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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
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1 to 17 of 17 Research Studies DisplayedBroecker M, Ponto K, Tredinnick R
SafeHOME: promoting safe transitions to the home.
This paper introduces the SafeHome Simulator system, a set of immersive Virtual Reality Training tools and display systems to train patients in safe discharge procedures in captured environments of their actual houses. The aim is to lower patient readmission by significantly improving discharge planning and training. The SafeHOME Simulator is a project currently under review.
AHRQ-funded; HS022548.
Citation: Broecker M, Ponto K, Tredinnick R .
SafeHOME: promoting safe transitions to the home.
Stud Health Technol Inform 2016;220:51-4.
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Keywords: Transitions of Care, Health Information Technology (HIT), Patient Safety, Patient Self-Management, Hospital Discharge
Werner NE, Gurses AP, Leff B
Improving care transitions across healthcare settings through a human factors approach.
This article describes how a systems' approach known as Human Factors and Ergonomics can complement and further strengthen efforts to improve care transitions.
AHRQ-funded; HS022916.
Citation: Werner NE, Gurses AP, Leff B .
Improving care transitions across healthcare settings through a human factors approach.
J Healthc Qual 2016 Nov/Dec;38(6):328-43. doi: 10.1097/jhq.0000000000000025.
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Keywords: Healthcare Delivery, Provider, Hospital Discharge, Patient Safety, Transitions of Care
Johnson SA, Shi J, Groner JI
Inter-facility transfer of pediatric burn patients from U.S. Emergency Departments.
This study described the epidemiology of pediatric burn patients seen in U.S. emergency departments (EDs) in order to determine factors associated with inter-facility transfer. It concluded that over 90 percent of pediatric burn ED patients meet ABA burn referral criteria but are not transferred from low volume hospitals.
AHRQ-funded; HS022277.
Citation: Johnson SA, Shi J, Groner JI .
Inter-facility transfer of pediatric burn patients from U.S. Emergency Departments.
Burns 2016 Nov;42(7):1413-22. doi: 10.1016/j.burns.2016.06.024.
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Keywords: Healthcare Cost and Utilization Project (HCUP), Transitions of Care, Children/Adolescents, Emergency Medical Services (EMS), Guidelines
Harrod M, Montoya A, Mody L
Challenges for nurses caring for individuals with peripherally inserted central catheters in skilled nursing facilities.
The researchers sought to understand the perceived preparedness of frontline nurses (registered nurses (RNs), licensed practical nurses (LPNs)), unit nurse managers, and skilled nursing facility (SNF) administrators in providing care for residents with peripherally inserted central catheters (PICCs) in SNFs. They noted differences between resident self-reported PICC concerns (quality of life) and those described by frontline nurses.
AHRQ-funded; HS019979; HS022835.
Citation: Harrod M, Montoya A, Mody L .
Challenges for nurses caring for individuals with peripherally inserted central catheters in skilled nursing facilities.
J Am Geriatr Soc 2016 Oct;64(10):2059-64. doi: 10.1111/jgs.14341.
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Keywords: Catheter-Associated Urinary Tract Infection (CAUTI), Communication, Nursing, Quality of Life, Transitions of Care
Jones CE, Hollis RH, Wahl TS
Transitional care interventions and hospital readmissions in surgical populations: a systematic review.
The researchers performed a systematic review of transitional care interventions and their effect on hospital readmissions after surgery. Discharge planning programs reduced readmissions by 11.5 percent , 12.5 percent, and 23 percent . Patient education interventions reduced readmissions by 14 percent and 23.5 percent . Primary care follow-up reduced readmissions by 8.3 percent for patients after high-risk surgeries . Home visits reduced readmissions by 7.7 percent and 4 percent, respectively.
AHRQ-funded; HS013852.
Citation: Jones CE, Hollis RH, Wahl TS .
Transitional care interventions and hospital readmissions in surgical populations: a systematic review.
Am J Surg 2016 Aug;212(2):327-35. doi: 10.1016/j.amjsurg.2016.04.004.
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Keywords: Education: Patient and Caregiver, Hospital Discharge, Hospital Readmissions, Transitions of Care
Donovan JL, Kanaan AO, Gurwitz JH
A pilot health information technology-based effort to increase the quality of transitions from skilled nursing facility to home: compelling evidence of high rate of adverse outcomes.
The authors investigated whether or not patients transferred from skilled nursing facilities to home may be at risk for adverse outcomes. They tracked rehospitalization within 30 days after discharge and adverse drug events within 45 days. They concluded that older adults discharged from skilled nursing facilities are at high risk of adverse outcomes immediately following discharge.
AHRQ-funded; HS017817.
Citation: Donovan JL, Kanaan AO, Gurwitz JH .
A pilot health information technology-based effort to increase the quality of transitions from skilled nursing facility to home: compelling evidence of high rate of adverse outcomes.
J Am Med Dir Assoc 2016 Apr;17(4):312-7. doi: 10.1016/j.jamda.2015.11.008.
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Keywords: Health Information Technology (HIT), Transitions of Care, Adverse Events, Elderly, Hospital Readmissions
Leyenaar JK, Lagu T, Lindenauer PK
Direct admission to the hospital: an alternative approach to hospitalization.
The authors discussed the role of hospital medicine in the changing epidemiology of hospital admissions, the potential risks and benefits of direct admission to the hospital, and the need for research to evaluate the safety and effectiveness of this admission approach. They proposed that transitions of care research and quality improvement be expanded to address transitions into the hospital.
AHRQ-funded; HS024133.
Citation: Leyenaar JK, Lagu T, Lindenauer PK .
Direct admission to the hospital: an alternative approach to hospitalization.
J Hosp Med 2016 Apr;11(4):303-5. doi: 10.1002/jhm.2512.
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Keywords: Emergency Department, Emergency Medical Services (EMS), Hospitalization, Transitions of Care
Vora AN, Peterson ED, Hellkamp AS
Care transitions after acute myocardial infarction for transferred-in versus direct-arrival patients.
Many patients in the United States require transfer from one hospital to another for acute myocardial infarction (MI) care. How well these transferred-in patients are transitioned back to their local community is unknown. This study found that transferred-in patients with acute MI are less likely to have outpatient clinic follow-up within 30 days and more likely to be readmitted within the first 30 days post discharge compared with direct-arrival patients.
AHRQ-funded; HS021092.
Citation: Vora AN, Peterson ED, Hellkamp AS .
Care transitions after acute myocardial infarction for transferred-in versus direct-arrival patients.
Circ Cardiovasc Qual Outcomes 2016 Mar;9(2):109-16. doi: 10.1161/circoutcomes.115.002108.
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Keywords: Transitions of Care, Hospital Readmissions, Cardiovascular Conditions, Patient-Centered Outcomes Research, Hospital Discharge
Dharmarajan K, Chaudhry SI
New approaches to reduce readmissions in patients with heart failure.
The authors discuss a study by Ong and colleagues that presents the results of Better Effectiveness After Transition–Heart Failure (BEATHF), a randomized clinical trial of a combined telemonitoring and care transitions intervention to prevent readmission in patients with heart failure. The BEAT-HF intervention did not lower readmissions after hospitalization for heart failure.
AHRQ-funded; HS023554.
Citation: Dharmarajan K, Chaudhry SI .
New approaches to reduce readmissions in patients with heart failure.
JAMA Intern Med 2016 Mar;176(3):318-20. doi: 10.1001/jamainternmed.2015.7993.
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Keywords: Heart Disease and Health, Hospital Discharge, Hospital Readmissions, Quality of Life, Transitions of Care
Kansagara D, Chiovaro JC, Kagen D
So many options, where do we start? An overview of the care transitions literature.
The purpose of this paper is to summarize the health and utilization effects of transitional care interventions, and to identify common themes about intervention types, patient populations, or settings that modify these effects. The authors found evidence that enhanced discharge planning and hospital-at-home interventions reduced readmissions. They further found that transitional care interventions reduced readmission in patients with congestive heart failure and general medical populations.
AHRQ-funded; HS022981.
Citation: Kansagara D, Chiovaro JC, Kagen D .
So many options, where do we start? An overview of the care transitions literature.
J Hosp Med 2016 Mar;11(3):221-30. doi: 10.1002/jhm.2502.
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Keywords: Caregiving, Hospital Discharge, Hospital Readmissions, Transitions of Care
Moyer VA, Papile LA, Eichenwald E
An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study.
The authors tested whether a multifaceted intervention that included a health coach to assist families and an enhanced personal health record to improve the quality of information available to parents and community professionals would decrease adverse events and improve family assessment of the transition of infants born prematurely or with complex medical problems to home. They found that a multicomponent discharge intervention designed to address specific problems identified using Healthcare Failure Modes and Effects Analysis did not reduce certain adverse outcomes in the post-discharge period.
AHRQ-funded; HS017889.
Citation: Moyer VA, Papile LA, Eichenwald E .
An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study.
BMJ Qual Saf 2014 Dec;23(12):e3. doi: 10.1136/bmjqs-2012-001726.
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Keywords: Neonatal Intensive Care Unit (NICU), Ambulatory Care and Surgery, Patient Safety, Quality Improvement, Transitions of Care
Davis AM, Brown RF, Taylor JL
Transition care for children with special health care needs.
This article examined 25 studies evaluating transition care programs for children with special health care needs moving from pediatric to adult care. The majority of studies concerned patients with diabetes or transplant patients.The authors also interviewed key informants representing clinicians who provide transition care. They found that there is no accepted way to measure transition success.
AHRQ-funded; 290201200009I
Citation: Davis AM, Brown RF, Taylor JL .
Transition care for children with special health care needs.
Pediatrics. 2014 Nov;134(5):900-8. doi: 10.1542/peds.2014-1909..
Keywords: Children/Adolescents, Transitions of Care, Chronic Conditions
Garfield CF, Lee Y, Kim HN
Paternal and maternal concerns for their very low-birth-weight infants transitioning from the NICU to home.
The authors examined the concerns and coping mechanisms of fathers and mothers of very low-birth-weight neonatal intensive care unit (NICU) infants as they transition to home from the NICU. They found that overriding concerns included pervasive uncertainty, lingering medical concerns, and partner-related adjustment concerns that differed by gender. They concluded that many parental concerns can be addressed with improved discharge information exchanges and anticipatory guidance.
AHRQ-funded; HS020316.
Citation: Garfield CF, Lee Y, Kim HN .
Paternal and maternal concerns for their very low-birth-weight infants transitioning from the NICU to home.
J Perinat Neonatal Nurs 2014 Oct-Dec;28(4):305-12. doi: 10.1097/jpn.0000000000000021.
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Keywords: Care Coordination, Hospital Discharge, Neonatal Intensive Care Unit (NICU), Newborns/Infants, Transitions of Care
Foster NA, Elfenbein DM, Kelley W, Jr.
Comparison of helicopter versus ground transport for the interfacility transport of isolated spinal injury.
The investigators aimed to determine whether ground transport (GT) for interfacility transfer of patients with spinal injury resulted in less favorable clinical outcomes compared with helicopter aeromedical transport systems (HEMS). They found that GT for interfacility transfer of patients with spinal injury appears to be safe and suitable for patients who lack other compelling reasons for HEMS.
AHRQ-funded; HS000032.
Citation: Foster NA, Elfenbein DM, Kelley W, Jr. .
Comparison of helicopter versus ground transport for the interfacility transport of isolated spinal injury.
Spine J 2014 Jul;14(7):1147-54. doi: 10.1016/j.spinee.2013.07.478.
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Keywords: Emergency Medical Services (EMS), Transitions of Care, Injuries and Wounds
O'Toole JK, West DC, Starmer AJ
Placing faculty development front and center in a multisite educational initiative: lessons from the I-PASS Handoff study.
The authors describe their experience developing a multi-institutional faculty development program to support the I-PASS (IIPE-PRIS Accelerating Safe Signouts) Study and offer a set of generalizable strategies to guide the creation of other large-scale, multi-institutional faculty development programs. They conclude that the lessons learned inform a set of key strategies that can be applied to a broad range of similar large-scale faculty development projects in the future.
AHRQ-funded; HS019456.
Citation: O'Toole JK, West DC, Starmer AJ .
Placing faculty development front and center in a multisite educational initiative: lessons from the I-PASS Handoff study.
Acad Pediatr 2014 May-Jun;14(3):221-4. doi: 10.1016/j.acap.2014.02.013.
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Keywords: Education: Curriculum, Provider, Patient-Centered Healthcare, Transitions of Care
Black JT, Romano PS, Sadeghi B
A remote monitoring and telephone nurse coaching intervention to reduce readmissions among patients with heart failure: study protocol for the Better
The objective of this randomized controlled comparative effectiveness study was to evaluate the effectiveness of a care transition intervention that included pre-discharge education about heart failure and post-discharge telephone nurse coaching combined with home telemonitoring of weight, blood pressure, heart rate, and symptoms in reducing all-cause 180-day hospital readmissions for older adults hospitalized with heart failure.
AHRQ-funded; HS019311.
Citation: Black JT, Romano PS, Sadeghi B .
A remote monitoring and telephone nurse coaching intervention to reduce readmissions among patients with heart failure: study protocol for the Better
Trials 2014 Apr 13;15:124. doi: 10.1186/1745-6215-15-124..
Keywords: Cardiovascular Conditions, Comparative Effectiveness, Health Information Technology (HIT), Heart Disease and Health, Hospital Readmissions, Telehealth, Transitions of Care
Ritholz MD, Wolpert H, Beste M
Patient-provider relationships across the transition from pediatric to adult diabetes care: a qualitative study.
The purpose of this study was to explore perceptions that emerging adults with type 1 diabetes (T1D) have of their patient-provider relationships across the transition from pediatric to adult care. Several themes emerged from the analysis including the importance of improving provider approaches to transition. Patients recommended that pediatric providers actively promote emerging adults’ autonomy while maintaining parental support.
AHRQ-funded; HS000063.
Citation: Ritholz MD, Wolpert H, Beste M .
Patient-provider relationships across the transition from pediatric to adult diabetes care: a qualitative study.
Diabetes Educ 2014 Jan-Feb;40(1):40-7. doi: 10.1177/0145721713513177..
Keywords: Chronic Conditions, Diabetes, Patient Experience, Clinician-Patient Communication, Transitions of Care
