Trial reportJournal of hospital medicine2021
The Effects of a Multifaceted Intervention to Improve Care Transitions Within an Accountable Care Organization: Results of a Stepped-Wedge Cluster-Randomized Trial.
Trial report in Journal of hospital medicine, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 12 papers, 3 of them syntheses that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
12 citing papers in PubMed, 3 syntheses or guidelines pooled it, 29 citations in OpenAlex.
- Community care navigation intervention for people who are at risk of unplanned hospital presentations.The Cochrane database of systematic reviews · 2025Pooled it
- Patient- and family-centred care transition interventions for adults: a systematic review and meta-analysis of RCTs.International journal for quality in health care : journal of the International Society for Quality in Health Care · 2023Pooled it
- Discharge planning from hospital.The Cochrane database of systematic reviews · 2022Pooled it
- Effect of an Advanced Community Paramedic Program to Shorten or Prevent Hospitalizations: A Pragmatic, Point-of-Care, Randomized Clinical Trial.Annals of family medicine · 2026Trial
- Effect of digital tools to promote hospital quality and safety on adverse events after discharge.Journal of the American Medical Informatics Association : JAMIA · 2024Trial
- Society for Maternal-Fetal Medicine Special Statement: Quality metrics for hypertensive disorders of pregnancy-patient education and transition to primary care.Pregnancy (Hoboken, N.J.) · 2025Article
- Are there opportunities to improve care as patients transition through the cancer care continuum? A scoping review.BMJ open · 2024Article
- Qualitative Assessment of a Novel Intervention to Reduce Hospital Readmission Risk Among People with Diabetes.Medical research archives · 2024Article
- Digitally powered care transitions: A paradigm shift for hospital medicine.Journal of hospital medicine · 2024Article
- Implementation of Complex Interventions: Lessons Learned From the Patient-Centered Outcomes Research Institute Transitional Care Portfolio.Medical care · 2021Article
- Interactive Digital Health Tools to Engage Patients and Caregivers in Discharge Preparation: Implementation Study.Journal of medical Internet research · 2020Article
- Care Navigation and Coordination Program on Reducing Hospital Use for Adults with Complex Health and Psychosocial Needs in South West Sydney, Australia.International journal of integrated careArticle
Corrections and comments
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Authors and funding
10 authors at 4 institutions in 1 country.
Funding
Abstract
backgroundTransitions from hospital to the ambulatory setting are high risk for patients in terms of adverse events, poor clinical outcomes, and readmission.
objectivesTo develop, implement, and refine a multifaceted care transitions intervention and evaluate its effects on postdischarge adverse events. DESIGN, SETTING, AND
participantsTwo-arm, single-blind (blinded outcomes assessor), stepped-wedge, cluster-randomized clinical trial. Participants were 1,679 adult patients who belonged to one of 17 primary care practices and were admitted to a medical or surgical service at either of two participating hospitals within a pioneer accountable care organization (ACO).
interventionsMulticomponent intervention in the 30 days following hospitalization, including inpatient pharmacist-led medication reconciliation, coordination of care between an inpatient "discharge advocate" and a primary care "responsible outpatient clinician," postdischarge phone calls, and postdischarge primary care visit. MAIN OUTCOMES AND MEASURES: The primary outcome was rate of postdischarge adverse events, as assessed by a 30-day postdischarge phone call and medical record review and adjudicated by two blinded physician reviewers. Secondary outcomes included preventable adverse events, new or worsening symptoms after discharge, and 30-day nonelective hospital readmission.
resultsAmong patients included in the study, 692 were assigned to usual care and 987 to the intervention. Patients in the intervention arm had a 45% relative reduction in postdischarge adverse events (18 vs 23 events per 100 patients; adjusted incidence rate ratio, 0.55; 95% CI, 0.35-0.84). Significant reductions were also seen in preventable adverse events and in new or worsening symptoms, but there was no difference in readmission rates.
conclusionA multifaceted intervention was associated with a significant reduction in postdischarge adverse events but no difference in 30-day readmission rates.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.