Hospital-to-Home Interventions, Use, and Satisfaction: A Meta-analysis.

CONTEXT: Hospital-to-home transitions are critical opportunities to promote patient safety and high-quality care. However, such transitions are often fraught with difficulties associated with increased health care use and poor patient satisfaction. OBJECTIVE: In this review, we determine which pediatric hospital discharge interventions affect subsequent health care use or parental satisfaction compared with usual care. DATA SOURCES: We searched 7 bibliographic databases and 5 pediatric journals. STUDY SELECTION: Inclusion criteria were: (1) available in English, (2) focused on children <18 years of age, (3) pediatric data reported separately from adult data, (4) not focused on normal newborns or pregnancy, (5) discharge intervention implemented in the inpatient setting, and (6) outcomes of health care use or caregiver satisfaction. Reviews, case studies, and commentaries were excluded. DATA EXTRACTION: Two reviewers independently abstracted data using modified Cochrane data collection forms and assessed quality using modified Downs and Black checklists. RESULTS: Seventy one articles met inclusion criteria. Although most interventions improved satisfaction, interventions variably reduced use. Interventions focused on follow-up care, discharge planning, teach back-based parental education, and contingency planning were associated with reduced use across patient groups. Bundled care coordination and family engagement interventions were associated with lower use in patients with chronic illnesses and neonates. LIMITATIONS: Variability limited findings and reduced generalizability. CONCLUSIONS: In this review, we highlight the utility of a pediatric discharge bundle in reducing health care use. Coordinating follow-up, discharge planning, teach back-based parental education, and contingency planning are potential foci for future efforts to improve hospital-to-home transitions.

Trial of labor and vaginal delivery rates in women with a prior cesarean.

OBJECTIVE: To evaluate evidence on trial of labor (TOL) and vaginal delivery rates in women with a prior cesarean and to understand the characteristics of women offered a trial of labor. DATA SOURCES: MEDLINE, DARE, and Cochrane databases were searched for articles evaluating mode of delivery for women with a prior cesarean delivery published between 1980 and September 2009. STUDY SELECTION: Studies were included if they involved human participants, were in English, conducted in the United States or in developed countries, and if they were rated fair or good base on U.S. Preventive Services Task Force (USPSTF) criteria. DATA EXTRACTION AND SYNTHESIS: The search yielded 3,134 abstracts: 69 full-text papers on TOL and vaginal birth after cesarean (VBAC) rates and 10 on predictors of TOL. The TOL rate in U.S. studies was 58% (95% CI [52, 65]) compared with 64% (95% CI [59, 70]) in non U.S. STUDIES: The TOL rate in the U.S. was 62% (95% CI [57, 66]) for studies completed prior to 1996 and dropped to 44% (95% CI [34, 53]) in studies launched after 1996, p = .016. In U.S. studies, 74% (95% CI [72, 76]) of women who had a TOL delivered vaginally. Women who had a prior vaginal birth or delivered at a large teaching hospital were more likely to be offered a TOL. CONCLUSIONS: Although the TOL rate has dropped since 1996, the rate of vaginal delivery after a TOL has remained constant. Efforts to increase rates of TOL will depend on patients understanding the risks and benefits of both options. Maternity providers are well positioned to provide key education and counseling when patients are not informed of their options.