Transition Processes, Principal Outcome Measures, and Assessment Time Frame by Study

StudyLevel of EvidenceaSample SizePopulation (Mean Age)Transition ProcessPatient Health OutcomesHealth Care Utilization/Cost
Anderson et al28,b 20053I: 44Elderly (78.5 y)TDE30-d Readmission:
C: 77PDFUI: 6% vs C: 22%*
Balaban et al29,b 20082I: 47AdultsTDECompleted f/u visit at 21 d:30-d ED visit: ND
C: 49(56 y)ITRI: 85% vs C: 59%**30-d Readmission: ND
SFUCompleted outpatient workup at 21 d:
PDFUI: 88% vs C: 69%
Chang et al38 20124I: 83AdultsSFUCompleted f/u visit at 30 d:14-d ED visit: ND
HC: 306(not reported)I: 78% vs C: 60%***
Coleman et al30,b 20043I: 158Elderly (77 y)TDE30-d ED visit:
C: 1235ITROR 0.76 (0.44–1.30)
SFU30-d Readmission:
PDFUOR 0.52 (0.28–0.96)*
Coleman et al31,b 20062I: 360Elderly (76 y)TDE30-d Readmission:
C: 352ITROR 0.59 (0.35–1.00)*
SFU30-d Cost:
PDFUI: $784 vs C: $918*
Dedhia et al32,b 20094I:185Elderly (77 y)TNAQuality of transitionc reported at 1 wk:30-d ED visit:
HC: 237TDEOR 3.49 (2.06–5.92)***OR 0.58 (0.34–0.98)*
Felt better than before hospitalization reported at 30 d:30-d Readmission:
OR 2.36 (1.41–3.95)**OR 0.55 (0.32–0.94)*
Knowledge of who to call with questions reported at 1 wk:
OR 15.87 (2.05–125.00)**
Finn et al33,b 20112I: 440AdultsTDESatisfied with discharge process (yes/no) reported at 2–4 wk:30-d ED visit:
C: 432(63 y)PDFUI: 97% vs C: 76%***I: 9% vs C: 9%
Felt safe going home reported at 2–4 wk:30 d Readmission:
I: 97% vs C: 92%I: 20% vs C: 18%
Knowledge of who to call with questions reported at 2–4 wk:
I: 95% vs C: 85%**
Knowledge of f/u plan reported at 2–4 wk:
I: 99% vs C: 87%***
Knowledge of medications reported at 2–4 wk:
I: 96% vs C: 87%**
Hussain-Rizvi et al25 20092I: 40Pediatric (3 y)TDEPresence of cough reported at 2 wk:
C: 46I: 13% vs C: 30%*
Presence of other symptoms reported at 2 wk: ND
Functional status reported at 2 wk: ND
Missed school/work reported at 2 wk: ND
Albuterol use reported at 2 wk: ND
MDIS use reported at 2 wk:
I: 95% vs C: 72%*
Jack et al34,b 20092I: 370Adults (50 y)TDEFelt prepared for discharge reported at 30 d:30-d ED visit:
C: 368TNAI: 65% vs C: 55%*I: 0.17 vs C: 0.25* (visits/pt/mo)
ITRKnowledge of discharge diagnosis reported at 30 d:30-d Readmission:
SFUI: 66% vs C: 57%*I: 0.15 vs C: 0.21 (readmits/pt/mo)
PDFUKnowledge of medications reported at 30 d:30-d Cost savings:
I: 89% v C: 83%*I: $412/pt
Knowledge of f/u appointments reported at 30 d:
I: 86% v C: 79%*
Completed f/u visit at 30 d:
I: 62% vs C: 44%***
Koehler et al35,b 20092I: 20Elderly (78 y)TDECombined 30-d ED visit and Readmission:
C: 21TNAI: 10% vs C: 38%*
Naylor et al39,b 20042I: 121Elderly (76 y)TNASatisfaction (0–100 scale where high scores are better) reported at 2 wk:30-d Readmission:
C: 118PDFUI: 83 vs C: 75***I: 13% vs C: 26%*
HRQOLd (0–5 scale representing lowest to highest quartile scores) reported at 2 wk:
I: 3.0 vs C: 2.7
Functional statuse reported at 2 wk: ND
Parry et al36,b 20092I: 44Elderly (81 y)TDE30-d Readmission:
C: 42ITRI: 7% vs C: 17%
Patel et al27 20094I: 158Pediatric (not reported)TDESatisfaction reported at 1 wk:
HC: 133I > C (numerical values not provided)
Warning signs identified (7-point scale where higher scores are better) reported at 1–2 d:
I: 4.3 vs C: 3.3***
Reese et al40 20033I: 15Adults (69 y)PDFUMissed f/u visit reported at 15 d: ND15-d ED visit:
C: 34I: 7% vs C: 18%
15-d Readmission:
I: 13% vs C: 15%
Yin et al262I: 124Pediatric (3.5 y)TDEMedication name error rates reported at 12 d (mean f/u):
C: 121I: 6.5% vs C: 13.2%
Medication dosing frequency error rates reported at 12 d (mean f/u):
I: 0% vs C: 15.1%**
Medication preparation error rates reported at 12 d (mean f/u):
I: 10.9% vs C: 28.3%*
Medication nonadherence rates reported at 12 d (mean f/u):
I: 9.3% vs C: 38%**
Medication dosing error rates by observation at 12 d (mean f/u):
I: 5.4% vs C: 47.8%***
Zorc et al37 20032I: 139Pediatric (8 y)SFUMissed school/work reported at 4 wk: ND30-d ED visit: ND
C: 139Return to baseline health status reported at 4 wk:
I: 82% vs C: 71%*
Using controller medication daily reported at 4 wk:
I: 54% vs C: 58%
Completed f/u visit at 4 wk:
I: 77% vs C: 51%***
  • C, control group; f/u, follow-up; HC, historic control group; HRQOL, health-related quality of life; I, intervention group; IDP, individualized discharge plan; ITR, individualized transition record; MDIS, metered dose inhaler with spacer; ND, no difference; PDFU, postdischarge telephone follow-up and home visits; pt, patient; SFU, assistance in scheduling follow-up appointments; TDE, patient- and family-tailored discharge education; TNA, transition needs assessment. *P < .05; **P < .01; ***P < .001.

  • a Based on the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence: 1 = systematic review; 2 = randomized trial; 3 = cohort study; 4 = case-control study; 5 = mechanism-based reasoning.

  • b Bundled intervention.

  • c Quality of transition assessed using the 15-item Care Transitions Measure.67

  • d HRQOL assessed by using the Minnesota Living with Heart Failure Questionnaire.68

  • e Functional status assessed by using the Enforced Social Dependency Scale.69