Transition of Care for Acute Stroke and Myocardial Infarction Patients

Despite advances in the quality of acute-care management of stroke and myocardial infarction (MI), there are gaps in knowledge about effective interventions to better manage the transition of care for patients with these complex health conditions. Transition of care is defined as "a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location," and is often provided by interdisciplinary teams of professionals. Indicators of potential transition problems include avoidable rehospitalizations and emergency room visits as well as poor functional status and quality of life. The first challenge of this systematic review was to consider the pathways for the transition of care. Transitions may include those that are direct to the outpatient environment as well as those to and from intermediate care environments. In addition, the components of transition of care may occur separately or in aggregate, which makes it important to know how the components are categorized and described within a clear taxonomy. The second challenge was to dissect those data relevant to the disease states of interest. The incidence of stroke and MI increases with age, as does the presence of other chronic conditions that may be driving downstream outcomes. Also, stroke and MI are not exclusively diseases of the elderly, so it is fundamental to explore stroke and MI transitions within the population as a whole as well as in the older or chronically ill population. While both stroke and MI result from disorders of the vascular system-and as such share many common risk factors-each medical condition presents unique challenges regarding transitions across care settings. Stroke patients more often transition from hospital to inpatient rehabilitation facilities, nursing homes for rehabilitation or palliative care, or home health services. Also, patients with stroke have more long-term physical disability and cognitive impairments that may require rehabilitative services or long-term institutional support. In contrast, patients with MI are more likely to be discharged directly home and receive outpatient transition of care services. Additionally, patients with stroke are more likely to be older, female, and African American than are patients with MI. As part of this systematic review, we explored features of transition of care that are common to both vascular disorders as well as features that are unique to disease-specific needs. The key questions considered in this review include: KQ1. For patients hospitalized with first or recurrent stroke or myocardial infarction (MI), what are the key components of transition of care services? Can these components be grouped in a taxonomy, and are they based on a particular theory? KQ2. For patients hospitalized with first or recurrent stroke or MI, do transition of care services improve functional status and quality of life and reduce hospital readmission, morbidity, and mortality (up to 1 year postevent)? KQ3. For patients hospitalized with first or recurrent stroke or MI, what are the associated risks, adverse events, or potential harms-both system-based and patient based- of transition of care services? KQ4. Do transition of care services improve aspects of systems of care for patients with stroke or MI ? Is there improved coordination among multiple subspecialty care providers, and are new providers added to the care plan as a result of transition of care services? KQ5. For patients hospitalized with first or recurrent stroke or MI, do benefits and harms of transition of care services vary by characteristics-both patient-based and system-based-such as disease etiology and severity, comorbidities, sociodemographic factors, training of the health care providers, participants (patients, caregivers), geography (rural/urban, regional variations), and insurance status?