Skip to main content

Table 4 Methodological overview of included studies

From: The role of hospitals in bridging the care continuum: a systematic review of coordination of care and follow-up for adults with chronic conditions

Reference Purpose Intervention Control group Findings
Transitional care interventions
 Abad-Corpa et al. 2013 [18] To evaluate effectiveness of protocoled intervention for hospital discharge and follow-up in primary care At the hospital, a coordinating nurse visited each patient in the experimental group to identify the main caregiver, provide information about the disease, explain treatment, identify care problems and needs, and facilitate communication between professionals. Twenty-four hours after discharge, the coordinating nurses informed the primary care nurses of patient discharge. The two nurses made the first home visit together. There were follow-up phone calls at 2, 6, 12, and 24 weeks after discharge.
Number of included participants n = 56.
In the control group, no extra plan was carried out and the specific healthcare protocol of each hospitalization unit was followed.
Number of included participants n = 87.
Improvement in quality of life at 12 and 24 weeks after discharge; level of knowledge of Chronic Obstructive Pulmonary Disease (COPD) revealed significant differences between the groups. No differences according to satisfaction or readmission rate. The intervention was ineffective in reducing readmission rates.
 Baldwin, Black & Hammond, 2014 [19] To develop a community nursing case management (CMM) program to decrease preventable readmissions to the hospital and emergency department by providing telephonic case management and, where needed, onsite assessment and treatment by a clinical nurse specialist (CNS) with prescriptive authority The patients were identified by CNS census review or referral from clinical nurse leaders, case managers, emergency department physicians, or staff, based on the program inclusion criteria. Once identified, the CNS meets with the patient during inpatient stay and discusses participation in the outpatient program. The CCM program consists of telephone appointments on a weekly basis, or more frequently, based on patient acuity, for a period of 30 days after discharge (goal).
Number of included participants n = 39.
No control group. A positive change in hospital culture since the program began. The CNS is receiving more referrals. There is also more dialogue between the CNS and hospitalists regarding the plan of care for patients who will be entering the CCM program after discharge. Participating patients interact with the CNS and have expressed gratitude for the program. Hospital and ED 30-day readmissions for program patients have decreased since the program began.
 Blue et al. 2001 [30] To determine whether specialist nurse interventions improve outcome in patients with chronic heart failure A specialist nurse led intervention starting at the hospital. The intervention consisted of a number of planned home visits of decreasing frequency, supplemented by telephone contact as needed. The aim was to educate the patient about heart failure and its treatment, optimize treatment (drugs, diet, exercise), monitor electrolyte concentrations, teach self-monitoring and management (especially the early detection and treatment of decompensation), liaise with other health care and social workers as required, and provide psychological support.
Number of included participants n = 84.
Patients in the usual care group were managed as usual by the admitting physician and, subsequently, general practitioner. They were not seen by the specialist nurses after hospital discharge.
Number of included participants n = 81.
31 patients (37%) in the intervention group died or were readmitted with heart failure compared with 45 (53%) in the usual care group. Compared with usual care, patients in the intervention group had fewer readmissions for any reason (86 vs. 114, P = 0.018), fewer admissions for heart failure (19 vs. 45, P < 0.001) and spent fewer days in hospital for heart failure (mean 3.43 vs. 7.46 days, P = 0.0051).
 Brand et al. 2004 [32] To determine whether a nurse-led chronic disease management model of transitional care reduces readmissions to acute care The intervention group received a comprehensive transitional care service with components allocated according to perceived and assessed need and patient preference. The patient was seen by the chronic disease nurse consultant in the 24 h before discharge from the ward and the following were completed: collection of predischarge data; screening for risk factors for readmission; development of a plan for follow-up in clinic; liaison with discharge planners, nursing staff and allied health staff, where appropriate; provision of an action plan for the patient; copy of discharge summary faxed to the patient’s general practitioner. The patient was seen again by the nurse in the chronic disease center within two weeks of discharge (or when the medical condition allowed).
Number of included participants n = 76.
Usual care.
Number of included participants n = 78.
There was no difference between the control and intervention groups in readmission rates or emergency department presentation rates at the three-month and six-month follow-ups. Scores for quality of life showed no difference between groups at three-month follow-up. There was no difference between the groups in the rate of visits to a general practitioner for the three months following their index admission. The findings from the qualitative process evaluation identified major issues that impacted on the effectiveness and sustainability of the transitional care service model: inadequate integration of the chronic disease nurse consultant into the existing general medical delivery of care model; inadequate stakeholder understanding of the role and scope of the chronic disease nurse consultant inadequate clerical support resources for the chronic disease nurse consultant; and lack of backfill for leave coverage, such that a 52-week-per-year service can be provided; inadequate integration of documentation into daily clinical practice.
 Cline et al. 1998 [31] To study the effects of a management program on hospitalization and health care costs one year after admission for heart failure A management program for heart failure starting at the hospital. The intervention group received education on heart failure and self-management, with follow up at an easy access, nurse-directed outpatient clinic for one year after discharge.
Number of included participants n = 56.
The control group was managed according to routine clinical practice.
Number of included participants n = 79.
The mean time to readmission was longer in the intervention group than in the control group and the number of days in hospital tended to be fewer. There was a trend towards a mean annual reduction in health care costs per patient in the intervention group compared with costs in the controls.
 Coleman et al. 2004 [28] To test whether an intervention designed to encourage older patients and their caregivers to assert a more active role during care transition can reduce rehospitalization rates The intervention was built on four pillars, or conceptual domains: (1) assistance with medication self-management, (2) a patient-centered record owned and maintained by the patient to facilitate cross-site information transfer, (3) timely follow-up with primary or specialty care, and (4) a list of red flags indicative of a worsening condition and instructions on how to respond to them. The four pillars were operationalized through the following two mechanisms: (1) a personal health record and (2) a series of visits and telephone calls with a transition coach.
Number of included participants n = 158.
Usual care.
Number of included participants n = 1235.
There was a significant difference in favor of the rehospitalization of intervention subjects with that of controls at 30 days, at 90 days, and at 180 days. Intervention patients reported high levels of confidence in obtaining essential information for managing their condition, communicating with members of the healthcare team, and understanding their medication regimen.
 Coleman et al. 2006 [29] To test whether a care transition intervention reduces rehospitalization rates The intervention was built on four pillars, or conceptual domains: (1) assistance with medication self-management, (2) a patient-centered record owned and maintained by the patient to facilitate cross-site information transfer, (3) timely follow-up with primary or specialty care, and (4) a list of red flags indicative of a worsening condition and instructions on how to respond to them. The four pillars were operationalized through the following two mechanisms: (1) a personal health record and (2) a series of visits and telephone calls with a transition coach.
Number of included participants n = 379.
Usual care.
Number of included participants n = 371.
Intervention patients had lower rehospitalization rates at 30 days and at 90 days than control subjects. Intervention patients had lower rehospitalization rates for the same condition that precipitated the index hospitalization at 90 days and at 180 days than the controls. The mean hospital costs were lower for intervention patients vs. controls at 180 days.
 Farrero et al. 2001 [24] To analyze the influence of a hospital-based home-care program (HCP) on the management of patients with COPD receiving long-term oxygen therapy The HCP applied to patients in the intervention group (HCP group) consisted of a monthly telephone call, home visits every three months, and home or hospital visits on a demand basis.
Number of included participants n = 60.
Patients in the control group were given conventional medical care.
Number of included participants n = 62.
During the follow-up period, there was a highly significant decrease in the mean number of emergency department visits also a significant decrease in hospital admissions and days of hospital stay in the HCP group. Cost analysis showed a total saving of 8.1 million pesetas ($46,823) in the HCP group, mainly due to a decrease in the use of hospital resources. There was no difference in pulmonary function, gas exchange, quality of life, or survival between the two groups.
 Harrison et al. 2002 [23] Evaluate whether the use of usual providers, and a reorganization of discharge planning and transition care with improved intersectoral linkages between nurses, could improve quality of life and utilization of health services for individuals admitted to hospital with heart failure The nurse-led intervention focused on the transition from hospital-to-home and supportive care for self-management two weeks after hospital discharge.
Number of included participants n = 92.
Usual care.
Number of included participants n = 100.
Six weeks after hospital discharge, the overall Minnesota Living with Heart Failure Questionnaire (MLHFQ) score was better among the transitional care patients than among the usual care patients. Similar results were found at twelve weeks after discharge for the overall MLHFQ and at six and twelve weeks after discharge for the MLHFQ’s Physical Dimension and Emotional Dimension subscales. Differences in generic quality life, as assessed by the SF-36 Physical component, Mental Component, and General Health subscales, were not significantly different between the transition and usual care groups. At twelve weeks after discharge, 31% of the usual care patients had been readmitted compared with 23% of the transitional care patients, and 46% of the usual care group had visited the emergency department, compared with 29% in the transitional care group.
 Jeangsawang et al. 2012 [27] To compare the outcomes of discharge planning and follow-up care, for elders with chronic healthcare conditions, among advanced practice nurse (APN), expert-by-experience nurses, and novice nurses who delivered care through a “Continuity of Care Program”, and to describe the benefits of APN care services from the perspectives of key stakeholders (e.g., healthcare colleagues and family caregivers) Continuity of Care Program: The discharge planning and postdischarge follow-up care was offered through the hospital ambulatory care unit. The program consisted of care services aimed at maximizing the patient’s health and functionability by addressing existing problems and preventing potential problems. The delivery of services involved the use of three levels of practitioners (novice, expert-by-experience, and advanced practice nurses) who functioned as primary home healthcare nurses. All three types of nurses used the same standard of care, addressed in the Continuity of Care Program, to guide their nursing interventions. Nursing interventions for discharge planning and postdischarge follow-up consisted of: preparing the patient and his/her family caregiver to be ready for the discharge; coordinating all aspects of the discharge and postdischarge follow-up plan; conducting a series of home visits to assess and monitor the caregiving ability of the family caregiver, and identify the presence of health-related complications and implement appropriate treatments; and, providing care management support to the family caregiver. These services began once a discharge consultation was requested by a physician and while the patient was still hospitalized.
Number of included participants
APN = 20; expert-by-experience nurses n = 40; Novice nurse n = 40.
  Only family members’ satisfaction with the nursing care their elder received was significantly different between the three groups. Although family caregivers in all three groups rated the quality of discharge planning and follow-up care as highly satisfactory, satisfaction with the APN care was significantly higher than satisfaction score with the expert-by-experience nurse and novice nurse care. The APN was seen as a useful healthcare provider in a complex healthcare system. Three themes emerged from the data: a) provision of comprehensive care for older patients with complex healthcare problems; b) professional interactions with patients and other members of the healthcare team; c) professional collaboration with the physician.
 Ledwidge et al. 2005 [22] To examine the additional benefits of extending the standard three-month heart failure (HF) program to six months on death and readmission over a two-year follow-up period Patients randomized to the HF program received weekly telephone calls from one of three experienced specialist HF nurses who, in most cases, was the specialist nurse who had managed the patient during the first three months following discharge. The purpose of these unscripted telephone calls was to determine clinical stability of the patient, address any questions or concerns they had and revise key education points as deemed necessary by the nurse. The key education points revised concerned daily weight monitoring, disease and medication understanding, compliance with prescribed therapy, and the dietary salt restriction. An in-house educational book about HF was supplied and used in the clinic and phone education sessions with patients and carers. This book served to standardize the education points provided to patients by nurses and covered the disease, its causes, associated symptoms and investigations, and pharmacological and nonpharmacological treatments. Patients were asked to attend the HF clinic at six and twelve weeks after randomization for formal clinical assessment by clinic medical and nursing staff. This included history and physical examination by a physician, review of HF medications and key education issues by the nurse, and a nutrition review by the dietician.
Number of included participants n = 62.
Usual care.
Number of included participants n = 68.
There was no measured clinical advantage in terms of death or HF readmission in extending a structured hospital-based disease management program for HF beyond three months after discharge. However, it appears that patients continue to need access to the service to help avoid clinical deterioration, and this may have implication for the optimal organization of such programs.
 Linden & Butterworth, 2014 [20] To inform the development of successful transitional care interventions The intervention included a comprehensive set of components: 1) predischarge components: patient education, discharge planning; medication reconciliation, scheduling of follow-up appointment; 2) postdischarge components: timely follow-up, follow-up telephone call, availability of patient hotline; and 3) bridging components: transition/health coach, patient-centered discharge instructions. Two postdischarge components were added-motivational interviewing-based health coaching and symptom monitoring using interactive voice responses.
Number of included participants n = 253.
Usual care.
Number of included participants n = 259.
There was no statistical difference between treatment groups on 30-day readmission incidence rates or 90-day readmission incidence rates. Groups also did not differ in Emergency Department visit incidence rates at 30 or 90 days. The mortality rate among patients with Chronic Heart Failure (CHF) showed no difference between groups. However, COPD mortality at 90 days was lower in the intervention group than in the usual care group.
 Naylor et al. 2004 [26] To examine the effectiveness of a transitional care intervention delivered by APNs to elders hospitalized with heart failure The intervention included all of the following components: (1) a standardized orientation and training program guided by a multidisciplinary team of heart failure experts to prepare APNs to address the unique needs of older adults and their caregivers throughout an acute episode of heart failure; (2) use of care management strategies foundational to the Quality–Cost Model of APN transitional care; and (3) APN implementation of an evidence-based protocol, guided by national heart failure guidelines and designed specifically for this patient group and their caregivers with a unique focus on comprehensive management of needs and therapies associated with an acute episode of heart failure complicated by multiple comorbid conditions. The protocol consisted of an initial APN visit within 24 h of index hospital admission, APN visits at least daily during the index hospitalization, at least eight APN home visits (one within 24 h of discharge), weekly visits during the first month (with one of these visits coinciding with the initial follow-up visit to the patient’s physician), bimonthly visits during the second and third months, additional APN visits based on patients’ needs, and APN telephone availability seven days a week.
Number of included participants n = 118.
Control group patients received care routine for the admitting hospital including site-specific heart failure patient management and discharge planning critical paths and if referred, standard home agency care consisting of comprehensive skilled home health services seven days a week. Standards of care for all study hospitals include institutional policies to guide, document, and evaluate discharge planning. The discharge planning process across hospital sites was similar. The attending physician was responsible for determining the discharge date, and the primary nurse, discharge planner, and physician collaborated on the design and implementation of the discharge plan. Standards and processes of care for the primary home care sites were also similar. These included use of liaison nurses to facilitate referrals to home care; availability of comprehensive, intermittent skilled home care services in patients’ residences seven days a week; and on-call registered nurse availability 24 h per day.
Number of included participants n = 121.
Time to first readmission or death was longer in intervention patients. At 52 weeks, patients in the intervention group had fewer readmissions and lower mean total costs. For intervention patients, only short-term improvements were demonstrated in overall quality of life, the physical dimension of quality of life, and patient satisfaction.
 Rauh et al. 1999 [21] An analysis of patients with a primary diagnosis of congestive heart failure at discharge, before and after the implementation of a comprehensive inpatient and outpatient congestive heart failure program consistent with the guidelines of the Agency for Health Care Policy and Research. A comprehensive inpatient and outpatient congestive heart failure program consisting of an intensive education program focusing on diet, compliance and symptom recognition, as well as outpatient infusions. It also incorporated aggressive pharmacological treatment for patients with advanced congestive heart failure.
Number of included participants n = 347
Historical comparative data of patients who received regular HF care.
Number of included participants n = 407.
Decreases in length of stay, admission and readmission rates, costs to the patient and provider.
 Williams et al. 2010 [25] To evaluate the effectiveness of a transitional care service on readmissions and length of stay in hospital for patients with CHF The transitional care intervention required the Clinical nurse specialist (CNS) to identify and recruit patients within 24–48 h of admission. The heart failure CNS visited this group of patients regularly on the wards throughout their admission, during which time they received information on their heart condition in preparation for discharge. The conversation was nurse-led, but was an interactive discussion between the patient and the nurse. The development of the intervention was based on facilitating the transition of the CHF patient from hospital to home. Therefore, follow-up arrangements either involved attendance at the nurse-led clinic or, where appropriate, home visits by the community heart failure nurse.
Number of included participants n = 47.
Historical comparative data of patients who received regular HF care.
Number of included participants n = 50.
The number of readmissions was higher in the control group compared with the transitional care group. Difference in length of stay for both groups almost achieved statistical significance. Patients gave positive feedback about the service.
Specialized care settings
 Akosah et al. 2002 [34] To determine if disease management in a short-term, aggressive-intervention heart failure clinic (HFC) following hospital discharge is associated with improved outcomes A heart failure clinic was designed as a multispecialty, short-term management program for patients with heart failure. The core management team is composed of three cardiologists with expertise in CHF, two nurse practitioners, and a nurse educator. The team interacts closely with other disciplines; including nephrology, pulmonology, and endocrinology to provide for easy access to reciprocal consultation services, such as a nutritionist and exercise physiologist. A plan of care is developed at enrolment. During this time, the patient’s medications are aggressively titrated, requiring frequent monitoring of laboratory values and physical examination. With intensive education, patients are taught self-care skills in the management of their disease. Timing of follow-up visits is flexible and individualized to each patient based on their response to therapy.
Number of included participants n = 38.
Patients were put in the control group if they had not been referred to the heart failure clinic, but had received follow-up care within the usual care system, and had left ventricular systolic dysfunction as the basis for their CHF.
Number of included participants n = 63.
There was a trend toward shorter times to the first outpatient visit following discharge, more outpatient visits within 90 days, and more patient-initiated contacts in the heart failure clinic group than in the control group. The combined hospital readmission and mortality rate at 90 days and a year was lower in the heart failure clinic group. There was a 77% relative risk reduction for 30-day hospital readmission in favor of heart failure clinic group, and a statistically lower rate of readmission at 90 days and a year. Utilization and maintenance of standardized CHF medications were significantly higher in patients who attended the heart failure clinic.
 Atienza et al. 2004 [35] Assess the effectiveness of a discharge and outpatient management program in a nonselected cohort of patients hospitalized for HF The intervention program consisted of three phases: 1) the patients and their family received formal education about their disease; 2) a visit to the primary care physician was scheduled within two weeks of discharge to monitor the patient’s clinical progress, identify incipient physical signs of decompensation, and reinforce knowledge; 3) regular follow-up visits to the outpatient heart failure clinic were scheduled every three months where, in addition to the routine clinical assessments, the cardiologist reviewed the patients’ performance and introduced corrective strategies to improve treatment adherence and response. The heart failure specialist coordinated visits to other specialists, diagnostic test and treatments prescribed by other instances.
A telemonitoring phase lasted from discharge until the end of the study.
Number of included participants n = 164.
Control patients received discharge planning according to routine protocol of study hospitals.
Number of included participants n = 174.
After a median of 509 days, there were fewer events (readmission or death) in the intervention than in the control group (156 vs. 250), which represents a 47% event reduction per observation year. At one year, time to first event, time to first all-cause and HF readmission, and time to death had increased in the intervention group. All-cause and HF readmission rates per observation year were significantly lower, quality of life improved, and overall cost of care was reduced in the intervention group.
 de la Porte et al. 2007 [36] To determine whether an intensive intervention at a heart failure (HF) clinic using a combination of a clinician and a cardiovascular nurse, both trained in HF, reduces the incidence of hospitalization for worsening HF or all-cause mortality (primary end point) and improves functional status (including left ventricular ejection fraction, New York Heart Association (NYHA) class, and quality of life) in patients with NYHA class III or IV The intervention consisted of 9 scheduled patient contacts—at day 3 by telephone, and at weeks 1, 3, 5, 7 and at months 3, 6, 9 and 12 by a visit—with a combined, intensive physician-and-nurse-directed HF outpatient clinic, starting within a week after hospital discharge from the hospital or referral from the outpatient clinic. Verbal and written comprehensive education, optimization of treatment, easy access to the clinic, recommendations for exercise and rest, and advice for symptom monitoring and self-care were provided.
Number of included participants n = 118.
Usual care. The number of admissions for worsening HF or all-cause deaths in the intervention group was lower than in the control group. There was an improvement in left ventricular ejection fraction in the intervention group compared with the usual care group. Patients in the intervention group were hospitalized for a total of 359 days compared with 644 days for those in the usual care group. Beneficial effects were also observed on NYHA classification, prescription of spironolactone, maximally reached dose of β-blockers, quality of life, self-care behavior, and healthcare costs.
Number of included participants n = 122.
 Hanumanthu et al. 1997 [37] To determine whether hospitalization rates and functional outcomes are improved when patients are managed by physicians with special expertise in heart failure working in a dedicated heart failure program Patients were followed on a long-term basis by three physicians who work exclusively with heart failure and heart transplantation patients. Two nurse coordinators assisted with the management of patients both during hospitalizations and as outpatients. Home health agencies were involved in the care of ≈10% of the patients. All patients referred to the program underwent echocardiographic evaluation and, whenever possible, cardiopulmonary exercise testing. Exercise testing is typically repeated at three to six months to monitor patient status, if the patient is able to exercise. Exercise testing with concurrent hemodynamic monitoring is used extensively in the evaluation and management of patients, as described previously. Program offices are based in a single area in the Vanderbilt outpatient office building. Cardiopulmonary exercise testing and exercise hemodynamic testing are performed by program staff in an outpatient laboratory adjacent to the office area.
Number of included participants n = 134.
  In the year before referral, 94% of patients were hospitalized (210 cardiovascular hospitalizations), compared with 44% of the patients during the year after referral (104 hospitalizations) (53% reduction). Heart failure decreased from 164 to 60 for all patients regardless of follow-up duration and decreased from 97 to 30 (69% reduction) for patients followed up at least a year after referral. Loop diuretic doses were on averaged doubled during the first six months after referral.
Hospital versus nonhospital care
 Chiu et al. 2001 [38] To compare the cost and effectiveness of long-term institutional care and home care Number of included participants: Patients receiving care in a chronic care unit in a hospital n = 106; patients admitted to nursing home n = 60; patients receiving professional home nursing care n = 60; patients returned home without receiving professional care n = 80   Caring for patients in their own homes was not only more expensive but was also less effective in improving ADL scores than caring for patients in nursing homes and in hospital chronic care units.
 Grunfeld et al. 1999 [43] To assess the effect on patient satisfaction of transferring primary responsibility for following up with women with breast cancer in remission from hospital outpatient clinics to general practice Routine follow-up in hospital outpatient clinics.
Number of included participants n = 138.
Routine follow-up with their own general practitioner, primary care. Number of included participants n = 122. The general practice group selected responses indicating greater satisfaction than did the hospital group on virtually every question. Furthermore, in the general practice group, there was a significant increase in satisfaction over baseline; a similar significant increase in satisfaction over baseline was not found in the hospital group.
 Luttik et al. 2014 [41] The aim of the current study was to determine whether long-term follow-up and treatment in primary care is equally effective as follow-up at a specialized heart failure clinic in terms of guideline adherence and patient adherence HF clinic; number of included participants n = 92 Primary care; Number of included participants n = 97 After twelve months, no differences between guideline adherence, as estimated by the Guideline Adherence Indicator, and patient adherence, were found between treatment groups. There was no difference in the number of deaths, and hospital readmissions for cardiovascular reasons were also similar. The total number of unplanned non- cardiovascular hospital readmissions, however, tended to be higher in the primary care group than in the HF clinic group.
 Moalosi et al. 2003 [39] To determine the affordability and cost effectiveness of home-based directly observed therapy compared to hospital-based for chronically ill tuberculosis patients, and to describe the characteristics of patients and their caregivers Home based directly observed therapy for chronically ill tuberculosis patients. Number of included participants patients n = 50. Hospital based directly observed therapy for chronically ill tuberculosis patients. Number of included participants (other TB patients) n = 56. Overall, home-based care reduced the cost per patient treated by 44% compared with hospital-based treatment. The cost to the caregiver was reduced by 23%, while the cost to the health system was reduced by 50%. Home-based care is more affordable and cost-effective than hospital-based care for chronically ill TB patients, although costs to caregivers remain high in relation to their incomes.
 Ricauda et al. 2008 [40] To evaluate hospital readmission rates and mortality at a six-month follow-up in selected elderly patients with acute exacerbation of COPD Inpatient care in a general medical ward. Number of included participants n = 52. Geriatric home hospitalization service. Number of included participants n = 52. There was a lower incidence of hospital readmissions for Geriatric home hospitalization service patients than for general medical ward patients at six- month follow-up (42% vs. 87%). Cumulative mortality at six months was 20.2% in the total sample, without significant differences between the two study groups. Patients managed in the Geriatric home hospitalization service had a longer mean length of stay than those cared for in the general medical ward. Only Geriatric home hospitalization service patients experienced improvements in depression and quality-of-life scores. On a cost per patient per day basis, Geriatric home hospitalization service costs were lower than costs in general medical ward.
 Sadatsafavi et al. 2013 [42] To examine if the secondary care provided by specialists following episodes of asthma-related hospitalization is associated with better outcomes compared with the primary care provided by general practitioners Secondary care group. Number of included participants n = 1044. Primary care group. Number of included participants n = 1044. There was no difference in the direct asthma-related costs and rate of readmission between the secondary and the primary care groups. Patients under secondary care had a higher rate of asthma-related outpatient service use, but a lower rate of short acting β-agonist dispensation. The proportion of days covered with a controller medication was higher among the secondary care group. Compared with those who received only primary care, patients who received secondary care showed evidence of more appropriate treatment. Nevertheless, there were no differences in the costs or the risk of readmission. Adherence to asthma medication in both groups was poor, indicating the need to raise the quality of the care provided by generalists and specialists alike.
 Shi et al. 2015 [33] To examine the impact of an integrated care delivery intervention on health care seeking and outcomes for chronically ill patients Interval counties with an integrated care delivery model for promoting appropriate health care utilization by improving access and coordination through the adoption of computerized clinical pathways, a shift from fee-for-service to case-based payment, performance-based payment for care providers, and information technology-based monitoring on service quality of health care facilities. Comparison between rural health stations and hospital users. Number of included participants n = 199 Control counties, comparison between rural health stations and hospital users. Number of included participants n = 172 Significant associations between types of health care facilities as well as value of care were observed in favor of the rural health stations.
 Vliet Vlieland et al. 1997 [44] To evaluate whether the improvement achieved by a short inpatient multidisciplinary treatment program could be maintained over a 1-year period Inpatient treatment consisted of primary medical and nursing care, daily exercise therapy, occupational therapy, and support from a social worker. Treatment goals and modalities were discussed during weekly multidisciplinary team conferences. During outpatient care, the prescription of medication and paramedical treatment was left to the attending rheumatologist at the outpatient clinic in both groups.
Number of included participants n = 39.
Treatment regimens normally employed in the outpatient clinic.
Number of included participants n = 41.
Averaged over the time points 2, 52, and 104 weeks, the improvement was significantly greater in the inpatient group than in the outpatient group, except for the erythrocyte sedimentation rate and Health Assessment Questionnaire score.
Experiences and expectations of patients
 Cowie et al. 2009 [46] To examine patients’ experiences of continuity of care in the context of different long-term conditions and models of care, and to explore implications for the future organization care of long-term conditions Number of included participants n = 33.   Multiple morbidity was frequent and experiences of continuity were framed within patients’ wider experiences of health care rather than the context of a particular diagnosis. Positive experiences of relational continuity were strongly associated with long-term general practitioner-led or specialist-led care. Management continuity was experienced in the context of shared care in terms of transitions between professionals or organizations. Access and flexibility issues were identified as important barriers or facilitators of continuity.
 Dossa et al. 2012 [55] Describe patient and caregiver experiences with care transitions following hospital discharge to home for patients with mobility impairments receiving physical and occupational therapy Number of included participants n = 18, nine patients, nine caregivers.   Breakdowns in communication in four domains impacted continuity of care and patient recovery: (a) poor communication between patients and providers regarding on-going care at home, (b) lack of clarity about who to contact after discharge, (c) Provider response to phone calls following discharge, and (d) provider–provider communication.
 Ireson et al. 2009 [48] To examine the quality of the information received by patients with a chronic condition from the referring and specialist physician in the specialist referral process and the relationship between the quality of information received and trust in physicians Number of included participants n = 250.   Most patients (85%) received good explanations of the reason for the specialist visit from the referring physician, yet 26% felt unprepared about what to expect. Trust in the referring physician was highly associated with the preparatory information patients received. Specialists gave good explanations of diagnosis and treatment, but 26% of patients received no information about follow-ups. Trust in the specialist correlated highly with good explanations of diagnosis, treatment, and self-management.
 Naithani et al. 2006 [45] To identify patients’ experiences and values with respect to continuity in diabetes care Number of included participants n = 25.   Patients’ accounts identified aspects of care they valued that were consistent with four dimensions of experienced continuity of care. These were receiving regular reviews with clinical testing and provision of advice over time (longitudinal continuity); having a relationship with a usual care provider who knew and understood them, was concerned and interested, and took time to listen and explain (relational continuity); flexibility of service provision in response to changing needs or situations (flexible continuity); and consistency and co-ordination between different members of staff, and between hospital and general practice or community settings (team and crossboundary continuity). Problems regarding a lack of experienced continuity mainly occurred at the transitions between sites of care, between providers, or with major changes in patients’ needs.
 Williams, 2004 [47] To investigate perceptions of quality of care by patients experiencing comorbidities who required an acute hospital stay Number of included participants n = 12.   Data analysis revealed three themes: poor continuity of care for comorbidities, the inevitability of something going wrong during acute care and chronic conditions persisting after discharge. Combinations of chronic illnesses and treatments affected these patients’ experiences of acute care and recovery after discharge. Medicalized conceptualizations of comorbidity failed to capture the underlying health care needs of these patients.