knowledge: the Chinese Stroke Prevention Knowledge Questionnaire (SPKQ) ・Caregiver-related burden: the Modified Caregiver Strain Index (CSI) ・The number of adverse events (secondary strokes, falls, pressure ulcers and urinary tract infections), and unplanned hospital readmissions |