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Table 5 Conclusions in included reviews

From: Interventions aimed at reducing problems in adult patients discharged from hospital to home: a systematic meta-review

Review Conclusions
Cameron 2002 The available trials had different aims, interventions and outcomes. Combined outcome measures (e.g. death or institutional care) tended to be better for patients receiving coordinated inpatient rehabilitation, but the results were heterogeneous and not statistically significant.
Cole 2001 There is little evidence that geriatric post-discharge services have an impact on the mental state of aged subjects.
Day 2004 This review generally supports the efficacy of specialist geriatric team services trained in geriatrics with a multidisciplinary collaborative focus undertaking assessment, rehabilitation and coordinated case management in community settings; both preventive care and supportive discharge in these settings appear to provide greater benefit over usual care; however these benefits are not consistent across all outcomes and although improvement in outcomes was often apparent, these were not always significant when compared with the comparison group. Efficacy of specialist geriatric services for inpatient settings was more diverse; this was due to the diversity of studies across the continuum of subacute, acute, postacute care in unit or ward settings with resulting heterogeneous outcomes and only some of these outcomes showing significance over usual care. With regard to day hospital and outpatient care, evidence for the efficacy of specialist geriatric services was lacking, with no conclusive evidence that the services are of greater benefit than usual care.
Gwadry 2004 This review suggests that specific heart failure targeted interventions significantly decrease hospital readmissions but do not affect mortality rates.
Handoll 2004 There is insufficient evidence from randomised trials to determine the effectiveness of the various mobilisation strategies that start either in the early post-operative period or during the later rehabilitation period
Hyde 2000 We believe that the results of this review provide reassurance that supporting discharge from hospital to home is of value. However, important sources of uncertainty remain, suggesting the need for further research. There was relative certainty that the proportion of those at home 6–12 months after admission is greater with supported discharge; this was associated with a consistent pattern of reduction in admission to long-stay care over the same period, without apparent increases in mortality. There was uncertainty about the effect of supported discharge on hospitalization. There were no rigorous data on functional status, patient and carer satisfaction and in consequence uncertainty about the overall effectiveness of supported discharge.
Kwan 2002 Use of stroke care pathways may be associated with positive and negative effects. Since most of the results have been derived from non-randomised studies, they are likely to be influenced by potential biases and confounding factors. There is currently insufficient supporting evidence to justify the routine implementation of care pathways for acute stroke management or stroke rehabilitation.
OST 2003 Therapy-based rehabilitation services targeted towards stroke patients living at home reduces the odds of a poor outcome and has a beneficial effect on a patient's ability to perform activities of daily living. However, the evidence is derived from a review of heterogeneous interventions and therefore further exploration of the interventions is justifiable.
Parker G 2000 Despite considerable recent development of different forms of care for older patients, evidence about effectiveness and costs is weak. However, evidence is also weak for longer-standing care models.
Parker S 2002 The evidence from these trials does not suggest that discharge arrangements have effects on mortality or length of hospital stay. This review supports the concept that arrangements for discharging older people from hospital can have beneficial effects on subsequent readmission rates. Interventions provided across the hospital-community interface, both in hospital and in the patient's home, showed the largest effects. Evidence from RCT's is not available to support the general adoption of discharge planning protocols, geriatric assessment processes or discharge support schemes as means of improving discharge outcomes.
Phillips 2004 Comprehensive discharge planning plus postdischarge support for older people with chronic heart failure significantly reduced readmission rates and may improve health outcomes such as survival and quality of life without increasing costs.
Richards 2003 The interventions provided and patient groups targeted by these services were heterogeneous. There was, however, some evidence that services combining needs assessment, discharge planning and a method for facilitating the implementation of these plans were more effective than services that do not include the latter action. The assessment of need may be insufficient in itself for the adequate provision of post-discharge care; needs assessment should be combined with a service that facilitates the implementation of care plans.
Shepperd 2001 This review does not support the development of hospital at home services as a cheaper alternative to in-patient care. Early discharge schemes for patients recovering from elective surgery and elderly patients with a medical condition may have a place in reducing the pressure on acute hospital beds, providing the views of the carers are taken into account. The evidence supporting hospital at home for patients recovering from stroke is conflicting. There is some evidence that admission avoidance schemes may provide a less costly alternative to hospital care.
Shepperd 2004 The impact of discharge planning on readmission rates, hospital length of stay, health outcomes and cost is uncertain.
Teasell 2003 Although the majority of studies reported no statistically significant differences in functional outcomes between the two groups, there was a reduction in hospital stays for patients receiving home-based therapy. These results suggest that patients with milder strokes who receive home-based therapies have similar functional outcomes to patients who receive traditional inpatient rehabilitation. There is strong evidence that high-level stroke patients discharged from an acute hospital unit can be rehabilitated in the community by an interdisciplinary stroke rehabilitation team without negative consequences. These patients attain similar functional outcomes compared to patients with equivalent stroke severity who receive inpatient rehabilitation. Community based programs also appear to reduce hospital length of stay, although we do not have evidence of an overall cost reduction. Although the effectiveness of early supported discharge programs for patients with moderate-to-severe deficits has not been well studied, limited evidence suggests that these patients are unsuitable candidates and should receive inpatient rehabilitation instead.