Transition of care for acute stroke and myocardial infarction patients: from hospitalization to rehabilitation, recovery, and secondary prevention

Olson DM, Prvu Bettger J, Alexander KP, Kendrick AS, Irvine JR, Wing L, Coeytaux RR, Dolor RJ, Duncan PW, Graffagnino C
Record ID 32010000181
Authors' objectives:

To review the available published literature to assess whether evidence supports a beneficial role for coordinated transition of care services for the postacute care of patients hospitalized with first or recurrent stroke or myocardial infarction (MI). This review was framed around five areas of investigation: (1) key components of transition of care services, (2) evidence for improvement in functional outcomes, morbidity, mortality, and quality of life, (3) associated risks or potential harms, (4) evidence for improvement in systems of care, and (5) evidence that benefits and harms vary by patient-based or system-based characteristics.

Authors' recomendations: Although a basis for the definition of transition of care exists, more consensus is needed on the definition of the interventions and the outcomes appropriate to those interventions.There was limited evidence that two components of hospital-initiated support for discharge (early supported discharge after stroke and specialty care followup after MI) were associated with beneficial effects. No other interventions had sufficient evidence of benefit based on the findings of this systematic review. The adoption of a standard set of definitions, a refinement in the methodology used to study transition of care, and appropriate selection of patient-centered and policy-relevant outcomes should be employed to draw valid conclusions pertaining to specific components of transition of care.
Project Status: Completed
Year Published: 2011
English language abstract: An English language summary is available
Publication Type: Not Assigned
Country: United States
MeSH Terms
  • Myocardial Infarction
  • Patient Discharge
  • Rehabilitation
  • Secondary Prevention
  • Stroke
Organisation Name: Agency for Healthcare Research and Quality
Contact Address: Center for Outcomes and Evidence Technology Assessment Program, 540 Gaither Road, Rockville, MD 20850, USA. Tel: +1 301 427 1610; Fax: +1 301 427 1639;
Contact Name:
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Copyright: Agency for Healthcare Research and Quality (AHRQ)
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