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Transitional Care After Hospitalization for Acute Stroke or Myocardial Infarction: A Systematic Review

Janet Prvu Bettger, ScD; Karen P. Alexander, MD; Rowena J. Dolor, MD; DaiWai M. Olson, PhD, RN; Amy S. Kendrick, RN, MSN; Liz Wing, MA; Remy R. Coeytaux, MD, PhD; Carmelo Graffagnino, MD; and Pamela W. Duncan, PhD
[+] Article and Author Information

From Duke University School of Nursing, Duke Evidence-based Practice Center, Duke Clinical Research Institute, Duke University School of Medicine, and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, and Sticht Center on Aging, Geriatrics, and Gerontology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.

Disclaimer: The authors of this report are responsible for its contents. Statements in the report should not be construed as endorsements by AHRQ or the U.S. Department of Health and Human Services.

Acknowledgment: The authors thank Dr. Shilpa Amin, AHRQ Task Order Officer, and Dr. Ethan Balk for their suggestions on improving the clarity of the report; Connie Schardt, MSLS, for help with the literature search and retrieval; and R. Julian Irvine, MCM, for his support in coordinating the efforts of the team, particularly with organizing and preparing the authors for each phase of the review.

Grant Support: This project was funded by the AHRQ (contract 290-2007-10066-I), U.S. Department of Health and Human Services.

Potential Conflicts of Interest: Dr. Prvu Bettger: Grant (money to institution): AHRQ. Grants/grants pending: AHRQ. Dr. Alexander: Grant (money to institution): AHRQ; Consultancy: Gilead Sciences; Grants/grants pending: Sanofi-Aventis. Drs. Dolor and Olson and Ms. Wing: Grant (money to institution): AHRQ. Dr. Coeytaux: Grants (money to institution): AHRQ. Dr. Graffagnino: Grant (money to institution): AHRQ; Consultancy: Novella; Grants/grants pending: Ornim; Payment for lectures: Zoll Circulation. Dr. Duncan: Grant (money to institution): AHRQ; Board membership: National Institute of Neurological Diseases and Stroke, National Institute on Aging, Claude D. Pepper Older Americans Independence Center, Veterans Affairs Rehabilitation Research and Development, North Carolina Falls Prevention Coalition; Consultancy: Allergan, GlaxoSmithKline; Employment: Wake Forest University School of Medicine; Expert testimony: AHRQ, National Institute of Neurological Diseases and Stroke Development of Common Data Elements for Stroke, Clinical Trials Chair of Outcomes Measures Subgroup, National Institute of Child Health and Human Development, Strategic Vision and Planning Co-Chair of Plasticity Workgroup; Awards: American Heart Association Stroke Council Award, Service Award from the American Heart Association/American Stroke Association for Leadership as the Chair of the Stroke Council; Grants/grants pending (money to institution): National Institute of Neurological Diseases and Stroke, Claude D. Pepper Older Americans Independence Center (funding agencies: National Institute of Aging, Singapore Ministry of Health); Royalties: University of Kansas Medical Center; Other relationships: spouse is co-owner of Health Profession Seminars. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-0271.

Requests for Single Reprints: Janet Prvu Bettger, ScD, Associate Professor, Duke University School of Nursing, Box 3322, Duke University Medical Center, 307 Trent Drive, Durham, NC 27710; e-mail, janet.bettger@duke.edu.

Current Author Addresses: Dr. Prvu Bettger: Duke University School of Nursing, Box 3322, Duke University Medical Center, 307 Trent Drive, Durham, NC 27710.

Drs. Alexander and Dolor: Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705.

Dr. Olson: Department of Neurology, Box 2900, Duke University Medical Center, Durham, NC 27710.

Ms. Kendrick, Ms. Wing, and Dr. Coeytaux: Duke Clinical Research Institute, Evidence-based Practice Center, 2400 Pratt Street, Durham, NC 27705.

Dr. Graffagnino: Department of Neurology, Box 2900 Duke University Medical Center, Durham, NC 27710.

Dr. Duncan: J. Paul Sticht Center on Aging & Rehabilitation, 1 Medical Center Boulevard, Winston-Salem, NC 27157.

Author Contributions: Conception and design: J. Prvu Bettger, K.P. Alexander, D.M. Olson, A.S. Kendrick, C. Graffagnino.

Analysis and interpretation of the data: J. Prvu Bettger, K.P. Alexander, R.J. Dolor, D.M. Olson, R.R. Coeytaux, C. Graffagnino, P.W. Duncan.

Drafting of the article: J. Prvu Bettger, K.P. Alexander, R.J. Dolor, D.M. Olson, C. Graffagnino, P.W. Duncan.

Critical revision of the article for important intellectual content: J. Prvu Bettger, K.P. Alexander, D.M. Olson, C. Graffagnino, P.W. Duncan.

Final approval of the article: J. Prvu Bettger, K.P. Alexander, R.J. Dolor, D.M. Olson, A.S. Kendrick, R.R. Coeytaux, C. Graffagnino, P.W. Duncan.

Obtaining of funding: C. Graffagnino.

Administrative, technical, or logistic support: K.P. Alexander, R.J. Dolor, D.M. Olson, A.S. Kendrick, L. Wing.

Collection and assembly of data: J. Prvu Bettger, K.P. Alexander, R.J. Dolor, D.M. Olson, A.S. Kendrick, L. Wing, R.R. Coeytaux, C. Graffagnino, P.W. Duncan.


Ann Intern Med. 2012;157(6):407-416. doi:10.7326/0003-4819-157-6-201209180-00004
Text Size: A A A

Background: Transitional care is a time-limited service to prevent discontinuous care and adverse outcomes, including rehospitalization.

Purpose: To describe transitional care interventions and evidence of benefit or harm in patients hospitalized for acute stroke or myocardial infarction (MI).

Data Sources: Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Cochrane Database of Systematic Reviews, and EMBASE, supplemented with manual searches of reference lists of relevant studies and review articles (January 2000 to March 2012).

Study Selection: 6 reviewers screened 5857 citations to identify English-language reports of trials or observational studies that compared transitional care with usual care among adults hospitalized for stroke or MI and that reported patient, caregiver, process, or systems outcomes within 1 year of hospital discharge.

Data Extraction: Data on study design, quality, population, intervention characteristics, and patient- and system-level outcomes were extracted by 3 reviewers and confirmed by 1 additional reviewer.

Data Synthesis: 62 articles representing 44 studies of transitional care for either acute stroke (27 studies) or MI (17 studies). Four intervention types were studied: hospital-initiated support ( n = 14), patient and family education ( n = 7), community-based support ( n = 20), and chronic disease management ( n = 3). Most studies (68%) were of fair quality. Overall, moderate-strength evidence showed that hospital-initiated support reduced length of stay for patients who had a stroke, and low-strength evidence showed that it reduced mortality for patients who had an MI. Evidence about benefits of other interventions and harms from transitional care services was insufficient.

Limitations: Few studies had high-quality research designs. The usual care comparator was often poorly defined. Applicability to U.S. clinical practice was limited; only 6 studies were conducted in the United States.

Conclusion: Available evidence shows that hospital-initiated transitional care can improve some outcomes in adults hospitalized for stroke or MI. Finding additional transitional care interventions that improve functional outcomes and prevent rehospitalizations and adverse events is a high priority for the growing population of patients who have an MI or a stroke.

Primary Funding Source: Agency for Healthcare Research and Quality.

Figures

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Figure 1.

Summary of evidence search and selection.

MA = meta-analysis; MI = myocardial infarction; SR = systematic review.

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Figure 2.

Transitional care intervention framework.

APN = advanced practice nurse; OT = occupational therapist; PT = physical therapist.

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