title: Transitional care interventions and hospital readmissions in surgical populations: a systematic review.
abstract: BACKGROUND
  Despite hospital readmission being a targeted quality metric, few studies have focused on the surgical patient population. We performed a systematic review of transitional care interventions and their effect on hospital readmissions after surgery.
  
  
  METHODS
  PubMed was searched for studies evaluating transitional care interventions in surgical populations within the years 1995 to 2015. Of 3,527 abstracts identified, 3 randomized controlled trials and 7 observational cohort studies met inclusion criteria.
  
  
  CONCLUSIONS
  Discharge planning programs reduced readmissions by 11.5% (P = .001), 12.5% (P = .04), and 23% (P = .26). Patient education interventions reduced readmissions by 14% (P = .28) and 23.5% (P < .05). Primary care follow-up reduced readmissions by 8.3% for patients after high-risk surgeries (P < .001). Home visits reduced readmissions by 7.69% (P = .023) and 4% (P = .161), respectively. Therefore, improving discharge planning, patient education, and follow-up communication may reduce readmissions.
authors.affiliation: University of Alabama-Birmingham, Department of Surgery; Birmingham Veterans Administration Hospital, Birmingham, AL.
authors.forename: Caroline E
authors.initials: CE
authors.lastname: Jones
authors.affiliation: University of Alabama-Birmingham, Department of Surgery; Birmingham Veterans Administration Hospital, Birmingham, AL.
authors.forename: Robert H
authors.initials: RH
authors.lastname: Hollis
authors.affiliation: University of Alabama-Birmingham, Department of Surgery; Birmingham Veterans Administration Hospital, Birmingham, AL.
authors.forename: Tyler S
authors.initials: TS
authors.lastname: Wahl
authors.affiliation: VA Boston Health Care System and Tufts University School of Medicine, Department of Surgery, Boston, MA.
authors.forename: Brad S
authors.initials: BS
authors.lastname: Oriel
authors.affiliation: VA Boston Health Care System and Tufts University School of Medicine, Department of Surgery, Boston, MA.
authors.forename: Kamal M F
authors.initials: KM
authors.lastname: Itani
authors.affiliation: University of Alabama-Birmingham, Department of Surgery; Birmingham Veterans Administration Hospital, Birmingham, AL.
authors.forename: Melanie S
authors.initials: MS
authors.lastname: Morris
authors.affiliation: Stanford University, Department of Surgery; VA Palo Alto Health Care System, Palo Alto, CA. Electronic address: mhawn@stanford.edu.
authors.forename: Mary T
authors.initials: MT
authors.lastname: Hawn
mesh_terms: D003266:Continuity of Patient Care; D006699:Home Care Services; D006801:Humans; D010351:Patient Discharge; D010353:Patient Education as Topic; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011182:Postoperative Care / Q000379:methods*; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*; D000069341:Transitional Care
keywords: Health services research; Hospital readmission; Patient discharge; Patient-centered care; Population health; Transitional care