Key result
A multifaceted transitional care intervention combining an exercise program, nurse home visits, and telephone follow-up significantly reduced unplanned hospital readmissions at 28 days (HR 0.28) compared to standard care in high-risk older adults.
Why the study?
Older adults recently discharged from acute hospital care are at increased risk of readmission, but the comparative effectiveness of different transitional care interventions remained unclear.
Do transitional care interventions reduce unplanned hospital readmissions in high-risk older adults?
RCT (n=222)
Single-blind
Computerised randomised program
Yes
Do transitional care interventions reduce unplanned hospital readmissions in high-risk older adults?
Hazard Ratio: 0.28 (95% CI 0.09–0.87)
Absolute Event Rate: 8% vs 25%
p-value: p=0.029
Multifaceted transitional care interventions, particularly those combining exercise and nurse follow-up, significantly reduce unplanned hospital readmissions in high-risk older adults up to 12 weeks post-discharge.
Supports short-term transitional care programs to lower early readmissions in high-risk elders; extends evidence on intervention components and 12-week benefit window.
BACKGROUND: Acute hospital services account for the largest proportion of health care system budgets, and older adults are the most frequent users. As a result, older people who have been recently discharged from hospital may be at greater risk of readmission. This study aims to evaluate the comparative effectiveness of transitional care interventions on unplanned hospital readmissions within 28 days, 12 weeks and 24 weeks following hospital discharge. METHOD: The present study was a randomised controlled trial (ACTRN12608000202369). The trial involved 222 participants who were recruited from medical wards in two metropolitan hospitals in Australia. Participants were eligible for inclusion if they were aged 65 years and over, admitted with a medical diagnosis and had at least one risk factor for readmission. Participants were randomised to one of four groups: standard care, exercise program only, Nurse Home visit and Telephone follow-up (N-HaT), or Exercise program and Nurse Home visit and Telephone follow-up (ExN-HaT). Socio-demographics, health and functional ability were assessed at baseline, 28 days, 12 weeks and 24 weeks. The primary outcome measure was unplanned hospital readmission which was defined as any hospital admission for an unforeseen or unplanned cause. RESULTS: Participants in the ExN-HaT or the N-HaT groups were 3.6 times and 2.6 times respectively significantly less likely to have an unplanned readmission 28 days following discharge (ExN-HaT group HR 0.28, 95% CI 0.09-0.87, p = 0.029; N-HaT group HR 0.38, 95% CI 0.13-1.07, p = 0.067). Participants in the ExN-HaT or the N-HaT groups were 2.13 and 2.63 times respectively less likely to have an unplanned readmission in the 12 weeks after discharge (ExN-HaT group HR 0.47, 95% CI 0.23-0.97, p = 0.014; N-HaT group HR 0.38, 95% CI 0.18-0.82, p = 0.040). At 24 weeks after discharge, there were no significant differences between groups. CONCLUSION: Multifaceted transitional care interventions across hospital and community settings are beneficial, with lower hospital readmission rates observed in those receiving more transitional intervention components, although only in first 12 weeks. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry ( ACTRN12608000202369 ).
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Finlayson et al. (2018) conducted an RCT in High risk for hospital readmission (n=222). Exercise program, Nurse Home visit, and Telephone follow-up (ExN-HaT) vs. Standard care was evaluated on Unplanned hospital readmission within 28 days (HR 0.28, 95% CI 0.09-0.87, p=0.029). A multifaceted transitional care intervention combining an exercise program, nurse home visits, and telephone follow-up significantly reduced unplanned hospital readmissions at 28 days (HR 0.28) compared to standard care in high-risk older adults.
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