Optimizing emergency department care transitions to outpatient settings: A systematic review and meta-analysis

Introduction: Suboptimal transitions from the emergency department (ED) to outpatient settings can result in poor care continuity, and subsequently higher costs to the healthcare system. We aimed to systematically review care transition interventions (CTIs) for adult patients to understand how effective ED-based CTIs are in reducing return visits to the ED and increasing follow-up visits with primary care physicians. Methods: We searched multiple databases and identified eligible published RCTs of ED-based CTIs affecting outpatient follow-up rates, ED readmission and hospital admission. Two independent authors reviewed titles and abstracts for potential inclusion and selected studies for full review. Study quality was assessed using the Cochrane risk-of-bias tool. ED-based CTIs were classified using a care continuity framework. Results: Our search generated 28,807 articles; 112 were selected for full-text review. Data were abstracted from 42 articles that met inclusion criteria. Pooling data from 20 studies (n = 8178 patients) found a relative increase in outpatient follow-up with ED-based CTIs compared to routine care (odds ratio 1.79, 95% confidence interval [CI] 1.43, 2.24). However, ED-based CTIs (20 studies, n = 8048 patients) had no significant effect on ED readmissions (odds ratio 1.02, 95% CI 0.87, 1.20]) or hospital admission after ED discharge (13 studies, n = 5742 patients) (odds ratio 0.99, 95% CI 0.86, 1.14) when compared to routine care. Twenty-two studies encompassed CTIs supporting all three functions of care continuity (information, communication and coordination). Conclusions: ED-based CTIs do not appear to reduce ED revisit or hospital admission after ED discharge but are effective in increasing follow-up.