Supplemental Table 2

Review Matrix on Clinical Strategies and programs

Author/journal/ Year/ Location / Design/sample/Level of evidence / Review Synthesis/Findings clinical strategies and programs / Strengths / Limitations
Cowper A. P., et al
Journal of American College of Cardiology.
(1997)
Hospital – community based / Logistic regression model. This study examined the impact of early hospital discharge on short-term clinical outcome in elderly patients with CABG in 1992.
The sample size was N=101, 812 patients.
Sample represented national population, including multi states. / Early discharge of elderly patients treated with CABG in non-HMO settings were not associated with higher 60-day rates of death or readmission. / It is a national study involving large sample size from multiple clinical site.
Prediction modeling is another strength.
Significant findings on prevalence of 60 day readmission was18%.
51% of readmissions were cardiovascular disease, 13 % were with respiratory disease, and 3% were with cerebrovascular disease.
The findings on readmission rate and causes have implication to the practice in prevention of readmission after CABG surgery. / This study may contain the limitations associated with secondary data analysis design.
Study findings are limited to the age group of 65 years and older.
Outpatient rehabilitation was not included in this study.
Yue Li, et al
Med Care
(2013)
Medicare Patients / Retrospective study: Regression model.
The purpose was to determine the effect of postoperative length of stay on 30-day readmission after coronary artery bypass surgery.
A sample size of N= 157,070 patient records was used from Medicare claims which were observed between the years 2007 to 2008. The sample represented the national population, including multi-states.
Level IV evidence. / Reduction in postoperative length of stay is associated with an increased risk for 30-day readmission among Medicare patients undergoing bypass surgery.
Readmission rate was 17%. / Predictive modeling with
Observed and unobserved confounding variables corrected in data analysis add strength to the design.
The study included a large sample size involving multi site clinical data.
Significant findings from this study may have implied to the discharge planning and process and prevention of readmissions. / The study may contain limitations associated with secondary data analysis, however co-variables and confounding factors have been statistically controlled within the analysis.
The generalization of the findings is limited to the Medicare claim cohorts.
CENTER FOR HEALTH CARE RESEARCH & TRANSFORMATION
(2013)
Multiple Sites involving muliptle states in USA / Quality outcome study reports, including Multiple Studies
Involving multiple clinical strategies and multiple sites RCT design.
The sample represented the national population, including multi-states.
Level II evidence. / The Transitions Program
Implemented 600 Health care institutions in 39 states
The program included RCT aimed to encourage patients and caregivers to have more active roles during care transitions to reduce readmissions.
All-cause readmission rates dropped to 8.3% from 11.9% in 30-day readmission.
The same diagnostic readmission rate fell to 3% from 5% in 30-day readmission.
Ever Care Model
Implemented in 30 states aimed to reduce hospital readmission by customizing patient care and improving care coordination.
Results from the quasi-experimental design showed the hospitalization rate reduced by 45%
ED visits cut by 50%
Cost effective management of cases saved $103,000
Guided Care
The program is implemented in eight health systems through the US.
Program goals are to improve health care quality and outcomes and reduce costs.
RCT results show a 29.7% reduction in home care visits; no statistical reduction in other service use was found. Kaiser Permanente patients, however, showed a drop in the use of skilled nursing facility and other health services.
Project BOOST
The program is implemented in several states, including 24 hospitals and provider organizations in Michigan.
Program goals are to reduce 30-day readmission rates; reduce length of hospital stay; improve patient satisfaction; and reduce the transition of care between inpatient and outpatient providers.
Project BOOST provides evidence-based clinical intervention tools.
Results from Atlanta’s Piedmont Hospital, since implementation in September 2008 show:
Reduced 30-day readmission (8.5% down, from 22.5%) for patients under the age 70.
Reduced 30-day readmission rate (22% down, from 26%) for patients over age 70.
Preliminary results from other pilot sites also indicate reductions in readmissions.
Project RED
The RED toolkit has been downloaded by 500 users. Joint Commission Resources provides technical assistance to 269 hospital organizations.
The program aims to reduce hospital readmissions by improving discharge processes.
The method can be applied to all discharged patients or limited to patients with specific conditions.
Making follow-up appointments.
Arranging post-discharge services and equipment.
Patient education and plan when red flags are identified.
Follow-up within 72 hours.
Approximately 30% decrease in hospital utilization within 30 days.
Approximately 34%lower observed costs for the intervention group.
The method was most effective for patients with high Utilization.
Transitional Care Model
The program is implemented in many states across the country.
Program goals are to improve coordination and continuity of care from hospital to home, and to help patients and their caregivers play an active role in their care.
The program focuses on older adults with complex needs.
Two RTC results have been documented. First study shows readmission rate down to 20% from 37%. A second study of elderly patients (65+) hospitalized with HF shows fewer readmissions. / The clinical report is the compilation of multiple clinical strategies for the prevention of 30-day readmission after CABG surgery.
Experimental design is a strength of the report.
The results support the effectiveness of clinical strategies in the reduction of readmissions, which has significant implication for the practice. / The study findings are limited to the selected sites for generalization. Replication may be required before the generalization to the population.
Bates OL, et al
Worldviews Evidence Based Nurs.
(2014)
Tertiary Care setting, single site in USA. / Quantitative comparative study (Single site).
Sample Size of N= 189 patient records at a tertiary care facility in the United States over a period of 2 years.
Level III evidence (quasi experimental).
Comparing outcomes between the group of patients prior to implementation of STAAR interventions and those who later received them.
Outcome variables include 30-day readmission rate and patient perception of experience of care. / STARR Interventions and Post CABG surgical patient care were the study variables. Outcome variable was 30 day readmission.
The readmission rate in the post - intervention group was decreased to 12% compared to 25.8% in the pre-intervention group.
Chronic lung disease was significant for readmission rates.
The deliberate incremental implementation of bundled initiatives is an effective strategy in reducing 30-day readmissions in post-CABG patients. / Interventional study testing the effectiveness of a clinical program of STARR intervention bundles in preventing 30 day readmission after CABG surgery is a major strength of this study design.
The significant findings supported the cause and effect relationship between intervention and 30 day readmission is are strength and they may be useful in guiding evidence based clinical practice. / The study may contain weaknesses associated with Quasi experimental design. Lack of randomization is a weakness to the internal validity of the design. Un- equivalent control group comparison may vary from a concurrent control group, which is another weakness in the design.
Single site study, which may require replication before the recommendation to the practice.
Clark M. A., et al
European Journal of Cardiovascular Prevention & Rehabilitation,
(2011)
Urban – Rural, West of Scotland / A prospective cohort analysis done using an Individualized Center-based cardiac Rehabilitation program (ICR) in a mixed urban-rural region of the west of Scotland, to a standardized cardiac rehabilitation program (SCR) provided at the same site three years previously. / ICR was associated with a reduction in hospital admission compared to SCR (HR: 0.664: 95% confidence interval 0.554 to 0.797)
ICR patients had significantly shorter hospitalizations (mean: 8.02 days versus 5.84 days, p<0.05)
ICR patients who attended at least 75% of the exercise sessions were significantly less likely to be hospitalized than individuals who partly attended (HR 2.39, 95% CI: 1.659 to 3.488) or did not participate (HR 2.16, 95% CI: 1.482 to 3.143) / Experimental study using Teach – Back discharge education and follow up care has been found useful in reducing 30 day readmissions. The Readmission rate among intervention group was 12% and among control group was 25.8%. / The study results may contain limitations associated with the un-equivalent control group.
Controlling for confounding variables is non evident.
The study results’ generalizationmay be limited to the study subjects and may require replication for the consistency.
Hansen LO, et al
Ann Intern MED
(2011)
Review included multi-site and multi nation studies. / Systematic review of Controlled trials, cohort studies or non-controlled before-after studies of interventions to reduce re-hospitalization that were reported within 30 days.
N=43; Level I evidence. / 43 articles were identified, and taxonomy was developed to categorize interventions into 3 domains that encompassed 12 distinct activities.
Pre-discharge interventions include patient education, medication reconciliation, discharge planning, and scheduling of a follow-up appointment before discharge.
Post-discharge interventions included follow-up telephone calls, patient-activated hotlines, timely communication with ambulatory provides, timely ambulatory provider follow-up, and post discharge home visits.
Bridging interventions included transition coaches, physician continuity across the inpatient and outpatient setting, and patient-centered discharge instruction.
No single intervention implemented alone was regularly associated with reduced risk for 30-days re-hospitalization. / The strength of this study is attributable to the review involving 43 interventional studies focused on 30-day readmission.
The interventions identified within the review may have implication for the prevention of 30-day readmission for CABG patients as well. / The review encompasses multiple interventions for reducing 30-day readmission. However, concluded no single intervention was helpful in reducing 30 day readmissions.
The findings may have limitation to the study sites and subjects in regard with generalization.
Fredericks S, Ibrahim S, Puri R
Prog Cardiovascular Nursing,
(2009)
Review of studies from multi sites and multi nations. / Systematic review.
Sample set consists of adults (> or = 18 years);
N=25
Level I evidence. / Interventions included in the individual study were CABG discharge education.
Outcome variables were Self-care knowledge, Self-care behavior, subjective experiences reflecting changes in a person’s bio-psychological function, sensation, or cognition.
Larger effect sizes for CABG patient education in which the content was individualized and given in a combination of media on an individual basis, and in more than one session. / The review included a meta - analysis, which is a strength to the design.
Inclusion of interventional studies is an added strength to the design and internal validity.
Findings suggest that using multiple media in CABG education was effective in self-care knowledge and behavior. This finding may have implication to the interventional strategies for preventing CABG readmission. / The limitation of the study may attribute to the small sample size within selected studies.
The study results are limited to the subjects for generalization.
Colella TJ, King KM
EUR J Cardiovascular Nursing,
(2004)
Review of multiple studies involving multiple sites. / Literature review aimed to investigate the theoretical assumptions that supports the professional guided peer support program that may enhance patient recovery after CABG surgery.
The review utilized online databases of the 15-year period preceding 2003.
The review contained 70 related references.
Level I evidence. / Key phrases of search included: peer support, social support, telephone follow up, cardiac surgery, cardiac recovery, and coronary artery bypass graft surgery.
The variables of the review included: peer support and peer support interventions in cardiac recovery after CABG surgery.
Results: Social support is a meta-construct which consists of supportive behavior, subjective appraisal of potential helping resources, and supportive resources;
Social support is associated with health care outcomes; peer support is a type of social support that contains information, feedback, and emotional assistance. Peer support is associated with cardiac recovery outcomes.
Further investigation is needed of peer support interventions. The influence of peer support interventions for recovery and health outcomes is necessary for patients. / The review provided a theoretical construct for peer support interventions and cardiac recovery for CABG surgery patients, which is the primary strength of this review.
The theoretical construct supported peer support as a clinical strategy to prevent CABG readmission, which may be useful in guiding future studies. / Very few interventional studies were available for the review on peer support and cardiac recovery outcomes.
Lack of well controlled interventional studies involving peer support interventions may limit the generalization of the review findings.
Mahler HI, et al
Evidence Based Nursing,
(2014)
California, USA / RCT study, Videotape review and randomized, un-blinded, controlled trial with a 6 month follow up.
Sample Size: N= 296 patients' records from 3 hospitals in San Diego, California, USA
Level II evidence. / The interventions included mastery tape and coping tape. Control group tape, including hospital regular discharge instructions.
The outcome variables were spouse’s feelings of preparedness for the recovery period, affective state, and emotional difficulties. In addition, patient affective states, postoperative problems, physician contacts, and readmission to the hospital.
Male and female spouses in the interventional group had greater feelings of preparedness (p< 0.05) than the spouses in the control group.
Videotape depicting mastery reduced problems requiring physician contact at 3 and 6 months and hospital readmission at 1 month for woman patients only (p< 0.05). / RCT design is the primary strength of the study, which has inbuilt control for extraneous variables and internal and external validity biases within the design.
Demonstration of significant effects of videotape intervention on spousal emotional outcomes: preparedness and coping of patient recovery and decreased recovery problems and readmission are major strengths of the study.
Generalizable knowledge towards clinical strategy in the prevention of readmission is a strength of this study.
A recent study, which may have reflections on contextual current health care developments. / The standardization of the interventional video tape tools may vary and the results may vary in different settings. The study findings may be limited to the study hospitals and subjects. Further replication may be needed before generalization.