Little evidence supports interventions to reduce hospital readmissions

There's no definitive evidence that any single intervention reduces 30-day hospital readmissions, a literature review concluded.

Researchers reviewed 43 studies that tested discharge interventions using an experimental or observational design and reported relative readmission outcomes for an intervention and control cohort.

They found that flaws in the literature prevented them from concluding that any single intervention was effective. For example, some study interventions weren't well described and couldn't be included in a meta-analysis. Many of the studies were single-institution assessments that lacked experimental designs while those that were randomized did not consistently show a significant effect. Several common interventions have not been studied outside of multicomponent “discharge bundles.” Results appeared in the Oct. 18 Annals of Internal Medicine.

The researchers were able to categorize 12 types of interventions into three domains: predischarge interventions (patient education, medication reconciliation, discharge planning, and scheduling follow-up appointments), postdischarge interventions (follow-up telephone calls, patient-activated hotlines, timely communication with ambulatory clinicians, timely ambulatory clinician follow-up, and postdischarge home visits), and bridging interventions before and after discharge (transition coaches, physician continuity across the inpatient and outpatient setting, and patient-centered discharge instructions).

Predischarge patient education and discharge planning were the most commonly evaluated interventions, appearing in 22 of the 43 studies. Of the 43 studies, 16 were randomized, controlled trials. Five of them documented statistically significant improvements in readmissions within 30 days. One of the five consisted of a single intervention in which high-risk patients received early discharge planning or usual care. Those randomly assigned to the treatment group experienced an absolute 11% reduction in 30-day rehospitalization.

Four randomized studies demonstrated statistically significant beneficial effects of multicomponent discharge bundles. Interventions common to these studies were the postdischarge telephone call and patient-centered discharge instructions. However, two randomized trials that included these two interventions among others in a bundle did not demonstrate significant reductions in 30-day rehospitalization. The other two randomized trials of follow-up calls as an isolated intervention also did not find a significant effect.

The authors wrote, “In this systematic review of studies evaluating interventions to reduce readmission within 30 days of hospital discharge, we did not identify a discrete intervention or bundle of interventions that appears to reliably reduce rehospitalization.... Overall, observational designs predominated, and studies were characterized by significant heterogeneity of intervention content and context. This has been acknowledged to be a common limitation in the patient safety literature.”

Still, promising avenues remain for study, including discharge instructions and telephone follow-up. Even though Medicare is expected to penalize hospitals with higher-than-average readmission rates, “[T]he current evidence base may not be adequate to facilitate change even for highly incentivized hospitals, and reconsideration of planned penalties may be reasonable,” the authors concluded.