Can individual caseworker-assigned discharge plans reduce readmissions for acute exacerbations in children with chronic respiratory disease?

Background

Acute exacerbations (flare-ups) of long-term breathing diseases in children leads to high use of health resources and poor quality of life for children and their families. Providing extra support and education to a child and his/her family during a hospitalisation for an acute flare-up may improve their quality of life and reduce future healthcare visits. A caseworker assigned to each child during a hospital admission may help provide individual education and discharge planning and ongoing support once the child has been discharged. We reviewed whether individualised case management support services during and following hospitalisation for acute flare-ups of long-term breathing diseases in children is beneficial. Specifically, we wanted to know if caseworkers can help prevent further hospital admissions and reduce the number of visits to other health services such as emergency departments and general practitioners.

Review question

Do individualised, caseworker-assigned discharge management plans prevent hospital readmissions for acute flare-ups in children with long-term breathing diseases?

Study characteristics

We included all randomised controlled trials (a type of study in which participants are assigned to a treatment group using a random method) that assessed whether those who received individualised caseworker discharge planned management (the intervention group) had better outcomes compared to those who received usual care (the control group). We considered the number of hospital readmissions, emergency department visits, and/or unscheduled general practitioner visits following discharge.

The evidence is current to 15 November 2017.

We found four studies that included 773 children aged 14 months to 16 years. All the studies involved children with asthma. The programme used for the discharge plan differed among the studies, but all were delivered by a trained asthma educator (lay health worker or nurse specifically trained on educating patients with asthma). The studies followed the children for 2 to 14 months after discharge. We could only include data from two studies in a combined analysis (i.e. the meta-analysis), as the other two studies also enrolled children who were not hospitalised, and we could not obtain data specific to the children who were hospitalised and one of those studies included children with acute wheezing illness( no previous asthma diagnosis); the data specific to this review could not be obtained.

Key results

In this review involving children hospitalised with asthma flare-ups, trained asthma educator-led and structured discharge plans that included follow-up support (compared to the control group) reduced the number of hospital readmissions for acute asthma. No clear benefit was seen on future emergency department or general practitioner visits for acute asthma. Data on cost-effectiveness, length of stay of future hospitalisations, and adherence to discharge medications were not available. One study reported quality of life and found no differences between the intervention and control group. There were no studies relating to other long-term breathing diseases.

Conclusions

Individual caseworker-assigned discharge planned management, as compared to non-caseworker-assigned management, may prevent readmissions to hospital for asthma flare-ups in children. However, the current evidence is limited to only two studies in children with asthma. Further studies are needed in a broad range of long-term breathing diseases in childhood.

Quality of the evidence

We considered the quality of the evidence to be moderate for the outcome of hospital readmissions and low for the outcomes of future emergency department visits and general practitioner consultations for asthma flare-ups.

Authors' conclusions: 

Current evidence suggests that individual caseworker-assigned discharge plans, as compared to non-caseworker-assigned plans, may be beneficial in preventing hospital readmissions for acute exacerbations in children with asthma. There was no clear indication that the intervention reduces emergency department and general practitioner attendances for asthma, and there is an absence of data for children with other chronic respiratory conditions. Given the potential benefit and cost savings to the healthcare sector and families if hospitalisations and outpatient attendances can be reduced, there is a need for further randomised controlled trials encompassing different chronic respiratory illnesses, ethnicity, socio-economic settings, and cost-effectiveness, as well as defining the essential components of a complex intervention.

Read the full abstract...
Background: 

Chronic respiratory conditions are major causes of mortality and morbidity. Children with chronic health conditions have increased morbidity associated with their physical, emotional, and general well-being. Acute respiratory exacerbations (AREs) are common in children with chronic respiratory disease, often requiring admission to hospital. Reducing the frequency of AREs and recurrent hospitalisations is therefore an important goal in the individual and public health management of chronic respiratory illnesses in children. Discharge planning is used to decide what a person needs for transition from one level of care to another and is usually considered in the context of discharge from hospital to the home. Discharge planning from hospital for ongoing management of an illness has historically been referral to a general practitioner or allied health professional or self management by the individual and their family with limited communication between the hospital and patient once discharged. Effective discharge planning can decrease the risk of recurrent AREs requiring medical care. An individual caseworker-assigned discharge plan may further decrease exacerbations.

Objectives: 

To evaluate the efficacy of individual caseworker-assigned discharge plans, as compared to non-caseworker-assigned plans, in preventing hospitalisation for AREs in children with chronic lung diseases such as asthma and bronchiectasis.

Search strategy: 

We searched the Cochrane Airways Group Specialised Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trials registries, and reference lists of articles. The latest searches were undertaken in November 2017.

Selection criteria: 

All randomised controlled trials comparing individual caseworker-assigned discharge planning compared to traditional discharge-planning approaches (including self management), and their effectiveness in reducing the subsequent need for emergency care for AREs (hospital admissions, emergency department visits, and/or unscheduled general practitioner visits) in children hospitalised with an acute exacerbation of chronic respiratory disease. We excluded studies that included children with cystic fibrosis.

Data collection and analysis: 

We used standard Cochrane Review methodological approaches. Relevant studies were independently selected in duplicate. Two review authors independently assessed trial quality and extracted data. We contacted the authors of one study for further information.

Main results: 

We included four studies involving a total of 773 randomised participants aged between 14 months and 16 years. All four studies involved children with asthma, with the case-planning undertaken by a trained nurse educator. However, the discharge planning/education differed among the studies. We could include data from only two studies (361 children) in the meta-analysis. Two further studies enrolled children in both inpatient and outpatient settings, and one of these studies also included children with acute wheezing illness (no previous asthma diagnosis); the data specific to this review could not be obtained. For the primary outcome of exacerbations requiring hospitalisation, those in the intervention group were significantly less likely to be rehospitalised (odds ratio (OR) 0.29, 95% confidence interval (CI) 0.16 to 0.50) compared to controls. This equates to 189 (95% CI 124 to 236) fewer admissions per 1000 children. No adverse events were reported in any study. In the context of substantial statistical heterogeneity between the two studies, there were no statistically significant effects on emergency department (OR 0.37, 95% CI 0.04 to 3.05) or general practitioner (OR 0.87, 95% CI 0.22 to 3.44) presentations. There were no data on cost-effectiveness, length of stay of subsequent hospitalisations, or adherence to medications. One study reported quality of life, with no significant differences observed between the intervention and control groups.

We considered three of the studies to have an unclear risk of bias, primarily due to inadequate description of the blinding of participants and investigators. The fourth study was assessed as at high risk of bias as a single unblinded investigator was used. Using the GRADE system, we assessed the quality of the evidence as moderate for the outcome of hospitalisation and low for the outcomes of emergency department visits and general practitioner consultations.

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