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