Transition of care for acute stroke and myocardial infarction patients: from hospitalization to rehabilitation, recovery, and secondary prevention.

Objectives: To review the available published literature to assess whether evidence supports a beneficial role for coordinated transition of care services for the postacute care of patients hospitalized with first or recurrent stroke or myocardial infarction (MI). This review was framed around five areas of investigation: (1) key components of transition of care services, (2) evidence for improvement in functional outcomes, morbidity, mortality, and quality of life, (3) associated risks or potential harms, (4) evidence for improvement in systems of care, and (5) evidence that benefits and harms vary by patient-based or system-based characteristics.

Data sources: MEDLINE(®), CINAHL(®), Cochrane Database of Systematic Reviews, and Embase(®).

Review methods: We included studies published in English from 2000 to 2011 that specified postacute hospitalization transition of care services as well as prevention of recurrent stroke or MI.

Results: A total of 62 articles representing 44 studies were included for data abstraction. Transition of care interventions were grouped into four categories: (1) hospital -initiated support for discharge was the initial stage in the transition of care process, (2) patient and family education interventions were started during hospitalization but were continued at the community level, (3) community-based models of support followed hospital discharge, and (4) chronic disease management models of care assumed the responsibility for long-term care. Early supported discharge after stroke was associated with reduced total hospital length of stay without adverse effects on functional recovery, and specialty care after MI was associated with reduced mortality. Because of several methodological shortcomings, most studies did not consistently demonstrate that any specific intervention resulted in improved patient-or system -based outcomes. Some studies included more than one intervention, which made it difficult to determine the effect of individual components on clinical outcomes. There was inconsistency in the definition of what constituted a component of transition of care compared to "standard care." Standard care was poorly defined, and nearly all studies were underpowered to demonstrate a statistical benefit. The endpoints varied greatly from study to study. Nearly all the studies were single-site based, and most (26 of 44) were conducted in countries with national health care systems quite different from that of the U.S., therefore limiting their generalizability.

Conclusions: Although a basis for the definition of transition of care exists, more consensus is needed on the definition of the interventions and the outcomes appropriate to those interventions. There was limited evidence that two components of hospital-initiated support for discharge (early supported discharge after stroke and specialty care followup after MI)were associated with beneficial effects. No other interventions had sufficient evidence of benefit based on the findings of this systematic review. The adoption of a standard set of definitions, a refinement in the methodology used to study transition of care, and appropriate selection of patient-centered and policy-relevant outcomes should be employed to draw valid conclusions pertaining to specific components of transition of care.