Penney Lauren S, Nahid Musarrat, Leykum Luci K, Lanham Holly Jordan, Noël Polly H, Finley Erin P, Pugh Jacqueline
South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX, 78229, USA.
Department of Medicine, The University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
BMC Health Serv Res. 2018 Nov 26;18(1):894. doi: 10.1186/s12913-018-3712-7.
Successfully transitioning patients from hospital to home is a complex, often uncertain task. Despite significant efforts to improve the effectiveness of care transitions, they remain a challenge across health care systems. The lens of complex adaptive systems (CAS) provides a theoretical approach for studying care transition interventions, with potential implications for intervention effectiveness. The aim of this study is to examine whether care transition interventions that are congruent with the complexity of the processes and conditions they are trying to improve will have better outcomes.
We identified a convenience sample of high-quality care transition intervention studies included in a care transition synthesis report by Kansagara and colleagues. After excluding studies that did not meet our criteria, we scored each study based on (1) the presence or absence of 5 CAS characteristics (learning, interconnections, self-organization, co-evolution, and emergence), as well as system-level interdependencies (resources and processes) in the intervention design, and (2) scored study readmission-related outcomes for effectiveness.
Forty-four of the 154 reviewed articles met our inclusion criteria; these studies reported on 46 interventions. Nearly all the interventions involved a change in interconnections between people compared with care as usual (96% of interventions), and added resources (98%) and processes (98%). Most contained elements impacting learning (67%) and self-organization (69%). No intervention reflected either co-evolution or emergence. Almost 40% of interventions were rated as effective in terms of impact on hospital readmissions. Chi square testing for an association between outcomes and CAS characteristics was not significant for learning or self-organization, however interventions rated as effective were significantly more likely to have both of these characteristics (78%) than interventions rated as having no effect (32%, p = 0.005).
Interventions with components that influenced learning and self-organization were associated with a significant improvement in hospital readmissions-related outcomes. Learning alone might be necessary but not be sufficient for improving transitions. However, building self-organization into the intervention might help people effectively respond to problems and adapt in uncertain situations to reduce the likelihood of readmission.
成功地帮助患者从医院过渡到家庭是一项复杂且通常充满不确定性的任务。尽管为提高护理过渡的有效性付出了巨大努力，但在整个医疗保健系统中，这仍然是一项挑战。复杂适应系统（CAS）的视角为研究护理过渡干预措施提供了一种理论方法，对干预效果可能会产生影响。本研究的目的是探讨与它们试图改善的过程和条件的复杂性相一致的护理过渡干预措施是否会产生更好的结果。
我们从Kansagara及其同事的护理过渡综合报告中确定了一个高质量护理过渡干预研究的便利样本。在排除不符合我们标准的研究后，我们根据以下两点对每项研究进行评分：（1）干预设计中是否存在5个CAS特征（学习、相互联系、自我组织、共同进化和涌现）以及系统层面的相互依存关系（资源和过程）；（2）对研究中与再入院相关的结果的有效性进行评分。
154篇综述文章中有44篇符合我们的纳入标准；这些研究报告了46项干预措施。与常规护理相比，几乎所有干预措施都涉及人与人之间联系的改变（96%的干预措施），并增加了资源（98%）和流程（98%）。大多数干预措施包含影响学习（67%）和自我组织（69%）的元素。没有一项干预措施体现共同进化或涌现。就对医院再入院的影响而言，近40%的干预措施被评为有效。对结果与CAS特征之间的关联进行卡方检验，学习或自我组织方面的检验结果不显著，然而，被评为有效的干预措施同时具有这两个特征的可能性（78%）显著高于被评为无效的干预措施（32%，p = 0.005）。
具有影响学习和自我组织成分的干预措施与医院再入院相关结果的显著改善有关。仅靠学习可能是必要的，但不足以改善过渡。然而，将自我组织纳入干预措施可能有助于人们有效应对问题并在不确定的情况下进行调整，以降低再入院的可能性。
