Date Presented 04/04/19
This systematic review investigates whether community transition programs reduce hospital readmissions and improve quality of life for adults ages 18 to 65 who experienced traumatic spinal cord injury and are making the initial transition from subacute rehabilitation back to the community. This review will enhance OTs’ familiarity with the evidence base for transition programs to inform practice and future program development.
Primary Author and Speaker: Raheleh Tschoepe
Additional Authors and Speakers: Anna Benfield
Contributing Authors: Vicki Mercer, Rachael Posey
PURPOSE: To systematically review evidence concerning the effects of community transition programs for adults with new traumatic spinal cord injury (TSCI) on hospital readmissions (HR) and quality of life (QOL). Acute inpatient length of stay (LOS) for this population has declined in recent decades (Chen, Apple, Hudson & Bode, 1999). Cardenas, Hoffman, Kirshblum, and McKinley (2004) discussed the association between decreased LOS and increased risk for HR. Occupational therapists (OTs) are positioned to develop and implement programming designed to support individuals with TSCI during the transition to home/community settings. This review synthesizes available research to inform and advance this aspect of clinical practice.
DESIGN: A systematic review of original research meeting the following inclusion criteria: 1) participants ages 18-65 with newly acquired TSCI making the transition from sub-acute care to the community; 2) intervention designed to support individuals navigating this transition; 3) HR or QOL outcome data
METHOD: The following electronic sources were searched for relevant literature: PubMed, Embase, CINAHL, Google Scholar, the Joanna Briggs Institute databases, OTseeker, and PEDro. The search strategy included terms relating to the population and intervention. There were no restrictions based on language, publication period, or study type. Two authors first independently screened titles/abstracts and then full texts for studies that met inclusion criteria. Authors discussed and resolved conflicts with a third author. For each study, two team members independently used the LEGEND tool to assess quality (Clark, Burkett, & Stanko-Lopp, 2009). We then extracted the study type, participant and intervention characteristics, comparator, and significant results.
RESULTS: Our search strategy yielded over 3,300 unique titles/abstracts. We selected 279 titles/abstracts for full text review and 20 articles met inclusion criteria. Studies included three good and six lesser quality randomized controlled trials (RCTs), two good and three lesser quality clinical controlled trials (CCTs), five lesser quality longitudinal studies, and one published abstract. The majority of interventions were conducted in home/community settings. Three inpatient programs were conducted exclusively during the pre-discharge period, three spanned the transition, and one provided post-discharge residential services. Studies included peer mentoring (n=5), telehealth (n=4), independent living services (n=4), patient navigation (n=3), education (n=3), and counseling (n=1). Intervention dosage varied both in duration and frequency. Programs ranged from a single visit to as many as 72 sessions over 24 months. Peer mentoring and telehealth programs typically represented more intensive interventions. Each program type, except counseling, was supported by statistically significant findings from at least one RCT or CCT. Ten studies found significant positive impact on either HR or QOL. Heterogeneous interventions and outcome metrics precluded meta-analysis. Overall quality of included studies was compromised by lack of power analyses, low sample sizes, insufficient analysis of participant characteristics and intervention protocol, and low intervention fidelity.
CONCLUSION: Studies in this review provide mixed evidence of transition program efficacy for improving QOL and reducing HR for individuals with new TSCI. The challenge to this body of evidence is the ability to demonstrate clear intervention-related outcomes for this heterogeneous population who receives care in complex and disparate systems. OTs must be informed about efforts to improve QOL and to reduce readmission to continue innovative practice, vigorous research, and systems-level change.
References
Chen, D., Apple, D. F., Hudson, L. M., Bode, R. (1999). Medical complications during acute rehabilitation following spinal cord injury: Current experience of the model systems. Archives of Physical Medicine and Rehabilitation, 80, 1397-1401. https://doi.org/10.1016/S0003-9993(99)90250-2
Cardenas, D. D., Hoffman, J. M., Kirshblum, S., & McKinley, W. (2004). Etiology and incidence of rehospitalization after traumatic spinal cord injury: A multicenter analysis. Archives of Physical Medicine and Rehabilitation, 85, 1757-1763. https://doi.org/10.1016/j.apmr.2004.03.016
Clark, E., Burkett, K., & Stanko-Lopp, D. (2009). Let Evidence Guide Every New Decision (LEGEND): An evidence evidence evaluation system for point-of-care clinicians and guideline development teams. Journal of Evaluation in Clinical Practice, 15(6), 1054-1060. https://doi.org/10.1111/j.1365-2753.2009.01314.x
