Table 2 Meta-analyses of randomized controlled trials of the effect of clinical interventions before and/or after hospital discharge on hospital readmission rates

Home care

Lambrinou et al. 2012 [32] (9)

Before hospital discharge: individualized patient education and discharge planning. After discharge: home care by cardiac community nurses or physicians

Takeda et al. 2012 [33] (10)

Disease management with home visits and phone calls

Multidisciplinary care

Tsai et al. 2005 [34] (6)

Chronic care model including: follow-up, planned visits, self-management (patient education)

Whellan et al. 2005 [35] (3)

Discharge planning and disease management with home nursing

Roccaforte et al. 2005 [36] (9)

Disease management interventions before and after discharge (education, discharge planning, home or clinic care)

Holland et al. 2005 [37] (8)

Multidisciplinary interventions with 1–8 home visits

Kim and Soeken 2005 [38] (7)

Inhospital assessment and education with follow up by phone and home visits

Gonseth et al. 2004 [39] (9)

Discharge planning and patient education with home visits, or telephone follow-up, or clinic follow-up

Phillips et al. 2004 [40] (9)

Discharge planning with

   A single home visit

   Home visits / frequent telephone contact

   Extended home care services

   Day Hospital services

McAlister et al. 2004 [41] (6)

Multidisciplinary team providing follow-up in a non-clinic setting

Gwadry et al. 2004 [42] (7)

Patient education and post discharge follow-up at home or by phone

Self-management

Kozak et al. 2007 [43] (6)

Education for self-management before or after discharge

   Face-to-face contact

   Combined telephone and face to face contact

Jovicic et al. 2006 [44] (8)

Patients assume primary role in managing their health after receiving education before discharge, with limited follow-up phone calls or home visits after discharge

McAlister et al. 2004 [41] (6)

Enhanced patient self-care activities

Pharmacist care

Koshman et al. 2008 [45] (8)

Pharmacist care in a multidisciplinary team, in hospital or in outpatient clinic, with or without home visits

Telemonitoring / structured telephone support

Inglis et al. 2011 [46] (10)

Telemonitoring Structured telephone support

Klersy et al. 2011 [47] (7)

Remote monitoring

Exercise training

Lloyd-Williams et al. 2002 [48](5)

Exercise training

Clinic follow up / telephone contact

Lambrinou et al. 2012 [32] (9)

Telephone follow-up

Clinic follow-up

Combination of settings

Takeda et al. 2012 [33] (10)

Clinic care

Kozak et al. 2007 [43] (6)

Education for self-management before or after discharge

     Telephone contact

Mistiaen and Poot 2006 [49] (8)

Telephone follow-up

Phillips et al. 2005 [50] (8)

Specialist nurse-led clinics:

     With hospital discharge planning

     No hospital discharge planning

Whellan et al. 2005 [35] (3)

Discharge planning and disease management with

     Follow up with cardiologist supervision

     Follow up with primary care physician supervision

     Telephone follow up

Holland et al. 2005 [37] (8)

Multidisciplinary interventions

Phone/mailing

Hospital/clinic/general practice

Phillips et al. 2004 [40] (9)

Comprehensive discharge planning with

     Clinic follow up / frequent telephone contact

McAlister et al. 2004 [41] (6)

Multidisciplinary team providing care

     In clinic

     By telephone follow-up

Heran et al. 2011 [51] (10)

Exercise-based cardiac rehabilitation

     Follow-up of 6 to 12 months

     Follow-up of 12 months or more

McAlister et al. 2001 [52] (6)

Secondary prevention programs

McLean et al. 2011 [53] (9)

Telehealthcare (personalized care at a distance)

     Readmissions within 3 months

     Readmissions within 12 months

Tapp et al. 2007 [54] (10)

Education interventions for adults who attend the emergency room for acute asthma

Tsai et al. 2005 [34] (6)

All types of interventions to improve care for asthma

Gibson et al. 2002 [55] (10)

Self-management education of adults with asthma

Gillespie et al. 2012 [56] (11)

Outcome: number of people sustaining fractures:

     Exercise

     Vitamin D (with or without calcium)

     Multifactorial intervention after assessment

Beswick et al. 2008 [57] (7)

Falls prevention interventions and community based care after hospital discharge

Kim & Soeken 2005 [38] (7)

Inhospital assessment and education with phone follow-up

Fearon et al. 2012 [58] (11)

Early supported discharge services

Shepperd et al. 2009 [59] (10)

Hospital at home early discharge:

     Patients after a stroke at 3 months

Handoll et al. 2011 [60] (11)

Improving mobility after surgery for hip fractures:

     Resistance training – at 12 weeks

     Resistance training – at 12 months

     High dose weight bearing (HRR at 16 weeks)

Khan et al. 2008 [61] (9)

Home-based multidisciplinary rehabilitation programs after joint replacement in chronic arthropathy

Smeenk et al. 1998 [62] (6)

Home care for patients with incurable cancer

Kim & Soeken 2005 [38] (7)

Inhospital assessment and education with phone follow-up

Jeppesen et al. 2012 [63] (11)

Hospital at home for acute exacerbations

Puhan et al. 2011 [64] (9)

Respiratory rehabilitation after acute exacerbations

Wong et al. 2011 [10] (11)

Nurses visited patients' homes, provided support, education, and monitoring of health.

Lemmens et al. 2009 [65] (7)

Disease-management interventions.

Shepperd et al. 2009b [59] (10)

Hospital at home after early discharge

Effing et al. 2007 [66] (11)

Self-management education

Adams et al. 2007 [67] (7)

Chronic Care Model Multicomponent intervention

Self-management

Kim & Soeken 2005 [38] (7)

Inhospital assessment and education with phone follow-up

Conroy et al. 2011 [68] (9)

Comprehensive geriatric assessment at hospital aimed at rapid discharge with varying degrees of community support

Vázquez & Martines 2011 [69](6)

Inhospital and at home medication reconciliation to prevent adverse events

Elkan et al. 2001 [70] (10)

Home visiting programs that offer health promotion and preventive care to older people.

Shepperd et al. 2009 [59] (10)

Hospital at home early discharge: Older patients with a mix of conditions

Shepperd et al. 2009 [71] (8)

Avoiding hospital admission through provision of hospital care at home

Latour et al. 2007 [72] (7)

Nurse-led case management for ambulatory complex patients in general health care

Kripalani et al. 2007 [73] (5)

Interventions to enhance medication adherence

Royal et al. 2006 [74] (10)

Pharmacists-led interventions in primary care to reduce medication related adverse events

Kim & Soeken 2005 [38] (7)

Inhospital assessment of frail patients with follow up by phone and home visits

Parker et al. 2002 [18] (9)

Discharge arrangements in hospital and/or in the community after discharge from hospital care.

     Both in hospital and in the patient’s home

     Patient’s home only

     Patient education and home follow up.

Mitchell et al. 2002 [75] (4)

Primary medical practitioner involvement with a specialist team

Hyde et al. 2000 [76] (6)

Supported discharge after acute admission of older patients. Home visits, with or without rehabilitation, commencing 1 week after discharge.

Stuck et al. 1993 [30] (6)

Comprehensive geriatric assessment.

     Home assessment service

     Hospital and home assessment service

     Outpatient assessment service