Methods
This systematic review followed the standard guidelines of Preferred
Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The
review protocol was registered with the PROSPERO international
prospective register of systematic reviews (registration number:
CRD42016049061)
Eligibility Criteria
Study design : all quantitative studies (randomized controlled
trials, observational or quasi-experimental studies, etc…).
Population : Older adults (aged 65 and over) from all countries,
being discharged from acute care hospital in-patient stays to a LTCF.
For the purpose of the study, LTC will be defined as health services
provided for people with complex health needs/moderate to extensive
functional deficits or chronic conditions, who are unable to remain at
home or in a supportive living environment, and involving nursing care
and personal care.23 Acute care hospital in-patient
stays could be for any health condition (i.e. frailty, geriatric
syndrome, hip fracture, stroke, Alzheimer/dementia, multimorbidity,
chronic disease exacerbation, oncology, infection…), planned or
unplanned.
Interventions : Any TCi, defined as “a set of actions designed to
ensure the coordination and continuity of healthcare as patients
transfer between different locations or different levels of care within
the same location”.24 In this study, TCis were
included if they targeted an acute care hospital in-patient discharge
back to a LTCF. TCis could include care/discharge planning in
conjunction with the patients/caregivers/nursing home personnel,
systematic medication reconciliation by a pharmacist,
telecare/telemedicine/telemonitoring, formal discharge summary,
structured follow-up and coordination among the different healthcare
professionals.
Outcomes : Any quality of care, patient-related and healthcare
services use reported outcomes.
A fully detailed list of inclusion/exclusion criteria is available in
Supplementary Table 1.
Data Sources and Searches
Systematic searches were performed in Medline, CINHAL, EMBASE, Cochrane
Central and Social Work Abstracts combining the concepts of LTC,
hospital, older population and transitional care. We used MeSH terms and
related and free key words (see Supplementary Table 2 for a more
detailed search strategy). Reference lists of included studies were
screened manually and companion papers were searched. Articles published
between January 1st, 1995 (first TCis) and October,
2016 were considered for inclusion.
Study Selection
Based on inclusion criteria, two reviewers (MLB, AS) independently
examined and selected the titles and abstracts obtained from the
database searches. Full texts of the selected references were then
retrieved and independently examined and selected by the same reviewers.
At each step, any disagreement was resolved by consensus and discussion
with a third reviewer (MW or IV).
Data Extraction and Quality
Assessment
Data on study characteristics (authors, publication date, title,
journal, study design), settings and participants (country, mean age,
proportion of female, sample size, percentage going to a LTCF, reason of
hospitalization, description of the intervention, healthcare
professionals involved in the intervention, any coordination measures
with the LTCF) were extracted from each study by two reviewers working
independently (MLB, AS) and reconciled. Outcomes on quality of care
(i.e. medication errors), patient-related (i.e. mortality,
health-related outcomes) and healthcare services use (readmission, ED
visits and total readmission days) were similarly extracted from the
studies for all reported time points.
Study quality was assessed independently by two reviewers (MLB, AS)
using the latest version Mixed Methods Appraisal Tool (MMAT), updated in
2018.25
Data Synthesis and
Analysis
The wide variety of the reported outcomes and the discrepancy of the
various cutoffs used (i.e. “Patients with at least 1 medication
error”, “Patients with at least 3 medication errors” and “Patients
with at least 5 medication errors”) precluded any meta-analysis
pooling. Thus, we conducted a narrative synthesis26 by
organizing the included studies into homogeneous groups according to the
outcome of interest.
We thus reported the results, regrouped by the main key study outcomes
identified: “Quality of care” (medication problems, and advance
directives), “Clinical outcomes” (mortality, mobility and function and
confusion/behavioral symptoms), “Services use” (hospital readmissions
and ED visits and hospital days) and “Satisfaction” with TCi (from
either healthcare professionals or patients/caregivers). We then looked
for patterns within and across groups and compared similarities and
differences.
A sensitivity analysis was performed by exploring the results with and
without the studies with at least one MMAT item with a negative response
in each identified study outcome.25