Transition of care of patients with chronic diseases and its relation with clinical and sociodemographic characteristics.
Larissa Berghetti, Márcia Baiocchi Amaral Danielle, Vanessa Dalsasso Batista Winter and 3 others
PMID 37820218WHAT IT FOUND
Adults with chronic diseases rated discharge transition overall satisfactory, but care plans scored lowest.
Patients without 30-day readmissions reported better preparation for self-management, though this study cannot prove cause.
Key findings
01Overall transition-of-care scores were satisfactory at 76.8±10.4, but the care-plan factor was lowest at 64.5±13.2.
02Patients who were not readmitted within 30 days had a higher preparation-for-self-management score (82.6±11.8).
03Indigenous patients scored 54.0±12.1 on care plan, compared with 65.7±15.0 for white patients; rural residents scored 63.1±15.1, compared with 65.9±15.0 for urban residents.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
It was a cross-sectional survey, so it can show associations but not cause and effect. It used a convenience sample from one hospital in southern Brazil during the pandemic, so it may not apply elsewhere. It relied on patient-reported perceptions of transition of care, not observed care quality or medical outcomes. Some patients were excluded if they had a guarded prognosis or could not answer the questionnaire, and 50 eligible patients were lost to telephone follow-up. The 70-point satisfactory threshold was a convention used by the authors, not a universal cutoff. Readmission was checked only within 30 days.
The easy way to misread this
Do not conclude that better self-management education caused fewer readmissions. This was a cross-sectional survey of patient perceptions, and the study did not test an intervention or prove cause and effect.