Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials

By A. Leppin, M. Gionfriddo, Maya E. Kessler, J. Brito, F. Mair, K. Gallacher, Zhen Wang, P. Erwin, Tanya Sylvester, Kasey R. Boehmer and 4 more. JAMA Internal Medicine, 2014

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Importance Reducing early (<30 days) hospital readmissions is a policy priority aimed at improving healthcare quality. The Cumulative Complexity Model conceptualizes patient context. It predicts that highly supportive discharge interventions will enhance patient capacity to enact burdensome self-care and avoid readmissions. Objectives To synthesize the evidence of the efficacy of interventions to reduce early hospital readmissions and identify intervention features—including their impact on treatment burden and on patients’ capacity to enact post-discharge self-care—that might explain their varying effects. Data Sources We searched electronic databases (1990 until April 1st, 2013), contacted experts, and reviewed bibliographies. Study Selection Randomized trials that assessed the effect of interventions on all-cause or unplanned readmissions within 30 days of discharge in adult patients admitted to the hospital for a medical or surgical cause for > 24 hours and discharged to home. Data extraction and Synthesis Reviewer pairs extracted trial characteristics and used an activity-based coding strategy to characterize the interventions; fidelity was confirmed with authors. Blinded to trial outcomes, reviewers noted the extent to which interventions placed additional work on patients after discharge or supported their capacity for self-care in accordance with the Cumulative Complexity Model. Main Outcome Relative risk of all-cause or unplanned readmission with or without out of hospital deaths at 30 days post-discharge. Results In 42 trials, the tested interventions prevented early readmissions [pooled random effects relative risk (RR) 0.82, 95% CI 0.73 to 0.91; p=.03; I2= 32%], a finding that was consistent across patient subgroups. Trials published before 2002 reported interventions that were 1.6 times more effective than those tested later (pinteraction = .01). In exploratory subgroup analyses, interventions with many components (pinteraction <.01), involving more individuals in care delivery (pinteraction = .05), and supporting patient capacity for self-care (pinteraction = .04) were 1.4, 1.3, and 1.3 times more effective than other interventions. A post-hoc regression model showed incremental value in providing comprehensive, post-discharge support to patients and caregivers. Conclusions Tested interventions are effective at reducing readmissions, but more effective interventions are complex and support patient capacity for self-care. Interventions tested more recently are less effective. Registration Number PROSPERO, CRD42013004773

Subfields: Cardiology and Cardiovascular Medicine, Emergency Medicine, Epidemiology

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