Effectiveness of patient-caregiver dyad discharge interventions on hospital readmissions of elderly patients with community acquired pneumonia: a systematic review

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Executive summaryBackgroundThe aim of discharge planning is to reduce unplanned readmission to the hospital and improve coordination of care. As the global population ages, including family caregivers in discharge planning maybe an effective strategy to improve patient outcomes and quality of care. In the United States, hospital readmission following discharge for community acquired pneumonia is a process measure utilized to evaluate discharge planning outcomes.ObjectivesThe objective of this systematic review was to identify the effect of patient-caregiver dyad discharge learning need interventions on unexpected readmissions within thirty days of elderly patients (65 years or older) with community acquired pneumonia.MethodsA systematic review of English language studies published and unpublished after 1991on patient and caregiver learning needs related to discharge education and unplanned hospital readmission. Studies including patients aged 65 and older experiencing discharge from a hospital setting, were the primary focus.A comprehensive search of electronic databases was performed for the period of 1991-2010 to find relevant studies. A three-stage search processwas used consisting of an initial database search, scanning of reference lists, citation searching of key papers, contact with authors via the Internet and through personal communication, keyword searching of the World Wide Web. Four authors independently undertook quality assessment and data analysis using the standardized critical appraisal and data extraction tool from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument. Data were summarized by use of narrative methods.Main resultsFive studies were pertinent to the review. Direct comparisons of the studies are limited due to different methods and subject participants. We found statistically significant results that caregiver education interventions impact positively on decreasing unplanned readmissions. Two randomized control trials and one quasi-experimental study were identified that addressed a multidisciplinary discharge education intervention which included caregivers of elderly pneumonia patients. Multidisciplinary care transition intervention was associated with fewer readmissions in thirty days (odds ratio = 0.55; 95% CI 0.32-0.94; odds ratio = 0.56; 95% CI 0.24-1.31; odds ratio= 0.41; 95% CI 0.28-0.75). One case control study and one quasi experimental study identified lack of documented patient or family education as independently associated with unplanned readmissions within thirty days in elderly patient populations that included chronic lung disease (odds ratio = 2.3; 95% CI = 1.2-4.5: odds ratio= 0.52; 95% CI = 0.28-0.96).Wherein, the first of these studies calculated the rate of readmission when caregiver education is omitted whilst the second calculated readmission when an educational intervention is included. However, whilst improved readmission rates with caregiver education was unlikely due to chance, due to the difficulties in isolating caregiver education as a direct intervention, issues of homogeneity limit the generalizability of this review.ConclusionsThis review highlights the dearth of information on the caregiver's need for specific information on discharge and the need for future research.Implications for practiceThere is little evidence that education interventions aimed at caregivers are uniformly effective in decreasing pneumonia readmission rates. The evidence suggests that a structured education intervention that includes caregivers probably brings about a small reduction in unexpected readmissions within thirty days for elderly patients with community acquired pneumonia. The specific caregiver learning needs assessment remains variable and uncertain.Implications for researchResearch has been aimed at implementation of community acquired pneumonia guidelines to improve mortality and unexpected readmissions within thirty days. However, quality of discharge teaching, a key component of coordinated care, is a strong predictor of readiness for discharge and readmission rates. There is a need for quality randomized studies evaluations of the outcomes specific to patient-caregiver dyad discharge interventions.

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