Introduction
Transitional care is defined as actions in the clinical encounter designed to ensure the coordination and continuity of healthcare for patients transferring between different locations or levels of care [
1]. There are many factors that contribute to gaps in the transition from hospital to home, including inadequate planning, insufficient patient/family education, and limited and fragmented access to essential services [
2]. These gaps are often compounded by limited financial resources, inadequate insurance coverage [
3], and lack of social support [
4].
Acute conditions are sudden, severe in their onset, and often require immediate medical attention that results in hospital admission [
5]. Patients who are hospitalized for acute conditions and their families could benefit from transitional care [
6,
7], as transitional care management in a variety of patient populations has led to improved patient and family outcomes, including improved patient QOL [
3,
8]. However, there are limited standards to guide transitional care of patients with acute conditions and the current state of “usual care” during the transition from acute hospital care to home has limited provider support or engagement to help patients and families navigate and access fragmented health and community-based services during the transition home from the hospital [
9,
10]. Of the existing transitional care intervention for patients hospitalized for acute conditions, few focus on patient QOL as the primary outcome. In addition, existing interventions use a variety of different intervention components, are not effective for patients of all races and ethnicities, do not address age-related differences in patient needs, and do incorporate family needs [
11‐
15].
To address these gaps in the literature, we draw from literature on transitional care interventions designed to improve QOL for younger adult patients (aged 18–64) hospitalized with acute conditions to inform development of transitional care interventions to improve QOL in patients with acute conditions. We emulate research on transitional care interventions for older adult patients with chronic conditions [
16,
17] by focusing solely on transitional care interventions for younger adult patients hospitalized for acute conditions. Thus, the purpose of this systematic literature review was to determine characteristics of transitional care intervention studies designed to improve QOL for younger adult patients (age 18–64) of different racial and ethnic groups who were hospitalized for an acute condition and discharged home.
Methods
The design and dissemination of findings for this systematic literature review followed the Preferred Reporting Items for Systemic Review and Meta-Analysis (PRISMA) statement [
18]. The study protocol was documented in the International Prospective Register of Systematic Reviews (PROSPERO), Registration Number: CRD42020147345 [
19].
Search terms for the study were initially developed with the study team in consultation with a medical librarian who specializes in systematic literature reviews. Pre-defined search terms were used to identify articles describing transitional care interventions used to improve QOL in younger adult patients with acute conditions or injuries. These included specific terms related to transitional care, hospitalization, outpatient care, and quality of life. The search strategy was reviewed by a second medical librarian before searching the following databases: PubMed, Embase, The Cumulative Index to Nursing and Allied Health Literature (CINHAL), and PsycINFO. The final search was conducted on November 19, 2019. The search excluded studies not published in English and studies of animals; we also excluded editorials, letters, case reports, and commentaries. The full electronic search strategy for one database (PubMed) is contained in Additional file
1.
Study eligibility characteristics
Inclusion criteria for studies included in this review:
1.
Patients in the sample were:
(a)
age 18–64 years [as the age-related needs and outcomes of younger and older adults differ [
20,
21]]
(b)
hospitalized in the last 30 days due to acute condition or injury
(c)
discharged to home/community from the acute hospital (intensive care unit, acute, or subacute unit) or a subsequent inpatient location (such as inpatient rehabilitation)
2.
Family members participating in the study (if applicable) were:
(b)
the anticipated, informal primary caregiver in unpaid role for a patient who meets eligibility based on patient criteria above
(c)
informal primary caregivers included immediate or extended family members or close friends of patient
3.
Primary study outcome: patient QOL
Exclusion criteria for studies:
1.
Patients in the sample:
(a)
had a planned hospitalization
(b)
were exclusively ≤ 17 and ≥ 65 years
2.
Family members participating in the study (if applicable):
(a)
had no plans to live with patient or spend ≥ 10 h per week with patient
(b)
were in a paid caregiving position
3.
QOL was not explicitly mentioned as the sole primary outcome (unless article was needed to provide context to a study that met inclusion criteria)
Study selection
Studies identified in each database were imported into Covidence [
22], a systematic review software, to facilitate study selection. Duplicates were removed. Five researchers independently screened titles and abstracts against the inclusion and exclusion criteria. Two authors evaluated each title/abstract, and there was 98% complete agreement between reviewers. A third reviewer who was not part of the title/abstract review resolved conflicts. The articles that advanced to full-text review were evaluated by two reviewers to select which studies met eligibility for data extraction and quality assessment.
Data collection process
The team collaborated to determine the data of interest from all studies prior to full-text article review. A draft data extraction spreadsheet was piloted with two full-text articles with the full team before finalizing the list of data to extract. We used a three-tiered review to extract data from the full-text articles. In the first-level, two researchers led a structural review, independently extracting the following information into a spreadsheet from each full-text article, including the article citation, country of study, study design, health condition of focus, inclusion/exclusion criteria, treatment intervention description, and QOL outcome measurement (i.e., name of measure). The second level of review used a content analysis to fully describe the treatment intervention description from each article specifying individual intervention components, facilitator type and training, intervention materials, and cultural tailoring. In the final-level of review, four researchers extracted participant characteristics and QOL-specific findings, including whether main findings were described by racial/ethnic subgroup. A single researcher extracted data from each assigned article and a second researcher audited the data extracted. Consensus was reached through discussion.
Quality assessment
The QualSyst Tool was used to evaluate methodological quality of each study that met the criteria for study inclusion [
23]. The QualSyst Tool includes 14 criteria for quantitative studies, with each criterion being rated yes (2 points), partial (1 point), no (0 points), or not applicable [
23]. Based on the QualSyst Tool’s criteria, each study is given a summary score, which is equivalent to the total sum divided by the total possible sum. The highest possible score for each study is 1.0 [
23]. The minimum threshold for summary scores is to be set by the research team and should be based on the distribution of summary scores for articles included in the review [
23]. We set our minimum threshold at 0.70. Quality assessment was conducted in pairs, whereby a single researcher assessed the quality of assigned articles and a second researcher audited the quality assessment. Disagreements in quality assessment were discussed until consensus was reached.
Discussion
The primary purpose of this systematic literature review was to determine characteristics of transitional care intervention studies designed to improve QOL for younger adult patients (age 18–64) of different racial and ethnic groups who were hospitalized for an acute condition and discharged home. Findings suggest wide variation on QOL instruments, intervention components, and description of facilitator training and intervention materials utilized in transitional care interventions for younger adult patients hospitalized with acute conditions. In addition, no studies specified cultural tailoring of interventions or analyzed findings by racial/ethnic subgroup.
Research has shown that transitional care interventions can address gaps in care with a variety of strategies, including individualized transitional care plans, post-discharge care coordination, and community-based service referrals [
16,
43‐
46]. Although diverse populations of younger adult patients hospitalized for acute conditions were included in this review, findings showed there are common components integrated into transitional care interventions for these patients. More specifically, the present study found that patient and family education, phone calls to patients, patient needs assessments, and home visits were most common components of transitional care interventions for younger adult patients with acute conditions. However, no studies specified which intervention component(s) were implemented to target improvements in patient QOL. Similarly, evidence is limited to indicate if any single transitional care intervention component is effective in improving QOL for patients with acute conditions. Additional research is needed to either power studies to test individual components or examine if specific mechanisms of action are effective in improving QOL for patients with acute conditions.
Reporting of facilitator training was limited in the studies included in this systematic review; training and characteristics of the training process are known to influence intervention outcomes [
47], and future studies should ensure reporting of this critical component in order to support optimal outcomes with translation of evidence to practice. In addition, half of studies in this review did not describe or make available the intervention materials provided to or used with study participants. Studies that discussed intervention materials had vague descriptions and companion articles to provide more details were not identified by authors. Describing study materials in detail and making materials available when disseminating findings can increase the likelihood of intervention adaptation or replication [
48]. Researchers should consider adopting the Template for Intervention Description and Replication (TIDieR) checklist and guide for better transparency in reporting [
49].
Culture, race and ethnicity are often under-addressed in intervention research [
50]. Although culture informs human behavior [
50,
51], there has been limited incorporation of culture into research, particularly into development of evidence-based interventions [
52]. None of the studies in this present review described cultural tailoring of their intervention. In addition, although race and ethnicity has been shown to influence response to intervention, few intervention studies report study findings by race or ethnicity to provide additional information on the efficacy or effectiveness of the intervention for various races [
53,
54]. Studies outside the United States did not report demographic differences by race or ethnicity, and it is unclear if any were present; no studies in this review described findings by racial/ethnic groups. As incorporating culture, race, and ethnicity into all phases of the research process can help to reduce health disparities [
55], future scholars should report the racial and ethnic composition of their sample, work to identify if needs differ by race and ethnicity in order to develop culturally-sensitive interventions, and consider analyzing findings by these important subgroups.
More specifically, researchers should design studies that allow space and time for cultural tailoring and should refer to existing resources for guidance on cultural tailoring of interventions, such as the NIH cultural framework for health and other publications on this topic [
50,
56‐
58]. Interventions can be culturally tailored to address needs and preferences of racial/ethnic minorities in multiple ways, often starting by gathering information on or from relevant stakeholders from the cultural or racial/ethnic groups of focus, by conducting literature reviews on cultural differences, or by conducting qualitative and/or quantitative studies to assess the group’s needs and preferences [
57]. Next, researchers should integrate the input from their stakeholders into the preliminary intervention protocol and materials and also consider translating intervention materials to language(s) used by the relevant stakeholders, where necessary [
57]. Subsequently, researchers should solicit additional qualitative feedback (often through individual or focus group interviews or use of usability testing strategies) from relevant stakeholders to determine their thoughts on the acceptability of the preliminary intervention protocol and materials; researchers should then use this feedback to refine the final intervention protocol and materials [
57]. Finally, after conducting the full trial using the culturally tailored intervention protocol and materials, researchers should analyze findings to determine presence of differences by subgroups, and consider conducting qualitative interviews with participants from relevant cultural or racial/ethnic groups to determine if further changes are needed [
57].
Findings from this present study can be used to inform development and testing of transitional care interventions in diverse patient populations. For instance, as no studies in this review focused on patients with traumatic brain injury, a patient population that has high rates of injury in younger adults [
59], findings from this present study can be used to inform development and testing of transitional care interventions that aim to improve quality of life in younger adult TBI patients. In addition, more work is needed to determine which intervention components adequately address the needs of patients and families during the transition from hospital to home. Similarly, as the majority of intervention components described in this review focus on the patient, more work is needed to determine appropriate intervention components to address the needs of family members of patients with acute conditions. Finally, more research is needed to determine how to culturally tailor transitional care interventions to address the needs and preferences of patients with acute conditions of all races and ethnicities.
Limitations
One limitation of this study includes risk of bias across studies due to variation in report of treatment intervention details and participant characteristics. Another limitation is that quantitative meta-analyses were not conducted because the interventions were too heterogeneous to be considered comparable and to draw a conclusion to recommend the benefit of any one approach. Other limitations are related to the nature of systematic literature reviews, including the risk of incomplete retrieval of identified research and reporting bias. To address risk of incomplete retrieval of identified research, our research team worked in pairs to conduct study selection and data extraction. To address reporting bias, we specify all data extraction items, and provide detailed overviews of data reported in our results.
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