Pediatric Discharge Systematic Review

Search Strategy

With the assistance of a research librarian, we searched MEDLINE and CINAHL (Cumulative Index to Nursing and Allied Health Literature) from the inception of these databases through to March 28, 2012 (for search strategies, see the Supporting Information, Appendix, Part 1, in the online version of this article).

Study Selection

Two authors (K.A. and C.K.) independently reviewed abstracts identified by the initial search, as well as abstracts of references of included articles. Eligibility criteria for inclusion in full review included: (1) discharge‐oriented process or intervention initiated in the inpatient setting, (2) study outcomes related to subsequent utilization including hospital readmission or emergency department visit after hospitalization, (3) child‐ or adolescent‐focused or child‐specific results presented separately, and (4) written or available in English. If abstract review did not sufficiently clarify whether all eligibility criteria were met, the article was included in the full review. Two authors (K.A. and C.K.) independently reviewed articles meeting criteria for full review to determine eligibility. Disagreements regarding inclusion in the final analysis were discussed with all 4 authors. We excluded studies in countries with low or lower‐middle incomes,[15] as discharge interventions in these countries may not be broadly applicable.

Data Abstraction, Quality Assessment, and Data Synthesis

Two authors (K.A. and C.K.) independently abstracted data using a modified Cochrane Collaboration data collection form.[16] We independently scored the included studies using the Downs and Black checklist, which assesses the risk of bias and the quality of both randomized and nonrandomized studies.[17] This checklist yields a composite score of 0 to 28 points, excluding the item assessing power. As many studies either lacked power calculations or included power calculations based on outcomes not included in our review, we performed calculations to determine the sample size needed to detect a decrease in readmission or ED utilization by 20% from baseline or control rates. Due to the heterogeneous nature of included studies in terms of population, interventions, study design, and outcomes, meta‐analysis was not performed.

Patient Populations and Intervention Timing and Components

Studies varied regarding the specific medical conditions they evaluated. Eight of the papers reported discharge interventions for children with asthma, 5 papers focused on discharge from the neonatal intensive care unit (NICU), and a final study discussed a discharge intervention for children with cancer (Table 1). Although our primary goal was to synthesize discharge interventions across pediatric conditions, we provide a summary of discharge interventions by condition (see Supporting Information, Appendix, Part 3, in the online version of this article).

Studies varied regarding the timing and nature of the intervention components. Eight discharge interventions included a major inpatient component, in addition to outpatient support or follow‐up.[21, 23, 24, 25, 26, 29, 32, 34] Two studies included an inpatient education component only.[22, 27] The remainder were initiated during index hospitalization but focused primarily on home visitation, enhanced follow‐up, and support after discharge (Figure 2).[28, 30, 31, 33]

Figure 2

Outcome Assessment Methods

Readmission and subsequent ED utilization events were identified using multiple techniques. Some authors accessed claims records to capture all outcomes.[30, 33] Others relied on chart review.[21, 25, 26, 27, 28, 31, 32] One study supplemented hospital records with outpatient records.[24] Some investigators used parental reports.[22, 23, 31] Two studies did not describe methods for identifying postdischarge events.[29, 34]

Study Quality

The quality of the included studies varied (Table 2). Many of the studies had inadequate sample size to detect a difference in either readmission or ED visit subsequent to discharge. Eight studies found differences in either subsequent ED utilization, hospitalization, or both and were considered adequately powered for these specific outcomes.[21, 23, 25, 26, 28, 30, 31, 32] In contrast, among studies with readmission as an outcome, 6 were not adequately powered to detect a difference in this particular outcome.[24, 30, 31, 32, 33, 34] In these 6 studies, all except 1 study³⁰ had <10% of the sample size required to detect differences in readmission. Further, 2 studies that examined ED utilization were underpowered to detect differences between intervention and control groups.[24, 26] We were unable to perform power calculations for 3 studies,[22, 27, 29] as the authors presented the number of events without clear denominators.

Excluding the assessment of statistical power, Downs and Black scores ranged from 10 to 23 (maximum 28 possible points) indicating varying quality. As would be expected with discharge interventions, studies did not blind participants; 2 studies did, however, appropriately blind the outcome evaluators to intervention assignment.[22, 30] Even though 10 out of the 14 studies were randomized controlled trials, randomization may not have been completely effective due to sample size being too small for effective randomization,[31] large numbers of excluded subjects after randomization,[30] and unclear randomization process.[34] Several studies had varying follow‐up periods for patients within a given study. For example, 3 NICU studies assessed readmission at 1‐year corrected age,[30, 31, 33] creating the analytic difficulty that the amount of time a given patient was at risk for readmission was dependent on when the patient was discharged, yet this was not accounted for in the analyses. Only 2 studies demonstrated low rates of loss to follow‐up (<10%).[30, 33] The remainder of the studies either had high incompletion/loss to follow‐up rates (>10%)[22, 24, 31] or did not report rates.[21, 23, 25, 26, 27, 28, 29, 32, 34] Finally, 3 studies recruited patients from multiple sites,[24, 31, 33] and none adjusted for potential differences in effect based on enrollment site.

Findings Across Patient Populations Regarding Readmission

Of the 4 studies that demonstrated change in overall readmission,[23, 25, 26, 28] all were asthma focused; 3 demonstrated a decrease in readmissions,[23, 25, 26] and 1 an increase in readmissions.[28] The 3 effective interventions included 1‐on‐1 inpatient education delivered by an asthma nurse, in addition to postdischarge follow‐up support, either by telephone or clinic visit. Two of these interventions provided rescue oral steroids to some patients on discharge.[25, 26] In contrast, a study from New Zealand evaluated a series of postdischarge visits using an existing public health nurse infrastructure and demonstrated an increase in readmission between 6 to 18 months after admission in European children.[28] An additional study focused on outpatient support after discharge from the NICU, and demonstrated a lower frequency of readmission to the intensive care unit without overall reduction of hospital readmission (Tables 1 and 2).[30]

Findings Across Patient Populations Regarding Subsequent ED Visits

Of all the discharge interventions, 6 demonstrated differences in return to the ED after discharge. Five studies described a decrease in ED visits after hospitalization,[23, 25, 30, 31, 32] and 1 showed an increase.[21] Three studies in the NICU population demonstrated decreased ED utilization through a combination of augmented family engagement during hospitalization and/or enhanced support after discharge. Two inpatient asthma education interventions with structured postdischarge follow‐up decreased return visitation to the ED.[23, 26] The intervention that worsened subsequent ED utilization (ie, increased ED visit hazard compared to matched controls) provided enhanced inpatient education to a nonrandom group of children hospitalized with asthma and provided a follow‐up phone call 3 weeks after discharge (Tables 1 and 2).[21]

Current Conceptual Framework

There are a number of existing discharge transitional care frameworks from prior studies[35, 36] and professional societies.[37] The Stepping Up to the Plate (SUTTP) alliance, a collaborative of 9 professional organizations, including the American Academy of Pediatrics, introduced 1 such framework in 2007. SUTTP sought to enhance care transitions by outlining principles of discharge transitional care including: (1) enhanced accountability, (2) creation of a central coordination hub charged with communicating expectations for care, (3) clear and direct communication of treatment plans and follow‐up, (4) timely feedback/feed‐forward of relevant information, and (5) involvement of family member at every stage.[38] In the context of the SUTTP framework, we present 3 hypotheses based on our findings to guide future work.

Persistent Literature Gaps

Follow‐up with a primary care provider after discharge is another intervention that might decrease postdischarge utilization. We did not identify any studies that specifically examined primary care follow‐up. However, 2 studies[43, 44] that did not meet our inclusion criteria (because they included adults and did not stratify by age group in the analysis) examined any outpatient follow‐up after discharge using state‐specific Medicaid claims. One study found that outpatient follow‐up after sickle cell hospitalization was associated with lower rates of readmission.[43] The other found no difference in readmission across multiple conditions.[44] One recent review of outpatient follow‐up from the ED for asthma found that even when increases in follow‐up were achieved, no reduction in the subsequent utilization was observed.[45]

Additional important questions remain underexplored. First, are condition‐specific interventions superior to those that span conditions? All of the interventions that demonstrated reductions in readmission were condition‐specific, yet no generic interventions met our inclusion criteria. Importantly, only 1 study[29] in our review examined discharge processes from 1 of the pediatric conditions with the most variation[8] in readmission. Further, no studies focused on children with complex medical conditions, who are known to be at increased risk of readmission,[46] indicating a sizable knowledge gap persists in understanding how to prevent readmissions in the most vulnerable pediatric populations.

Lastly, who are the most appropriate effector individuals for discharge‐focused transitional care interventions? Demographically matched effector individuals have shown promise in improving care using community health workers.[47, 48] The degree to which the identity of the intervener mediates subsequent ED and hospital utilization warrants further investigation.

Limitations of This Systematic Review

The studies included in this review assessed different outcomes at different intervals, precluding meta‐analysis. With greater consistency in the collection of data on the quality of discharge processes and their subsequent outcomes, future studies may offer further clarity as to which discharge‐oriented practices are more effective than others. Because we only identified literature in 3 pediatric conditions, generalizability beyond these conditions may be limited. The settings of the interventions also occurred in multiple countries; we excluded countries from low or low‐middle incomes to facilitate generalizability. As many of the discharge processes contained multiple interventions, it is not possible to ascertain which, if any, singular action may decrease posthospitalization utilization. Additionally, some of the included interventions are older, and it is plausible that discharge processes have evolved with the expansion of the hospitalist model.

Methods of data collection influence the quality of results in the included studies. Most of the studies included in this review used either medical record review or parental self‐report of utilization. Parental report may be sufficient for hospitalizations and ED utilization; however, it is subject to recall bias. Chart review likely underestimates the number of postdischarge events, depending on the individual institution's proportion of the market and the tendency of individuals to seek care at multiple institutions. Claims data may offer the most accurate assessments of ED and hospital utilization and cost, but can be more difficult to obtain and do not provide the same potential for granularity as parent report or medical records review.

Finally, subsequent ED visits, readmissions, and cost may not be the best measures of the quality of discharge transitional care. A number of tools have been developed to more specifically evaluate the quality of transitional care in adults,[49, 50] including a validated instrument that consists of only 3 items,[50] which primarily assesses the extent to which patients are prepared for self‐care upon discharge. For pediatric populations, validated tools assessing caregiver experience with discharge[51] and discharge readiness[52] are also available. These instruments may assist those interested in assessing process‐related outcomes that specifically assess discharge transitional care elements and may mediate subsequent ED visits or hospitalizations.

Search Strategy

With the assistance of a research librarian, we searched MEDLINE and CINAHL (Cumulative Index to Nursing and Allied Health Literature) from the inception of these databases through to March 28, 2012 (for search strategies, see the Supporting Information, Appendix, Part 1, in the online version of this article).

Study Selection

Two authors (K.A. and C.K.) independently reviewed abstracts identified by the initial search, as well as abstracts of references of included articles. Eligibility criteria for inclusion in full review included: (1) discharge‐oriented process or intervention initiated in the inpatient setting, (2) study outcomes related to subsequent utilization including hospital readmission or emergency department visit after hospitalization, (3) child‐ or adolescent‐focused or child‐specific results presented separately, and (4) written or available in English. If abstract review did not sufficiently clarify whether all eligibility criteria were met, the article was included in the full review. Two authors (K.A. and C.K.) independently reviewed articles meeting criteria for full review to determine eligibility. Disagreements regarding inclusion in the final analysis were discussed with all 4 authors. We excluded studies in countries with low or lower‐middle incomes,[15] as discharge interventions in these countries may not be broadly applicable.

Data Abstraction, Quality Assessment, and Data Synthesis

Two authors (K.A. and C.K.) independently abstracted data using a modified Cochrane Collaboration data collection form.[16] We independently scored the included studies using the Downs and Black checklist, which assesses the risk of bias and the quality of both randomized and nonrandomized studies.[17] This checklist yields a composite score of 0 to 28 points, excluding the item assessing power. As many studies either lacked power calculations or included power calculations based on outcomes not included in our review, we performed calculations to determine the sample size needed to detect a decrease in readmission or ED utilization by 20% from baseline or control rates. Due to the heterogeneous nature of included studies in terms of population, interventions, study design, and outcomes, meta‐analysis was not performed.

Patient Populations and Intervention Timing and Components

Studies varied regarding the specific medical conditions they evaluated. Eight of the papers reported discharge interventions for children with asthma, 5 papers focused on discharge from the neonatal intensive care unit (NICU), and a final study discussed a discharge intervention for children with cancer (Table 1). Although our primary goal was to synthesize discharge interventions across pediatric conditions, we provide a summary of discharge interventions by condition (see Supporting Information, Appendix, Part 3, in the online version of this article).

Studies varied regarding the timing and nature of the intervention components. Eight discharge interventions included a major inpatient component, in addition to outpatient support or follow‐up.[21, 23, 24, 25, 26, 29, 32, 34] Two studies included an inpatient education component only.[22, 27] The remainder were initiated during index hospitalization but focused primarily on home visitation, enhanced follow‐up, and support after discharge (Figure 2).[28, 30, 31, 33]

Figure 2

Outcome Assessment Methods

Readmission and subsequent ED utilization events were identified using multiple techniques. Some authors accessed claims records to capture all outcomes.[30, 33] Others relied on chart review.[21, 25, 26, 27, 28, 31, 32] One study supplemented hospital records with outpatient records.[24] Some investigators used parental reports.[22, 23, 31] Two studies did not describe methods for identifying postdischarge events.[29, 34]

Study Quality

The quality of the included studies varied (Table 2). Many of the studies had inadequate sample size to detect a difference in either readmission or ED visit subsequent to discharge. Eight studies found differences in either subsequent ED utilization, hospitalization, or both and were considered adequately powered for these specific outcomes.[21, 23, 25, 26, 28, 30, 31, 32] In contrast, among studies with readmission as an outcome, 6 were not adequately powered to detect a difference in this particular outcome.[24, 30, 31, 32, 33, 34] In these 6 studies, all except 1 study³⁰ had <10% of the sample size required to detect differences in readmission. Further, 2 studies that examined ED utilization were underpowered to detect differences between intervention and control groups.[24, 26] We were unable to perform power calculations for 3 studies,[22, 27, 29] as the authors presented the number of events without clear denominators.

Excluding the assessment of statistical power, Downs and Black scores ranged from 10 to 23 (maximum 28 possible points) indicating varying quality. As would be expected with discharge interventions, studies did not blind participants; 2 studies did, however, appropriately blind the outcome evaluators to intervention assignment.[22, 30] Even though 10 out of the 14 studies were randomized controlled trials, randomization may not have been completely effective due to sample size being too small for effective randomization,[31] large numbers of excluded subjects after randomization,[30] and unclear randomization process.[34] Several studies had varying follow‐up periods for patients within a given study. For example, 3 NICU studies assessed readmission at 1‐year corrected age,[30, 31, 33] creating the analytic difficulty that the amount of time a given patient was at risk for readmission was dependent on when the patient was discharged, yet this was not accounted for in the analyses. Only 2 studies demonstrated low rates of loss to follow‐up (<10%).[30, 33] The remainder of the studies either had high incompletion/loss to follow‐up rates (>10%)[22, 24, 31] or did not report rates.[21, 23, 25, 26, 27, 28, 29, 32, 34] Finally, 3 studies recruited patients from multiple sites,[24, 31, 33] and none adjusted for potential differences in effect based on enrollment site.

Findings Across Patient Populations Regarding Readmission

Of the 4 studies that demonstrated change in overall readmission,[23, 25, 26, 28] all were asthma focused; 3 demonstrated a decrease in readmissions,[23, 25, 26] and 1 an increase in readmissions.[28] The 3 effective interventions included 1‐on‐1 inpatient education delivered by an asthma nurse, in addition to postdischarge follow‐up support, either by telephone or clinic visit. Two of these interventions provided rescue oral steroids to some patients on discharge.[25, 26] In contrast, a study from New Zealand evaluated a series of postdischarge visits using an existing public health nurse infrastructure and demonstrated an increase in readmission between 6 to 18 months after admission in European children.[28] An additional study focused on outpatient support after discharge from the NICU, and demonstrated a lower frequency of readmission to the intensive care unit without overall reduction of hospital readmission (Tables 1 and 2).[30]

Findings Across Patient Populations Regarding Subsequent ED Visits

Of all the discharge interventions, 6 demonstrated differences in return to the ED after discharge. Five studies described a decrease in ED visits after hospitalization,[23, 25, 30, 31, 32] and 1 showed an increase.[21] Three studies in the NICU population demonstrated decreased ED utilization through a combination of augmented family engagement during hospitalization and/or enhanced support after discharge. Two inpatient asthma education interventions with structured postdischarge follow‐up decreased return visitation to the ED.[23, 26] The intervention that worsened subsequent ED utilization (ie, increased ED visit hazard compared to matched controls) provided enhanced inpatient education to a nonrandom group of children hospitalized with asthma and provided a follow‐up phone call 3 weeks after discharge (Tables 1 and 2).[21]

Current Conceptual Framework

There are a number of existing discharge transitional care frameworks from prior studies[35, 36] and professional societies.[37] The Stepping Up to the Plate (SUTTP) alliance, a collaborative of 9 professional organizations, including the American Academy of Pediatrics, introduced 1 such framework in 2007. SUTTP sought to enhance care transitions by outlining principles of discharge transitional care including: (1) enhanced accountability, (2) creation of a central coordination hub charged with communicating expectations for care, (3) clear and direct communication of treatment plans and follow‐up, (4) timely feedback/feed‐forward of relevant information, and (5) involvement of family member at every stage.[38] In the context of the SUTTP framework, we present 3 hypotheses based on our findings to guide future work.

Persistent Literature Gaps

Follow‐up with a primary care provider after discharge is another intervention that might decrease postdischarge utilization. We did not identify any studies that specifically examined primary care follow‐up. However, 2 studies[43, 44] that did not meet our inclusion criteria (because they included adults and did not stratify by age group in the analysis) examined any outpatient follow‐up after discharge using state‐specific Medicaid claims. One study found that outpatient follow‐up after sickle cell hospitalization was associated with lower rates of readmission.[43] The other found no difference in readmission across multiple conditions.[44] One recent review of outpatient follow‐up from the ED for asthma found that even when increases in follow‐up were achieved, no reduction in the subsequent utilization was observed.[45]

Additional important questions remain underexplored. First, are condition‐specific interventions superior to those that span conditions? All of the interventions that demonstrated reductions in readmission were condition‐specific, yet no generic interventions met our inclusion criteria. Importantly, only 1 study[29] in our review examined discharge processes from 1 of the pediatric conditions with the most variation[8] in readmission. Further, no studies focused on children with complex medical conditions, who are known to be at increased risk of readmission,[46] indicating a sizable knowledge gap persists in understanding how to prevent readmissions in the most vulnerable pediatric populations.

Lastly, who are the most appropriate effector individuals for discharge‐focused transitional care interventions? Demographically matched effector individuals have shown promise in improving care using community health workers.[47, 48] The degree to which the identity of the intervener mediates subsequent ED and hospital utilization warrants further investigation.

Limitations of This Systematic Review

The studies included in this review assessed different outcomes at different intervals, precluding meta‐analysis. With greater consistency in the collection of data on the quality of discharge processes and their subsequent outcomes, future studies may offer further clarity as to which discharge‐oriented practices are more effective than others. Because we only identified literature in 3 pediatric conditions, generalizability beyond these conditions may be limited. The settings of the interventions also occurred in multiple countries; we excluded countries from low or low‐middle incomes to facilitate generalizability. As many of the discharge processes contained multiple interventions, it is not possible to ascertain which, if any, singular action may decrease posthospitalization utilization. Additionally, some of the included interventions are older, and it is plausible that discharge processes have evolved with the expansion of the hospitalist model.

Methods of data collection influence the quality of results in the included studies. Most of the studies included in this review used either medical record review or parental self‐report of utilization. Parental report may be sufficient for hospitalizations and ED utilization; however, it is subject to recall bias. Chart review likely underestimates the number of postdischarge events, depending on the individual institution's proportion of the market and the tendency of individuals to seek care at multiple institutions. Claims data may offer the most accurate assessments of ED and hospital utilization and cost, but can be more difficult to obtain and do not provide the same potential for granularity as parent report or medical records review.

Finally, subsequent ED visits, readmissions, and cost may not be the best measures of the quality of discharge transitional care. A number of tools have been developed to more specifically evaluate the quality of transitional care in adults,[49, 50] including a validated instrument that consists of only 3 items,[50] which primarily assesses the extent to which patients are prepared for self‐care upon discharge. For pediatric populations, validated tools assessing caregiver experience with discharge[51] and discharge readiness[52] are also available. These instruments may assist those interested in assessing process‐related outcomes that specifically assess discharge transitional care elements and may mediate subsequent ED visits or hospitalizations.

Search Strategy

With the assistance of a research librarian, we searched MEDLINE and CINAHL (Cumulative Index to Nursing and Allied Health Literature) from the inception of these databases through to March 28, 2012 (for search strategies, see the Supporting Information, Appendix, Part 1, in the online version of this article).

Study Selection

Two authors (K.A. and C.K.) independently reviewed abstracts identified by the initial search, as well as abstracts of references of included articles. Eligibility criteria for inclusion in full review included: (1) discharge‐oriented process or intervention initiated in the inpatient setting, (2) study outcomes related to subsequent utilization including hospital readmission or emergency department visit after hospitalization, (3) child‐ or adolescent‐focused or child‐specific results presented separately, and (4) written or available in English. If abstract review did not sufficiently clarify whether all eligibility criteria were met, the article was included in the full review. Two authors (K.A. and C.K.) independently reviewed articles meeting criteria for full review to determine eligibility. Disagreements regarding inclusion in the final analysis were discussed with all 4 authors. We excluded studies in countries with low or lower‐middle incomes,[15] as discharge interventions in these countries may not be broadly applicable.

Data Abstraction, Quality Assessment, and Data Synthesis

Two authors (K.A. and C.K.) independently abstracted data using a modified Cochrane Collaboration data collection form.[16] We independently scored the included studies using the Downs and Black checklist, which assesses the risk of bias and the quality of both randomized and nonrandomized studies.[17] This checklist yields a composite score of 0 to 28 points, excluding the item assessing power. As many studies either lacked power calculations or included power calculations based on outcomes not included in our review, we performed calculations to determine the sample size needed to detect a decrease in readmission or ED utilization by 20% from baseline or control rates. Due to the heterogeneous nature of included studies in terms of population, interventions, study design, and outcomes, meta‐analysis was not performed.

Patient Populations and Intervention Timing and Components

Studies varied regarding the specific medical conditions they evaluated. Eight of the papers reported discharge interventions for children with asthma, 5 papers focused on discharge from the neonatal intensive care unit (NICU), and a final study discussed a discharge intervention for children with cancer (Table 1). Although our primary goal was to synthesize discharge interventions across pediatric conditions, we provide a summary of discharge interventions by condition (see Supporting Information, Appendix, Part 3, in the online version of this article).

Studies varied regarding the timing and nature of the intervention components. Eight discharge interventions included a major inpatient component, in addition to outpatient support or follow‐up.[21, 23, 24, 25, 26, 29, 32, 34] Two studies included an inpatient education component only.[22, 27] The remainder were initiated during index hospitalization but focused primarily on home visitation, enhanced follow‐up, and support after discharge (Figure 2).[28, 30, 31, 33]

Figure 2

Outcome Assessment Methods

Readmission and subsequent ED utilization events were identified using multiple techniques. Some authors accessed claims records to capture all outcomes.[30, 33] Others relied on chart review.[21, 25, 26, 27, 28, 31, 32] One study supplemented hospital records with outpatient records.[24] Some investigators used parental reports.[22, 23, 31] Two studies did not describe methods for identifying postdischarge events.[29, 34]

Study Quality

The quality of the included studies varied (Table 2). Many of the studies had inadequate sample size to detect a difference in either readmission or ED visit subsequent to discharge. Eight studies found differences in either subsequent ED utilization, hospitalization, or both and were considered adequately powered for these specific outcomes.[21, 23, 25, 26, 28, 30, 31, 32] In contrast, among studies with readmission as an outcome, 6 were not adequately powered to detect a difference in this particular outcome.[24, 30, 31, 32, 33, 34] In these 6 studies, all except 1 study³⁰ had <10% of the sample size required to detect differences in readmission. Further, 2 studies that examined ED utilization were underpowered to detect differences between intervention and control groups.[24, 26] We were unable to perform power calculations for 3 studies,[22, 27, 29] as the authors presented the number of events without clear denominators.

Excluding the assessment of statistical power, Downs and Black scores ranged from 10 to 23 (maximum 28 possible points) indicating varying quality. As would be expected with discharge interventions, studies did not blind participants; 2 studies did, however, appropriately blind the outcome evaluators to intervention assignment.[22, 30] Even though 10 out of the 14 studies were randomized controlled trials, randomization may not have been completely effective due to sample size being too small for effective randomization,[31] large numbers of excluded subjects after randomization,[30] and unclear randomization process.[34] Several studies had varying follow‐up periods for patients within a given study. For example, 3 NICU studies assessed readmission at 1‐year corrected age,[30, 31, 33] creating the analytic difficulty that the amount of time a given patient was at risk for readmission was dependent on when the patient was discharged, yet this was not accounted for in the analyses. Only 2 studies demonstrated low rates of loss to follow‐up (<10%).[30, 33] The remainder of the studies either had high incompletion/loss to follow‐up rates (>10%)[22, 24, 31] or did not report rates.[21, 23, 25, 26, 27, 28, 29, 32, 34] Finally, 3 studies recruited patients from multiple sites,[24, 31, 33] and none adjusted for potential differences in effect based on enrollment site.

Findings Across Patient Populations Regarding Readmission

Of the 4 studies that demonstrated change in overall readmission,[23, 25, 26, 28] all were asthma focused; 3 demonstrated a decrease in readmissions,[23, 25, 26] and 1 an increase in readmissions.[28] The 3 effective interventions included 1‐on‐1 inpatient education delivered by an asthma nurse, in addition to postdischarge follow‐up support, either by telephone or clinic visit. Two of these interventions provided rescue oral steroids to some patients on discharge.[25, 26] In contrast, a study from New Zealand evaluated a series of postdischarge visits using an existing public health nurse infrastructure and demonstrated an increase in readmission between 6 to 18 months after admission in European children.[28] An additional study focused on outpatient support after discharge from the NICU, and demonstrated a lower frequency of readmission to the intensive care unit without overall reduction of hospital readmission (Tables 1 and 2).[30]

Findings Across Patient Populations Regarding Subsequent ED Visits

Of all the discharge interventions, 6 demonstrated differences in return to the ED after discharge. Five studies described a decrease in ED visits after hospitalization,[23, 25, 30, 31, 32] and 1 showed an increase.[21] Three studies in the NICU population demonstrated decreased ED utilization through a combination of augmented family engagement during hospitalization and/or enhanced support after discharge. Two inpatient asthma education interventions with structured postdischarge follow‐up decreased return visitation to the ED.[23, 26] The intervention that worsened subsequent ED utilization (ie, increased ED visit hazard compared to matched controls) provided enhanced inpatient education to a nonrandom group of children hospitalized with asthma and provided a follow‐up phone call 3 weeks after discharge (Tables 1 and 2).[21]

Current Conceptual Framework

There are a number of existing discharge transitional care frameworks from prior studies[35, 36] and professional societies.[37] The Stepping Up to the Plate (SUTTP) alliance, a collaborative of 9 professional organizations, including the American Academy of Pediatrics, introduced 1 such framework in 2007. SUTTP sought to enhance care transitions by outlining principles of discharge transitional care including: (1) enhanced accountability, (2) creation of a central coordination hub charged with communicating expectations for care, (3) clear and direct communication of treatment plans and follow‐up, (4) timely feedback/feed‐forward of relevant information, and (5) involvement of family member at every stage.[38] In the context of the SUTTP framework, we present 3 hypotheses based on our findings to guide future work.

Persistent Literature Gaps

Follow‐up with a primary care provider after discharge is another intervention that might decrease postdischarge utilization. We did not identify any studies that specifically examined primary care follow‐up. However, 2 studies[43, 44] that did not meet our inclusion criteria (because they included adults and did not stratify by age group in the analysis) examined any outpatient follow‐up after discharge using state‐specific Medicaid claims. One study found that outpatient follow‐up after sickle cell hospitalization was associated with lower rates of readmission.[43] The other found no difference in readmission across multiple conditions.[44] One recent review of outpatient follow‐up from the ED for asthma found that even when increases in follow‐up were achieved, no reduction in the subsequent utilization was observed.[45]

Additional important questions remain underexplored. First, are condition‐specific interventions superior to those that span conditions? All of the interventions that demonstrated reductions in readmission were condition‐specific, yet no generic interventions met our inclusion criteria. Importantly, only 1 study[29] in our review examined discharge processes from 1 of the pediatric conditions with the most variation[8] in readmission. Further, no studies focused on children with complex medical conditions, who are known to be at increased risk of readmission,[46] indicating a sizable knowledge gap persists in understanding how to prevent readmissions in the most vulnerable pediatric populations.

Lastly, who are the most appropriate effector individuals for discharge‐focused transitional care interventions? Demographically matched effector individuals have shown promise in improving care using community health workers.[47, 48] The degree to which the identity of the intervener mediates subsequent ED and hospital utilization warrants further investigation.

Limitations of This Systematic Review

The studies included in this review assessed different outcomes at different intervals, precluding meta‐analysis. With greater consistency in the collection of data on the quality of discharge processes and their subsequent outcomes, future studies may offer further clarity as to which discharge‐oriented practices are more effective than others. Because we only identified literature in 3 pediatric conditions, generalizability beyond these conditions may be limited. The settings of the interventions also occurred in multiple countries; we excluded countries from low or low‐middle incomes to facilitate generalizability. As many of the discharge processes contained multiple interventions, it is not possible to ascertain which, if any, singular action may decrease posthospitalization utilization. Additionally, some of the included interventions are older, and it is plausible that discharge processes have evolved with the expansion of the hospitalist model.

Methods of data collection influence the quality of results in the included studies. Most of the studies included in this review used either medical record review or parental self‐report of utilization. Parental report may be sufficient for hospitalizations and ED utilization; however, it is subject to recall bias. Chart review likely underestimates the number of postdischarge events, depending on the individual institution's proportion of the market and the tendency of individuals to seek care at multiple institutions. Claims data may offer the most accurate assessments of ED and hospital utilization and cost, but can be more difficult to obtain and do not provide the same potential for granularity as parent report or medical records review.

Finally, subsequent ED visits, readmissions, and cost may not be the best measures of the quality of discharge transitional care. A number of tools have been developed to more specifically evaluate the quality of transitional care in adults,[49, 50] including a validated instrument that consists of only 3 items,[50] which primarily assesses the extent to which patients are prepared for self‐care upon discharge. For pediatric populations, validated tools assessing caregiver experience with discharge[51] and discharge readiness[52] are also available. These instruments may assist those interested in assessing process‐related outcomes that specifically assess discharge transitional care elements and may mediate subsequent ED visits or hospitalizations.