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Cochrane Database of Systematic Reviews Discharge planning from hospital (Review) Gonçalves-Bradley DC, Lannin

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NA, Clemson LM, Cameron ID, Shepperd S Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD000313. DOI: 10.1002/14651858.CD000313.pub5. www.cochranelibrary.com Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. TABLE OF CONTENTS HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . . BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.1. Comparison 1 Effect of discharge planning on hospital length of stay, Outcome 1 Hospital length of stay older patients with a medical condition. . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.2. Comparison 1 Effect of discharge planning on hospital length of stay, Outcome 2 Sensitivity analysis imputing missing SD for Kennedy trial. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.3. Comparison 1 Effect of discharge planning on hospital length of stay, Outcome 3 Hospital length of stay older surgical patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.4. Comparison 1 Effect of discharge planning on hospital length of stay, Outcome 4 Hospital length of stay older medical and surgical patients. . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.1. Comparison 2 Effect of discharge planning on unscheduled readmission rates, Outcome 1 Within 3 months of discharge from hospital. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 4.1. Comparison 4 Effect of discharge planning on patients’ place of discharge, Outcome 1 Patients discharged from hospital to home. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 4.4. Comparison 4 Effect of discharge planning on patients’ place of discharge, Outcome 4 Older patients admitted to hospital following a fall in residential care at 1 year. . . . . . . . . . . . . . . . . . . . . Analysis 5.1. Comparison 5 Effect of discharge planning on mortality, Outcome 1 Mortality at 6 to 9 months. . . Analysis 6.4. Comparison 6 Effect of discharge planning on patient health outcomes, Outcome 4 Falls at follow-up: patients admitted to hospital following a fall. . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 8.5. Comparison 8 Effect of discharge planning on hospital care costs, Outcome 5 Hospital outpatient department attendance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 8.6. Comparison 8 Effect of discharge planning on hospital care costs, Outcome 6 First visits to the emergency room. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 1 1 2 3 6 7 7 9 10 13 16 18 18 19 25 67 71 72 73 73 74 79 81 81 88 93 94 97 100 101 101 102 102 102 102 103 i [Intervention Review] Discharge planning from hospital Daniela C. Gonçalves-Bradley1 , Natasha A Lannin2 , Lindy M Clemson3 , Ian D Cameron4 , Sasha Shepperd1 1 Nuffield Department of Population Health, University of Oxford, Oxford, UK. 2 Occupational Therapy, Alfred Health, Prahran, Australia. 3 Faculty of Health Sciences, University of Sydney, Lidcombe, Australia. 4 John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District, St Leonards, Australia Contact address: Sasha Shepperd, Nuffield Department of Population Health, University of Oxford, Oxford, UK. sasha.shepperd@ndph.ox.ac.uk. Editorial group: Cochrane Effective Practice and Organisation of Care Group. Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 1, 2016. Citation: Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD000313. DOI: 10.1002/14651858.CD000313.pub5. Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and to improve the co-ordination of services following discharge from hospital.This is the third update of the original review. Objectives To assess the effectiveness of planning the discharge of individual patients moving from hospital. Search methods We updated the review using the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 9), MEDLINE, EMBASE, CINAHL, the Social Science Citation Index (last searched in October 2015), and the US National Institutes of Health trial register (ClinicalTrials.gov). Selection criteria Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to individual participants. Participants were hospital inpatients. Data collection and analysis Two authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies according to patient groups (elderly medical patients, patients recovering from surgery, and those with a mix of conditions) and by outcome. We performed our statistical analysis according to the intention-to-treat principle, calculating risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible because of differences in the reporting of outcomes, we summarised the reported data in the text. Main results We included 30 trials (11,964 participants), including six identified in this update. Twenty-one trials recruited older participants with a medical condition, five recruited participants with a mix of medical and surgical conditions, one recruited participants from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials recruited participants admitted to hospital following a fall. Hospital length of stay and readmissions to hospital were reduced for participants admitted to hospital with Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 1 a medical diagnosis and who were allocated to discharge planning (length of stay MD − 0.73, 95% CI − 1.33 to − 0.12, 12 trials, moderate certainty evidence; readmission rates RR 0.87, 95% CI 0.79 to 0.97, 15 trials, moderate certainty evidence). It is uncertain whether discharge planning reduces readmission rates for patients admitted to hospital following a fall (RR 1.36, 95% CI 0.46 to 4.01, 2 trials, very low certainty evidence). For elderly patients with a medical condition, there was little or no difference between groups for mortality (RR 0.99, 95% CI 0.79 to 1.24, moderate certainty). There was also little evidence regarding mortality for participants recovering from surgery or who had a mix of medical and surgical conditions. Discharge planning may lead to increased satisfaction for patients and healthcare professionals (low certainty evidence, six trials). It is uncertain whether there is any difference in the cost of care when discharge planning is implemented with patients who have a medical condition (very low certainty evidence, five trials). Authors’ conclusions A discharge plan tailored to the individual patient probably brings about a small reduction in hospital length of stay and reduces the risk of readmission to hospital at three months follow-up for older people with a medical condition. Discharge planning may lead to increased satisfaction with healthcare for patients and professionals. There is little evidence that discharge planning reduces costs to the health service. PLAIN LANGUAGE SUMMARY Discharge planning from hospital Background Discharge planning is the development of a personalised plan for each patient who is leaving hospital, with the aim of containing costs and improving patient outcomes. Discharge planning should ensure that patients leave hospital at an appropriate time in their care and that, with adequate notice, the provision of postdischarge services will be organised. Objectives We systematically searched for trials to see the effect of developing personalised plans for patients leaving the hospital. This is the third update of the original review. Main results We found 30 trials that compared personalised discharge plans versus standard discharge care. Twenty of those studies included older adults. Authors’ conclusions This review indicates that a personalised discharge plan probably brings about a small reduction in hospital length of stay (mean difference − 0.73 days) and readmission rates for elderly patients who were admitted to hospital with a medical condition, and may increase patient satisfaction. It may also increase professionals’ satisfaction, though there is little evidence to support this. It is not clear if discharge planning reduces costs to the health services. Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 2 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation] Effect of discharge planning on patients admitted to hospital with a medical condition Patient or population: patients adm itted to hospital Settings: hospital Intervention: discharge planning Outcomes Illustrative comparative risks* (95% CI) Assumed risk Without planning Relative effect (95% CI) No. of participants (studies) Certainty of the evi- Comments dence (GRADE) 4743 (15) ⊕⊕⊕ moderate a – 110 (2) ⊕ very lowb – Corresponding risk discharge With discharge planning Unscheduled readmis- Study population admitted with a medical con- RR 0.87 sion within 3 months of dition (0.79 to 0.97) discharge from hospital 254 per 1000 221 per 1000 (200 to 246) M oderate risk population 285 per 1000 248 per 1000 (225 to 276) Study population admitted following a fall 93 per 1000 126 per 1000 (43 to 371) M oderate risk population 92 per 1000 125 per 1000 (42 to 369) RR 1.36 (0.46 to 4.01) 3 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Hospital length of stay Study population admitted with a medical con- Follow-up: 3 to 6 dition m onths The m ean hospital length of stay ranged across control groups f rom 5.2 to 12.4 daysc 2193 (12 studies) ⊕⊕⊕ moderate d – The m ean hospital length of stay in the intervention groups was 0.73 lower (95% CI 1.33 to 0.12 lower) Satisfaction Discharge planning m ay lead to increased satis- 6 studies f action f or patients and healthcare prof essionals ⊕⊕ low Patient satisf action was m easured in dif f erent ways, and f indings were not consistent across studies. Only 6/ 30 studies reported data f or this outcom e Costs A lower readm ission rate f or those receiving 5 studies discharge planning m ay be associated with lower health service costs in the short term . Dif f erences in use of prim ary care varied ⊕ very low Findings were inconsistent. Healthcare resources that were assessed varied am ong studies, e.g., prim ary care visits, readm ission, length of stay, laboratory services, m edication, diagnostic im aging. The charges used to cost the healthcare resources also varied * The basis f or the assumed risk (e.g. the m edian control group risk across studies) is provided in f ootnotes. The corresponding risk (and its 95% conf idence interval) is based on the assum ed risk in the com parison group and the relative effect of the intervention (and its 95% CI). CI: Conf idence interval; RR: Risk ratio. 4 Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. GRADE Working Group grades of evidence High:This research provides a very good indication of the likely ef f ect. The likelihood that the ef f ect will be substantially dif f erent (i.e., large enough to af f ect a decision) is low. M oderate: This research provides a good indication of the likely ef f ect. The likelihood that the ef f ect will be substantially dif f erent is m oderate. Low: This research provides som e indication of the likely ef f ect. However, the likelihood that it will be substantially dif f erent is high. Very low: This research does not provide a reliable indication of the likely ef f ect. The likelihood that the ef f ect will be substantially dif f erent is very high a The evidence was downgraded to m oderate as allocation concealm ent was unclear f or 5 of the 15 trials. The evidence was downgraded because of im precision in the results due to 2 sm all trials. c The range excludes length of stay of 45 days reported by Sulch, as this was an outlier. d The evidence was downgraded to m oderate as concealm ent of random allocation was unclear f or 6 of the 11 trials. b xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx 5 BACKGROUND Cost containment strategies that aim to limit healthcare-related costs while still promoting quality are a feature of all healthcare systems, especially for acute hospital services (Bodenheimer 2005). Recent trends include specifically targeting those patients who incur greater healthcare expenditures, decreasing the length of stay for inpatient care, reducing the number of long-stay beds, moving care into the community, increasing the use of day surgery, providing increased levels of acute care at home (’hospital at home’) and implementing policies such as discharge planning. There is evidence to suggest that discharge planning (i.e. an individualised plan for a patient prior to them leaving hospital for home) combined with additional postdischarge support can reduce unplanned readmission to hospital for patients with congestive heart failure (Phillips 2004). A reduction in readmissions will decrease inpatient costs; however, this reduction in costs may be offset by an increase in the provision of community services as a result of planning. In the United States, unplanned hospitalisations accounted for 17% of all Medicare hospital payments in 2004, and one quarter of all hospital admissions were 30-day readmissions (Jencks 2009). Even a small reduction in readmission rates could have a substantial financial impact (Burgess 2014). Description of the intervention Discharge planning is the development of an individualised discharge plan for a patient prior to them leaving hospital for home. The discharge plan can be a stand-alone intervention or may be embedded within another intervention, for example, as a component of stroke unit care or as part of the comprehensive geriatric assessment process (Ellis 2011; Langhorne 2002; Rubenstein 1984). Discharge planning may also extend across healthcare settings and include postdischarge support (Parker 2002; Phillips 2004). How the intervention might work The aim of discharge planning is to improve the efficiency and quality of healthcare delivery by reducing delayed discharge from hospital, facilitating the transition of patients from a hospital to a postdischarge setting, providing patients with information about their condition and, if required, postdischarge healthcare. Discharge planning may contain costs and improve patient outcomes. For example, discharge planning may influence both the hospital length of stay and the pattern of care within the community, including the follow-up rate and outpatient assessment, by bridging the gap between hospital and home (Balaban 2008). Description of the condition It has been estimated that one-fifth of all hospital discharges are delayed for non-medical reasons (McDonagh 2000). Despite recent advances in electronic records, patient pathways and technology-assisted decision support, the following three factors, identified over 30 years ago (Barker 1985), remain causes of delayed discharge from hospital (Dept of Health 2003): inadequate patient assessment by health professionals, resulting in problems such as poor knowledge of the patient’s social circumstances and poor organisation of postdischarge health and social care; the late booking of transport services to take a patient home, which prevents timely discharge from hospital; and poor communication between the hospital, follow-up care and community service providers. Organisational factors, including the number of times a patient is moved while in hospital and the discharge arrangements, are more strongly associated with delayed discharge than patient factors such as functional limitations or cognitive function (Challis 2014). The transition of patients from hospital to postdischarge healthcare, residential or the home setting has the potential to disrupt continuity of care and may increase the risk of an adverse event due to an inadequate planning of a patient’s discharge (Kripalani 2007). Poor communication between the secondary care and the postdischarge setting can result in key clinical information not reaching primary care providers, with patients remaining unaware of information that might help them manage their condition and prepare for discharge from hospital. Why it is important to do this review The emphasis placed on discharge planning varies between countries. In the USA, discharge planning is mandatory for hospitals participating in the Medicare and Medicaid programmes. In the UK, the Department of Health has published guidance on discharge practice for health and social care (Dept of Health 2010). Clinical guidance issued by professional bodies in the UK (Future Hospital Comission 2013), the USA (Dept Health Human Services 2013), Australia (Aus NZ Soc Geriat Med 2008) and Canada (Health Qual Ontario 2013), all highlight the importance of planning discharge as soon as the patient is admitted, involving a multidisciplinary team to provide a thorough assessment, establishing continuous communication with the patient and the care givers, working towards shared decision-making and self-management, and liaising with health and social services in the community-particularly primary care. However, procedures may vary between specialities and healthcare professionals in the same hospital (Ubbink 2014). We have conducted a systematic review of discharge planning to categorise the different types of study populations and discharge plans being implemented, and to assess the effectiveness of organising services in this way. The focus of this review is the effectiveness of discharge planning implemented in an acute hospital setting. This is the third update of the original review. Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 6 OBJECTIVES Types of participants The main objective was to assess the effectiveness of planning the discharge of individual patients moving from hospital. All patients in hospital (acute, rehabilitation or community) irrespective of age, gender or condition. The specific objectives were as follow: Does discharge planning improve the appropriate use of acute care 1. Effect of discharge planning on length of stay in hospital compared to usual care. 2. Effect of discharge planning on unscheduled readmission rates compared to usual care 3. Effect of discharge planning on other process variables: patients’ place of discharge. Does discharge planning improve or (at least) have no adverse effect on patient outcome? 1. Effect of discharge planning on mortality rate compared to usual care. 2. Effect of discharge planning on patient health outcomes compared to usual care. 3. Effect of discharge planning on the incidence of complications related to the initial admission compared to usual care. 4. Effect of discharge planning on the satisfaction of patient, care givers and healthcare professionals compared to usual care. Does discharge planning reduce overall costs of healthcare? 1. Effect of discharge planning on hospital care costs compared to usual care. 2. Effect of discharge planning on community care costs compared to usual care. 3. Effect of discharge planning on overall costs of healthcare compared to usual care. 4. Effect of discharge planning on the use of medication. METHODS Criteria for considering studies for this review Types of studies Randomised controlled trials. Types of interventions We defined discharge planning as the development of an individualised discharge plan for a patient prior to them leaving hospital for home or residential care. Where possible, we divided the process of discharge planning according to the steps identified by Marks 1994: • pre-admission assessment (where possible); • case finding on admission; • inpatient assessment and preparation of a discharge plan based on individual patient needs, for example a multidisciplinary assessment involving the patient and their family, and communication between relevant professionals within the hospital; • implementation of the discharge plan, which should be consistent with the assessment and requires documentation of the discharge process; • monitoring in the form of an audit to assess if the discharge plan was implemented. We excluded studies from the review if they did not include an assessment or implementation phase in discharge planning; if it was not possible to separate the effects of discharge planning from the other components of a multifaceted intervention or if discharge planning appeared to be a minor part of a multifaceted intervention; or if the focus was on the provision of care after discharge from hospital. We excluded interventions where the focus was on the provision of care after discharge from hospital, and those in which discharge planning was part of a larger package of care but the process and components were poorly described. The control group had to receive standard care with no individualised discharge plan. Types of outcome measures We addressed the effect of discharge planning across several areas: the use of acute care, patient outcomes and healthcare costs. Main outcomes 1. Length of stay in hospital 2. Readmission rate to hospital Other outcomes 1. Complications related to the initial admission 2. Place of discharge 3. Mortality rate 4. Patient health status, including psychological health 5. Patient satisfaction 6. Care giver and healthcare professional satisfaction 7. Psychological health of care givers 8. Healthcare costs of discharge planning Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 7 i) Hospital care costs and use ii) Primary and community care cost 9. The use of medication for trials evaluating a pharmacy discharge plan Search methods for identification of studies Electronic searches We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 9), the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register (March 2009), MEDLINE via OvidSP (1946 to October 2015), EMBASE via OvidSP (1974 to October 2015), CINAHL via EbscoHOST (1980 to October 2015), Social Science Citation Index via ISI Web of Knowledge (1975 to October 2015), EconLit (1969 to 1996), SIGLE (grey literature) (1980 to 1996), PsycLIT (1974 to 1996) and PsycINFO (2012 to October 2015). We detail the search strategies for this update in Appendix 1. Searching other resources We checked the reference lists of included studies and related systematic reviews using PDQ-Evidence (PDQ-Evidence 2015). We handsearched the US National Institutes of Health trial register (ClinicalTrials.gov 2015) and reviewed the reference lists of all included studies. When necessary, we contacted individual trialists to clarify issues and to identify unpublished data. identify publications that appeared to be eligible for this review. Two authors (of DCGB, IC, NL and LC) then independently assessed the full text of all potentially relevant papers in order to select studies for inclusion. We settled any disagreements by discussion, or by liaising with SS. We excluded trials when discharge planning was part of a broader package of inpatient care. We made a post hoc decision to exclude any studies that did not describe the study design or did not report results for the control group. We report details of why we excluded studies in the ’Characteristics of excluded studies’ table. Data extraction and management For this update, two authors working independently (of DCGB, IC, NL and LC) extracted data from each article. For the original review and two subsequent updates, we used a data extraction form developed by EPOC, modified and amended for the purposes of this review. For the current version of the review we used an adapted version of the Cochrane good practice extraction form (EPOC 2015). We extracted information on study characteristics (first author, year of publication, aim, setting, design, unit of allocation, duration, ethical approval, funding sources), participant characteristics (method of recruitment, inclusion/exclusion criteria, total number, withdrawals and drop-outs, socio-demographic indicators, subgroups), intervention (setting, pre-admission assessment, case finding on admission, inpatient assessment and preparation of discharge plan, implementation of discharge plan, monitoring phase, and comparison), and outcomes. Assessment of risk of bias in included studies Data collection and analysis For this update we followed the same methods defined in the protocol and used in previous versions of this systematic review. Risk of bias of each included study was assessed using the Cochrane Risk of Bias criteria. We created a summary of findings table using the following outcomes: unscheduled hospital readmission, hospital length of stay, satisfaction and costs. We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and risk of bias) to assess the certainty of the evidence as it relates to the main outcomes (Guyatt 2008). We used methods and recommendations described in Section 8.5 and Chapter 12 of the Cochrane Handbook (Higgins 2011). We justified all decisions to down- or up-grade the certainty of evidence using footnotes to aid readers’ understanding of the review where necessary. We assessed the quality of the selected trials using the criteria presented in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011): random sequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting, and baseline data. For this update, two reviewers (of DCGB, IC, NL and LC) independently assessed the risk of bias. We resolved disagreements by discussing each case with a third reviewer (SS). Unit of analysis issues All the included studies were parallel RCTs, where participants were individually allocated to the treatment or control groups. Selection of studies Dealing with missing data For this update, two authors (of DCGB, IC, NL and LC) read all the abstracts in the records retrieved by the electronic searches to We contacted investigators for missing data; for this update two provided unpublished data (Goldman 2014; Lainscak 2013). Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 8 Assessment of heterogeneity We quantified heterogeneity among trials using the I2 statistic and Cochrane’s Q test (Cochrane 1954). The I2 statistic quantifies the percentage of the total variation across studies that is due to heterogeneity rather than chance (Higgins 2003); smaller percentages suggest less observed heterogeneity. Data synthesis The primary analysis was a comparison of discharge planning versus routine discharge care for each outcome listed in Types of outcome measures. We calculated risk ratios (RR) for the dichotomous outcomes mortality, unscheduled readmission and discharge destination, with 95% confidence intervals (CI) for all point estimates; and combined data using the fixed effects model. Values under 1 indicated outcomes favouring discharge planning. We calculated mean differences (MD) for the hospital length of stay. We judged combining data from the included studies inappropriate for the other outcomes, including patient health outcomes, satisfaction, medication, healthcare costs, and use of other postdischarge healthcare services (primary care, outpatient, and emergency room), due to the different methods of measuring and reporting these outcomes. We created a ’Summary of findings’ table for the main outcomes of hospital length of stay and unscheduled readmission, and for the secondary outcomes of satisfaction and cost. We used GRADE worksheets to assess the certainty of the evidence (GRADEpro GDT 2015). Subgroup analysis and investigation of heterogeneity In order to reduce differences between trials, we grouped trial results by participants’ condition (patients with a medical condition, a surgical condition, or patients recruited to a trial with a mix of conditions), as the discharge planning needs for patients admitted to hospital for surgery might differ from those for patients admitted with an acute medical condition or with multiple medical conditions. We performed post hoc subgroup analyses for participants admitted to hospital following a fall and participants admitted to a mental health setting, as we found more than one study for each subgroup and considered that these participant groups, as well as their discharge needs, might differ from both surgical and medical patients. Sensitivity analysis We performed a post hoc sensitivity analysis by imputing a missing standard deviation for one trial (Kennedy 1987). RESULTS Description of studies Results of the search Previous versions of the review identified 4676 records, of which we excluded 4526 after screening the title and abstract. The main reasons for exclusion were ineligible study design, intervention or both. Of the 150 full-text records assessed, we excluded 126 and included 24 (Balaban 2008; Bolas 2004; Eggink 2010; Evans 1993; Harrison 2002; Hendriksen 1990; Jack 2009; Kennedy 1987; Laramee 2003; Legrain 2011; Lin 2009; Moher 1992; Naji 1999; Naughton 1994; Naylor 1994; Nazareth 2001; Pardessus 2002; Parfrey 1994; Preen 2005; Rich 1993a; Rich 1995a; Shaw 2000; Sulch 2000; Weinberger 1996). For this review update, we identified 1796 records, of which we excluded 1703 after screening the title and abstract. After retrieving the full text of the remaining 93 studies, we identified six eligible trials (12 publications), which we included in this update (Farris 2014; Gillespie 2009; Goldman 2014; Kripalani 2012; Lainscak 2013; Lindpaintner 2013) (Figure 1). These 30 trials recruited a total of 11,964 participants. One of the trials included in the review was translated from Danish to English (Hendriksen 1990). Follow-up times varied from five days to 12 months. Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 9 Figure 1. PRISMA flow diagram Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 10 Included studies The trials included in the review evaluated broadly similar discharge planning interventions, which included assessment, planning, implementation and monitoring phases, although seven trials did not describe a monitoring phase (Eggink 2010; Evans 1993; Moher 1992; Naji 1999; Parfrey 1994; Shaw 2000; Sulch 2000); see Characteristics of included studies. The intervention was implemented at varying times during a participant’s stay in hospital, from admission to three days prior to discharge. For one trial it was not clear when the intervention, which consisted of liaising with the community healthcare providers about the patient’s specific needs, was implemented (Lainscak 2013). Another trial conducted a needs assessment and implementation of the discharge plan in two separate encounters, but if discharge occurred the same day as enrolment, then both phases occurred in one session (Kripalani 2012). Seven trials evaluated a pharmacy discharge plan implemented by a hospital pharmacy. For six of those trials the participants’ medication was rationalised and prescriptions checked for errors by the hospital consultant, GP, community pharmacist or all of those. These professionals also received a pharmacy discharge plan, and participants received information about their medication (Bolas 2004; Eggink 2010; Farris 2014; Gillespie 2009; Nazareth 2001; Shaw 2000). For the seventh trial, the research team contacted the physicians treating the participant, both in the hospital and in the community, but only if they had identified medicationrelated problems during the monitoring phase of the intervention (Kripalani 2012). In all but two trials a named healthcare professional coordinated the discharge plan. Of the 30 included trials, 12 provided a postdischarge phone call, four a visit, and two a phone call and a visit. The study population differed between the trials. Twenty-one trials recruited participants with a medical condition (Balaban 2008; Bolas 2004; Eggink 2010; Farris 2014; Gillespie 2009; Goldman 2014; Harrison 2002; Jack 2009; Kennedy 1987; Kripalani 2012; Lainscak 2013; Laramee 2003; Legrain 2011; Moher 1992; Naughton 1994; Nazareth 2001; Preen 2005; Rich 1993a; Rich 1995a; Sulch 2000; Weinberger 1996), with six of these recruiting participants with heart failure (Eggink 2010; Harrison 2002; Kripalani 2012; Laramee 2003; Rich 1993a; Rich 1995a). Two trials recruited older people (> 65 years) admitted to hospital following a fall (Lin 2009; Pardessus 2002), five recruited participants with a mix of medical and surgical conditions (Evans 1993; Farris 2014; Hendriksen 1990; Naylor 1994; Parfrey 1994), and two recruited participants from an acute psychiatric ward (Naji 1999; Shaw 2000), one of which also recruited participants from the elderly care ward (Shaw 2000). Two trials used a questionnaire designed to identify participants likely to require discharge planning (Evans 1993; Parfrey 1994). The majority of trials included a patient education component, and two trials included the participant’s care giver in the formal assessment process (Lainscak 2013; Naylor 1994). The average age of participants recruited to 10 of the trials was > 75 years; in seven trials, between 70 and 75 years, and in the remaining trials, < 70 years. In two trials, both recruiting participants from a psychiatric hospital, the participants were under 50 years of age. The description of the type of care the control group received varied. Two trials did not describe the care that the control group received (Kennedy 1987; Shaw 2000) and another reported it only as best usual care (Lindpaintner 2013). Twenty-one trials described the control group as receiving usual care with some discharge planning but without a formal link through a coordinator to other departments and services, although other services were available on request from nursing or medical staff (Balaban 2008; Eggink 2010; Evans 1993; Gillespie 2009; Goldman 2014; Harrison 2002; Hendriksen 1990; Jack 2009; Laramee 2003; Legrain 2011; Lin 2009; Moher 1992; Naji 1999; Naylor 1994; Naughton 1994; Pardessus 2002; Parfrey 1994; Preen 2005; Rich 1993a; Rich 1995a; Weinberger 1996). The control groups in seven trials that evaluated the effectiveness of a pharmacy discharge plan did not have access to a review and discharge plan by a pharmacist (Bolas 2004; Eggink 2010; Farris 2014; Gillespie 2009; Kripalani 2012; Nazareth 2001; Shaw 2000). In one trial, the control group received multidisciplinary care that was not defined in advance but was determined by the participants’ progress (Sulch 2000). Two trials considered the potential influence of language fluency (Balaban 2008; Goldman 2014), while two looked at health literacy (Jack 2009; Kripalani 2012). Excluded studies The main reason for excluding trials was due to multifaceted interventions, of which discharge planning was only a minor part. Some trials reported interventions of postdischarge care, whereas for others the control group also received some component of the discharge planning intervention. We excluded a small number of trials that did not include an assessment phase (Characteristics of excluded studies). Risk of bias in included studies Eighteen trials reported adequate allocation concealment (Farris 2014; Gillespie 2009; Goldman 2014; Harrison 2002; Jack 2009; Kennedy 1987; Kripalani 2012; Lainscak 2013; Legrain 2011; Naji 1999; Naughton 1994; Nazareth 2001; Preen 2005; Parfrey 1994; Rich 1995a; Shaw 2000; Sulch 2000; Weinberger 1996). All but two trials collected data at baseline (Balaban 2008; Pardessus 2002), and we assessed 21 trials as having a low risk of bias for measurement of the primary outcomes (readmission Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 11 and length of stay), as investigators used routinely collected data to measure these outcomes (Balaban 2008; Eggink 2010; Evans 1993; Farris 2014; Gillespie 2009; Goldman 2014; Hendriksen 1990; Jack 2009; Kennedy 1987; Lainscak 2013; Laramee 2003; Legrain 2011; Moher 1992; Naji 1999; Naughton 1994; Nazareth 2001; Pardessus 2002; Parfrey 1994; Rich 1993a; Rich 1995a; Weinberger 1996). We assessed one pilot trial as having a high risk of bias for the outcome readmission, which was ascertained by interview rather than through routine data collection (Lindpaintner 2013) (Figure 2). Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 12 Figure 2. Methodological quality summary: review authors’ judgements about each methodological quality item for each included study. Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 13 Effects of interventions See: Summary of findings for the main comparison Effect of discharge planning on readmission and hospital length of stay Does discharge planning improve the appropriate use of acute care? Hospital length of stay There was a small reduction in hospital length of stay for those allocated to discharge planning in trials recruiting older people following a medical admission (mean difference (MD) − 0.73, 95% confidence interval (CI) − 1.33 to − 0.12; 12 trials, moderate certainty evidence, Analysis 1.1; Harrison 2002; Gillespie 2009; Kennedy 1987; Laramee 2003; Lindpaintner 2013; Moher 1992; Naughton 1994; Naylor 1994; Preen 2005; Rich 1993a; Rich 1995a; Sulch 2000). This reduction increased slightly in a sensitivity analysis imputing a missing standard deviation for Kennedy 1987 (MD − 0.98, 95% CI − 1.57 to − 0.38; Analysis 1.2). There was no evidence of statistical heterogeneity. Two trials recruiting participants recovering from surgery reported a difference of − 0.06 day (95% CI − 1.23 to 1.11) (Analysis 1.3; Lin 2009; Naylor 1994); and two trials recruiting a combination of participants recovering from surgery and those with a medical condition a mean difference of − 0.60 (95% CI − 2.38 to 1.18) (Analysis 1.4; Evans 1993; Hendriksen 1990). We did not include these four trials in the pooled analysis as they recruited participants from different settings. Parfrey 1994 recruited participants from two hospitals and reported a reduction in length of stay for those receiving discharge planning in one hospital only (median difference − 0.80 days, P = 0.03). Readmission rates For elderly participants with a medical condition, there was a lower readmission rate in the discharge planning group at three months of discharge (RR 0.87, 95% CI 0.79 to 0.97; 15 trials, moderate certainty evidence, Analysis 2.1.1; Balaban 2008; Farris 2014; Goldman 2014; Harrison 2002; Jack 2009; Kennedy 1987; Lainscak 2013; Laramee 2003; Legrain 2011; Moher 1992; Naylor 1994; Nazareth 2001; Rich 1993a; Rich 1995a; Shaw 2000), with no evidence of statistical heterogeneity. It is uncertain whether discharge planning reduces readmission rates for participants admitted to hospital following a fall (RR 1.36, 95% CI 0.46 to 4.01, very low certainty evidence, two trials, Analysis 2.1.2). Evans 1993 recruited a mix of participants, reporting a reduction in readmissions for those receiving discharge planning (difference − 11%, 95% CI − 17% to − 4%) at four weeks follow-up, but not at nine months follow-up (difference − 6%, 95% CI − 12.5% to 0.84%; P = 0.08). One small pilot trial reported similar readmission rates for both groups at 5 and 30 days but did not provide enough data to be included in the pooled analysis (Lindpaintner 2013; Analysis 2.3). One trial recruiting people recovering from surgery reported the difference in readmission rates + 3% (95% CI − 7% to 13%; Analysis 2.4; Naylor 1994), and a trial recruiting participants admitted to acute psychiatric wards reported a difference +7% (95% CI − 1% to 17%; Analysis 2.5; Naji 1999). Days in hospital due to unscheduled readmission We are uncertain whether discharge planning has an effect on days in hospital due to an unscheduled readmission, for patients with a medical condition (Analysis 3.1) or surgical patients (Analysis 3.3). For participants with a mix of medical and surgical conditions, Evans 1993 reported that patients receiving discharge planning spent fewer days in hospital at 9-month follow-up (MD − 2.00; 95% CI − 3.18 to − 0.82), but there was little to no difference for the participants recruited by Hendriksen 1990 and Rich 1993a (Analysis 3.2). Place of discharge Seven trials reported the place of discharge. Discharge planning may not affect the proportion of patients discharged to home rather than to residential care (RR 1.03, 95% CI 0.93 to 1.14; Analysis 4.1; Moher 1992; Sulch 2000, low certainty evidence) or to a nursing home (Hendriksen 1990; Naughton 1994). One other trial reported that there were no differences between treatment and control groups regarding the likelihood of being discharged into an institutional setting (Analysis 4.2; Goldman 2014). One trial reported that all participants allocated to the control group were discharged home and 83% of participants in the treatment group were discharged home (difference 17%; 95% CI 2% to 34%; Analysis 4.2; Lindpaintner 2013). These trials were not included in the pooled analysis as they excluded patients with a high likelihood of being discharged to an institutional setting. Evans 1993 recruited both medical and surgical patients, reporting that a greater proportion of participants allocated to discharge planning went home compared with those receiving no formal discharge planning (difference 6%, 95% CI 0.4% to 12%; Analysis 4.3). For patients admitted to hospital after a fall, it is uncertain if discharge planning had an effect on place of discharge (OR 0.46, 95% CI 0.15 to 1.40; Analysis 4.4). Does discharge planning improve or (at least) have no adverse effect on patient outcome? Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 14 Mortality rate For elderly participants with a medical condition (usually heart failure), and those admitted to hospital following a fall, it is uncertain if discharge planning has an effect on mortality at 4- to 6month follow-up (RR 1.02, 95% CI 0.83 to 1.27; Analysis 5.1.1; Goldman 2014; Lainscak 2013; Laramee 2003; Legrain 2011; Nazareth 2001; Rich 1995a; Sulch 2000) (RR 1.33, 95% CI 0.33 to 5.45; Analysis 5.1.2; Pardessus 2002). Evans 1993 recruited a mix of surgical and medical patients, reporting data for mortality at 9-month follow-up (treatment: 66/ 417 (15.8%), control: 67/418 (16%); difference − 0.2%, 95% CI − 0.04% to 0.5%; Analysis 5.2). Gillespie 2009 recruited participants with a medical condition, reporting the number of participants in the treatment and control groups that died during the 12-month follow-up (treatment: 57/182 (31%), control: 61/186 (33%); difference − 2%, 95% CI − 11% to 8%; Analysis 5.3). Complication rate No trials reported on the effect of discharge planning on the incidence of complications related to the initial admission. Form Health Survey (SF-36); investigators reported improvements at 3-month follow-up for the treatment group for the mental health aspects of social functioning (MD 15.18 (SD 43.67); P = 0.03), vitality (MD 12.59 (SD 36.66); P = 0.004), the physical aspects of bodily pain (MD 16.58 (SD 48.7); P = 0.009), and general health perceptions (MD 12.76 (SD 36.31); P = 0.03); see Analysis 6.2. Pardessus 2002 recruited participants admitted for a fall and reported a reduction of autonomy in daily living activities in the control group measured by the Functional Autonomy Measurement System, whereas the treatment group maintained their baseline function at 6 months and had a small reduction at 12 months (6-month MD − 8.18 (SD 4.94), P < 0.001; 12-month MD − 9.73 (SD 5.43), P < 0.001; see Analysis 6.3). Pardessus 2002 reported the number of falls at 12-month follow-up (RR 0.87, 95% CI 0.50 to 1.49; Pardessus 2002; Analysis 6.4). Naji 1999 recruited participants admitted to a psychiatric unit and reported that at 1-month postdischarge those who received discharge planning had a higher median score on the HADS depression scale (treatment: median: 9.5, IQR: 5.0, 13.3; control: median: 7.0, IQR: 3.0, 11.0, P = 0.016; Analysis 6.5). There was little to no difference between groups for anxiety and behavioural symptoms (Analysis 6.5). Patient health status Thirteen trials measured patient-assessed outcomes, including functional status, mental well-being, perception of health, self-esteem, and affect. Information about the scoring systems for patient-assessed health outcomes are provided in the notes of Analysis 6.1, Analysis 6.2 and Analysis 6.3. We are uncertain whether discharge planning improves patient-assessed health outcomes. Three trials did not publish follow-up data (Kennedy 1987; Naylor 1994; Weinberger 1996), and for five trials there was little to no difference in mean scores between groups (Evans 1993; Harrison 2002; Lainscak 2013; Nazareth 2001; Preen 2005; Analysis 6.1). Rich 1995a recruited participants with heart failure, reporting an improvement on the total score for the Chronic Heart Failure Questionnaire (MD 22.1 (SD 20.8); P = 0.001; a lower score indicates poor quality of life). Sulch 2000 recruited participants recovering from a stroke, reporting an improvement in function between weeks 4 and 12 for those allocated to the control group, and similar scores for the remaining mean point estimates on the Barthel index. Quality of life, as measured by the EuroQol, showed between-group differences at 26 weeks, favouring the control group (72 points for the control group versus 63 points for the treatment group; P < 0.005), but the same point estimates were reported for the Rankin score and the Hospital Anxiety and Depression scale (HADS) (Sulch 2000). Lindpaintner 2013, recruiting participants with a mixed medical background, reported that there were no differences for patient health-related quality of life or care giver burden at 5 or 30 days (no data reported, other than describing no difference). Lin 2009, recruiting participants recovering from a hip fracture, measured patient-reported health status with the 36-item Short Satisfaction of patients, care givers and healthcare professionals Discharge planning may lead to increased satisfaction for patients and healthcare professionals (six trials, low certainty evidence due to inconsistent findings and few studies reporting data for this outcome). Two trials, recruiting participants with a medical condition, reported increased patient satisfaction for those allocated to discharge planning. In one trial follow-up was at 1 and 6 months, with the greatest improvement reported for participants’ perceptions of continuity of care and non-financial access to medical care (no data reported) (Weinberger 1996). In the second trial, participants reported increased satisfaction with hospital care, hospital discharge and home recovery (no data reported; Laramee 2003; Analysis 7.1.1). In two trials evaluating a pharmacy discharge plan, Nazareth 2001 reported patient satisfaction to be the same in both groups (6-month MD 0.20 (SD 1.19), 95% CI − 0.01 to 0.4), and Bolas 2004 reported that the pharmacy discharge letter improved the standard of information exchange at discharge, as assessed by primary care practitioners (PCP) and community pharmacists (57% and 95% agreed, respectively; Analysis 7.1.2). In Lindpaintner 2013, PCPs and visiting nurses providing care to participants in the treatment group reported similar 5-day satisfaction with the discharge process as PCPs and visiting nurses whose patients were in the control group (PCP: treatment: median = 1, interquartile range (IQR) = 1 to 2; control: median = 2, IQR = 1 to 3; nurses: treatment: median = 1, IQR = 1-2; control: 2, IQR = 1 to 4). The same study reported that at 30-day follow-up, care givers for participants in the treatment group were more satisfied Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 15 (treatment: median = 1, IQR = 1 to 2; control: median = 2, IQR = 1 to 3). In Moher 1992, a subgroup of 40 participants admitted to general medical units, mainly for circulatory, respiratory or digestive problems, completed a satisfaction questionnaire, reporting increased satisfaction with discharge planning (difference 27%, P < 0.001, 95% CI 2% to 52%). Does discharge planning reduce overall costs of healthcare? Healthcare costs Hospital care costs and use It is uncertain whether there is any difference in hospital care cost when discharge planning is implemented with patients with a medical condition (very low certainty evidence, five trials). A lower readmission rate for those receiving discharge planning may be associated with lower health service costs in the short term, but findings were inconsistent. In Naylor 1994, recruiting participants with a medical condition, both groups incurred similar costs for their initial hospital stay. A difference was reported for hospital charges, which included readmission costs, at two weeks follow-up (difference − USD 170,247, 95% CI − USD 253,000 to − USD 87,000, 276 participants, savings per participant not reported) and at two to six weeks follow-up (difference − USD 137,508, 95% CI − USD 210,000 to − USD 67,000), with participants receiving discharge planning incurring lower costs (Analysis 8.1). Naughton 1994 reported lower costs for laboratory services for participants receiving discharge planning (MD per participant − GBP 295, 95% CI − GBP 564 to − GBP 26), but not for diagnostic imaging, pharmacy, rehabilitation or total costs (Analysis 8.1). In Jack 2009, the difference between study groups in total cost for the health service (combining actual hospital utilisation cost and estimated outpatient cost) for 738 participants was USD 149,995, an average of USD 412 per person who received the intervention. In Gillespie 2009, hospital costs were reported (difference: − USD 400, 95% CI − USD 4000 to USD 3200; Analysis 8.1). Difference in costs were not reported in studies recruiting participants with surgical conditions (Analysis 8.2), admitted to a psychiatric unit (Analysis 8.3) or to a general medical service (Analysis 8.4). Naughton 1994 reported that the overall health service costs were lower for the treatment group, but with a high level of uncertainty (MD − USD 1949, 95% CI − USD 4204 to USD 306). Jack 2009 reported a difference between study groups in total cost (combining actual hospital utilisation cost and estimated outpatient cost) of USD 149,995 for 738 participants, which translated to an average of USD 412 per person who received the intervention; this represents a 33.9% lower observed cost for the treatment group. The cost savings balanced against the cost of the intervention were reported to be EUR 519 per participant in one trial based in Paris (Legrain 2011), and − USD 460 in a trial based in the US (Rich 1995a) (RR 0.80, 95% CI 0.61 to 1.07). One trial reported the number of hospital outpatient visits (RR 1.07, 95% CI 0.74 to 1.56; Nazareth 2001; Analysis 8.5). Two trials (Farris 2014; Harrison 2002) assessed the effect of discharge planning on the number of days from discharge until the first visit to the emergency department, reporting little to no difference for those receiving discharge planning or usual care (RR 0.80, 95% CI 0.61 to 1.07; Analysis 8.6). Primary and community care costs It is uncertain if discharge planning impacts on primary and community care costs. Weinberger 1996 measured the use of primary care and reported an increase in the use of primary care by those allocated to discharge planning (median time from hospital discharge to first primary care consultation, treatment = seven days, control = 13 days; P < 0.001; mean number of visits to general medical clinic for treatment group was 3.7 days, control group 2.2 days; P < 0.001). Nazareth 2001 reported that the same proportion of participants in both groups consulted with their general practitioner at three months (MD 2.7%, 95% CI − 7.4% to 12.7%) and six months (MD 0.3%, 95% CI − 11.6% to 12.3%). Farris 2014 assessed unscheduled office visits, reporting a difference of 0% (95% CI − 5% to 5%) at 30-days and 4% (95% CI − 2% to 9%) at 90-days. Goldman 2014 reported an MD of 4%, 95% CI − 3.7% to 11.5%, at 30 days. See Analysis 9.1. Medication use Trials evaluating the effectiveness of a pharmacy discharge plan measured different outcomes related to medication, including the mean number of problems (e.g., difficulty obtaining a prescription from the general practitioner) (Analysis 10.1), adherence to medicines (Analysis 10.2), and knowledge about the prescribed medication (Analysis 10.3). Nazareth 2001 reported data related to adherence to medication regimen, knowledge about medicines and hoarding of medicines (Analysis 10.2, Analysis 10.3, Analysis 10.4). In Eggink 2010, data on medication errors were reported following a review of medication by a pharmacist; 68% in the control group had at least one discrepancy or medication error compared to 39% in the treatment group (RR 0.57, 95% CI 0.37 to 0.88; Analysis 10.5). Kripalani 2012 assessed clinically important medication errors, reporting similar results for both groups at 30 days (RR = 0.92, 95% CI 0.77 to 1.10; Analysis 10.5). Farris 2014 compared medication appropriateness at 30 and 90 days (Analysis 10.6). DISCUSSION Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 16 Summary of main results This review assessed the effectiveness of discharge planning in hospital. Thirty randomised controlled trials met the pre-specified criteria for inclusion. We were able to pool the data from trials recruiting older participants with a medical condition and found that discharge planning probably results in a small reduction in hospital length of stay (just under a day; moderate certainty evidence,12 trials) and unscheduled readmission (approximately three fewer readmissions per 100 participants; moderate certainty evidence, 15 trials). It is uncertain whether discharge planning reduces readmission rates for patients admitted to hospital following a fall (very low certainty evidence, two trials). Discharge planning may lead to increased satisfaction for patients and healthcare professionals (low certainty evidence, six trials). It is uncertain whether there is any difference in the cost of care when discharge planning is implemented with patients who have a medical condition (very low certainty evidence, five trials). A lower readmission rate for those receiving discharge planning may be associated with lower health service costs in the short term, but findings were inconsistent. Overall completeness and applicability of evidence A key issue in interpreting the evidence is the definition of the intervention and the subsequent understanding of the relative contribution of each element. While authors of all of the trials provided some description of the intervention, it was not possible to assess how some components of the process compared between trials. For example, Naylor 1994 and Lainscak 2013 formalised the inclusion of the participants’ care givers into the assessment process and the discharge plan. Although some of the other trials mentioned this aspect, the degree to which this was done was not always apparent (Evans 1993; Hendriksen 1990; Kennedy 1987; Laramee 2003; Naughton 1994). The majority of the trials also included a patient education component within the discharge planning process. In one trial, which recruited participants admitted to hospital following a fall, the discharge plan included a pre-discharge home visit that was specific to this group of patients, by an occupational therapist and rehabilitation doctor (Pardessus 2002). In another trial, hospital and community nurses worked together on the discharge plan (Harrison 2002). Two of the trials used an assessment tool to find cases eligible for discharge planning (Evans 1993; Parfrey 1994). The monitoring of discharge planning also differed. For example, in one trial this was done primarily by telephone, while in Weinberger 1996 participants were given appointments to attend a primary care clinic. Seven trials evaluated the effectiveness of a pharmacy discharge plan (Bolas 2004; Eggink 2010; Farris 2014; Gillespie 2009; Kripalani 2012; Nazareth 2001; Shaw 2000). Of those seven trials, four reported data for readmission, with no differences between treatment and control groups (Farris 2014; Gillespie 2009; Nazareth 2001; Shaw 2000). The evidence was mixed for the use of medication: three trials reported improvements with medication use between groups (Bolas 2004; Eggink 2010; Shaw 2000), and three trials did not (Farris 2014; Kripalani 2012; Nazareth 2001). However, the interpretation of these data is limited by the heterogeneity of the outcomes measured. An additional problem, common to other trials, was the difficulty in assessing if contamination between the treatment and control groups occurred. Four trials considered equity, assessing the potentially disadvantageous effect of language and health literacy by performing subgroup analyses of participants whose first language was not English (Balaban 2008; Goldman 2014) and who had low health literacy, respectively (Jack 2009; Kripalani 2012). There was mixed evidence for non-English speakers, and the evidence does not seem to support an increased or decreased effect of discharge planning for patients with low health literacy. The context in which an intervention such as discharge planning is delivered may also play a role, not only in the way the intervention is delivered but in the way services are configured for the control group. Thirteen of the trials included in this review were based in the USA, five in the UK, three in Canada, two in France, one in Australia, one in Sweden, one in Denmark, one in the Netherlands, one in Taipei, one in Slovenia, and one in Switzerland. In each country the orientation of primary care services differs, which may affect communication between services. Different perceptions of care by professionals of alternative care settings and country-specific funding arrangements may also influence timely discharge. The point in a patient’s hospital admission when discharge planning was implemented also varied across studies. Two trials reported discharge planning commencing from the time a patient was admitted to hospital (Parfrey 1994; Sulch 2000), and another stated that discharge planning was implemented three days prior to discharge (Weinberger 1996). The timing of delivery of an intervention such as discharge planning, which depends on organising other services, will have some bearing on how quickly these services can begin providing care. The patient population may also impact on outcome. For example, 99 patients recruited to the trial by Weinberger were experiencing major complications from their chronic disease and this, combined with an intervention also designed to increase the intensity of primary care services, may explain the observed increase in readmission days for those receiving the intervention. Similarly, Goldman postulates that educating patients in the treatment group about medication and side effects might have made them more likely to visit the emergency department (Goldman 2014). Quality of the evidence All studies included in this review were randomised controlled trials, and we considered most of them to have a low risk of bias. There was consistency among trials recruiting patients with a medical condition for the main outcomes of readmission and length of stay, and a moderate level of certainty for these outcomes. A Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 17 small number of studies reported data on cost to the health service and potential cost savings; the findings from these studies are less certain due to different mechanisms for costing and charging (very low certainty evidence, five trials). Similarly few studies assessed patient satisfaction, and of those that did there is some evidence of increased satisfaction in patients experiencing discharge planning. However, this evidence base is small and the effects of discharge planning on patient satisfaction are uncertain (low certainty evidence, six trials). Agreements and disagreements with other studies or reviews Systematic reviews have been published in related areas, for example, Stuck 1993 and Ellis 2011 evaluated geriatric assessment that included discharge planning as part of a broader package of care, and Kwan 2004 looked at integrated care pathways for stroke. This latter review concluded that this type of care may be associated with both positive and negative effects on the organisation of care and clinical outcomes. Parker 2002 included discharge planning interventions that were implemented in a hospital setting, comprehensive geriatric assessment, discharge support arrangements and educational interventions, concluding that interventions providing an educational component had an effect on reducing readmission rates. The interventions evaluated by the majority of trials included in this review had an element of patient education. Leppin 2014 reviewed interventions aimed at reducing early hospital readmissions (< 30 days) for adults discharged home versus any other comparator. Their results indicated that those interventions that were more complex, promoted patient self-care and were conducted less recently were more likely to be effective. The authors speculate that an increased standard of care, along with a shift on the interventions being tested, might explain their finding of more recent interventions being less effective. AUTHORS’ CONCLUSIONS Implications for practice This review indicates that a structured discharge plan tailored to the individual probably brings about a small reduction in hospital length of stay and unscheduled readmission for elderly patients with a medical condition. The impact on health outcomes is uncertain. Even a small reduction in length of stay could free up capacity for subsequent admissions in a system where there is a shortage of acute hospital beds and indicates that discharge planning does not delay discharge from hospital. This is reassuring, as interventions comprised of several components may delay discharge if the components are implemented sequentially. However, increasing capacity by reducing length of stay is likely to increase costs, as acute hospitals will admit more patients who require acute hospital care. It is not clear if costs are reduced or shifted from secondary to primary care or to patients and care givers as a result of discharge planning. Implications for research Surprisingly, some of the stated policy aims of discharge planning, for instance bridging the gap between hospital and home, were not reflected in the trials included in this review. An important element of discharge planning is the effectiveness of communication between hospital and community, yet the trials included in this review did not report on the quality of communication. The expectation is that discharge planning will ensure that patients are discharged from hospital at an appropriate time in their care and, with adequate notice, will facilitate the organisation and provision of other services. A high level of communication between the discharge planner and the service providers outside the hospital setting is clearly important. Future well-conducted studies should continue to collect data on readmissions and hospital length of stay and promote the application of the results by providing details of the intervention and the context in which it was delivered. Investigators should develop safeguards against contamination of the control group, for example by appropriately designing clusterrandomised trials or documenting the adoption of discharge planning by the control group. Conducting research on the impact of a delayed discharge on overall bed utilisation and cost-effectiveness to the health service, and of increasing capacity by a reduction in hospital length of stay would improve the evidence base of interventions, such as discharge planning, that are designed to improve the efficiency of healthcare services (Hawkes 2015). ACKNOWLEDGEMENTS Diana Harwood for assisting in scanning abstracts retrieved from electronic searches for the original review; Andy Oxman for commenting on all versions of this review; Jeremy Grimshaw and Darryl Wieland for helpful comments on earlier drafts and Luciana Ballini, Tomas Pantoja, Craig Ramsey, Darryl Weiland and Kirsten Woodend for comments on the previous update; Nia Roberts for conducting the literature searches; and Julie Parkes, Christopher Phillips, Jacqueline McClaran, Sarah Barras, and Annie McCluskey for contributing to previous versions of this review (Parkes 2000; Shepperd 2010, Shepperd 2013). Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 18 REFERENCES References to studies included in this review Balaban 2008 {published data only} Balaban RB, Weissman JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. 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Effect of clinical pharmacist intervention on medication discrepancies following hospital discharge. International Journal of Clinical Pharmacy 2014;36(2):430–7. ∗ Farris KB, Carter BL, Xu J, Dawson JD, Shelsky C, Weetman DB, et al. Effect of a care transition intervention by pharmacists: an RCT. BMC Health Services Research 2014;14:406. Israel EN, Farley TM, Farris KB, Carter BL. Underutilization of cardiovascular medications: effect of a continuity-ofcare program. American Journal of Health-System Pharmacy 2013;70(18):1592–1600. Gillespie 2009 {published data only} Gillespie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Archives of Internal Medicine 2009;169(9):849–900. Goldman 2014 {published and unpublished data} Goldman. Request of extra data for Support From Hospital to Home for Elders [personal communication]. Email to D Gonçalves-Bradley 10 April 2015. Goldman LE, Sarkar U, Kessell E, Critchfield J, Schneidermann M, Pierluissi E, et al. Support for hospital to home for elders: a randomized control trial of an inpatient discharge intervention among a diverse elderly population. Journal of General Internal Medicine 2013; Vol. 28, issue Supplement 1:S189–S190. ∗ Goldman LE, Sarkar U, Kessell E, Guzman D, Schneidermann M, Pierluissi E, et al. Support from hospital to home for elders: a randomized trial. Annals of Internal Medicine 2014;161(7):472–81. Greysen SR, Hoi-Cheung D, Garcia V, Kessell E, Sarkar U, Goldman L, et al. “Missing pieces”–functional, social, and environmental barriers to recovery for vulnerable older adults transitioning from hospital to home. Journal of the American Geriatrics Society 2014;62(8):1556–61. [DOI: 10.1111/jgs.12928] Harrison 2002 {published data only} Harrison MB, Browne GB, Roberts J, Tugwell P, Gafni A, Graham I. Quality of life of the effectiveness of two models of hospital-to-home transition. Medical Care 2002;40(4): 271–82. Hendriksen 1990 {published data only} Hendriksen C, Stromgard E, Sorensen K. Current cooperation concerning admission to and discharge from geriatric hospitals [Nyt samarbejde om gamle menneskers syehusindlaeggelse og – udskrivelse]. Nordisk Medicin 1990; 105(2):58–60. Hendriksen C, Strømgård E, Sørensen KH. Cooperation concerning admission to and discharge of elderly people from the hospital. 1. The coordinated contributions of home care personnel [Samarbejde om gamle menneskers sygehusindlaeggelse og – udskrivelse. 1. Hjemmesygeplejerskens koordinerende indsats pa sygehuset]. Ugeskrift For Laeger 1989;151(24):1531–4. Jack 2009 {published data only} Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. A reengineered hospital discharge program to decrease rehospitalization. Annals of Internal Medicine 2009;150(3):178–87. Kennedy 1987 {published data only} Kennedy L, Neidlinger S, Scroggins K. Effective comprehensive discharge planning. Gerontologist 1987;27 (5):577–80. Kripalani 2012 {published data only} Bell SP, Schnipper JL, Goggins KM, Bian A, Shintani A, Roumie CL, et al. Effect of a pharmacist counseling intervention on healthcare utilization after hospital discharge: a randomized controlled trial. Journal of General Internal Medicine 2015;30(Supplement 2):S55. ∗ Kripalani S, Roumie CL, Dalal AK, Cawthon C, Businger A, Eden SK, et al. PILL-CVD (Pharmacist Intervention for Low Literacy in Cardiovascular Disease) Study Group. Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. Annals of Internal Medicine 2012;157(1):1–10. Schnipper JL, Roumie CL, Cawthon C, Businger A, Dalal AK, Mugalla I, et al. PILL-CVD Study Group. Rationale and design of the Pharmacist Intervention for Low Literacy Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 19 in Cardiovascular Disease (PILL-CVD) study. Circulation: Cardiovascular Quality and Outcomes 2010;3(2):212–19. Lainscak 2013 {published and unpublished data} Farkas J, Kadivec S, Kosnik M, Lainscak M. Effectiveness of discharge-coordinator intervention in patients with chronic obstructive pulmonary disease: study protocol of a randomized controlled clinical trial. Respiratory Medicine 2011;105(Suppl 1):S26–S30. Lainscak M. Request of extra data for “Discharge Coordinator intervention” [personal communication]. Email sent to D Gonçalves-Bradley 15 April 2015. Lainscak M, Kadivec S, Kosnik M, Benedik B, Bratkovic M, Jakhel T, et al. Discharge coordinator intervention prevents hospitalisations in patients with COPD: a randomized controlled trial. European Respiratory Journal 2012;40(S56): P2895. ∗ Lainscak M, Kadivec S, Kosnik M, Benedik B, Bratkovic M, Jakhel T, et al. Discharge coordinator intervention prevents hospitalizations in patients with COPD: a randomized controlled trial. Journal of the American Medical Directors Association 2013;14(6):450.e1–6. Laramee 2003 {published data only} Laramee AS, Levinsky SK, Sargent J, Ross R, Callas P. Case management in a heterogeneous congestive heart failure population. Archives of Internal Medicine 2003;163:809–17. Legrain 2011 {published data only} Bonnet-Zamponi D, D’Arailh L, Konrat C, Delpierre S, Lieberherr D, Lemaire A, et al. Optimzation of Medication in AGEd study group. Drug-related readmissions to medical units of older adults discharged from acute geriatric units: results of the Optimization of Medication in AGEd multicenter randomized controlled trial. Journal of the American Geriatrics Society 2013;61(1):113–21. Legrain S, Tubach F, Bonnet-Zamponi D, Lemaire A, Aquino J, Paillaud E, et al. A new multimodal geriatric discharge planning intervention to prevent emergency visits and rehospitalizations of older adults: the optimization of medication in AGEd multicentre randomised controlled trial. Journal of the American Geriatric Society 2011;59(11): 2017–28. Lin 2009 {published data only} Lin PC, Wang CH, Chen CS, Liao LP, Kao SF, Wu HF. To evaluate the effectiveness of a discharge planning programme for hip fracture patients. Journal of Clinical Nursing 2009;18(11):1632–9. Lindpaintner 2013 {published data only} Lindpaintner LS, Gasser JT, Schramm MS, Cina-Tschumi B, Müller B, Beer JH. Discharge intervention pilot improves satisfaction for patients and professionals. European Journal of Internal Medicine 2013;24(8):756–62. Moher 1992 {published data only} Moher D, Weinberg A, Hanlon R, Runnalls K. Effects of a medical team coordinator on length of hospital stay. Canadian Medical Association Journal 1992;146(4):511–5. Naji 1999 {published data only} Naji SA, Howie FL, Cameron IM, Walker SA, Andrew J, Eagles JM. Discharging psychiatric in-patients back to primary care: a pragmatic randomized controlled trial of a novel discharge protocol. Primary Care Psychiatry 1999;5 (3):109–15. Naughton 1994 {published data only} Naughton B, Moran M, Feinglass J, Falconer J. Reducing hospital costs for the geriatric patient admitted from the emergency department: a randomised trial. Journal of the American Geriatrics Society 1994;42(10):1045–9. Naylor 1994 {published data only} Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Annals of Internal Medicine 1994;120(12):999–1006. Nazareth 2001 {published data only} Nazareth I, Burton A, Shulman S, Smith P, Haines A, Timberal H. A pharmacy discharge plan for hospitalized elderly patients – a randomized controlled trial. Age and Ageing 2001;30(1):33–40. Pardessus 2002 {published data only} Pardessus V, Puisieux F, Di Pompeo C, Gaudefroy C, Thevenon A, Dewailly P. Benefits of home visits for falls and autonomy in the elderly: a randomized trial study. American Journal of Physical Medicine & Rehabilitation 2002;81(4): 247–52. Parfrey 1994 {published data only} Parfrey PS, Gardner E, Vavasour H, Harnett JD, McManamon C, McDonald J, et al. The feasibility and efficacy of early discharge planning initiated by the admitting department in two acute care hospitals. Clinical and Investigative Medicine 1994;17(2):88–96. Preen 2005 {published data only} Preen DB, Preen DB, Bailey BES, Wright A, Kendall P, Phillips M, et al. Effects of a multidisciplinary, post discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial. International Journal for Quality in Health Care 2005;17(1):43–51. Rich 1993a {published data only} Rich MW, Vinson JM, Sperry JC, Shah AS, Spinner LR, Chung M, et al. Prevention of readmission in elderly patients with congestive heart failure: results of a prospective randomised pilot study. Journal of General Internal Medicine 1993;8(11):585–90. Rich 1995a {published data only} Rich MW, Beckham V, Wittenberg C, Leven C, Freedland KE, Carney RM. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. New England Journal of Medicine 1995;333 (18):1190–5. Shaw 2000 {published data only} Shaw H, Mackie CA, Sharkie I. Evaluation of effect of pharmacy discharge planning on medication problems Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 20 experienced by discharged acute admission mental health patients. International Journal of Pharmacy Practice 2000;8 (2):144–53. Sulch 2000 {published data only} Sulch D, Perez I, Melbourn A, Kalra L. Randomized controlled trial of integrated (managed) care pathway for stroke rehabilitation. Stroke 2000;31(8):1929–34. Weinberger 1996 {published data only} Weinberger M, Oddone EZ, Henderson WG. Does increased access to primary care reduce hospital admissions? Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmissions. New England Journal of Medicine 1996;334(22):1441–7. References to studies excluded from this review Applegate 1990 {published data only} Applegate WB, Miller ST, Graney MJ, Elam JT, Akins DE. A randomized controlled trial of a geriatric assessment unit in a community rehabilitation hospital. New England Journal of Medicine 1990;322(22):1572–8. Brooten 1987 {published data only} Brooten D, Kumar S, Brown LP, Butts P, Finkler SA, Bakewell-Sachs S, et al. A randomized clinical trial of early hospital discharge and home follow-up of very-low-birthweight infants. NLN Publications 1987;21-2194:95–106. Brooten 1994 {published data only} Brooten D, Roncoli M, Finkler S, Arnold L, Cohen A, Mennuti M. A randomized trial of early hospital discharge and home follow-up of women having cesarean birth. Obstetrics and Gynecology 1994;84(5):832–8. Carty 1990 {published data only} Carty EM, Bradley CF. A randomized, controlled evaluation of early postpartum hospital discharge. Birth 1990;17(4): 199–204. Casiro 1993 {published data only} Casiro OG, McKenzie ME, McFadyen L, Shapiro C, Seshia MM, MacDonald N, et al. Earlier discharge with community-based intervention for low birth weight infants: a randomized trial. Pediatrics 1993;92(1):128–34. Choong 2000 {published data only} Choong PFM, Langford AK, Dowsey MM, Santamaria NM. Clinical pathway for fractured neck of femur: a prospective controlled study. Medical Journal of Australia 2000;172(9):423–6. in women and infants after cesarean birth. Journal of Perinatology 1994;14(1):36–40. Dudas 2001 {published data only} Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. American Journal of Medicine 2001;111(9b):26s–30s. Englander 2014 {published data only} Englander H, Michaels L, Chan B, Kansagara D. The care transitions innovation (C-TraIn) for socioeconomically disadvantaged adults: results of a cluster randomized controlled trial. Journal of General Internal Medicine 2014; 29(11):460–7. Epstein 1990 {published data only} Epstein AM, Hall JA, Fretwell M, Feldstein M, DeCiantis ML, Tognetti J, et al. Consultative geriatric assessment for ambulatory patients. A randomized trial in a health maintenance organization. JAMA 1990;263(4):538–44. Fretwell 1990 {published data only} Fretwell MD, Raymond PM, McGarvey ST, Owens N, Traines M, Silliman RA, et al. The Senior Care Study. A controlled trial of a consultative/unit-based geriatric assessment program in acute care. Journal of the American Geriatrics Society 1990;38(10):1073–81. Gayton 1987 {published data only} Gayton D, Wood-Dauphinee S, De Lorimer M, Tousignant P, Hanley J. Trial of a geriatric consultation team in an acute care hospital. Journal of the American Geriatrics Society 1987;35(8):726–36. Germain 1995 {published data only} Germain M, Knoeffel F, Wieland D, Rubenstein LZ. A geriatric assessment and intervention team for hospital inpatients awaiting transfer to a geriatric unit: a randomized trial. Aging (Milan, Italy) 1995;7(1):55–60. Gillette 1991 {published data only} Gillette Y, Hansen NB, Robinson JL, Kirkpatrick K, Grywalski R. Hospital-based case management for medically fragile infants: results of a randomized trial. Patient Education and Counseling 1991;17(1):59–70. González-Guerrero 2014 {published data only} González-Guerreroa JL, Alonso-Fernándeza T, GarcíaMayolín N, Gusi N, Ribera-Casado JM. Effectiveness of a follow-up program for elderly heart failure patients after hospital discharge. A randomized controlled trial. European Geriatric Medicine 2014;5(4):252–7. Haggmark 1997 {published data only} Häggmark C, Nilsson B. Effects of an intervention programme for improved discharge planning. Nordic Journal of Nursing Research 1997;17(2):4–8. Cossette 2015 {published data only} Cossette S, Frasure-Smith N, Vadeboncoeur A, McCusker J, Guertin MC. The impact of an emergency department nursing intervention on continuity of care, self-care capacities and psychological symptoms: secondary outcomes of a randomized controlled trial. International Journal of Nursing Studies 2015;52(3):666–76. [DOI: 10.1016/ j.ijnurstu.2014.12.007] Hansen 1992 {published data only} Hansen FR, Spedtsberg K, Schroll M. Geriatric follow-up by home visits after discharge from hospital: a randomized controlled trial. Age and Ageing 1992;21(6):445–50. Donahue 1994 {published data only} Donahue D, Brooten D, Roncoli M, Arnold L, Knapp H, Borucki L, et al. Acute care visits and rehospitalization Hickey 2000 {published data only} Hickey ML, Cook FE, Rossi LR, Connor J, Dutkiewicz C, McCabe Hassan S, et al. Effect of case managers with a Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 21 general medical patient population. Journal of Evaluation in Clinical Practice 2000;6(1):23–9. Hogan 1990 {published data only} Hogan DB, Fox RA. A prospective controlled trial of a geriatric consultation team in an acute-care hospital. Age and Ageing 1990;19(2):107–13. Jenkins 1996 {published data only} Jenkins HM, Blank V, Miller K, Turner J, Stanwick RS. A randomized single-blind evaluation of a discharge teaching book for pediatric patients with burns. Journal of Burn Care & Rehabilitation 1996;17(1):49–61. Karppi 1995 {published data only} Karppi P, Tilvis R. Effectiveness of a Finnish geriatric inpatient assessment. Two-year follow up of a randomized clinical trial on community-dwelling patients. Scandinavian Journal of Primary Health Care 1995;13(2):93–8. Kleinpell 2004 {published data only} Kleimpell RM. Randomized trial of an intensive care unitbased early discharge planning intervention for critically ill elderly patients. American Journal of Critical Care 2004;13 (4):335–45. Kravitz 1994 {published data only} Kravitz RL, Reuben DB, Davis JW, Mitchell A, Hemmerling K, Kington RS, et al. Geriatric home assessment after hospital discharge. Journal of the American Geriatrics Society 1994;42(12):1229–34. Landefield 1995 {published data only} Landefield CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J. A randomized controlled trial of care in a hospital medical unit especially designed to improve functional outcomes of acutely ill older patients. New England Journal of Medicine 1995;332(20):1338–44. McGrory 1994 {published data only} McGrory A, Assmann S. A study investigating primary nursing, discharge teaching, and patient satisfaction of ambulatory cataract patients. Insight 1994;19(2):8-13, 29. McInnes 1999 {published data only} McInnes E, Mira M, Atkin N, Kennedy P, Cullen J. Can GP input into discharge planning result in better outcomes for the frail aged: results from a randomized controlled trial. Family Practice 1999;16(3):289–93. Melin 1993 {published data only} Melin AL, Hakansson S, Bygren LO. The cost-effectiveness of rehabilitation in the home: a study of Swedish elderly. American Journal of Public Health 1993;83:356–62. Melin 1995a {published data only} Melin AL. A randomized trial of multidisciplinary in-home care for frail elderly patients awaiting hospital discharge. Aging 1995;7(3):247–50. Melin 1995b {published data only} Melin AL, Wieland D, Harker JO, Bygren LO. Health outcomes of a post-hospital in-home team care: secondary analysis of a Swedish trial. Journal of the American Geriatrics Society 1995;43(3):301–7. Murray 1995 {published data only} Murray SK, Garraway WM, Akhtar AJ, Prescott RJ. Communication between home and hospital in the management of acute stroke in the elderly: results from a controlled trial. Health Bulletin 1995;40(5):214–9. Naylor 1999 {published data only} Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized controlled trial. JAMA 1999;281(7):613–20. Linden 2014 {published data only} Linden A, Butterworth S. A comprehensive hospital-based intervention to reduce readmissions for chronically ill patients: a randomized controlled trial. American Journal of Managed Care 2014;20(10):783–92. Naylor 2004 {published data only} Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Sanford Schwartz J. Transitional care of older adults hospitalized with heart failure: a randomised controlled trial. Journal of the American Geriatrics Society 2004;52(5):675–84. Loffler 2014 {published data only} Löffler C, Drewelow E, Paschka SD, Frankenstein M, Eger L, Jatsch L, et al. Optimizing polypharmacy among elderly hospital patients with chronic diseases-study protocol of the cluster randomized controlled POLITE-RCT trial. Implementation Science 2014;9:151. Nickerson 2005 {published data only} Nickerson A, McKinnon NJ, Roberst N, Saulnier L. Drug therapy problems, inconsistencies and omissions identified during a medication reconciliation and seamless care service. Healthcare Quarterly 2005;8(Spec No):65–72. Martin 1994 {published data only} Martin F, Oyewole A, Moloney A. A randomized controlled trial of a high support hospital discharge team for elderly people. Age and Ageing 1994;23(3):228–34. Marusic 2013 {published data only} Marusic S, Gojo-Tomic N, Erdeljic V, Bacic-Vrca V, Franic M, Kirin M, et al. The effect of pharmacotherapeutic counseling on readmissions and emergency department visits. International Journal of Clinical Pharmacy 2013;35 (1):37–44. Nikolaus 1995 {published data only} Nikolaus T, Specht-Leible N, Bach M, WittmannJennewein C, Oster P, Schlierf G. Effectiveness of hospitalbased geriatric evaluation and management and home intervention team (GEM-HIT): rationale and design of a 5-year randomized trial. Zeitschrift für Gerontologie und Geriatrie 1995;28(1):47–53. Reuben 1995 {published data only} Reuben DB, Borok GM, Wolde-Tsadik G, Ershoff DH, Fishman LK, Ambrosini VL, et al. A randomized trial of comprehensive geriatric assessment in the care of Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 22 hospitalized patients. New England Journal of Medicine 1995;332(20):1345–50. Rich 1993b {published data only} Rich MW, Vinson JM, Sperry JC, Shah AS, Spinner LR, Chung MK, et al. Prevention of readmission in elderly patients with congestive heart failure: results of a prospective, randomized pilot study. Journal of General Internal Medicine 1993;8(11):585–90. Rich 1995b {published data only} Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. New England Journal of Medicine 1995;333 (18):1190–5. Rubenstein 1984 {published data only} Rubenstein LZ, Josephson KR, Wieland GD, English PA, Sayre JA, Kane RL. Effectiveness of a geriatric evaluation unit. A randomized clinical trial. New England Journal of Medicine 1984;311(26):1664–70. Saleh 2012 {published data only} Saleh SS, Freire C, Morris-Dickinson G, Shannon T. An effectiveness and cost-benefit analysis of a hospitalbased discharge transition program for elderly Medicare recipients. Journal of the American Geriatrics Society 2012; 60(6):1051–6. Saltz 1988 {published data only} Saltz CC, McVey LJ, Becker PM, Feussner JR, Cohen HJ. Impact of a geriatric consultation team on discharge placement and repeat hospitalization. Gerontologist 1988;28 (3):344–50. Shah 2013 {published data only} Shah M, Norwood CA, Farias S, Ibrahim S, Chong PH, Fogelfeld L. Diabetes transitional care from inpatient to outpatient setting: pharmacist discharge counseling. Journal of Pharmacy Practice 2013;26(2):120–4. Sharif 2014 {published data only} Sharif F, Moshkelgosha F, Molazem Z, Najafi Kalyani M, Vossughi M. The effects of discharge plan on stress, anxiety and depression in patients undergoing percutaneous transluminal coronary angioplasty: a randomized controlled trial. International Journal of Community Based Nursing & Midwifery 2014;2(2):60–8. Thomas 1993 {published data only} Thomas DR, Brahan R, Haywood BP. Inpatient community-based geriatric assessment reduces subsequent mortality. Journal of the American Geriatrics Society 1993;41 (2):101–4. Townsend 1988 {published data only} Townsend J, Piper M, Frank AO, Dyer S, North WR, Meade TW. Reduction in hospital readmission stay of elderly patients by a community based hospital discharge scheme: a randomized controlled trial. BMJ 1988;297 (6647):544–7. Tseng 2012 {published data only} Tseng MY, Shyu YI, Liang J. Functional recovery of older hip-fracture patients after interdisciplinary intervention follows three distinct trajectories. The Gerontologist 2012;52 (6):833–42. Victor 1988 {published data only} Victor CR, Vetter NJ. Rearranging the deckchairs on the Titanic: failure of an augmented home help scheme after discharge to reduce the length of stay in hospital. Archives of Gerontology and Geriatrics 1988;7(1):83–91. Voirol 2004 {published data only} Voirol P, Kayser SR, Chang CY, Chang QL, Youmans SL. Impact of pharmacists’ interventions on the pediatric discharge medication process. Annals of Pharmacotherapy 2004;38(10):1597–602. Winograd 1993 {published data only} Winograd CH, Gerety MB, Lai NA. A negative trial of inpatient geriatric consultation. Lessons learned and recommendations for future research. Archives of Internal Medicine 1993;153(17):2017–23. Yeung 2012 {published data only} Yeung, SM. The effects of a transitional care programme using holistic care interventions for Chinese stroke survivors and their care providers: A randomized controlled trial. The Effects of a Transitional Care Programme Using Holistic Care Interventions for Chinese Stroke Survivors and Their Care Providers: A Randomized Controlled Trial. Hong Kong: Hong Kong Polytechnic University, 2012. References to ongoing studies Shyu 2010 {published data only} Shyu YI, Liang J, Wu CC, Su JY, Cheng HS, Chou SW, et al. Two-year effects of interdisciplinary intervention for hip fracture in older Taiwanese. Journal of the American Geriatrics Society 2010;58(6):1081–9. NCT02112227 {published data only} NCT02112227. Patient-centered Care Transitions in Heart Failure (PACT-HF). clinicaltrials.gov/ct2/show/ NCT02112227 (accessed 2 June 2015). Siu 1996 {published data only} Siu AL, Kravitz RL, Keeler E, Hemmerling K, Kington R, Davis JW, et al. Postdischarge geriatric assessment of hospitalized frail elderly patients. Archives of Internal Medicine 1996;156(1):76–81. NCT02202096 {published data only} NCT02202096. A pilot randomized trial of a comprehensive transitional care program for colorectal cancer patients. clinicaltrials.gov/ct2/show/NCT02202096 (accessed 2 June 2015). Smith 1988 {published data only} Smith DM, Weinberger M, Katz BP, Moore PS. Postdischarge care and readmissions. Medical Care 1988;26 (7):699–708. NCT02295319 {published data only} NCT02295319. The impact of individual-based discharges from acute admission units to home. clinicaltrials.gov/ct2/ show/NCT02295319 (accessed 2 June 2015). Discharge planning from hospital (Review) Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 23 NCT02351648 {published data only} NCT02351648. A randomised control trial of a transitional care model in Singapore General Hospital. clinicaltrials.gov/ ct2/show/NCT02351648 (accessed 2 June 2015). Dept of Health 2010 Department of Health. Ready to Go? Planning the Discharge and the Transfer of Patients from Hospital and Intermediate Care. London: Department of Health, 2010. NCT02388711 {published data only} NCT02388711. A trial of the C-TraC intervention for dementia patients. clinicaltrials.gov/ct2/show/ NCT02388711 (accessed 2 June 2015). Ellis 2011 Ellis G, Whitehead MA, O’Neill D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews 2011, Issue 7. [DOI: 10.1002/ 14651858.CD006211.pub2] NCT02421133 {published data only} NCT02421133. Impact of a transitional care program on 30-day hospital readmissions for elderly patients discharged from a short stay geriatric ward (PROUST). clinicaltrials.gov/ct2/show/NCT02421133 (accessed 2 June 2015). Additional references Aus NZ Soc Geriat Med 2008 Australia and New Zealand Society for Geriatric Medicine. Position statement No. 15: Discharge planning. Australia and New Zealand Society for Geriatric Medicine, 2008. Barker 1985 Barker WH, Williams TF, Zimmer JG, Van Buren C, Vincent SJ, Pickrel SG. Geriatric consultation teams in acute hospitals: impact on back-up of elderly patients. Journal of the American Geriatrics Society 1985;33(6):422–8. Bodenheimer 2005 Bodenheimer T, Fernandez A. High and rising health care costs. Part 4: Can costs be controlled while preserving quality?. Annals of Internal Medicine 2005;143(1):26–31. Burgess 2014 Burgess JF, Hockenberry JM. Can all cause readmission policy improve quality or lower expenditures? A historical perspective on current initiatives. Health Economics, Policy and Law 2014;9(2):193–213. Challis 2014 Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. International Journal of Geriatric Psychiatry 2014; 29(2):160–8. ClinicalTrials.gov 2015 ClinicalTrials.gov. ClinicalTrials.gov. Retrieved from https:/ /clinicaltrials.gov/ (accessed 12/10/15). Cochrane 1954 Cochran WG. The combination of estimates from different experiments. Biometrics 1954;10:101–29. Dept Health Human Services 2013 Department of Health and Human Services. Discharge Planning. Washington D.C.: Department of Health and Human Services, Centers for Medicare and Medicaid Services, 2013. Dept of Health 2003 Department of Health. Discharge from Hospital: Pathway, Process and Practice. A Manual of Discharge Practice for Health and Social Care Commissioners, Managers and Practitioners. London: Department of Health, 2003. EPOC 2015 Effective Practice, Organisation of Care (EPOC). Data extraction and management. EPOC Resources for review authors. Oslo: Norwegian Knowledge Centre for the Health Services; 2013. Available at: http://epoc.cochrane.org/ epoc-specific-resources-review-authors. Future Hospital Comission 2013 Future Hospital Comission. Future hospital: Caring for medical patients. A report from the Future Hospital Comission to the Royal College of Physicians. Royal College of Physicians (ISBN 9781860165184), 2013. GRADEpro GDT 2015 [Computer program] McMaster University (developed by Evidence Prime, Inc.). GRADEpro Guideline Development Tool. Available from www.gradepro.org: McMaster University (developed by Evidence Prime, Inc.), 2015. Guyatt 2008 Guyatt GH, Oxman AD, Vist G, Kunz R, Falck-YtterY, Alonso-Coello P, Schünemann HJ, for the GRADEWorking Group. Rating quality of evidence and strength of recommendations GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-926. Hawkes 2015 Hawkes N. Providing care at home will not save money for N…
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