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QUESTION: Does discharge planning from hospital to home improve patient care and reduce healthcare costs?
Studies were identified by searching Medline (1966–96), EMBASE/Excerpta Medica (1980–96), Sigle (1980–96), Bioethics (1985–96), Health Plan (all years), Assia (all years), PsycLIT (1974–96), CINAHL (1982–96), the Cochrane Library (all years), EconLit (1969–96), Social Science Citation Index (1992–6), and the Cochrane Effective Practice and Organisation of Care (EPOC) specialised register; reviewing reference lists of relevant articles; and contacting experts.
Randomised controlled trials and other controlled trials were selected if they included patients in acute, rehabilitation, or community hospitals and assessed a discharge planning intervention (development of an individualised discharge plan for a patient before discharge). Studies were excluded if they did not include an assessment and implementation phase or if discharge planning was provided as part of a multifaceted intervention.
Data were extracted on study design, participants, setting, intervention, and outcomes. The 2 authors independently assessed the methodological quality of studies by using a modified version of the EPOC criteria. Main outcomes included process of care (length of hospital stay, unscheduled readmissions, and complications), patient outcomes (mortality, health outcome, and satisfaction with care), and healthcare costs (hospital, community, and overall costs).
8 randomised controlled trials comparing discharge planning with usual care met the inclusion criteria. The table summarises the findings for various outcomes and patient groups. Because of study variation, only 1 meta-analysis was possible. This analysis of 4 studies of elderly medical patients showed a non-significant difference in length of hospital stay favouring discharge planning (weighted mean difference –1.01, 95% CI –2.06 to 0.05).
Evidence of the effectiveness of discharge planning is equivocal.
In this review by Parkes and Shepperd, discharge planning is defined as the development of individualised discharge plans for patients before they are discharged home from the hospital. Such planning should improve care and reduce the necessity for premature readmission.
In this report, and in the articles reviewed, descriptions of the discharge planning process, and of the care provided to control groups, were unclear and variable between studies. Dissection of the discharge planning process from overall care is difficult and limits the application of this information to one's own practice setting.
Studies were identified for this review by searching relevant databases to 1996. I identified 2 more recent articles of discharge planning for children with asthma and for the elderly that came to similar conclusions.1, 2
The reviewers' conclusions are appropriately conservative. Although 8 studies were reviewed, meta-analysis was not possible because of differences in the patient populations. The clinical outcomes were equivocal in all groups. The review and the original articles would have to be carefully examined before one could recommend widespread application of the information. Despite the lack of evidence for or against discharge planning, I believe that all patients admitted to hospital should receive such planning because it makes sense to do so. But more effective means of planning are clearly needed.
Source of funding: National Health Service Research and Development.
For correspondence: Dr S Shepperd, Department of Primary Care, University of Oxford, Old Road, Headington, Oxford OX3 7LF, UK. Fax +44 (0)1865 227 036.
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