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Table 1 Characteristics of included papers

From: Avoiding unnecessary hospitalisation for patients with chronic conditions: a systematic review of implementation determinants for hospital avoidance programmes

Study Country Study type/design Setting Patient population Sites Chronic care condition Type of hospital avoidance programme Outcomes assessed
Acton et al. [50] USA Quantitative—RCT pilot Hospital Adult in-patients with type 1 or 2 DM, with home experience of using basal-bolus insulin 1 DM Self-managed insulin Length of stay
Axon et al. [51] USA Mixed methods Various: hospital, home, hospices CHF, COPD, pneumonia, AMI patients 68 CHF + COPD 1. Risk assessment
2. Education (teach back)
3. Follow-up (phone calls and appointments)
4. Transition (records, coaching), discharge summaries
5. Multidisciplinary rounds
Hospital readmissions
Benzo et al. [52] USA Qualitative Hospital Inpatient admitted with acute exacerbation of COPD 1 COPD Pulmonary rehabilitation and exercise Hospital readmissions
Fisher et al. [53] USA Qualitative Hospital Patients with severe exacerbations of COPD 7 COPD Non-invasive ventilation Length of stay
Hopkinson et al. [54] UK Mixed methods Hospital Inpatients admitted with acute exacerbation of COPD 1 COPD 1. Discharge care bundle
2. Post discharge follow-up phone call
Hospital readmissions
Lennox et al. [47] UK Qualitative Hospital Inpatients admitted with acute exacerbation of COPD 7 COPD Care bundle Hospital readmissions
Length of stay
Morton et al. [55] UK Mixed methods Hospital Admitted patients with acute exacerbation of COPD 31 COPD Admission and discharge care bundles Hospital readmissions
Nguyen et al. [56] Canada Mixed methods Hospital HF patients (> 65) attending the general hospital Heart Function Clinic 1 CHF Technology-based decision support to support self-care in older HF patients and their care partners Hospital readmissions
Seys et al. [57] Belgium, Italy, and Portugal Quantitative Hospital Inpatients admitted with acute exacerbation of COPD 19 COPD Care pathway Hospital readmissions
Willemse et al. [58] Belgium Qualitative Primary and secondary care Community-based CHF patients 7 CHF Telemonitoring and self-management Hospital readmissions
Wood et al. [59]
Study 1
USA Quantitative Hospital Inpatients admitted with first diagnosis of HF in a military healthcare facility 1 CHF Practice changes
1. Education tool which included instructions on medications, daily weights, exercise, sodium intake, reporting symptoms, recording follow-up appointments.
2. Making a patient follow-up appointment in HF facility within 10 days
Hospital readmissions
Wood et al. [59]
Study 2
USA Quantitative Hospital Patients with a history of HF discharged to participating SNFs in a civilian healthcare facility 1 CHF Handoff protocol established to aid in the transition of care from inpatient to outpatient setting Hospital readmissions
Wright et al. [60] New Zealand Quantitative–RCT Hospital Admitted with first diagnosis or an exacerbation of pre-existing HF 1 CHF Self-management Hospital readmissions
Yeager et al. [61] USA Qualitative Hospitals and health centres > 65 years diagnosed with DM plus one other chronic condition and Medicare eligible 6 DM Care coordination model Hospital admissions
Emergency department presentations
  1. DM diabetes mellitus, CHF congestive heart failure, HF heart failure, AMI acute myocardial infarction, COPD chronic obstructive pulmonary disease, SNF skilled nursing facility, RCT randomised controlled trial