Discussion
This systematic review presents the effects of TCi on quality of care,
clinical outcomes and healthcare services use outcomes among older
adults transferring from the acute care to the LTCF setting. Medications
problems (quality of care), hospital readmission and ED visits
(healthcare services use) and hospital days (healthcare services use)
were the most documented outcomes, with data from six, six and five
studies respectively. The reported results were however inconsistent.
Medications problems as an outcome seemed nevertheless to hold the most
promising results, with four individual studies out of six reporting
significantly favorable results with TCi.12,16,27,28Additionally, high levels of satisfaction were achieved with TCi.
Our results show that medications problem outcomes are the most likely
to be reported as benefiting from TCi. Indeed, medications problems
could represent an important target to improve care during transitions
from acute care to LTC. More studies investigating more closely this
outcome would be needed to confirm these results. Yet, previous studies
reported that adverse drug events attributable to medication changes
occur in 20% of patients going from acute care to
LTC,31 with medication errors occurring during these
transitions as being most harmful to patients.32 In
the context where information gaps are reported in over 85% of
transfers between ED and LTC,33 this suggests that
medications problems might be addressed by improving communication.
Indeed, all four interventions where the situation improved
significantly involved a specific discharge summary or communication
form sent to the LTC setting before or at the time of patient transfer.
These interventions further emphasized the importance of medication
clarification, either through a formal medication
reconciliation16,27,28 or via completion and
transmission of a discharge prescriptions form.12 It
is worth noting that these four studies also involved a pharmacist as
key healthcare professional in carrying out the
intervention.12,16,27,28 Of the studies where no
effect was reported, one used fax as a communication
strategy,18 and important concerns have been raised
about the use of this technology.34 The other was a
quality improvement pilot study that was possibly insufficiently powered
to detect a significant change (10 patients in each group). The authors
of this pilot study raised the issue of a possible unsuccessful
implementation of the intervention and important group differences,
notably in their health status and medication orders
patterns.20
Our results further suggested that increased communication between
hospitals and LTC, including medication reconciliation or specific
transfer forms, was not enough to decrease healthcare services use
(hospital readmission and ED visits, hospital days). In this regard, the
timing of the communication might be a key element to consider. Indeed,
the recommendations to improve transitional care were not only to
increase the communication per se but rather to “facilitate the timely
transfer of essential information across settings”.7In the case of the acute care to LTCF transition, this “timely”
criterion could translate into the early transmission of the medications
list before discharge, to ensure that the medications are ready to be
administered upon patient’s arrival and to avoid delayed
doses.12 This would further allow LTCF’s physicians
time to review the patients’ chart and status at an appropriate time
rather than through an urgent visit or via a locum
tenens.12
Among the frail population residing in LTC, transfers to the acute care
setting are challenging and stressful life events.8This is especially true for cognitively impaired
patients,35 who constitute between 45-84% of the LTC
population.1,36 To address this issue, upstream
interventions aiming to reduce potentially avoidable transfers to acute
care are warranted.8,37 Admissions to acute care,
however, cannot always be prevented, and may continue to represent a
part of the care trajectory for some patients,13,14with a 2000 study suggesting that 60% of hospital admissions are
necessary and recommended.15 As part of quality
improvement initiatives, several LTCFs worldwide have implemented
interventions to reduce potentially avoidable hospital
admissions,38 and TCi between these two care settings
remain a highly relevant research area. The characteristics and
particular components of impactful and efficient TCi in this specific
context are still to be determined.
Our study also highlights the high levels of satisfaction reported by
patients, caregiver and physicians with TCi. Enhanced continuity of care
associated with TCi is particularly valued by older vulnerable patients,
and can foster a strong foundation for a better communication with
patients, and caregivers. It can also result in a greater sense of
security and trust in the healthcare system overall.39In our review, the three studies reporting high satisfaction involved
either phone calls or in-person support and sharing of
information.12,29,30 Additionally, gaps in information
exchange during transitions resulting in missing data from the medical
charts of transferred patients can lead to frustration, increased
work-stress and feelings of inadequacy and guilt among healthcare
professionals working in LTC.10 TCi focusing on
improving inter-facility communication are therefore also warranted.
This review has many strengths, starting with its systematic design and
exhaustive literature search. Another strength is the fact that we
focused specifically at TCi for older patients transitioning from acute
care to LTC setting. Our review’s principle limitation stems from
heterogeneity in both the outcomes reported from each study and in the
various tools used as interventions. This prevented us from conducting a
meta-analysis and pooling results, but it did allow for a narrative
synthesis that provides a rich and in-depth overview of the available
relevant literature. Our study also suffered from a paucity of eligible
articles in our sample. We identified only 11 studies, among which only
2 were randomized trials, whereas reviews reporting on TCi in other
settings are usually much larger, with some reporting on up to 92
studies.22 Our small sample also limited our pooling
possibilities and further highlights the need for more TCi studies
targeting transfers to the LTC setting. Lastly, our sample quality
appraisal MMAT scoring revealed reporting issues among several studies
in our sample, with 4 studies receiving at least one negative MMAT item
response, and a total of 7 where it was unclear whether or not an MMAT
criterion was satisfied. P-values were also not routinely reported.
Future studies should aim to report standardized outcomes and their
related p-values, using validated and relevant indicators to facilitate
the pooling of data. Authors should also strengthen their efforts
towards higher quality of reporting.
Conclusions and
implications
TCi targeting older adults being transferred from acute care to the LTC
setting aim to improve the transitions for the most vulnerable among the
geriatric population.1 Our review, however, was able
to identify only a limited number of relevant studies, in spite of
conducting an exhaustive search, and found that the literature is
fraught with inconsistent results. In the identified interventions, a
focus on medication reconciliation and timely intra-institutional
communication appear to be important components that improve the acute
care to LTCF transitions in this population. Future research should
include well-designed large-scale TCi using standardized and validated
outcome measures in order to improve our understanding of the effects of
TCi on LTC patients being discharged from acute care.