Table 1
Inclusion criteria for eligible systematic reviews (SRs) and randomized controlled trials (RCTs).
| INCLUSION CRITERIA | ELIGIBLE SRS | ELIGIBLE RCTS |
|---|---|---|
| Participants |
| |
| Interventions | Any pre-emptive peri-discharge complex interventions for reducing readmissions. | |
| Comparisons | Any types of control as comparisons, including usual care. | |
| Outcomes | Eligible SRs should report readmission outcomes in both intervention and control groups. | Eligible RCTs should report 30-day all-cause or 30-day COPD-related readmissions in both intervention and control groups |
Figure 1
Flowchart of literature search and selection for systematic reviews and randomized controlled trials.
Keys: SRs: systematic reviews; RCTs: randomized controlled trials.
Table 2
Main characteristics of included randomized controlled trials (RCTs) (n = 11).
| FIRST AUTHOR, YEAR OF PUBLICATION | COUNTRY | FOLLOW-UP PERIOD OF THE STUDY | INTERVENTIONS/COMPARATORS | NO. OF PATIENTS IN THE GROUP (A/R) | AGE RANGE/MEAN ± SD (YEARS) | GENDER N (% MALE) | PRIMARY OUTCOME: 30-DAY ALL-CAUSE READMISSIONS: NO. OF EVENTS (%) | SECONDARY OUTCOME: 30-DAY COPD-RELATED READMISSIONS: NO. OF EVENTS (%) | SECONDARY OUTCOME: 30-DAY MORTALITY: NO. OF EVENTS (%) | SECONDARY OUTCOME: 3-MONTH ALL-CAUSE READMISSIONS: NO. OF EVENTS (%) | SECONDARY OUTCOME: 6-MONTH ALL-CAUSE READMISSIONS: NO. OF EVENTS (%) |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Benzo 2016 | USA | Sept 2010–Aug 2014 | Discharge rehabilitation | 108/108 | 67.9 ± 9.8 | 46(42.6) | 5(4.6) | 2(1.9) | NR | 15(13.9) | 28(25.9) |
| Usual care | 107/107 | 68.1 ± 9.2 | 51(47.7) | 12(11.2) | 10(9.4) | NR | 27(25.2) | 40(37.4) | |||
| Cotton 2000 | UK | NR | Early discharge intervention | 41/41 | 65.7 ± 1.6 | 19(46.3) | 6(14.6) | NR | NR | NR | NR |
| Usual care | 40/49 | 68.0 ± 1.2 | 16(32.7) | 6(12.2) | NR | NR | NR | NR | |||
| Eaton 2009 | New Zealand | Jun 2005–Oct 2006 | Discharge rehabilitation | 47/47 | 70.1 ± 10.3 | 21(44.7) | NR | 3(6.4) | NR | 11(23.4) | NR |
| Discharge education | 50/50 | 69.7 ± 9.4 | 21(42.0) | NR | 4(8.0) | NR | 16(32.0) | NR | |||
| Hornikx 2015 | Belgium | Apr 2013–Apr 2014 | Home based telemedicine | 12/15 | 66 ± 7 | 8 (53.3) | 4(26.7) | NR | NR | NR | NR |
| Rehabilitation education | 15/15 | 68 ± 6 | 9 (60.0) | 6(40.0) | NR | NR | NR | NR | |||
| Jabkobsen 2015 | Denmark | Jun 2010– Dec 2011 | Home based telemedicine | 29/29 | NR | 11 (37.9) | 8(27.6) | NR | NR | 10(34.5) | 13(44.8) |
| Usual care | 28/28 | NR | 11 (39.3) | 6(21.4) | NR | NR | 11(39.3) | 14(50.0) | |||
| Jennings 2014 | USA | Feb 2010–Apr 2013 | Discharge coordinator intervention | 93/93 | 64.9 ± 10.9 | 40(43.4) | 18(19.4) | NR | NR | NR | NR |
| Discharge education | 79/79 | 64.4 ± 10.5 | 37(46.8) | 18(22.8) | NR | NR | NR | NR | |||
| Johnson 2016 | UK | Jan 2013–Sep 2014 | Supported self-management program | 35/39 | 67.6 ± 8.5 | 15(38.5) | NR | 5(12.8) | NR | 12(30.8) | NR |
| Follow up appointment | 36/39 | 68.3 ± 7.7 | 13(33.3) | NR | 10(25.6) | NR | 13(33.3) | NR | |||
| Kwok 2004 | Hong Kong | Mar 1999– Aug 2000 | Supported self-management program | 70/77 | 75.3 ± 7.0 | 56(72.7) | 33(42.9) | NR | NR | NR | 53(68.8) |
| Follow up appointment | 79/80 | 74.2 ± 5.7 | 55(68.8) | 29(36.3) | NR | NR | NR | 49(61.3) | |||
| Lainscak 2013 | Slovenia | Nov 2009–Dec 2011 | Discharge coordinator intervention | 118/118 | 71 ± 9 | 81(68.6) | 7(5.9) | 3(2.5) | 1(0.8) | 25(21.2） | 37(31.4) |
| Rehabilitation education | 135/135 | 71 ± 9 | 101(74.8) | 8(5.9) | 8(5.9) | 6(4.4) | 39(28.9) | 60(44.4) | |||
| Lavesen 2016 | Denmark | Dec 2010–May 2012 | Early discharge intervention | 101/119 | 69.7 ± 10.3 | 46 (38.7) | 25(21) | NR | 2(1.7) | NR | NR |
| Usual care | 77/94 | 70.9 ± 9.8 | 37 (39.4) | 22(23.4) | NR | 3(3.2) | NR | NR | |||
| Wong 2005 | Hong Kong | NR | Supported self-management program | 30/30 | 72.8 ± 8.3 | 27(90.0) | 5(16.7) | NR | NR | NR | NR |
| Usual care | 30/30 | 74.4 ± 7.4 | 20(66.7) | 8(26.7) | NR | NR | NR | NR |
[i] Notes: A: number of patients analysed; R: number of patients randomized; SD: standard deviation; NR: not reported. COPD: Chronic Obstructive Pulmonary Disease.
Usual care is defined as routine care provided by the hospital.
Table 3
Components of peri-discharge complex interventions evaluated in included randomized controlled trials (RCTs).
| PERI-DISCHARGE COMPLEX INTERVENTIONS | RCTS | COMMON COMPONENTS | CA | CM | DP | FS | PC | PE | PI | RI | SM | TE | TM |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Discharge coordinator intervention | Jennings 2014 | CA+PE+PI+TE | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 0 | 1 | 0 |
| Lainscak 2013 | CA+PE+PI+TE | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 0 | 1 | 0 | |
| Discharge educationa | Eaton 2009 | PE+SM | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | 0 | 0 |
| Jennings 2014 | PE+SM | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | |
| Discharge rehabilitation | Benzo 2016 | DP+PC+RI+SM | 0 | 0 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 0 | 0 |
| Eaton 2009 | DP+PC+RI+SM | 0 | 0 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 0 | 0 | |
| Early discharge intervention | Cotton 2000 | CM+DP+TE | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 |
| Lavesen 2016 | CM+DP+TE | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | |
| Follow up appointmentb | Johnson 2016 | FS+PC | 0 | 0 | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 |
| Kwok 2004 | FS+PC | 0 | 0 | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | |
| Home based telemedicine | Hornikx 2015 | SM+TM | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 1 |
| Jabkobsen 2015 | SM+TM | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 1 | |
| Rehabilitation educationc | Hornikx 2015 | PE+RI | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 1 | 0 | 0 | 0 |
| Lainscak 2013 | PE+RI | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 1 | 0 | 0 | 0 | |
| Supported self-management program | Johnson 2016 | PE+PI+SM+TE | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 0 |
| Kwok 2004 | PE+PI+SM+TE | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 0 | |
| Wong 2005 | PE+PI+SM+TE | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 0 |
[i] Notes: CA: Case Management; CM: Timely Primary Care Provider Communication; DP: Discharge planning; FS: Follow-Up Scheduled; PC: Provider Continuity; PE: Patient Education; PI: Patient Centred Discharge Instructions; RI: Rehab Intervention; SM: Self-Management; TE: Telephone follow up; TM: Telemonitoring.
*: Value of “0” means that the component (column) was not presented in the complex intervention package.
†: Value of “1” means that the component (column) was presented in the complex intervention package.
a: Discharge education is the control intervention of Eaton 2009 and Jennings 2014.
b: Follow up appointment is the control intervention of Johnson 2016 and Kwok 2004.
c: Rehabilitation education is the control intervention of Hornikx 2015 and Lainscak 2013.
Definition for each component could be found in Appendix 3.
Table 4
Effect estimates and quality of evidence ratings for comparisons of pier-discharge complex interventions in pairwise meta-analyses sensitivity, and subgroup analysis.
| OUTCOMES | STUDY DESIGN/PARTICIPANTS | RISK OF BIAS | INCONSISTENCY | INDIRECTNESS | IMPRECISION | PUBLICATION BIAS | POOLED RR (95% CI) | QUALITY |
|---|---|---|---|---|---|---|---|---|
| 30-day all-cause readmissions | Nine RCTs/1247 participants | No seriousa | No serious inconsistency | No serious indirectness | No serious imprecision | N/A | 0.95(0.76,1.19) | ⨁⨁⨁⨁ High |
| 30-day COPD-related readmissions | Four RCTs/643 participants | No serious | No serious inconsistency | No serious indirectness | No serious | N/A | 0.45(0.24,0.84) | ⨁⨁⨁⨁ High |
| 30-day mortality | Two RCTs/466 participants | No serious | No serious inconsistency | No serious indirectness | Serious imprecisionb | N/A | 0.35(0.09,1.34) | ⨁⨁⨁◯ Moderate |
| 3-month all-cause readmissions | Five RCTs/700 participants | No serious | No serious inconsistency | No serious indirectness | No serious | N/A | 0.74(0.57,0.95) | ⨁⨁⨁⨁ High |
| 6-month all-cause readmissions | Four RCTs/682 participants | No serious | Serious inconsistencyc | No serious indirectness | No serious | N/A | 0.85(0.64,1.14) | ⨁⨁⨁◯ Moderate |
| 30-day all-cause readmissions (Sensitivity analysis focusing on RCTs with low risk of bias) | Three RCTs/444 participants | No serious | No serious inconsistency | No serious indirectness | Serious imprecisionb | N/A | 0.80(0.47,1.38) | ⨁⨁⨁◯ Moderate |
| 30-day all-cause readmissions (in subgroup 1: rehabilitation education as control interventions) | Two RCTs/283 participants | No serious | No serious inconsistencyd | No serious indirectness | Very serious imprecisione | N/A | 0.83(0.40,1.69) | ⨁⨁◯◯ Low |
| 30-day all-cause readmissions (in subgroup 2: usual care as control interventions) | Five RCTs/918 participants | No seriousa | No serious inconsistencyd | No serious indirectness | No serious | N/A | 0.85(0.60,1.21) | ⨁⨁⨁⨁ High |
[i] GRADE Working Group grades of evidence.
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
Abbreviations: CI, confidence interval; NA: Not applicable; COPD: chronic obstructive pulmonary disease; RCT: Randomized control trial; RR: risk ratio.
a: Most information is from studies at low risk of bias or some concerns. Plausible bias is unlikely to seriously alter the results.
b: The quality of evidence is downgraded one level for serious imprecision because the 95% CI overlaps the RR of 1.0 but includes important benefit or important harm (RR estimates below 0.5 and above 2.0 are considered clinically important).
c: The quality of evidence is downgraded one level for serious inconsistency. Statistical test from pairwise meta-analysis suggests substantial heterogeneity with an I2 value of 63%.
d: The quality of evidence for subgroup analysis is not downgraded for inconsistency as there is little variability in results between studies and no suggestion of a subgroup effect.
e: The quality of evidence is downgraded two level for very serious imprecision because the 95% CI overlaps the RR of 1.0, but includes important benefit or important harm (RR estimates below 0.5 and above 2.0 are considered clinically important); and the small sample size (less than 200 per group) that may not sufficient to ensure prognostic balance.
N/A: Not applicable for publication bias because of less than 10 individual studies.
Figure 2
Network plot of comparisons among 8 different peri-discharge complex interventions and usual care in the network meta-analysis for reducing 30-day all-cause readmissions among COPD patients.
Notes: Peri-discharge complex interventions and usual care are described in Table 1 and 2. Nodes represent theinterventions, node sizes correspond to the number of studies involved, lines connecting nodes represent direct comparisons between pairs of interventions. Width of the lines represents the proportion of the number of trials for each comparison as compared to total number of trials. Line colour indicates different overall risk of bias levels, with red referring to high risk of bias, green referring to low risk of bias, and black referring to some concerns.