Shepperd S, Parkes J, McClaran J, Phillips Chospitalmedicine.ucsf.edu/improve/literature/discharge_committee...Discharge planning from hospital to home (Review) Shepperd S, Parkes

Discharge planning from hospital to home (Review)

Shepperd S, Parkes J, McClaran J, Phillips C

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library

2008, Issue 3

http://www.thecochranelibrary.com

1Discharge planning from hospital to home (Review)

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . .

3SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . .

4METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . .

8ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11Characteristics of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15Characteristics of excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17Comparison 01. Hospital length of stay . . . . . . . . . . . . . . . . . . . . . . . . . . .

17Comparison 02. Effect of discharge planning on unscheduled readmission rates . . . . . . . . . . . . .

17Comparison 03. Effect of discharge planning on days in hospital due to unscheduled readmission . . . . . . .

17Comparison 04. Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18Comparison 05. Effect of discharge planning on patient health outcomes . . . . . . . . . . . . . . .

18Comparison 06. Effect of discharge planning on health care costs . . . . . . . . . . . . . . . . . .

18Comparison 07. Effect of discharge planning on use of primary care services . . . . . . . . . . . . . .

18Comparison 08. Effect of discharge planning on patients’ place of discharge . . . . . . . . . . . . . .

18Comparison 09. Outpatient attendance . . . . . . . . . . . . . . . . . . . . . . . . . . .

19Comparison 10. Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21Analysis 01.01. Comparison 01 Hospital length of stay, Outcome 01 hospital length of stay elderly medical patients .

21Analysis 01.02. Comparison 01 Hospital length of stay, Outcome 02 hospital length of stay - elderly medical and surgical

patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22Analysis 01.03. Comparison 01 Hospital length of stay, Outcome 03 hospital length of stay - elderly surgical patients

22Analysis 02.01. Comparison 02 Effect of discharge planning on unscheduled readmission rates, Outcome 01 Patients

with a medical condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


who have had surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


with medical or surgical condition . . . . . . . . . . . . . . . . . . . . . . . . . . .

24Analysis 02.04. Comparison 02 Effect of discharge planning on unscheduled readmission rates, Outcome 04 unscheduled

readmission within 3 months of discharge from hospital . . . . . . . . . . . . . . . . . . .

24Analysis 03.01. Comparison 03 Effect of discharge planning on days in hospital due to unscheduled readmission,

Outcome 01 Patients with a medical or surgical condition . . . . . . . . . . . . . . . . . .


Outcome 02 Patients with a medical condition . . . . . . . . . . . . . . . . . . . . . .

iDischarge planning from hospital to home (Review)



Outcome 03 Patients with a surgical condition . . . . . . . . . . . . . . . . . . . . . .

25Analysis 04.01. Comparison 04 Mortality, Outcome 01 Mortality at 6 to 9 months . . . . . . . . . . . .

25Analysis 04.04. Comparison 04 Mortality, Outcome 04 Mortality for trials recruiting both patients with a medical

condition and those recovering from surgery . . . . . . . . . . . . . . . . . . . . . . .

26Analysis 05.01. Comparison 05 Effect of discharge planning on patient health outcomes, Outcome 01 Patients with a

medical condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


surgical condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


medical or surgical condition . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30Analysis 05.04. Comparison 05 Effect of discharge planning on patient health outcomes, Outcome 04 Effect of discharge

planning on patients’ and carers’ satisfaction . . . . . . . . . . . . . . . . . . . . . . .

31Analysis 06.01. Comparison 06 Effect of discharge planning on health care costs, Outcome 01 Patients with a medical

condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

31Analysis 06.02. Comparison 06 Effect of discharge planning on health care costs, Outcome 02 Patients with a surgical

condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

32Analysis 07.01. Comparison 07 Effect of discharge planning on use of primary care services, Outcome 01 Patients with a


32Analysis 08.01. Comparison 08 Effect of discharge planning on patients’ place of discharge, Outcome 01 Patients with a


33Analysis 08.02. Comparison 08 Effect of discharge planning on patients’ place of discharge, Outcome 02 Patients with a

medical or surgical condition . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33Analysis 08.03. Comparison 08 Effect of discharge planning on patients’ place of discharge, Outcome 03 Patients

discharged from hospital to home . . . . . . . . . . . . . . . . . . . . . . . . . . .

34Analysis 09.01. Comparison 09 Outpatient attendance, Outcome 01 Elderly medical patients at 6 months . . . .

34Analysis 10.01. Comparison 10 Medication, Outcome 01 Medication problems after being discharged from hospital

34Analysis 10.02. Comparison 10 Medication, Outcome 02 Adherence to medicines . . . . . . . . . . . .

34Analysis 10.03. Comparison 10 Medication, Outcome 03 Knowledge about medicines . . . . . . . . . . .

35Analysis 10.04. Comparison 10 Medication, Outcome 04 Hoarding of medicines . . . . . . . . . . . .

iiDischarge planning from hospital to home (Review)


Discharge planning from hospital to home (Review)

Shepperd S, Parkes J, McClaran J, Phillips C

This record should be cited as:

Shepperd S, Parkes J, McClaran J, Phillips C. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews

2004, Issue 1. Art. No.: CD000313. DOI: 10.1002/14651858.CD000313.pub2.

This version first published online: 26 January 2004 in Issue 1, 2004.

Date of most recent substantive amendment: 25 September 2003

A B S T R A C T

Background

Discharge planning is a routine feature of health systems in many countries. The aim is to reduce hospital length of stay and unplanned

readmission to hospital, and improve the co ordination of services following discharge from hospital thereby bridging the gap between

hospital and place of discharge. Sometimes discharge planning is offered as part of an integrated package of care, which may cover both

the hospital and community. The focus of this review is discharge planning that occurs while a patient is in hospital; we exclude studies

that evaluate dischage planning with follow up care.

Objectives

To determine the effectiveness of planning the discharge of patients moving from hospital.

Search strategy

Relevant studies were identified using Medline, Embase, SIGLE database for grey literature, Bioethics database, Health Plan, Psych.

Lit, Sociofile, CINAHL, Cochrane Library, Econ Lit, Social Science Citation Index, EPOC register. The review was updated using the

EPOC trials register in August 2002.

Selection criteria

Study design: randomised controlled trials (RCTs) that compare discharge planning (the development of an individualised discharge

plan) with routine discharge care. Participants: all patients in hospital. Intervention: the development of an individualised discharge

plan.

Data collection and analysis

Data analysis and quality assessment was undertaken independently by two reviewers using a data checklist. Studies are grouped

according to patient group (elderly medical patients, surgical patients, and those with a mix of conditions), and by outcome.

Main results

Three new studies were included in this update. In total we included eleven RCTS: 6 trials recruited patients with a medical condition

(2,368 patients), and four recruited patients with a mix of medical and surgical conditions (2,983 patients), one of these four recruited

medical and surgical patients as separate groups, and the final trial recruited 97 patients in a psychiatric hospital and from a general

hospital. We failed to detect a difference between groups in mortality for elderly patients with a medical condition (OR 1.44 95% CI

0.82 to 2.51), hospital length of stay (weighted mean difference -0.86, 95% CI -1.9 to 0.18), readmission rates (OR 0.91 95% CI

0.67 to 1.23) and being discharged from hospital to home (OR 1.15 95% CI 0.72 to 1.82). This was also the case for trials recruiting

patients recovering from surgery and those recruiting patients with a mix of medical and surgical conditions. One trial comparing a

structured care pathway for patients recovering from a stroke with multidisciplinary care reported a significant rate of improvement

in functional ability and quality of life for the control group (median change in Barthel score between 4 to 12 weeks of 2 points for

the treatment group, versus 6 for the control group, p<0.01); (Euroqol scores at 6 months 63 for the treatment group, vs. 72 for the

control group, p<0.005). Two trials reported that patients with medical conditions allocated to discharge planning reported increased

satisfaction compared with those who received routine discharge. No statistically significant differences were reported for overall health

care costs.



Authors’ conclusions

The impact of discharge planning on readmission rates, hospital length of stay, health outcomes and cost is uncertain. This reflects a

lack of power as the degree to which we could pool data was restricted by the different reported measures of outcome. It is possible

that even a small reduction in length of stay, or readmission rate, could have an impact on the timeliness of subsequent admissions in

a system where there is an shortage of acute hospital beds.

P L A I N L A N G U A G E S U M M A R Y

The impact of discharge planning on readmission rates, hospital length of stay, health outcomes, and cost to patients and health care

providers is uncertain.

Discharge planning is the development of a discharge plan for the patient prior to leaving hospital, with the aim of containing costs

and improving patient outcomes. The development of a discharge plan is increasingly becoming part of an integrated package of care,

making it difficult to study the effects of discharge planning alone. Although the impact of discharge planning may be small, it is

possible that even a small reduction in length of stay or readmission rate could free up capacity for subsequent admissions in a health

care system where there is a shortage of acute hospital beds.

B A C K G R O U N D

Cost containment is a feature of all health care systems, espe-

cially for acute hospital services (Schwartz 1991). Recent trends

include decreasing the lengths of stay for inpatient care; reducing

the number of long stay beds; moving care into the community;

an increased use of day surgery; providing increased levels of acute

care at home (“hospital at home”), and policies such as discharge

planning. The aim of these policies has been to contain costs, and

improve patient outcomes. For example discharge planning may

influence both the length of hospital stay and the pattern of care

within the community by bridging the gap between hospital and

home (Townsend 1988). Medical or non medical reasons may de-

lay a patient’s discharge from hospital. It has been estimated that

30% of all hospital discharges are delayed for non-medical reasons

(Selker 1989). Despite recent advances in electronic records, pa-

tient pathways and technology assisted decision support, the fol-

lowing factors identified nearly 20 years ago (Barker 1985) remain

causes of delayed discharge from hospital (Dept of Health 2003):

1. Inadequate assessment of the patient by health care professionals

resulting in, for example, a poor knowledge of the patient’s social

circumstances.

2. Poor organisation, for example late booking of transport pre-

venting timely discharge from hospital.

3. Poor communication between the hospital and providers of

services in the community.

It has been suggested that discharge planning can reduce un-

planned readmission to hospital. Formal assessment of patients

prior to discharge and adequate provision of care following dis-

charge may reduce the likelihood of referral back to hospital with

preventable problems (Williams 1988). A reduction in readmis-

sions will decrease inpatient costs; however, this reduction in costs

may be offset by an increase in the provision of community services

as a result of planning. In the USA 42% of the national health care

budget is spent on in-patient care, and readmissions account for

one quarter of Medicare inpatient expenditure (Anderson 1984).

Even a small reduction in readmission rates could have a substan-

tial financial impact (Anderson 1985).

The emphasis placed on discharge planning varies between coun-

tries. In the United States discharge planning is mandatory for hos-

pitals participating in the Medicare and Medicaid programmes.

In the UK the Department of Health has published guidance

on discharge practice for health and social care (Dept of Health

2003). However, procedures may vary between specialities in the

same hospital (Brent Soc Ser 1991; Young 1991; Victor 1988),

and sometimes may be embedded in another intervention, such

as a specialised assessment unit (Rubenstein) or home follow-up

(Parker 2002). These disparities make it difficult to interpret data

on the effectiveness of discharge planning. We have conducted a

systematic review of discharge planning to categorise the different

types of interventions and study populations, and to assess the

effectiveness of organising services in this way.

We have excluded interventions that provide care after discharge

from hospital, and those in which discharge planning is part of a

larger package of care but is poorly described.

O B J E C T I V E S

To determine the effectiveness of planning the discharge of patients

from hospital to home. The following questions were addressed:

Does discharge planning improve the process of patient care?

1. Effect of discharge planning on length of stay in hospital com-

pared to usual care.



2. Effect of discharge planning on unscheduled readmission rates

compared to usual care.

3. Effect of discharge planning on the incidence of complications

related to the initial admission compared to usual care.

4. Effect of discharge planning on other process variables: patients’

place of discarge

Does discharge planning improve or (at least) have no adverse

effect on patient outcome?

5. Effect of discharge planning on mortality rate compared to usual

care.

6. Effect of discharge planning on patient health outcomes com-


7. Effect of discharge planning on patients’ and carers’ satisfaction


Does discharge planning reduce overall costs of health care?

8. Effect of discharge planning on hospital care costs compared to

usual care.

9. Effect of discharge planning on community care costs compared

to usual care.

10. Effect of discharge planning on overall costs of health care


11. Effect of discharge planning on the use of medication

C R I T E R I A F O R C O N S I D E R I N G

S T U D I E S F O R T H I S R E V I E W

Types of studies

1. Randomised controlled trials

2. Controlled trials

Types of participants

All patients in hospital (acute, rehabilitation or community) irre-

spective of age, gender or condition.

Types of intervention

Discharge planning is defined as the development of an individu-

alised discharge plan for the patient prior to them leaving hospital

for home. Where possible the process of discharge planning will be

divided according to the steps identified by Marks (Marks 1994):

a) Pre-admission assessment (where possible).

b) Case finding on admission.

c) In-patient assessment and preparation of a discharge plan based

on individual patient needs.

d) Implementation of the discharge plan.

e) Monitoring.

Studies that did not include an assessment and implementation

phase, those where it was not possible to separate the effects of dis-

charge planning from the other components of the intervention,

and those that provided care after discharge from hospital were

excluded from the review.

Types of outcome measures

We included studies that reported any clinically important out-

comes, these cover:

1) Length of stay in hospital.

2) Readmission rate to hospital.

3) Complication rate.

4) Place of discharge.

5) Mortality rate.

6) Patient health status.

7) Patient satisfaction.

8) Carer satisfaction- professional and non-professional.

9) Psychological health of patient.

10) Psychological health of carers.

11) Cost of discharge planning to the hospital and to the commu-

nity.

12) The use of medication for trials evaluating a pharmacy dis-

charge plan was included in the update to reflect the focus of the

intervention for two trials.

S E A R C H M E T H O D S F O R

I D E N T I F I C A T I O N O F S T U D I E S

See: Cochrane Effective Practice and Organisation of Care Group

methods used in reviews.

Relevant studies as described were identified in the following

way:

1.MEDLINE search of years 1966-1996, using patient

discharge(tw), hospital discharge(tw),discharg* plan*(tw),

hospital near discharge(tw), readmissions (tw), length of stay (tw),

patient discharge (mh), patient readmission (mh) in combination

with the optimally sensitive search strategy (OSS) developed by

the UKCC (Dickersin 1994) to identify randomised controlled

trials.

2. Embase database search of years 1980-1996 using the

following terms, patient discharg*, discharge plan*, hospital

discharg*, readmission will be added to an optimally sensitive

search strategy to identify randomised controlled trials.

3. SIGLE database search for grey literature 1980-1996, using

search terms discharg* plan, patient discharge, hospital discharge.

4. Bioethics database 1985-1996, using search terms discharg*

plan*.

5. Health Plan database search for all available years, using search

terms discharge plan*, patient discharge, hospital discharge,

readmission.

6. ASSIA database search for all available years, using search

terms discharge plan*, patient discharg*, hospital discharg*.

7. Psych.Lit database search 1974-1996. The search terms will be

discharge plan, hospital discharge.

8. Sociofile database search using discharge plan*.



9. CINAHL nursing database search of years 1982-1996, using

search terms discharge plan*. patient discharge, length of stay

hospital discharg*.

10 Cochrane Library using search terms discharg* plan*, hospital

discharge, patient discharge for all available years.

11. Econ Lit 1969-1996, using search terms discharge plan*.

12. Personal liaison with interested colleagues.

13. EPOC register using relevant terms from EPOC taxonomy.

14. Searching reference lists of review articles and trials.

15. Contact with individual trialists whose trials are included in

the review, to clarify issues, to identify unpublished data, and

to establish awareness of work published and unpublished in

discharge planning.

Additional search terms were added as identified from relevant

articles.

The review was updated using the EPOC trials register in August

2002.

M E T H O D S O F T H E R E V I E W

Three reviewers (SS and JP, or SS and DH) independently selected

the studies to be included in the primary review, and two reviewers

independently selected studies for the update (SS and JM). Any

disagreement was settled by discussion. The quality of the selected

trials was assessed using the criteria described by the EPOC group

(see methods used in reviews under editorial information in group

details). SS and JP, and SS and JM independently assessed the

methodological quality and undertook data extraction using a

checklist developed by EPOC, modified and amended for the

purposes of this review. JP and SS contacted all investigators for

missing data; however, none provided unpublished data.

The primary analysis was a comparison of discharge planning

versus routine discharge care for each of the review questions. The

intention was to group the studies and undertake an exploratory

analysis of the standardised mean differences. We undertook meta

analysis for the effects of discharge planning on mortality, length of

hosptial stay, unscheduled readmission to hospital, and discharge

destination using the fixed effects model to calcuate the Peto odds

ratio. However combining the studies was judged inappropriate

for the other outcomes due to the different methods of measuring

and reporting the remaining outcome variables. We grouped trial

results by participants (patients with a medical condition, a surgical

condition, or patients recruited to a trial with a mix of conditions)

as the discharge planning needs for patients admitted to hospital

for elective surgery could differ from those who are elderly and

are admitted with an acute medical condition, or with multiple

medical conditions. Confidence intervals were calculated when

the authors did not report these.

Methods used to exclude trials from the review:

The decision to exclude trials where discharge planning was part

of a broader package of inpatient care was dependent on the detail

provided by the authors. We also excluded any studies that had

major methodological weaknesses despite fulfilling our criteria for

inclusion; details of why studies were excluded are reported in the

excluded studies section.

D E S C R I P T I O N O F S T U D I E S

Electronic searching yielded a total of 3112 citations. From these

abstracts 55 studies appeared to meet the entry criteria and were

retrieved for further assessment. Eleven trials [Kennedy; Hen-

driksen; Moher; Evans; Naughton; Naylor; Parfrey; Weinberger;

Nazareth; Shaw; Sulch] met all the review criteria and the re-

maining 44 were excluded (see excluded trials table). One of the

trials included in the review was translated from Danish to En-

glish [Hendriksen] the remaining trials were published in English.

Three of these trials [Sulch; Nazareth; Shaw] were identifed for

the recent update of the review. Two of the trials in the update

assessed the effectiveness of a pharmacy discharge plan, one for

elderly patients with a medical condition and the other recruited

both elderly patients and those admitted to a psychiatric hospital

and reported results across both conditions. The third trial in the

update evaluated an integrated care pathway which consisted of

rehabiliation and discharge planning for patients recovering from

a stroke.

Follow-up times varied from 2 weeks to 9 months. The trials in-

cluded in the review evaluated a broadly similar intervention of

discharge planning which included an assessment, planning, im-

plementation and monitoring phase, although two trials did not

describe a monitoring phase (see Characteristics of included stud-

ies). However, the intervention was implemented at varying times

during a patient’s stay in hospital, from admission to 3 days prior

to discharge. The study population differed between the trials. Six

trials recruited patients with a medical condition; one of these trials

included a group of patients with a surgical condition, three trials

recruited patients with a mix of medical and surgical conditions.

Two trials used a questionnaire designed to identify patients likely

to require discharge planning [Evans; Parfrey]. Patients recruited

to nine of the trials were elderly. One trial recruited patients across

two hospitals and reported data separately for the each of the hos-

pitals. For hospital A the average age was 53 years, and for hospital

B 56 years [Parfrey]. Another trial evaluating a pharmacy discharge

plan recruited patients aged from 23 to 86 years [Shaw].

The description of the type of care the control group received var-

ied. One trial did not describe the care received by the control

group [Kennedy]. Six trials described the control group as receiv-

ing usual care with some discharge planning but without a formal

link through a co ordinator to other departments and services,

although other services were available on request from nursing

or medical staff [Hendriksen; Moher; Naylor; Naughton; Parfrey;

Weinberger]. One trial explictly stated that the control group did

not receive discharge planning [Evans]. The control groups in two



of the trials included in the update that evaluated the effective-

ness of a pharmacy discharge plan did not have access to a review

and discharge plan by a pharmacist [Nazareth; Shaw]. In the third

trial included in the update the control group received multidisci-

plinary care which was not defined in advance but was determined

by the patients’ progress [Sulch].

M E T H O D O L O G I C A L Q U A L I T Y

Seven criteria are recommended by EPOC to judge the quality

of randomised studies, these are described elsewhere (see METH-

ODS USED IN REVIEWS under EDITORIAL INFORMA-

TION in GROUP DETAILS). One of the criteria, follow-up of

professionals, was not relevant to the trials included in this review.

The remaining six criteria were used, and showed that the quality

of the trials was variable, only 5 trials reported full concealment of

allocation, there was insufficient information to determine if this

was attained in the remaining 6 trials. Only four trials reported

blinded assessment of outcomes, and two trials reported no base-

line measurements.

R E S U L T S

Does discharge planning improve the process of patient care?

Comparison 1. Effect of discharge planning on length of stay in

hospital compared to usual care.

We failed to detect a statistically significant difference between

groups from a pooled analysis for hospital length of stay of elderly

patients with a medical condition (weighted mean difference -

0.86, 95% CI -1.9 to 0.18) [Kennedy; Moher; Naughton; Naylor;

Sulch]. Trials not included in the pooled analysis did not report a

significant difference in length of stay for surgical patients (differ-

ence +1.0 day, 95% CI -2.0 to 4.0) [Naylor], or for a mixed group

of patients recovering from surgery or with a medical condition

(difference -3.3 days, p>0.05 [Hendriksen]; difference -0.6, 95%

CI -2.38 to 1.18 [Evans]). Only one trial [Parfrey], recruiting from

two hospitals, reported a small significant reduction in length of

stay for patients receiving discharge planning in one hospital only

(median difference - 0.8 days, p<0.03).

Comparison 2. Effect of discharge planning on unscheduled read-

mission rates compared to usual care.

Seven trials measured readmission to hospital, results were reported

as rates of readmission to hospital or days spent in hospital as

a result of readmission. We pooled readmission data for the tri-

als recruiting elderly patients with a medical condition reporting

readmission rates at up to 3 months of discharge from hospital

[Kennedy; Moher; Naylor; Shaw; Nazareth]. We failed to detect a

difference between those allocated to discharge planning and those

in the control group (OR 0.91, 95% CI 0.67 to 1.23). One trial

not included in the pooled analysis presented readmission data

in a number of different ways [Weinberger]. Although a statisti-

cally significant increase in mean monthly readmission rate was

observed at six months follow-up for patients receiving discharge

planning (intervention group = 0.19 (sd+0.4) control group = 0.14

(sd+ 0.2) p= 0.005), and for the mean number of readmission days

(intervention 10.2 (19.8), control 8.8 (19.7) p<0.04), no statisti-

cally significant difference was detected at 6 months follow-up for

the proportions of patients readmitted to hospital (intervention =

49% control = 44% p = 0.06) [Weinberger]. One trial reported

a significant reduction in readmission days for patients allocated

to discharge planning (mean difference -33 days at 2 to 6 weeks

follow-up, 95% CI -53 to -13) [Naylor]; however, this difference

was not detected at longer term follow-up. These findings were

not replicated in another trial measuring readmission days at 1

year follow-up (difference +2 days, p >0.05 [Hendriksen].

No significant reduction in readmission rates (difference +3%,

95% CI-7% to 13%), or days in hospital due to readmission (dif-

ference +26 days, 95% CI -8 to +60 at 6 - 12 weeks) were reported

for patients recovering from surgery [Naylor].

Only one trial recruiting a mix of patients reported data on read-

mission [Evans]. A statistically significant decrease in readmissions

was observed for those receiving discharge planning (difference -

11%, 95% CI -17% to -4%) at 4 weeks follow-up; however, this

difference was not detected at 9 months follow-up (difference -

6%, 95% CI -12.5% to 0.84%; p>0.08). There was a significant

reduction in the days in hospital due to readmission (difference -

2.0, 95% CI -3.18 to -0.82).

Comparison 3. Effect of discharge planning on the incidence of

complications related to the initial admission compared to usual

care.

No studies provided data for this comparison.

Comparison 4. Effects of discharge planning on other process

variables: patients’ place of discharge.

Five trials provided data on patients’ place of discharge. A meta

analysis looking at the proportion of patients being discharged

home failed to detect a statistical difference between groups (OR

1.15, 95% CI 0.72 to 1.82) [Moher; Sulch]. One trial [Evans] re-

cruiting both medical and surgical patients reported that a greater

proportion of patients allocated to discharge planning were dis-

charged home compared with those receiving no formal discharge

planning (difference 6% 95% CI 0.4% to 12%), this difference

increased at 9 months follow up (difference 8.3% 95% CI 1.6% to

15%). Two trials failed to detect a difference in the proportion of

patients discharged to a nursing home [Naughton; Hendriksen].

Does discharge planning improve or (at least) have no adverse

effect on patient outcome?

Comparison 5. Effect of discharge planning on mortality rate com-


A meta analysis of 2 trials failed to detect a statistically significant

difference in mortality at 9 months (OR 1.44, 95% CI 0.82 to



2.51) [Nazareth; Sulch]. The two trials recruited different pop-

ulations, one recruited elderly patients with a range of medical

conditions and the other patients recovering from a stroke. One

study [Evans] recruiting a mix of surgical and medical patients

failed to detect a difference between groups at 9 months follow up

(treatment group 66/417 (16%), compared with 67/418 (16%)

in the control group).

Comparison 6. Effect of discharge planning on patient health out-

comes compared to usual care.

Six trials measured patient outcomes including functional status,

mental well-being, perception of health, self-esteem and affect.

Three of these trials did not publish follow up data [Kennedy;

Naylor; Weinberger]. One trial recruiting patients with medical

conditions reported no differences between groups for functional

status (mean difference on the Barthel Index -1.2, 95% CI -4.05

to 1.65, [Evans]), whereas another trial recruiting patients recov-

ering from a stroke reported a significant improvement from 4 to

12 weeks for those allocated to the control group, who received

conventional multidisciplinary care, on the Barthel score (median

change: control group 6 versus treatment group 2, p<0.01), and

for a change in the Euroqol score at 26 weeks (control group 72

versus treatment group 63 p<0.005), but failed to detect a dif-

ference for the Rankin score and the hospital anxiety and depres-

sion scale [Sulch]. A trial evaluating a pharmacy discharge plan

for elderly medical patients failed to detect a difference with the

General Well Being questionnaire (mean difference 0.1, 95% CI

-0.14 to 0.34) at 6 months [Nazareth].

Comparison 7. Effect of discharge planning on patients’ and carers’

satisfaction compared to usual care.

One trial recruiting patients with a medical condition reported

increased patient satisfaction for those allocated to discharge plan-

ning at one and six months follow up, with the greatest differences

reported for patients’ perceptions of continuity of care and non fi-

nancial access to medical care [Weinberger]. Another trial recruit-

ing fewer patients failed to detect a difference between groups for

patient satisfaction at three and six months follow up [Nazareth].

In the study by Moher a subgroup of 40 patients, who were asked

to complete a satisfaction questionnaire, reported increased sat-

isfaction with discharge planning (difference 27%, p<0.05, 95%

CI 2% to 52%) [Moher].

Does discharge planning reduce overall costs of health care?

Comparison 8. Effect of discharge planning on hospital care costs


In the study by Naylor [Naylor] involving patients with a med-

ical condition no significant differences for costs between the

two groups for their initial hospital stay were observed. However,

a significant difference for hospital costs was detected for total

charges including readmission costs at 2 weeks follow-up (dif-

ference-$170,247, 95%CI -$253,000 to -$87,000) and at 2 to

6 weeks follow-up (difference -$137,508, 95%CI -$210,000 to

-$67,000) with patients receiving discharge planning incurring

lower costs. No significant difference in costs was detected for pa-

tients with surgical conditions in the same study [Naylor].

The study by Naughton [Naughton] observed lower costs for lab-

oratory services for patients receiving discharge planning (mean

difference per patient -£295, 95% CI -£564 to -£26).

Comparison 9. Effect of discharge planning on community care

costs compared to usual care.

No studies provided cost data for this comparison. Weinberger

[Weinberger] measured the use of primary care and reported a

significant increase in the use of primary care by those allocated to

discharge planning (median time from hospital discharge to first

primary care consultation t=7 days, c=13 days, p<0.001; mean

number of visits to general medical clinic t=3.7 days, c=2.2 days

p<0.001). One trial provided data on general practitioner con-

sultations and failed to detect a difference between groups at 3

months (mean difference 2.7%, 95% CI -7.4% to 12.7%) and

at 6 months (mean difference 0.3% 95% CI -11.6% to 12.3%)

[Nazareth].

Comparison 10. Effect of discharge planning on overall costs of

health care compared to usual care.

One trial [Naughton] reported no significant difference between

the groups for overall health service costs.

Comparison 11. Effect of a pharmacy discharge plan on the use

of medication.

Both trials evaluating the effectiveness of a pharmacy discharge

plan measured different outcomes related to medication. Shaw

[Shaw] failed to detect a difference in the mean number of prob-

lems with medication reported (at 12 weeks T=1.4 (SD 1.2) n=21,

C=2.4 (SD 1.6) n=14). Problems included difficulty obtaining

a prescription from the general practicioner (GP), insufficient

knowledge about the medication and non compliance. Nazareth

also failed to detect a difference between groups for adherence to

medicines, knowledge about medicines and hoarding of medicines

[Nazareth].

D I S C U S S I O N

This review assessed the effectiveness of discharge planning in hos-

pital. Eleven randomised controlled trials met the pre-set criteria

for inclusion, three of these were included in this update. Meta-

analysis of 5 trials recruiting elderly medical patients failed to de-

tect a difference for the primary measures of outcome of length

of stay and readmission to hospital within 3 months of discharge.

However, it could be argued that even a small reduction in length

of stay or readmission to hospital may have an impact on the

timeliness of subsequent admissions in a system where there is a

shortage of acute hospital beds. A pooled analysis of two trials, one

recruiting patients recovering from a stroke [Sulch] and the other

elderly patients with a mix of conditions [Nazareth], suggests a

non significant increase in the odds of death of 44%, with 95%



CI of 0.82 to 2.51 at 6 to 9 months follow up. If true this result

is potentially important; however, interpretation is limited by the

small number of trials (2 trials with 152 [Sulch] and 362 patients

[Nazareth]), and the different patient populations and interven-

tions. Participants in the Sulch trial were recovering from a stroke

requiring inpatient hospital rehabilitation and had an average age

of 74 to 75 years. Most of the deaths occured after discharge from

hospital. Interestingly Sulch reported a quicker improvement in

quality of life and activities of daily living for the control group,

the authors speculate that this surprise finding may be due to a

less structured, more flexible approach to continuing patient as-

sessment. The mean age of participants in the trial evaluating a

pharmacy discharge plan was 84 years, and participants had an av-

erage of three chronic conitions. Mortality should be measured in

future trials to explore this finding. No differences in other health

outcomes were reported, and there is some evidence to suggest that

patients receiving discharge planning experience increased levels

of satisfaction with their care [Moher; Weinberger].

Two trials examining cost to the health service of implementing

discharge planning failed to detect a difference in health service

costs between those receiving discharge planning and those receiv-

ing standard care [Naughton; Naylor]. In one trial [Naylor] costs

to the health service were calculated using hospital charges, not

on the basis of resources used. The method of costing was not

described in the second trial [Naughton]. Although the costs re-

ported by the two trials differ, the variation in charges between dif-

ferent provider units makes it difficult to comment on the mean-

ing of these differences.

A key issue in interpreting the evidence is the definition of the in-

tervention and the subsequent understanding of the relative con-

tribution of each element. Authors of all of the trials provided

some description of the intervention, however it was not possi-

ble to assess how some components of the process compared be-

tween trials. For example the trial conducted by Naylor [Naylor]

formalised the inclusion of the patient’s caregiver into the assess-

ment process, and included the caregiver in the development of

the discharge plan. Although inclusion of the caregiver or fam-

ily was mentioned by the majority of the other trials [Kennedy;

Hendriksen; Evans; Naughton] the degree to which this was done

was not always apparent. Two of the trials [Evans; Parfrey] used

an assessment tool to find cases eligible for discharge planning.

The monitoring of discharge planning also differed. In one trial

this was done primarily by telephone [Naylor]; and in another

trial patients were given appointments to attend a primary care

clinic [Weinberger]. The context in which an intervention such

as discharge planning is delivered may also play a role, not only

in the way the intervention is delivered but in the way services

are configured for the control group. Five of the trials included

in this review were based in the USA, three in the UK, two in

Canada and one in Denmark. In each country the orientation

of primary care services differs, which may affect communication

between services. Different perceptions of care by professionals of

alternative care settings, and funding arrangements, may also in-

fluence timely discharge. The point in a patient’s hospital admis-

sion when discharge planning was implemented also varied across

studies. Two trials reported discharge planning commencing from

the time a patient was admitted to hospital [Parfrey; Sulch] and

another that discharge planning was implemented three days prior

to discharge [Weinberger]. The timing of an intervention such as

discharge planning, which depends on organising other services,

will have some bearing on how quickly these services can begin

delivering care. The patient population may also impact on out-

come; for example, patients recruited to the trial by Weinberger

were experiencing major complications from their chronic disease,

and this combined with an intervention designed to increase the

intensity of primary care services may explain the observed in-

crease in readmission days for those receiving the intervention.

Interestingly in the update of this review we only identified three

trials that met our inclusion criteria [Nazareth; Shaw; Sulch]. Two

trials focused on specific interventions examining the impact of

a pharmacy discharge plan on readmission rates, and other out-

comes such as knowledge of medication and health status. The

third trial evaluated the effectiveness of an integrated care pathway

that focused on rehabiliation and used a structured approach to

discharge planning for patients recovering from a stroke. With the

move towards care pathways it is possible that discharge planning

will be less frequently implemented as an intervention in isolation,

but will be part of an integrated package of care. This will present

further challenges in interpreting the evidence as it will become

more difficult to understand the relative contribution of each as-

pect of health care.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

This review indicates that the impact of discharge planning that

occurs while a patient is in hospital is uncertain on readmission

rates, hospital length of stay and health outcomes. However, it is

possible that even a small reduction in length of stay or readmission

rate could free up capacity for subsequent admissions in a system

where there is a shortage of acute hospital beds. It is not clear if

costs are reduced or shifted from secondary to primary care as a

result of discharge planning. Interestingly there is no evidence that

health care services outside a secondary care setting have adopted

discharge planning, despite patients’ requirements, and hence the

appropriateness of a place of care, changing over time; and waiting

lists for placement in a nursing home or for home care services.

Systematic reviews have been published in related areas; for ex-

ample, geriatric assessment which includes discharge planning as

part of a broader package of care (Stuck, 1993), and integrated

care pathways for stroke. This latter review concluded that this

type of care may be associated with both positive and negative ef-



fects on the process of care and clinical outcomes (Kwan 2003). A

recently published review by Parker included discharge planning

interventions that were in a hospital setting, comprehensive geri-

atric assessment, discharge support arrangements and educational

interventions, and concluded that interventions providing an ed-

ucational component had an effect on reducing readmission rates

(Parker 2002).

Implications for research

Surprisingly some of the stated policy aims of discharge planning

(bridging the gap between hospital and home) were not reflected

in the trials included in this review. An important element of dis-

charge planning is the effectiveness of communication between

hospital and community, yet this was not reported in any of the

trials included in this review. The expectation is that discharge

planning will ensure that patients are discharged from hospital

at an appropriate time in their care, and with adequate notice,

to organise the provision of other services. A high level of com-

munication between the discharge planner and the providers of

services outside the hospital setting is clearly important. Future

well conducted studies should collect mortality data to provide a

more robust estimate of this important outcome, and ensure the

generalisability of results by providing details of the intervention

and the context in which it was delivered. Safeguards should be

developed against contamination of the control group, for exam-

ple through the design of trials employing cluster randomisation.

Methods should be developed to measure the impact of a delayed

or inappropriate discharge on overall bed utilisation.

F E E D B A C K

Cochrane Highly Sensitive Search Strategy

Summary

The Cochrane Highly Sensitive Search Strategy should BE REF-

ERENCED ’Dickersin K, Scherer R, Lefebvre C. Identifying rel-

evant studies for systematic reviews. BMJ 1994;309:1286-91’ in-

stead of ’Anonymous. Medline optimally sensitive search strategy

(OSS) for SilverPlatter. Workshop on Identifying and Registering

Trials. UK Cochrane Centre, 1996’.

Author’s reply

This change has now been made.

Contributors

Mike Clarke

P O T E N T I A L C O N F L I C T O F

I N T E R E S T

None

A C K N O W L E D G E M E N T S

Diana Harwood for assisting in scanning abstracts retrieved from

electronic searches, NHS R&D Anglia and Oxford for contribut-

ing to the funding of the original review Jeremy Grimshaw, Andy

Oxman and Daryl Wieland for helpful comments on earlier drafts.

S O U R C E S O F S U P P O R T

External sources of support

• Imperial College School of Medicine UK

Internal sources of support

• Anglia and Oxford Regional Research and Development Pro-

gramme. UK

R E F E R E N C E S

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Stuck, AE, Sui AL, Wieland, GD, Adams, J, Rubenstein, LS. Com-

prehensive geriatric assessment: a meta analysis of controlled trials.

Lancet 1993;342:1032–1036.

Townsend 1988

Townsend J, Piper M, Frank AO, Dyer S, North WR, Meade TW.

Reduction in hospital readmission stay of elderly patients by a com-

munity based hospital discharge scheme: a randomised controlled

trial. BMJ 1988;297:544–7.

Victor 1988

Victor CR, Vetter NJ. Preparing the elderly for discharge from hospi-

tal: a neglected aspect of patient care?. Age Ageing 1988;17:155–63.

Williams 1988

Williams EI, Fitton F. Factors affecting early unplanned readmission

of elderly patients to hospital. BMJ 1988;297:784–7.

Young 1991

Young E, et al.Older people at the interface. A study of the provision of

services within Parkside Health Authority [occasional paper]. London:

Dept Gen Practice St Mary’s Hospital, 1991.

T A B L E S

Characteristics of included studies

Study Evans

Methods RCT

Participants Elderly medical, neurological, surgical

average age

T=66.6

C=67.9

Number recruited:

T=417

C=418

Interventions Discharge planning by physician and research assistant. Questionnaire to identify eligible patients followed

by assessment, planning, implementation, monitoring

Setting: V A Hospital, Seattle

Outcomes Hospital length of stay, re admission to hospital, discharge destination, health status

Notes Also validated an instrument to assess high risk patients

Intervention implemented on day 3 of hospital admission

Allocation concealment B – Unclear

Study Hendriksen

Methods RCT



Characteristics of included studies (Continued )

Participants Elderly patients admitted to 4 wards, including surgical

median age

T=76.5

C=76.6

Number recruited:

T=135

C=138

Interventions Discharge planning by co ordinator, a project /community nurse (assessment, planning, implementation,

monitoring)

Setting: Hospital in suburb of Copenhagen

Outcomes Hospital length of stay, re admission to hospital, discharge destination

Notes Details of measures of outcome not provided. Translated from Danish.

Intervention implemented at time of admission


Study Kennedy

Methods RCT

Participants Elderly acute care medical patients

average age

T=80.1

C=80.5

Number recruited:

T=39

C=41

Interventions Discharge planning protocol by geriatric nurse, and research assistant (assessment, planning, implementation,

monitoring)

Setting: Setting: 500 bed non-profit acute care teaching hospital, Texas

Outcomes Hospital length of stay, re admission to hospital, discharge destination, health status

Notes Not clear when intervention implemented

Allocation concealment A – Adequate

Study Moher

Methods RCT

Participants Elderly medical patients

average age

T=66.3

C=64.3

Number recruited:

T=136

C=131

Interventions Discharge planning - medical team co ordinator (nurse) (assessment, planning, implementation)

Setting: 2 clinical teaching units,

Ottawa

Outcomes Hospital length of stay, re admission to hospital, discharge destination, patient satisfaction




Notes Baseline data recorded only on age, sex, diagnosis

Not clear when intervention implemented


Study Naughton

Methods RCT

Participants Elderly medical patients admitted from emergency department

Average age

80 yrs

Number recruited:

T=51

C=60

Interventions Discharge planning- geriatrician and social worker: assessment, planning, intervention and monitoring

Setting: Private, non-profit, academic medical centre,

Chicago

Outcomes Hospital length of stay, discharge destination, health service costs

Notes Intervention implemented at time of admission


Study Naylor

Methods RCT

Participants Elderly medical and cardiac surgery patients

Average

76 years

Number recruited:

T=140

C=136

Interventions Discharge planning by geriatric nurse specialist (assessment, planning, implementation and monitoring

Setting: Hospital of the University of Pennsylvania

Outcomes Hospital length of stay, re admission to hospital, health status, health service costs

Notes Intervention implemented at time of admission


Study Nazareth

Methods RCT

Participants Elderly patients, aged 75 years and over, on 4 or more medicines who were discharged from 3 acute wards

and one long stay ward. Each patient had a mean of 3 chronic medical conditions, and was on a mean of 3

drugs (SD 2) at discharge. Mean age of participants 84 years (SD 5.2)

Interventions Hospital pharmacist assessed patients medication, rationalized the drug treatment, provided information and

liaised with carer and community professionals. An aim was to optimize communication between secondary

and primary care professionals Copy of the discharge plan were given to the patient, carer, community

pharmacist and GP.

Follow up visit by community hospital at 7 to 14 days after discharge to check medication and intervene if

necessary. Subsequent visits arranged if appropriate.




Includes an assessment, planning, implementation and monitoring phase.

Outcomes Hospital re admission; mortality; quality of life; client satisfaction; knowledge and adherence to prescribed

drugs; consultation with GP.

Notes


Study Parfrey

Methods RCT

Participants Medical and surgical patients

Average

Hospital A

53 yrs

Number recruited:

Hospital A

T=421

C=420

Interventions Discharge planning - admitting department personnel referred to nursing, social work, physiotherapy, oc-

cupational therapy, or dietary services for possible discharge planning (questionnaire to identify eligible pa-

tients): assessment, planning, implementation.

Setting: Newfoundland

Outcomes Hospital length of stay

Notes Also validated an instrument to assess high risk patients.

Intervention implemented at time of admission


Study Shaw

Methods RCT

Participants Patients discharged from a psychiatric hospital or care of the elderly ward with a mean age of 47 (SD 17)

years. 82% in the intervention group were diagnosed with an affective disorder, and 57% in the control

group. 43% in the intervention group were diagnosed with a psychotic disorder, and 16% in the control

group. Number of drugs on admission ranged from 1 to 10.

Interventions A pharmacy discharge checklist to identify particular problems, such as therapeutic drug monitoring, com-

pliance aid requirements, and side effects. Patients’ knowledge, obtained from a questionnaire up to 7 days

prior to discharge, was completed by all recruited patients, was incorporated into the checklist and specific

information provided to patients prior to discharge. A pharmacy discharge plan was supplied to the patients’

community pharmacist for the intervention group. Includes an assessment, planning, implementation and

monitoring phase.

Outcomes Re admission to hospital, re admission due to non compliance, medication problems after being discharged

from hospital

Notes


Study Sulch

Methods RCT

Participants Patients with a mean age (SD)



T=75 (11) years

C=74 (10) years

recovering from a stroke (excluded those with a mild deficit and those with severe cognitive or physical

disability)

Interventions Rehabilitation and discharge planning, with regular review of discharge plan. Senior nurse implemented the

integrated care pathway (ICP). Multi disciplinary training preceded implementation of the ICP. ICP was

piloted for 3 months prior to recruitment to the trial. To avoid contamination the multidisciplinary process

of care received by the control group was reviewed with a 3 month run in period to ensure implementation.

Groups received comparable amount of physiotherapy and occupational therapy.

Outcomes Length of hospital stay; discharge destination; mortality at 26 weeks; mortality or institutionalization; activ-

ities of daily living index; anxiety and depression; quality of life

Notes


Study Weinberger

Methods RCT

Participants Patients with diabetes mellitus, heart failure, chronic obstructive pulmonary disease

average age

T=63.0

C=62.6

Number recruited:

T=695

C=701

Interventions Discharge planning: nurse and primary care physician at each site - assessment, planning, implementation,

monitoring

Setting: 9 V A hospitals

Outcomes Re admission to hospital, health status, patient satisfaction, intensity of primary care

Notes Discharge planning within 3 days of discharge.

9 VA hospitals participated in the trial.

Discharge planning within 3 days of discharge


Characteristics of excluded studies

Study Reason for exclusion

Applegate RCT: discharge planning plus geriatric assessment unit

Brooten Discharge planning plus home care package

Brooten D Discharge planning plus home care package plus counselling

Carty Early post partum hospital discharge

Casiro Intervention: DP plus home care package

Choong

Intervention: clinical pathway for patients with a fractured neck of femur, discharge planning is not described

Donahue Intervention discharge planning plus post discharge care package

Dudas



Characteristics of excluded studies (Continued )

Intervention is focused on telephone follow up not idscharge planning. Randomised to groups after discharge

from hospital.

Epstein RCT. Consultative geriatric assessment and limited follow-up

Fretwell RCT. Consultative inpatient multidisciplinary team care

Gayton Controlled trial. Inpatient geriatric consultation team

Germain Geriatric assessment and intervention team

Gillette Hospital based case management team for neo natal intensive care

Haggmark

Study design not clear

Hansen RCT. Follow-up home visits

Hendriksen cooperati Post discharge care

Hogan Controlled trial of geriatric consultation team and follow-up after discharge

Jenkins RCT. Discharge teaching book

Karppi Discharge planning plus geriatric assessment unit

Kravitz Nested cohort study of post-discharge follow-up

Landefield Special unit plus rehabilitation

Martin RCT of discharge planning plus hospital at home

McGrory Assessed primary nursing and discharge teaching

Melin RCT (secondary analysis). In home primary care

Melin health Post discharge care

Melin re-hab Post discharge care

Murray Controlled trial. Communication between hospital and home

Naylor comp RCT. Discharge planning and home follow-up

Nikolaus Pilot study for comprehensive geriatric assessment

Reuben RCT of comprehensive geriatric assessment in HMO setting

Rich Discharge planning plus home care package

Rich prevention Pilot study of discharge planning plus home care package

Rubenstein Discharge planning plus geriatric assessment unit

Saltz RCT. Effect of geriatric consultation team on discharge placement

Siu Geriatric assessment started at hospital and continued at home

Smith RCT. Post discharge intervention to reduce non elective readmission

Thomas RCT. Comprehensive geriatric consultation team

Townsend Post discharge care

Victor Augmented home help scheme

Winograd RCT. In patient interdisciplinary geriatric assessment team



A N A L Y S E S

Comparison 01. Hospital length of stay

Outcome titleNo. of

studies

No. of

participants Statistical method Effect size

01 hospital length of stay elderly

medical patients

5 748 Weighted Mean Difference (Fixed) 95% CI -0.86 [-1.90, 0.18]

02 hospital length of stay - elderly

medical and surgical patients

2 1108 Weighted Mean Difference (Fixed) 95% CI -0.60 [-2.38, 1.18]

03 hospital length of stay - elderly

surgical patients

1 134 Weighted Mean Difference (Fixed) 95% CI 1.00 [-2.00, 4.00]

Comparison 02. Effect of discharge planning on unscheduled readmission rates

Outcome titleNo. of

studies

No. of


01 Patients with a medical

condition

Other data No numeric data

02 Patients who have had surgery Other data No numeric data

03 Patients with medical or

surgical condition


04 unscheduled readmission

within 3 months of discharge

from hospital

5 925 Peto Odds Ratio 95% CI 0.91 [0.67, 1.23]

Comparison 03. Effect of discharge planning on days in hospital due to unscheduled readmission

Outcome titleNo. of

studies

No. of


01 Patients with a medical or

surgical condition



condition


03 Patients with a surgical

condition


Comparison 04. Mortality

Outcome titleNo. of

studies

No. of


01 Mortality at 6 to 9 months 2 440 Peto Odds Ratio 95% CI 1.44 [0.82, 2.51]

04 Mortality for trials recruiting

both patients with a medical

condition and those recovering

from surgery




Comparison 05. Effect of discharge planning on patient health outcomes

Outcome titleNo. of

studies

No. of



condition



condition



surgical condition


04 Effect of discharge planning on

patients’ and carers’ satisfaction


Comparison 06. Effect of discharge planning on health care costs

Outcome titleNo. of

studies

No. of



condition



condition


Comparison 07. Effect of discharge planning on use of primary care services

Outcome titleNo. of

studies

No. of



condition


Comparison 08. Effect of discharge planning on patients’ place of discharge

Outcome titleNo. of

studies

No. of



condition



surgical condition


03 Patients discharged from

hospital to home


Comparison 09. Outpatient attendance

Outcome titleNo. of

studies

No. of


01 Elderly medical patients at 6

months




Comparison 10. Medication

Outcome titleNo. of

studies

No. of


01 Medication problems after

being discharged from hospital


02 Adherence to medicines Other data No numeric data

03 Knowledge about medicines Other data No numeric data

04 Hoarding of medicines Other data No numeric data

I N D E X T E R M S

Medical Subject Headings (MeSH)

Controlled Clinical Trials as Topic; Health Care Costs; Length of Stay; Outcome Assessment (Health Care); ∗Patient Discharge; Patient

Readmission; Randomized Controlled Trials as Topic

MeSH check words

Humans

C O V E R S H E E T

Title Discharge planning from hospital to home

Authors Shepperd S, Parkes J, McClaran J, Phillips C

Contribution of author(s) Sasha Shepperd (SS) co authored the protocol for the review with JP, obtained funding for

the review, helped JP develop the search strategy, scan abstracts, and data extraction. SS

took the lead in writing the review, did the data analysis, constructed the results tables, and

responded to refereess comments. SS updated the review.

Julie Parkes (JP) co authored the protocol, performed the electronic and non-electronic

searches, retrieved relevant articles and did the initial sifting of these articles using the

exclusion and inclusion criteria to produce the included studies for the review, assisted

with data extraction, contacted authors of the included studies and relevant experts, and

produced the first draft of the review.

Jacqueline McClaren assisted with data extraction for the update of the review, interpretation

of the studies and commented on drafts of the update.

Chris Phillips assisted with the identification of studies for the update of the review and

commented on a draft of the update.

Diana Harwood (DH) assisted with scanning abstracts retrieved from electronic searches.

Issue protocol first published /

Review first published 2000/4

Date of most recent amendment 02 March 2004

Date of most recent

SUBSTANTIVE amendment

25 September 2003

What’s New Three studies were included in the update, taking the total number of trials included in the

review to 11. The inclusion of these three trials has had little effect on the overall results of

the review. The impact of discharge planning on readmission rates, hospital length of stay,

health outcomes (including mortality) and cost remains uncertain. This reflects a lack of

power as the degree to which we could pool data was restricted by the different reported

measures of outcome. However, it is possible that even a small reduction in length of stay,



or readmission rate, could have an impact on the timeliness of subsequent admissions in a

system where there is an shortage of acute hospital beds.

Date new studies sought but

none found

Information not supplied by author

Date new studies found but not

yet included/excluded


Date new studies found and

included/excluded


Date authors’ conclusions

section amended


Contact address Dr Sasha Shepperd

Associate Director, Health Sciences

Continuing Professional Development Centre

Department of Continuing Education

University of Oxford

16/17 St. Ebbes Street

Oxford

OX1 1PT

UK

E-mail: [email protected]

Tel: +44 1865 286948

DOI 10.1002/14651858.CD000313.pub2

Cochrane Library number CD000313

Editorial group Cochrane Effective Practice and Organisation of Care Group

Editorial group code HM-EPOC



G R A P H S A N D O T H E R T A B L E S

Analysis 01.01. Comparison 01 Hospital length of stay, Outcome 01 hospital length of stay elderly medical

patients

Review: Discharge planning from hospital to home

Comparison: 01 Hospital length of stay

Outcome: 01 hospital length of stay elderly medical patients

Study discharge planning control Weighted Mean Difference (Fixed) Weight Weighted Mean Difference (Fixed)

N Mean(SD) N Mean(SD) 95% CI (%) 95% CI

Kennedy 39 7.80 (0.0) 41 9.70 (0.0) 0.0 Not estimable

Moher 136 7.43 (6.33) 131 9.40 (8.97) 31.1 -1.97 [ -3.84, -0.10 ]

Naughton 51 5.40 (5.50) 60 7.00 (7.00) 20.1 -1.60 [ -3.93, 0.73 ]

Naylor 72 7.40 (3.80) 66 7.50 (5.20) 46.4 -0.10 [ -1.63, 1.43 ]

Sulch 76 50.00 (19.00) 76 45.00 (23.00) 2.4 5.00 [ -1.71, 11.71 ]

Total (95% CI) 374 374 100.0 -0.86 [ -1.90, 0.18 ]

Test for heterogeneity chi-square=5.62 df=3 p=0.13 I2 =46.6%

Test for overall effect z=1.62 p=0.1

-10 -5 0 5 10

Favours treatment Favours control

Analysis 01.02. Comparison 01 Hospital length of stay, Outcome 02 hospital length of stay - elderly medical

and surgical patients



Outcome: 02 hospital length of stay - elderly medical and surgical patients

Study discharge planning Control Weighted Mean Difference (Fixed) Weight Weighted Mean Difference (Fixed)


Evans 417 11.90 (12.70) 418 12.50 (13.50) 100.0 -0.60 [ -2.38, 1.18 ]

Hendriksen 135 11.00 (0.0) 138 14.30 (0.0) 0.0 Not estimable

Total (95% CI) 552 556 100.0 -0.60 [ -2.38, 1.18 ]

Test for heterogeneity: not applicable


-10 -5 0 5 10




Analysis 01.03. Comparison 01 Hospital length of stay, Outcome 03 hospital length of stay - elderly surgical

patients



Outcome: 03 hospital length of stay - elderly surgical patients

Study discharge planning Control Weighted Mean Difference (Fixed) Weight Weighted Mean Difference (Fixed)


Naylor 68 15.80 (9.40) 66 14.80 (8.30) 100.0 1.00 [ -2.00, 4.00 ]

Total (95% CI) 68 66 100.0 1.00 [ -2.00, 4.00 ]



-10 -5 0 5 10


Analysis 02.01. Comparison 02 Effect of discharge planning on unscheduled readmission rates, Outcome 01

Patients with a medical condition

Patients with a medical conditionStudy readmission rates notes

Kennedy at 1 week:

t = 2/38 (5%) c = 8/40 (20%)

difference -15% 95% CI -29% to -0.4%

at 8 weeks:

t = 11/39 (28%) c = 14/40 (35%)

difference -7%, 95% CI -27.2% to 13.6%

Moher At 2 weeks:

t = 22/136 (16%) c = 18/131 (14%)

difference 2% 95% CI -6% to 11% p £0.58

Naylor Within 6 to 12 weeks:

t=11/72 (15%)

c=11/70 (16%)

difference 1% 95% CI -8% to 12%

Authors also report readmission data for 2 to 6 weeks

follow-up.

Nazareth At 3 months:

T=64/164 (39%)

C=69/176 (39.2%)

Difference 0.18 (95% CI -10.6% to 10.2%)

At 6 months:

T=38/136 (27.9%)

C=43/151 (28.4%)

Difference 0.54 (95% CI -11 to 9.9%)

Shaw At 3 months

T=5/51 (10%)

C=12/46 (26%)

OR 3.25, 95% CI 0.94 to 12.76, p=0.06

Authors also report data for readmission due to non

compliance of medication:

At 3 months

T=4/51 (8%)

C=7/46 (15%)

Difference -7%



Patients with a medical condition (Continued )

Study readmission rates notes

95% CI -0.2 to 0.05

Weinberger Number of readmissions per month

t = 0.19 (+0.4) (n=695) c = 0.14 (+ 0.2) p= 0.005 (n=701)

at 6 months: t = 49% c = 44% p 0.06

treatment group readmitted “sooner” (p 0.07)

Non parametic test used to calculate p values for monthly

readmissions


Patients who have had surgery

Patients who have had surgeryStudy readmission rates notes

Naylor Within 6 to 12 weeks:

t=7/68 ((10%)

c=5/66 (7%)

difference 3% 95% CI 7% to 13%


Patients with medical or surgical condition

Patients with medical or surgical conditionStudy readmission rates notes

Evans at 4 weeks:

t = 103/417 (24%) c = 147/418 (35%)

difference -10.5% 95% CI -16.6% to -4.3% p <0.001

at 9 months:

t = 229/417 (55%) c = 254/418 (61%)

difference -5.8% 95% CI -12.5% to 0.84% p 0.08




unscheduled readmission within 3 months of discharge from hospital


Comparison: 02 Effect of discharge planning on unscheduled readmission rates

Outcome: 04 unscheduled readmission within 3 months of discharge from hospital

Study Treatment Control Peto Odds Ratio Weight Peto Odds Ratio

n/N n/N 95% CI (%) 95% CI

Kennedy 11/39 14/40 10.5 0.73 [ 0.29, 1.88 ]

Moher 22/136 18/131 20.6 1.21 [ 0.62, 2.37 ]

Naylor 11/72 11/70 11.3 0.97 [ 0.39, 2.39 ]

Nazareth 64/164 69/176 49.0 0.99 [ 0.64, 1.53 ]

Shaw 5/51 12/46 8.5 0.33 [ 0.12, 0.93 ]

Total (95% CI) 462 463 100.0 0.91 [ 0.67, 1.23 ]

Total events: 113 (Treatment), 124 (Control)



0.1 0.2 0.5 1 2 5 10


Analysis 03.01. Comparison 03 Effect of discharge planning on days in hospital due to unscheduled

readmission, Outcome 01 Patients with a medical or surgical condition

Patients with a medical or surgical conditionStudy days in hospital notes

Evans readmission days at 9 months:

t = 10.1 ± 8.3

c = 12.1 ± 9.1

p 0.001

95% CI -3.18 to -0.82

Hendriksen T =15.5 days per readmission

C=13.5 days per readmission

P=>.05


readmission, Outcome 02 Patients with a medical condition

Patients with a medical conditionStudy days in hospital notes

Naylor medical readmission days

2weeks: t=21days (n=72) c=73 days (n=70)

difference -52 days 95% CI -78 to -26

2-6weeks: t=16 days (n=72) c=49 days (n=70)

difference -33 days 95% CI -53 to -13




Study days in hospital notes

6-12 weeks: t=94 days (n=72) c=100 days (n=70)

difference -6 days 95% CI -83 to 71

Weinberger medical readmission days at 6 months follow up: t=10.2 (19.8) c=8.8 (19.7) difference 1.4 days p<0.04


readmission, Outcome 03 Patients with a surgical condition

Patients with a surgical conditionStudy days in hospital notes

Naylor surgical readmission days

2 weeks: t=34 days (n=68) c=32 days (n=66)

difference 2 days 95% CI -13 to 17

2-6 weeks: t=63 (n=68) c=52 (n=66)

difference 11 days 95% CI -20 to 52

6-12 weeks: t=52 (n=68) c=26 (n=66) difference 26 days 95% CI -8 to 60

Analysis 04.01. Comparison 04 Mortality, Outcome 01 Mortality at 6 to 9 months


Comparison: 04 Mortality

Outcome: 01 Mortality at 6 to 9 months


n/N n/N 95% CI (%) 95% CI

Nazareth 22/137 19/151 71.0 1.33 [ 0.69, 2.57 ]

Sulch 10/76 6/76 29.0 1.74 [ 0.62, 4.89 ]

Total (95% CI) 213 227 100.0 1.44 [ 0.82, 2.51 ]




0.001 0.01 0.1 1 10 100 1000


Analysis 04.04. Comparison 04 Mortality, Outcome 04 Mortality for trials recruiting both patients with a

medical condition and those recovering from surgery

Mortality for trials recruiting both patients with a medical condition and those recovering from surgeryStudy Mortality @ 9 months notes

Evans t=66/417 (16%)

c=67/418 (16%)



Analysis 05.01. Comparison 05 Effect of discharge planning on patient health outcomes, Outcome 01




Patients with a medical conditionStudy pt health outcomes notes

Kennedy Long Term Care Information System (LTCIS)

Health and functional status

(also measures services required)

No data reported

Naylor Data aggregated for both groups. Mean Enforced Social Dependency Scale

increased from 19.6 to 26.3 p<0.01

No data reported for each group. Decline in functional status reported for all

patients.

Functional status. Scale measured:

Mental status

Perception of health

Self esteem

Affect

Nazareth General well being questionnaire 1=ill health

5=good health

At 3 months:

T=76, mean 2.4 (SD 0.7)

C=73 mean 2.4 (SD 0.6)

At 6 months

T=62, mean 2.5 (SD 0.6)

C=61 mean 2.4 (SD 0.7)

Mean difference 0.1 (95% CI -0.14 to 0.34)

Sulch Barthel activities of daily living

Median scores

At 4 weeks

T=13

C=11

At 12 weeks

T=15

C=17

At 26 weeks

T=17

C=17

median change from 4 to 12 weeks

P<0.01

Rankin score

Median score

At 4 weeks

T=1

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Study pt health outcomes notes

C=1

At 12 weeks

T=3

C=3

At 26 weeks

T=3

C=3

Hospital anxiety and depression scale

Anxiety:

Median scores

At 4 weeks

T=5

C=5

At 12 weeks

T=4

C=4

At 26 weeks

T=4

C=4

Depression

Median scores

At 4 weeks

T=6

C=5

At 12 weeks

T=5

C=5

At 26 weeks

T=5

C=5

Euroqol

At 4 weeks

T=41

C=44

Median scores

At 4 weeks

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Study pt health outcomes notes

T=41

C=44

P=0.1

At 12 weeks

T=59

C=65

P=0.07

At 26 weeks

T=63

C=72

P<0.005

Weinberger at 1 month: no significant differences

p 0.99

at 3 months: no significant differences

p 0.53

SF 36

No data shown

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Patients with a surgical condition

Patients with a surgical conditionStudy pt health outcomes notes

Naylor No differences between groups reported No data reported


Patients with a medical or surgical condition

Patients with a medical or surgical conditionStudy pt health outcomes notes

Evans At 1 month: mean (sd)

T=85.3 (21.0) n=417

C=86.5 (21.0) n=418

Difference -1.2, 95% CI -4.05 to 1.65

Barthel score

(scale 1 to 100)

Analysis 05.04. Comparison 05 Effect of discharge planning on patient health outcomes, Outcome 04 Effect

of discharge planning on patients’ and carers’ satisfaction

Effect of discharge planning on patients’ and carers’ satisfactionStudy pt health outcomes notes

Moher Satisfied with medical care:

t=89%

c=62%

p <0.05

difference 27%

95% CI 2% to 52%

“Please rate how satisfied you were with the care you

received….”

Subgroup of 40 patients, responses from 18 in the

treatment group and 21 in the control group

Nazareth Client satisfaction questionnaire score (1=dissatisfied,

4=satisfied)

At 3 months:

T=76, mean 3.3 (SD 0.6)

C=73 mean 3.3 (SD 0.6)

At 6 months

T=62, mean 3.4 (SD 0.6)

C=61 mean 3.2 (SD 0.6)


Weinberger at 1 month:

treatment group more satisfied

p <0.001

at 6 months:

treatment group more satisfied

p <0.001. Authors report differences were greatest for

patients perceptions of continuity of care and non financial

access to medical care

Patient Satisfaction Questionnaire, 11 domains with a 5

point scale



Analysis 06.01. Comparison 06 Effect of discharge planning on health care costs, Outcome 01 Patients with a

medical condition

Patients with a medical conditionStudy costs notes

Naughton Mean total hospital costs per patient ($):

t = 4,525 ± 5,087

c = 6,474 ± 7,000

p 0.093

Mean costs for services per patient ($):

laboratory:

t = 518 ± 523 c = 813 ± 839 p 0.026

difference £295

95% CI -£564 to -£26.0

diagnostic imaging:

t = 67 ± 145 c = 84 ± 151 p 0.539

pharmacy:

t = 165 ± 278 c = 389 ± 886 p 0.068

rehabilitation:

t = 98 ± 254 c = 115 ± 201 p 0.696

Number:

T=51

C=60

total cost of hospital care including breakdown of

costs for laboratory, diagnostic imaging, pharmacy and

rehabilitation services

Naylor initial stay mean charges ($):

t = 24,352 ± 15,920 (n= 72)

c = 23,810 ± 18,449 (n=70)

difference 542 (CI -5,121 to 6,205)

medical readmission total charges in $ (CIs are in

thousands):

at 2 wks:

t = 68,754 c = 239,002 diff = -170,247 (CI -253 to -87)

2-6 wks:

t = 52,384 c = 189,892 diff = -137,508 (CI -210 to -67)

6-12 wks:

t = 471,456 c = 340,496 diff = 130,960 (CI -205 to 467)

Charge data were used to calculate the cost of the initial

hospitalisation.

Readmission costs were calculated using the mean charge

per day of the index hospitalisations times the actual

number of days of subsequent hospitalisations, as patients

were re admitted to a variety of hospitals with a wide range

of charges.

Total charges including readmission charges (first

readmission only if multiple readmissions)

Analysis 06.02. Comparison 06 Effect of discharge planning on health care costs, Outcome 02 Patients with a

surgical condition

Patients with a surgical conditionStudy costs notes

Naylor surgical initial stay mean charges ($):

t = 105,936 ± 52,356 (n=68)

c = 98,640 ± 52,331 (n=66)

difference 7,296 (CI -5,141 to 19,733)

surgical readmission total charges ($):

at 2 wks:

t = 111,316 c = 104768 diff = 6,548 (CI -43 to 56)

2-6 wks:

t = 209,536 c = 170,248 diff = 39,288 (CI -66 to 144)

6-12 wks:

t = 170,248 c = 85,124 diff = 85,124 (CI -28 to 198)

Charge data were used to calculate the cost of the initial

hospitalisation

Total charges including readmission charges (first

readmission only if multiple readmissions)

Readmission costs were calculated using the mean charge per

day of the index hospitalisations times the actual number

of days of subsequent hospitalisations, as patients were

readmitted to a variety of hospitals with a wide range of

charges.



Analysis 07.01. Comparison 07 Effect of discharge planning on use of primary care services, Outcome 01


Patients with a medical conditionStudy use of services notes

Nazareth General practice attendance:

At 3 months:

T=101/130 (77.7%)

C=108/144 (75%)

Difference 2.7% (-7.4 to 12.7%)

At 6 months:

T=76/107 (71%)

C=82/116 (70.7%)

Difference 0.3% (-11.6 to 12.3%)

Weinberger Median time from hospital discharge to the first visit:

Treatment 7 days

Control 13 days

p<0.001

Visit at least one general medicine clinic in 6 month follow up:

Treatment 646/695 (93%)

Control 540/701 (77%)

difference 16%

95% CI 12.3% to 19.6%

P<0.001

Mean number of visits to general medical clinic:

Treatment 3.7

Control 2.2

P<0.001

Analysis 08.01. Comparison 08 Effect of discharge planning on patients’ place of discharge, Outcome 01


Patients with a medical conditionStudy place of discharge notes

Kennedy at 2 weeks:

87% no change in placement from time of discharge to 2 week follow up time (both groups)

at 4 weeks: majority no change (both groups)

No data shown

Moher Discharged to home:

t = 111/136 (82%)

c = 104/131 (79%)

difference 2.2% 95% CI -7.3% to 11.7%

Naughton Discharged to nursing home:

t=3/51 (5.9%) c= 2/60 (3.3%)

difference 2.5% 95% CI -5.3% to 10.4%

Sulch Discharged home:

T=56/76 (74%)

C=54/76 (71%)

Discharged to an institution:

T=10/76 (13%)




Study place of discharge notes

C=16/76 (21%)

OR 1.5 95% CI 0.5 to 2.8


Patients with a medical or surgical condition

Patients with a medical or surgical conditionStudy place of discharge notes

Evans Discharged to home:

t = 330/417 (79%)

c = 305/418 (73%)

p 0.05 difference 6% 95% CI 0.39% to 12%

home at 9 months:

t = 259/417 (62%)

c = 225/418 (54%)

p 0.05 difference 8.3% 95% CI 1.6% to 15%

Hendriksen Discharged to nursing home:

t=0/135 (0%) c=3/138 (2%)

Difference -2% 95% CI -4.6% to 0.26%

At 6 months: admitted to another institution

t=3/135 (2%) c=14/138 (10%)

difference -8% 95% CI -13.5% to -2.3%


Patients discharged from hospital to home


Comparison: 08 Effect of discharge planning on patients’ place of discharge

Outcome: 03 Patients discharged from hospital to home

Study intervention control group Peto Odds Ratio Weight Peto Odds Ratio

n/N n/N 95% CI (%) 95% CI

Moher 111/136 104/131 57.9 1.15 [ 0.63, 2.11 ]

Sulch 56/76 54/76 42.1 1.14 [ 0.56, 2.31 ]

Total (95% CI) 212 207 100.0 1.15 [ 0.72, 1.82 ]

Total events: 167 (intervention), 158 (control group)



0.1 0.2 0.5 1 2 5 10




Analysis 09.01. Comparison 09 Outpatient attendance, Outcome 01 Elderly medical patients at 6 months


Comparison: 09 Outpatient attendance

Outcome: 01 Elderly medical patients at 6 months


n/N n/N 95% CI (%) 95% CI

Nazareth 39/137 40/151 100.0 1.10 [ 0.66, 1.85 ]

Total (95% CI) 137 151 100.0 1.10 [ 0.66, 1.85 ]




0.1 0.2 0.5 1 2 5 10


Analysis 10.01. Comparison 10 Medication, Outcome 01 Medication problems after being discharged from

hospital

Medication problems after being discharged from hospitalStudy number of problems notes

Shaw Mean number of problems (SD)

At 1 week

T=2.0 (1.3)

C=2.5 (1.6)

At 4 weeks

T=1.9 (1.5)

C=2.9 (1.8)

At 12 weeks

T=1.4 (1.2)

C=2.4 (1.6)

Problems included difficulty obtaining a prescription from the GP; insufficient knowledge

about medication; non compliance

Analysis 10.02. Comparison 10 Medication, Outcome 02 Adherence to medicines

Adherence to medicinesStudy adherence to meds notes


T=79, mean 0.75 (SD 0.3)

C=72 mean 0.75 (SD 0.28)

At 6 months

T=60, mean 0.78 (SD 0.3)

C=58 mean 0.78 (SD 0.3)

0=none

1=total/highes level

Analysis 10.03. Comparison 10 Medication, Outcome 03 Knowledge about medicines



Knowledge about medicinesStudy knowledge notes


T=86, mean 0.69 (SD 0.33)

C=83 mean 0.62 (SD 0.34)

At 6 months

T=65, mean 0.69 (SD 0.35)

C=68 mean 0.68 (SD 0.3)


0=none


Analysis 10.04. Comparison 10 Medication, Outcome 04 Hoarding of medicines

Hoarding of medicinesStudy hoarding notes


T=87, mean 0.006 (SD 0.04)

C=82 mean 0.005 (SD 0.03)


At 6 months

T=70, mean 0.02 (SD 0.13)

C=69 mean 0.013 (SD 0.06)


0=none




Documents

Shepperd S, Parkes J, McClaran J, Phillips Chospitalmedicine.ucsf.edu/improve/literature/discharge_committee...Discharge planning from hospital to home (Review) Shepperd S, Parkes