Author
PREYDE Michele; MACAULAY Cheryl; DINGWALL Tracey;
Discharge planning from hospital to home for elderly patients: a meta-analysis.
Journal citation/publication details
Journal of Evidence-Based Social Work, 6(2), 2009, pp198-216.
Summary
Twenty five studies, including 21 randomised controlled trials, on augmented discharge planning were included in this systematic review and meta-analysis. Overall the results were mixed with no clear indication of an intervention effect on hospital outcomes, patient outcomes or functional status. Effect size was computed for statistically significant results and found to be large for patient satisfaction and moderate for quality of life and readmission rates. Only one of the studies examined discharge planning involving social workers, pointing to a need for further research.
Context
An aging population, the effect of social problems on hospital readmission rates, and psychopathology in elderly patients all indicate a need for quality discharge planning by skilled personnel such as social workers. Previous reviews have not identified primary studies published in social work journals. The aim of this systematic review was to extend the scope of previous reviews in the field by examining studies without exclusion on the basis of the type of discharge plan or the healthcare system in the study country.
Methods
What sources were searched?
Medline, CINAHL, PsycINFO, Social Sciences Citation Index, Social Services Abstracts, Abstracts in Social Gerontology, and PubMed were searched for studies published between 1995 and 2005.
What search terms/strategies were used?
The following terms were used for keyword and title searching: discharge* plan*, discharge, elderly, effectiveness, evaluation, and patient discharge*. Specific search strategies are not included.
What criteria were used to decide on which studies to include?
The following inclusion criteria were employed: discharge planning, including studies covering hospital and home; randomised controlled, or quasi-experimental, trial; elderly population aged 65+, or where the mean age of the sample was 65+; and an outcome measure of one or more of hospital length of stay, readmission rate, costs, quality of life, patient well-being, or patient satisfaction.
Who decided on their relevance and quality?
Two named authors independently reviewed studies for inclusion; disagreements were resolved by consensus. Quality assessment was carried out using a modified version of the five point rating scale developed by Jadad et al. (Table 1).
How many studies were included and where were they from?
Of the 3,327 initially identified 3,254 were excluded on reviewing the titles and abstracts. The remaining 73 papers were assessed against the inclusion criteria and a further 35 were excluded. Further analysis led to another 13 exclusions; the final number of studies included in the review was 25. There is no indication as to where the studies were carried out.
How were the study findings combined?
Data was extracted onto standardised forms. Effects sizes (Cohen's d) were calculated where the results were statistically significant and clinically meaningful differences were reported, and where data was available from the researchers.
Findings of the review
All but four of the studies were randomised controlled trials. The period of follow-up ranged from seven days to two years, with most between three to six months. There is no indication of sample sizes. Only two studies achieved the highest quality assessment rating of 5; the mean score was 3.12 (SD 0.92, range 2-5).
Ten studies focused on elderly patients with specific high risks (e.g. congestive heart failure, orthopaedic problems) where the study intervention was designed to specifically target the risks. In over half (13/25) of the studies the intervention included a follow-up telephone call or home visit. Most of the studies (21/25) were involved patient-centred, comprehensive discharge planning. The focus of the other four studies was: pharmacological management; to nurture a friendly environment; hospital care at home; and the involvement of the patient's family doctor in discharge planning. Only one study involved intervention co-ordinated by social work.
Hospital outcomes
Of the nineteen trials which assessed length of stay (LOS) nine found no significant differences between the intervention and control groups, eight reported significantly shortened overall LOS and two found longer LOS. Most studies reported data on hospital readmissions and the majority reported no significant effects. Of the studies reporting on hospital based costs five found intervention group savings, three found no differences in costs and two studies which measured readmission costs reported significant savings in intervention groups. The findings on community-based costs, measured in three trials, were inconclusive.
Patient outcomes
Most of the studies that measured mortality found no significant difference between intervention and control groups. Mixed results were obtained from the studies which measured Quality of Life and Well-being; five of the 11 trials measuring QoL reported no significant difference between intervention and control groups.
Functional status
No effect on function (most commonly assessed using an Activities of Daily Living scale) was found in most of the studies in which this outcome was measured.
Patient satisfaction
Five of the seven studies measuring patient satisfaction found that intervention groups were significantly more satisfied with the care received than control groups.
Augmented discharge planning had a large effect on patient satisfaction (mean ES 0.83), a moderate effect on QoL (ES 0.45) and readmission (ES 0.45) and a small effect on function (ES 0.31) and length of stay (ES 0.26). There was no statistically significant relationship between effect size and type of intervention, quality assessment rating and type of intervention, or effect size and quality assessment rating.
Authors' conclusions
'Augmented discharge planning appears to have a robust effect on patient satisfaction and moderate effects on quality of life and hospital resources'. Inadequate reporting of methods and outcome data was a limitation of many of the studies. The lack of evidence for social work coordinated discharge planning highlights the need for primary research in this field.
Implications for policy or practice
'None are discussed.