111318, 10(24 PMThe Civil War and Industrialization Scoring .docx

11/13/18, 10(24 PMThe Civil War and Industrialization Scoring
Guide
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The Civil War and Industrialization Scoring Guide
CRITERIA NON-PERFORMANCE BASIC PROFICIENT
DISTINGUISHED
Analyze the concept
that the war was one
between industry
and agriculture, with
industry coming out
the winner.
Does not analyze
the concept that
the war was one
between industry
and agriculture,
with industry
coming out the
winner.
Describes but does
not analyze the
concept that the

war was one
between industry
and agriculture, with
industry coming out
the winner.
Analyzes the
concept that the
war was one
between
industry and
agriculture, with
industry coming
out the winner.
Analyzes the concept that the war
was one between industry and
agriculture, with industry coming out
the winner using examples and
citations from peer-reviewed
sources.
Examine ways in
which the Civil War
was a catalyst for
economic change.
Does not
examine ways in
which the Civil
War was a
catalyst for
economic
change.
Lists ways in which

the Civil War was a
catalyst for
economic change.
Examines ways
in which the
Civil War was a
catalyst for
economic
change.
Examines ways in which the Civil
War was a catalyst for economic
change using examples and citations
from peer-reviewed sources.
Analyze how the
cultural shift after
the Civil War was not
easily embraced.
Does not analyze
how the cultural
shift after the Civil
War was not
easily embraced.
Describes how the
cultural shift after
the Civil War was
not easily
embraced.
Analyzes how
the cultural shift
after the Civil

War was not
easily
embraced.
Analyzes how the cultural shift after
the Civil War was not easily
embraced using examples and
sources.
Explain how the Civil
War still has an
emotional impact on
people living today.
Does not explain
how the Civil War
still has an
emotional impact
on people living
today.
List ways in which
the Civil War still
has an emotional
impact on people
living today.
Explains how
the Civil War still
has an
emotional
impact on
people living
today.

Analyzes how the Civil War still has
an emotional impact on people living
today.
Analyze the
economics of
slavery.
Does not analyze
the economics of
slavery.
Discusses the
economics of
slavery.
Analyzes the
economics of
slavery.
Analyzes the economics of slavery
using real-world examples and
sources.
Communicate
effectively in a
variety of formats.
Does not
communicate
effectively in a
variety of formats.
Communicates in a
manner that is

effective but
sometimes lacks
clarity, conciseness,
organization, or
proper grammar.
Communicates
effectively in a
variety of
formats.
Communicates in a professional
manner using scholarly resources
that support the analysis by
connecting concepts through clear,
concise, well-organized, and
grammatically correct writing that
incorporates appropriate APA style
conventions.
Research
Original Investigation
Preventing 30-D ay Hospital Readmissions
A Systematic Review and Meta-analysis of Randomized Trials
Aaron L. Leppin. MD; Michael R. Gionfriddo, PharmD; Maya
Kessler, MD; Juan Pablo Brito, MBBS;
Frances S. Mair, MD; Katie Gallacher, MBChB; Zhen Wang,
PhD; Patricia J. Erwin. MLS; Tanya Sylvester, BS;
Kasey Boehmer, BA; Henry H. Ting, MD, MBA; M. Hassan
Murad, MD; Nathan D. Shippee, PhD;
V ictor M. Montori, MD

IMPORTANCE Reducing early (<30 days) hospital
readmissions is a policy priority aimed at
improving health care quality. The cumulative complexity
model conceptualizes patient
context. It predicts that highly supportive discharge
interventions will enhance patient
capacity to enact burdensome self-care and avoid readmissions.
OBJECTIVE To synthesize the evidence o f the efficacy o f
interventions to reduce early
hospital readmissions and identify intervention features-
including their impact on treatment
burden and on patients' capacity to enact postdischarge self-
care-that might explain their
varying effects.
DATA SOURCES We searched PubMed, Ovid MEDLINE, Ovid
EMBASE, EBSCO CINAHL, and
Scopus (1990 until April 1,2013), contacted experts, and
reviewed bibliographies.
s t u d y SELECTION Randomized trials that assessed the
effect o f interventions on all-cause or
unplanned readmissions within 30 days o f discharge in adult
patients hospitalized for a
medical or surgical cause for more than 24 hours and discharged
to home.
DATA EXTRACTION a n d SYNTHESIS Reviewer pairs
extracted trial characteristics and used an
activity-based coding strategy to characterize the interventions;
fidelity was confirmed with
authors. Blinded to trial outcomes, reviewers noted the extent
to which interventions placed
additional work on patients after discharge or supported their

capacity for self-care in
accordance w ith the cumulative complexity model.
m a in outcomes a n d measures Relative risk o f all-cause or
unplanned readmission w ith or
w ithout out-of-hospital deaths at 30 days postdischarge.
RESULTS In 42 trials, the tested interventions prevented early
readmissions (pooled
random-effects relative risk, 0.82 [95% Cl, 0.73-0.91]; P < .001;
I2 = 31%), a finding that was
consistent across patient subgroups. Trials published before 20
0 2 reported interventions
that were 1.6 times more effective than those tested later
(interaction P = .01). In exploratory
subgroup analyses, interventions with many components
(interaction P = .001), involving
more individuals in care delivery (interaction P = .05), and
supporting patient capacity for
self-care (interaction P = .04) were 1.4,1.3, and 1.3 times more
effective than other
interventions, respectively. A post hoc regression model showed
incremental value in
providing comprehensive, postdischarge support to patients and
caregivers.
CONCLUSIONS AND relevance Tested interventions are
effective at reducing readmissions,
but more effective interventions are complex and support
patient capacity for self-care.
Interventions tested more recently are less effective.
JAMA Intern Med. 2014:174(7):1095-1107.
doLlO.lOOl/jamainternmed.2014.1608
Published online May 12,2014.

Author Affiliations: Author
affiliations are listed at the end of this
article.
Corresponding Author: Victor M.
Montori, MD, Knowledge and
Evaluation Research Unit,
Department of Medicine, Mayo Clinic,
200 First StSW, Plummer Bldg,
Rochester. MN 55905 (montori.victor
@mayo.edu).
[J Supplemental con tent at
jamainternalmedicine.com
1095
R e s e a rc h O r ig in a l In v e s tig a t io n P r e v e n tin g 3
0 - D a y H o s p ita l R e a d m is s io n s
E
arly hospital readm issions have been recognized as a
com m on and costly occurrence, particularly am ong el-
derly and high-risk patients. One in 5 Medicare benefi-
ciaries is readm itted w ithin 30 days, for example, at a cost of
m ore th an $26 billion per year.1 To encourage im provem ent
in
th e quality o f care and a reduction in unnecessary health ex-
pense, policymakers, reim bursem ent strategists, and the US
governm ent have m ade reducing 30-day hospital read m is-
sions a national priority.2"4 Achieving th is goal, however, re-
quires a more complete understanding of the underlying causes
o f readm ission.

The cum ulative com plexity m odel (CuCoM)5 is a fram e-
work developed by our research group th at conceptualizes p a-
tie n t co n tex t as a balance b etw e en w orkload an d
capacity
(Figure 1). Workload consists o f all th e work of being a
patient
and includes efforts to u n d erstan d and plan for care, to
enroll
th e s u p p o rt o f o th e rs , an d to access an d u se h e a lth
care
services.6,7 Capacity is determ ined by th e quality and avail-
ability o f resources th a t patients can mobilize to carry out this
work (physical an d m ental health, social capital, financial re-
sources, and environm ental assets). The CuCoM is novel in its
consideration of th e effects o f treatm ent burden on patient
con-
text, and it illustrates how infeasible, u n su p p o rted , and
con-
text-irreverent care can lead to poor health outcom es and re-
du ced h ea lth care effectiveness. Because p atien ts recently
discharged from th e hospital are in a state o f extrem e physi-
ologic and psychological vulnerability,8 their capacity for en -
acting self-care is low. The CuCoM predicts th at, unless suffi-
cient support is given to enhance patient and caregiver capacity
to carry o u t th e work o f patienthood, placing highly b u rd
en -
some discharge dem ands on these patients will lead to poor
outcom es and hospital readm ission.
To evaluate th e validity o f th e CuCoM and provide hy-
pothesis-generating work in th e understanding of patient con-
text, we chose to synthesize th e evidence on the efficacy of
interventions to reduce early hospital readm issions. In p ar-
ticular, we sought to determ ine th e degree to w hich a n u m -
ber o f intervention ch aracteristics-in clu d in g their im pact

on
p a tie n t cap acity an d w o rk lo a d -m ig h t acco u n t for d
iffer-
ences in their effectiveness.
F ig u r e 1. T h e C u m u l a t i v e C o m p l e x i t y M o d
e l
P a tie n t c o n t e x t is r e p r e s e n te d as a b a la n c e b e
t w e e n w o r k lo a d a n d c a p a c ity .
T h is b a la n c e m u s t b e o p t im iz e d t o e n s u r e c
a re e ffe c tiv e n e s s a n d im p r o v e
o u t c o m e s . In t u r n , t h e o u t c o m e s a c h ie v e d
fe e d b a c k t o a f f e c t t h e
w o r k lo a d - c a p a c ity b a la n c e .
Methods
A registered protocol (PROSPERO CRD42013004773) guided
the
conduct o f this review,9 w hich we report in adherence to th e
Preferred Reporting Item s for Systematic Reviews and M eta-
analyses (PRISMA) S tatem ent.10
Eligibility Criteria
Eligible studies were random ized trials reported in English or
Spanish, since 1990, th a t assessed th e effectiveness o f peri-
discharge interventions vs any com parator on th e risk of early
(ie, w ithin 30 days o f discharge) all-cause or u n p lan n ed
read-
m issions w ith or w ith o u t out-of-hospital deaths. The in te r-
vention had to focus its efforts on th e hospital-to-hom e tra n -
sition, perm it patients across arm s to have otherw ise similar

in p atien t experiences, and be generalizable to contexts b e -
yond a single p atien t diagnosis. Adult patients had to be a d -
m itted from th e com m unity to an inpatient ward for at least
24 hours w ith a medical or surgical cause. Studies including
o b ste tric or p sy ch iatric ad m issio n s or only in clu d in g
d is-
charges to skilled n u rsin g or reh a b ilita tio n facilities w
ere
excluded.
Info rm ation Sources
In co lla b o ra tio n w ith an e x p e rie n c e d re s e a rc h
lib ra ria n
(P.J.E.), w e se a rc h e d in April o f 2013 th e follow ing d a
ta -
b a s e s : P u bM ed, Ovid MEDLINE, Ovid EMBASE, EBSCO
CINAHL, a n d S co p u s. T h e c o m p le te s e a rc h s tr a
te g y is
re p o rte d in eA ppendix 1 (in S u p plem ent). Two review ers
(T.S. a n d A .L.L.) h a n d - s e a r c h e d th e b ib lio g ra p
h ie s o f
in c lu d ed stu d ie s an d rec en t review s. E xperts in th e
field
w ere asked to identify additional references.
Study Selection
F our rev ie w ers (A.L.L., M.R.G., J.P.B., a n d T.S.) w o rk ed
in d e p en d e n tly an d co n sid ered th e eligibility o f c an
d id ate
articles by exam ining th eir titles and abstracts, and th en th e
full version o f articles identified as potentially eligible by at
least 1 reviewer. Conflicts about th e eligibility of full articles
w ere resolved by discussion an d consensus. Eligibility was
delayed for studies reporting outcom es incompletely, p e n d -
ing au th o r contact.

Data Collection
After creating and piloting a standardized form, the review -
ers (A.L.L., M.R.G., and J.P.B.), working independently and in
duplicate an d using a w eb-based program (DistillerSR), ab -
stracted details about th e p atien t population, th e in te rv en
-
tions com pared, and th e outcom es reported.
We abstracted details o f th e interventions tested verba-
tim from either th e trial report or a cited protocol, lim iting
our
focus to th e period o f hospitalization until 30 days after dis-
charge, and identifying th e “n et intervention” by selecting out
activities th a t occurred in th e intervention arm b u t n o t in
th e
control arm . These activities w ere coded using a taxonom y
adapted from H ansen e t al11 (Table 1). We also noted th e n u
m -
ber o f m eaningfully involved individuals participating in th e
1 0 9 6 J A M A I n t e r n a l M e d ic in e J u ly 2 0 1 4 V
o lu m e 174, N u m b e r 7 ja m a in t e r n a lm e d ic in e .c o
m
Preventing 30-Day Hospital Readmissions Original
Investigation Research
intervention’s delivery and the number of meaningful inter
actions these individuals had with patients. Meaningfully in-
volved individuals played a structured and requisite function
in the delivery of central aspects of the intervention (eg, a phy-
sician who might be contacted only as needed would not be
considered meaningfully involved). Similarly, meaningful pa-
tient interactions were defined as those that were the pro-

posed sources of the intervention’s effectiveness (eg, a nurse
visiting a patient only to deliver educational materials but not
to actually engage in educational activity would not be con-
sidered a meaningful interaction). Two team members (A.L.L.
and M.R.G.) created summary descriptions of the interven-
tions in a standardized format; these were shared with each
author to confirm their fidelity to what happened in the trial.
After calibrating judgments on a pilot sample, 2 raters fa-
miliar with the CuCoM (F.S.M. and K.G.), not involved in data
collection and blinded to trial results, evaluated each stan-
dardized intervention description on a scale of l (substan-
tially decrease) to 4 (no effect) to 7 (substantially increase) to
reflect the degree to which the intervention was likely to affect
patient workload and patient capacity for self-care. The im-
pact on patient capacity was rated with perfect agreement 50%
of the time and within l point of difference in 42% of cases (8%
differed by 2 points). Because no interventions were rated to
decrease patient capacity and all mean ratings fell within the
range of 4.0 to 5.5, we elected to dichotomize the variable
(threshold of >5 for increasing capacity) for analysis. Work-
load was more difficult to assess reliably: perfect agreement
and minor disagreement (±1 point) were seen in 29% and 44%
of cases, respectively, with 27% of cases differing by 2 or more
points. This variable was divided into 3 categories (increase,
decrease, no change).
For each included trial, we extracted or computed the risk
of early readmission for each arm, analyzing patients as ran-
domized (intention to treat analysis). We used the number ran-
domized as the denominator except when the number of pa-
tients discharged was reported and differed from the number
randomized. We selected the outcome to extract on the basis
of an ad hoc hierarchy of outcomes of interest, with priority
given to unplanned readmissions, then to all-cause readmis-
sions, and finally to the composite end points of unplanned

and all-cause readmissions plus out-of-hospital deaths, re-
spectively. Outcomes were extracted and analyzed at the lon-
gest period of follow-up, up to 30 days from discharge. Exami-
nation of trials reporting the effect of interventions on more
than 1 of these outcomes revealed that treatment effects were
consistent across them (data not shown).
Risk o f Bias
Two raters (A.L.L. and M.K.) worked independently and in du-
plicate to determine the extent to which each trial was at risk
of bias using a standardized form based on the Cochrane Col-
laboration’s tool.12 The assessment considered the quality of
the randomization sequence generation, allocation conceal-
ment, blinding of outcome assessors, the potential for miss-
ing outcomes (ie, likelihood of missing readmissions to other
hospitals), and the proportion of patients lost to follow-up. For
missing outcomes, “high risk of bias” was assigned when the
Table 1. A c tiv ity -B a s e d C odin g F ra m e w o rk f o r D
ischarge In te rv e n tio n s
Label A ctivity Observed
Discharge
planning
Simply thinking about and formalizing an approach to
prepare for discharge when this did not occur in any way in
the control arm
Case
management
Logistical coordination of care and/or resources not
specifically focused on self-management and either not
occurring in control arm or occurring to lesser degree

Telephone
follow-up
Use of a telephone or videophone for provider-initiated
communication after discharge that does not occur in the
control arm
Telemonitoring Use o f remote technology designed fo r the
patient to
transm it objective measures of health status w ith or
w ithout connected subjective assessment
Patient
education
Patient-directed education related to diagnosis or
treatm ent rationale but not focused on encouraging self-
management and not occurring in control arm
Self-management Patient-directed education or coaching
directly focused on
improving patient's ability to self-manage care needs that
does not happen in control arm
Medication
intervention
Medication reconciliation or special education aimed at
improving medication understanding or adherence; often
conducted by a pharmacist but need not be
Home visits Physical visitation by intervention provider to
patient's
place of residence when this does not happen in control arm

Follow-up
scheduled
Scheduling of a follow -up visit prior to discharge when this
is not done in the control arm or is done less reliably
Patient-centered
discharge
instructions
Some difference in the form at or usability of discharge
materials to make them more accessible or relevant
compared w ith control
Clinician
continuity
Increased provider presence on both sides o f the hospital-
to-hom e transition compared w ith control; may include
involvement o f PCP in inpatient care or strategic follow -up
w ith inpatient clinician after discharge or "bridging"
clinician
Timely follow-up Postdischarge follow -up visit or
communication with
patient when this either does not occur or occurs at a later
date in the control arm
Timely PCP
communication
Engagement with PCP in communication about patient
status when this either does not occur or occurs at a later
date in the control arm
Patient hotline Presence of an open line fo r patient-initiated

communication when this either does not exist in the
control arm or is more restricted in availability or
usefulness
Rehabilitation
intervention
Patient-directed rehabilitation efforts that are not entirely
diagnosis specific but aimed at improving functional status
and do not exist in the control arm
Streamlining A general streamlining o f services provided, often
with
dedicated assignment of responsibility, when this does not
occur in the control arm
Making requisite Increasing the use or quality of services
currently available
but underutilized compared w ith the situation in the
control arm
Other Special situations unique to the intervention (eg,
caregiver
education, peer mentoring)
Abbreviation: PCP, prim ary care provider.
readmissions data came from internal health system records
only. To assess for publication bias, we examined a funnel plot
for asymmetry and conducted asymmetry regression accord-
ing to Sterne and Egger13 and determined the associated P
value.
Data Synthesis
We used random-effects meta-analyses to estimate pooled risk
ratios and 95% confidence intervals for early readmission.14,15

We tested for heterogeneity of effect on this outcome using the
Cochran Q x2 te st16 and estim ated between-trial inconsis-
tency not due to chance using the P statistic.17
jamainternalmedicine.com JAM A In te rn a l M edicine July
2014 Volume 174, Number 7 1097
R e s e a rc h O r ig in a l I n v e s t ig a t io n P r e v e n tin g
3 0 - D a y H o s p ita l R e a d m is s io n s
To explore th e effects o f p atien t, intervention, and o u t-
come characteristics on th e im pact o f m easured intervention
effectiveness, we conducted planned subgroup analyses, te st-
ing variables 1 at a tim e.
Patient characteristics tested were age (m ean >65 years or
not), diagnosis (h eart failure or o th er), an d h o sp ital w ard
(general medical or other). Intervention characteristics tested
included th e num ber o f u n iq u e activities involved in th e
in -
tervention, th e n um ber o f unique individuals or roles m ean-
ingfully involved in its delivery, the minimum num ber of m
ean-
in g fu l p a tie n t in te ra c tio n s o ccu rrin g w ith in 30
days, th e
location o f th e intervention activity (ie, w h eth er it occurred
entirely during th e inpatient stay, after discharge, or as a com
-
bination th a t “bridged” th e transition), w h eth er th e
interven-
tion was rated to increase or decrease p atien t w orkload, and
w h eth er th e intervention w as rated to increase p atien t
capac-
ity (no intervention was found th a t decreased patient capac-

ity for self-care). Ad hoc variables tested were year o f publi-
c a tio n a n d ty p e o f o u tc o m e r e p o r te d (ie , u n p
la n n e d
readm issions vs other).
In form ed by th e findings o f th e ex p lo rato ry subgroup
analyses and our initial hypotheses, we constructed a post hoc
m etaregression m odel to te st a variable th a t reflected th e d
e-
gree to w hich discharge interventions provided com prehen-
sive p atien t and caregiver support. This “com prehensive su p
p o rt” variable could re tu rn values w ith in a range o f 0 to 4
“p oints” on th e basis o f w h eth er th e intervention (1) was
rated
to increase p atien t capacity, (2) had at least 5 (75th percentile
o f distribution) unique intervention activities, (3) had at least
5 (75th percen tile o f d istrib u tio n ) m eaningful p atien t co
n -
tacts, and (4) h ad at least 2 (75th percentile o f distribution) in
-
dividuals involved in its delivery. We created 3 categories for
this variable: interventions w ith zero points (category 1), in -
terventions w ith 1 or 2 points (category 2), and interventions
w ith 3 or 4 points (category 3). To control for changes in s ta n
-
dard care delivery over tim e, we adjusted on th e basis o f the
year o f publication variable.
Results
Study Selection
Our initial database search generated 1128 reports (eFigure 1
in Supplement). Through abstract and title screening, 256 re-
p o rts w ere id e n tified for fu ll-tex t review. D uring fu ll-tex
t
screening (agreement, 89%), 24 were selected for inclusion and

39 were set aside for au th o r contact prior to making a d eci-
sion. Of 7 potentially eligible studies identified from bibliog-
raphies and expert consultation, 2 were included and 1 was set
aside for au th o r contact. Of th e 40 trials requiring au th o r
con-
ta ct for a final eligibility decision, 21 were deem ed eligible.
Of
th e 48 apparently eligible trials, 1 was found ineligible after
the
au th o r confirm ed th a t readm ission data were collected only
for readm issions related to th e index diagnosis.18 The final
sam ple therefore com prised 47 trials from 46 reports.19"64
Of th e 47 eligible trials, 42 con trib u ted data for th e pri-
m ary meta-analysis, and 5 (those th a t reported num bers o f
re-
adm issions rath er th a n th e n um ber o f p atien ts readm
itted)
w ere analyzed separately.31,45,50,55,61 A com plete list o f
ex-
cluded full-text studies w ith rationale for exclusion is avail-
able in eAppendix 2 (in Supplement).
Study Characteristics
Table 2 d es crib es th e in c lu d e d tria ls . M any w ere sin g
le -
center trials taking place in academ ic m edical centers, enroll-
ing few patients (eg, 22 trials enrolled <200 patients), and re-
porting 30-day readm issions. Most interventions tested took
place in b oth the inpatient and o u tp atien t settings. The coded
activity analysis is reported in eTable 1 (in Supplement). In
gen-
eral, interventions included anyw here from 1 to 7 unique ac-
tivities. Case m anagement, patient education, hom e visits, and
self-m anagem ent support were com m only present in n et ac-

tivity descriptions (eTable 1 in Supplement). Trial authors re-
sponded to confirm ation requests for 34 of th e 47 n et in ter-
v e n tio n d e s c r ip tio n s . T h re e a u th o r s r e q u e s
te d m in o r
modifications and 1 au th o r m ade major modifications to
these
descriptions.
Most studies were at low risk o f bias (eTable 2 and eFig-
ure 2 in Supplement). The m ost com m on methodological limi-
tation of these trials was th e lack o f a reliable m ethod for
deal-
ing w ith missing data.
Meta-analysis
In th e 42 trials reporting readm ission rates, th e overall
pooled
relative risk (RR) o f readm ission w ithin 30 days w as O.82
(95%
Cl, 0.73-0.91; P < .001) (Figure 2). Inconsistency across trials
was low (P = 31%). Funnel plot exam ination show ed asym -
m etry suggestive o f publication bias in th e context o f smaller
studies (eFigure 3 in Supplem ent), and the Egger test was sig-
nificant (P = .02). The 5 trials reporting n u m ber o f readm is-
sions (rather th an num ber o f patients w ith readm issions)
had
a pooled relative risk o f readm ission o f 0.93 (95% Cl, 0.72-
1.20; P = 23% ; P = .59). Although this result was consistent
with
th e risk found in trials reporting readm ission rates (interac-
tio n P = .38), we opted n o t to include th ese trials in
subgroup
analyses.
Subgroup analyses failed to find an interaction betw een
trial results and p atien t characteristics or outcom e m easured

(Table 3). A num ber o f intervention characteristics, however,
d id in te ra c t w ith m e a su re d effec tiv e n ess. T h ese in
c lu d e
w hether th e intervention was rated to augm ent patient capac-
ity for self-care (RR, 0.68 [95% Cl, 0.53-0.86] w hen it was and
RR, 0.88 [95% Cl, O.8O-O.97] w h en it w as n o t; in te ractio
n
P = .04), w h eth er th e intervention had at least 5 unique, com
-
p o n en t activities (RR, 0.63 [95% Cl, 0.53-0.76] w h en it did
and
RR, 0.91 [95% Cl, 0.81-1.01] w h e n it d id n o t; in te ra c tio
n
P = .001), an d w h eth er th e in terv en tio n had at least 2 in
d i-
viduals involved in delivery (RR, 0.69 [95% Cl, O.57-O.84] w
hen
it did and RR, 0.87 [95% Cl, 0.77-0.98] w hen it did not; in ter-
action P = .05). Studies testin g in terventions m ore recently
were associated w ith reduced effectiveness (RR, 0.89 [95% Cl,
O.81-O.97] w hen published in 2002 or later and RR, 0.56 [95%
Cl, 0.40-0.79] w h en p u b lis h e d p rio r to 2002; in te ra c
tio n
P = .01). Other characteristics of th e interventions, such as
their
rated effect on patient w orkload and th e site o f delivery, had
no significant interaction w ith th e intervention effect.
1098 JAMA Internal Medicine J u ly 2 0 1 4 V o lu m e 174,
N u m b e r 7 ja m a in t e r n a lm e d ic in e .c o m

Table 2. Study Characteristics3
Source Setting Population
Added Intervention
Program
Baseline Control
Activity
Outcome
Time
Reported
Patients
Discharged,
No.
Activities6/
People'/
Interactions8
Included in
Intervention,
No. Capacity' Workload' Location9
Melton
e ta l,19 2012
48 US
states
Commercially
insured for 3
acute DRGs

Risk-prioritized
telephone follow-up
Nonprioritized
telephone
follow-up
UR, 1 mo 3988 1/1/1 4.0 3.5 OP
Marusicetal,20
2013
Academic
hospital in
Croatia
Elderly patients
receiving >2
medications for
chronic disease
Specialized
pharmacotherapeutic
counseling
Standard
discharge
planning and
usual
information
about drugs
from physician
UR, 1 mo 160 2/1/1 4.0 3.5 IP

Altfeldetal,21
2012
US Elderly patients
receiving >7
medications
with
psychosocial
need
Targeted telephone
follow-up program
Standard
discharge
planning without
any follow-up
contact
ACR, 1 mo 906 2/1/1 5.0 2.0 OP
Davis eta l,22
2012
Academic
center, US
Patients with HF
with mild
cognitive
impairment
Self-management
focused education
program

Standard
discharge HF
teaching and
booklet
ACR, 1 mo 125 5/1/2 5.0 3.5 Both
Bowles et al,23
2011
Urban
community,
US
Mostly black
patients with HF
under specific
home care
agency
Telehomecare
substitution of
traditional home care
Clinical pathway
for HF and home
care
ACR, 1 mo 218 1/2/5 4.0 5.5 OP
Finn etal,24
201 l h
Academic
center, US

General medical
patients of
academic center;
approximately
25% discharged
toSNF
Embedded nurse
practitioner into
academic team to
improve discharge
process
Standard
discharge
planning with
follow-up
scheduled by
resident
ACR, 1 mo 646 2/1/1 4.0 2.5 IP
Wong e ta l,25
2011
Large
general
hospital,
Hong Kong
Elderly general
medical
population
Use of nurse case
managers and trained

volunteers to improve
transition through
health-social
partnership
Usual discharge
planning for
follow-up and
support
ACR, 1 mo 686 4/3/5 4.5 3.5 Both
Leventhal
e ta l,26 2011
University
hospital,
Switzerland
Elderly patients
with HF
Outpatient,
interdisciplinary
education and
support program
Standard care
with HF
consultation,
education
booklet
ACR, 1 mo 34 5/1/4 4.5 4.0 OP
Rytter et al,27

2010
Single
center,
Denmark
Elderly patients
from medical or
geriatric ward
Use of mandatory
home visits to
improve follow-up
from PCP and district
nurses
Standard
discharge
procedures and
letters
ACR, 1 mo 331 4/2/2 4.0 2.5 OP
Koehler etal,28
2009
Academic
center, US
Elderly general
medical patients
expected to
return to home
or assisted living
Supplemental care

bundle that shifted
responsibilities from
nurses to care
coordinators and
added follow-up
Nursing staff do
medication
reconciliation,
discharge
medication
teaching, and
education;
pharmacist
review
UR, 1 mo 41 6/2/5 4.5 4.0 Both
Braun,29 2009 Medical
center,
Israel
General medical
patients
Use of tight telephone Standard
follow-up, especially discharge
to improve adherence planning and
summary
ACR, 1 mo 400 1/1/2 4.5 3.0 OP
Courtney
eta l,30 2009

Tertiary
center,
Australia
Elderly general
medical patients
at high risk
Individualized,
exercise-based care
plan for elderly
Routine
discharge and
rehabilitation
advice, planning
UR, 1 mo 128 6/2/5 5.0 5.0 Both
Jack e ta l,31
2009
Academic,
urban,
safety net
center, US
General medical
patients; 51%
black
Standardized
discharge package to
minimize failures
using discharge
planners and

pharmacists
Similar to
intervention but
uncoordinated
ACRE, 1 mo 738 6/2/3 5.0 2.5 Both
(continued)
jamainternalmedidne.com JAMA Internal Medicine July 2014
Volume 174, Number 7 1099
Research Original Investigation Preventing 30-Day Hospital
Readmissions
Table 2. Study Characteristics3 (continued)
Activities3/
People1/
Interactions3
Source Setting Population
Added Intervention
Program
Baseline Control
Activity
Outcome
Time
Reported

Patients
Discharged,
No.
Included in
Intervention,
No. Capacity' Workloadf Location9
Wakefield
e ta l,32 2008
VA medical
center,
Iowa, US
Men w ith HF;
mean age, 69 y
Telehealth-facilitated Usual discharge
postdischarge support teaching and
program follow -up
ACR, 1 mo 148 2 /1 /5 5.0 5.0 OP
Balaban
e ta l,33 2008
Small Culturally and
community linguistically
teaching diverse general
hospital, US medical or
surgical patients

Program to promptly
reconnect patients to
medical home
through discharge
form
Standard
discharge
planning and
instruction
ACR, 1 mo 96 3 /2 /2 5.0 2.5 Both
Wong
e ta l,34 2 0 08
3 Regional
hospitals,
Hong Kong
Elderly patients
readmitted to
department of
medicine
Preventive,
postdischarge home
visits fo r high-risk
patients
Standard
discharge
planning and
instruction
UR, 1 mo 354 2 /1 /2 4.0 4.0 Both

Coleman
e ta l,35 2006
Single
center, US
Elderly medical
patients who
were in
capitated
delivery system;
approximately
20% discharged
to SNF
Use o f transition
coaches and personal
health record to equip
patients and
caregivers to be more
active in care
Not well
reported
UR, 1 mo 750 5 /1 /5 4.5 5.0 Both
Linne et al,3e
2006
Multiple
community
hospitals,
Sweden

Patients w ith HF;
discharge
disposition not
reported
Use computer-based
education session in
discharge process
Standard HF
education and
materials
ACR, 1 mo 230 2 /0 /0 4.0 4.5 Both
Casas et al,37
2006
2 Tertiary
centers, 1
in Spain and
l i n
Belgium
Elderly patients
w ith COPD
Integrated care plan Standard
to generate synergy discharge
and avoid redundancy protocol w ithout
between inpatient and support o f nurse
outpatient care teams or call center
fo r patients with
COPD
ACR, 1 mo 155 7 /3 /5 5.0 4.5 Both

Riegel et al,38
2006
2 Mexican
Community Americans with
hospitals, HF who were
southern old, ill, and
California, poorly
US acculturated
Telephone case
management program
to improve discharge
transition in Mexican
Americans
Nonstandardized, ACR, 1 mo
HF education
often in English
135 5 /1 /1 5.5 3.0 OP
Koelling
e ta l,39 2 005
University Selected
hospital, US patients w ith HF;
mean age, 65 y
Single predischarge
education session
Standard
discharge

information and
education,
booklet
ACR, 1 mo 223 2 /1 /1 4.5 4.5 IP
Mejhert
e ta l,40 2 0 04
University
hospital,
Sweden
Elderly patients
w ith HF
Nurse-driven,
protocol-based
outpatient
management program
Standard
discharge care;
usual follow -up
ACR+D, 1
mo
196 3 /2 /1 5.0 4.5 OP
Kwok et al,41
2004
2 Acute
hospitals,
Hong Kong

Elderly patients
w ith chronic
lung disease at
high risk
Community
nurse-supported
program based on
weekly
home visits
Standard
follow -up with
home visits as
needed
UR, lm o 157 4 /1 /5 5.5 4.5 Both
Doughty
et a l 42 2002"
Single Patients w ith HF;
center, New dispositions not
Zealand reported
Outpatient,
integrated
management program
for HF
Usual care under
PCP
ACR, 1 mo 197 6 /3 /1 4.5 5.0 OP

Jaarsma
e ta l,43 1999
University Elderly patients
Hospital, w ith HF; mean
Netherlands age, 73 y
Nurse-led education
and support program
w ith follow -up home
visit
Usual care; no
structured
education,
follow -up call,
or home visit
ACR, 1 mo 179 3 /1 /3 4.0 3.5 Both
Naylor et al,44
1999
2 Urban
academic
hospitals,
US
Elderly medical
and surgical
patients; 45%
black
Advanced practice
nurse-directed
program that stressed

continuity, home and
telephone
follow -up
Routine
discharge
planning and
home care
ACR, 1 mo 363 5 /1 /4 5.5 2.5 Both
Stewart et al,45
1998
Tertiary
referral
center,
Australia
General medical
and surgical
patients; 83%
considered high
Risk-targeted, home-
based intervention by
nurse and pharmacist
Discharge
planning with
follow -up w ithin
2 wk
UR+DE, 1
mo

762 5 /2 /3 5.0 2.5 Both
risk
(continued)
1100 JAMA Internal Medicine July 2014 Volume 174, Number
7 jamainternalmedicine.com
Table 2. Study Characteristics3 (continued)
Activities11/
People11/
Interactions11
Outcome Patients Included in
Added Intervention Baseline Control Time Discharged,
Intervention,
Source Setting Population Program Activity Reported No. No.
Capacity' Workload1 Location9
Dunn et al,46
1995
Geriatric
hospital,
England
Geriatric ward
patients; mean
age, 83 y

Single home visit from Usual discharge
public health nurse process
ACR, 1 mo 204 2 /1 /1 4.5 3.0 OP
Rich et al,47
1995
Single
academic
center, US
High-risk,
elderly patients
w ith HF
Nurse-directed,
m ultidisciplinary
intervention w ith
home visit follow -up
Conventional
care by PCP
ACR, 1 mo 274 6 /4 /5 5.5 2.0 Both
Naylor et al,48
1994
Single
university
hospital, US
Elderly patients
w ith or w ithout

caregiver for
medical cardiac
diagnosis
Individualized,
comprehensive
program directed by
clinical nurse
specialists, including
home follow -up
Robust but not
individualized
routine
discharge plan
ACR, 2 wk 142 5 /1 /4 4.5 2.0 Both
Naylor et at,48
1994
Single
university
hospital, US
Elderly patients
w ith or w ithout
caregiver for
surgical cardiac
diagnosis
Individualized,
comprehensive
program directed by
clinical nurse
specialists, including

home follow -up
Robust but not
individualized
routine
discharge plan
ACR, 2 wk 134 5 /1 /4 4.5 2.0 Both
Naylor et al,49
1990
Urban
medical
center, US
Elderly general
medical or
surgical patients
Comprehensive,
individualized
discharge planning
protocol w ith home
follow -up directed by
nurse specialists
Nurse-directed
routine
discharge
planning
ACR, 2 wk 40 4 /1 /4 4.0 3.0 Both
Kulshreshtha
e ta l,50 2010

Urban Patients w ith HF;
teaching could enter
hospital, US study up to 2
weeks after
discharge
Remote monitoring Not well
follow -up program fo r described
ambulatory patients
ACRE, 1 mo 150 2 /1 /5 5.5 5.5 OP
Graumlich
e ta l,512009h
Tertiary General medical
teaching patients at high
hospital, US risk of
readmission
Discharge software to
improve
communication and
address deficiencies
Usual care with
handwritten
discharge forms
ACR, 1 mo 631 3 /1 /0 4.0 3.0 IP
Atienza et al,52
2004

3 Tertiary
university
hospitals,
Spain
Patients w ith HF;
mean age, 68 y
Hospital discharge
and outpatient
disease management
program
Variable and
nonstructured;
PCP follow -up
ACR, 1 mo 338 5 /2 /2 4.5 4.0 Both
R ie g e le ta l,53
2004
2 Hospitals
in suburban
Southwest,
US
Patients w ith HF
in integrated
health system;
mean age, 73 y
Use of peer mentors
to improve self-care
in recently discharged

patients
Inpatient HF
education;
support groups
available
ACR, 1 mo 88 1 /1 /2 4.5 3.0 OP
Stowasser
e ta l,54 2 0 02
2 Large
hospitals,
Australia
General medical
and surgical
patients
Medication liaison
service to improve
communication of
medication-related
issues through
discharge process
Routine care and
pharmacist
medication
review,
discharge
planning
UR, 1 mo 240 3 /1 /0 4.0 3.0 IP

Li e ta l,55 2012 Academic Elderly patients
center, New and their fam ily
York, US caregivers
Training of fam ily
caregivers to prepare
fo r anticipated
postdischarge role
Routine care
w ith practical
information
given to
caregivers
ACRE, 2 wk 407 1 /0 /0 4.5 3.5 IP
Shyu e ta l,56
2005
Large,
single
center,
Taiwan
Elderly patients
w ith hip fracture
Interdisciplinary
program of geriatric
consultation, rehab,
and discharge
planning service
Routine care and
inpatient

physical therapy
w ithout home
visits
ACR, 1 mo 137 4 /3 /5 5.5 3.5 Both
Angermann
e ta l,57 2012
9 Centers,
Germany
Patients w ith HF;
mean age, 69 y
Nurse-coordinated
disease management
program that
emphasized a "call
and care center"
Standard
discharge
planning and
follow -up
ACR, 1 mo 715 4 /1 /5 4.5 4.5 Both
Naylor e ta l,58
2004
5 Academic
and
Elderly patients
with HF; 36%

Advanced practice
nurse-directed care
Standard, site-
specific HF
ACR+D, 1
mo
239 6 /1 /5 5.0 3.0 Both
community black program with discharge
hospitals, emphasis on comorbid planning and
US and chronic condition follow -up
management;
included home
follow -up
(continued)
jamainternalmedicine.com JAMA Internal Medicine July 2014
T a b le 2 . S t u d y C h a r a c t e r i s t i c s 3 ( c o n t i n u e
d )
S o u rce S e ttin g P o p u la tio n
A d d e d I n te r v e n tio n
P ro g ra m

B a s e lin e C o n tr o l
A c t i v i t y
O u tc o m e
T im e
R e p o rte d
P a tie n ts
D is c h a rg e d ,
N o.
A c t iv it ie s 6/
P e o p le 1/
In te r a c tio n s 6
In c lu d e d in
I n te r v e n tio n ,
N o. C a p a c ity " W o r k lo a d ' L o c a tio n 9
S tro m b e rg
e t a l , 59 2 0 0 3
1 U n iv e r s ity E ld e rly p a tie n ts
a n d 2 w it h HF
c o u n ty
h o s p ita ls ,
S w e d e n
R e q u is ite f o l lo w - u p in
s p e c ia liz e d , p r o t o c o l-
d r iv e n , n u r s e -le d HF
c lin ic

C o n v e n tio n a l
p r im a r y ca re
f o llo w - u p
ACR+D, 1
m o
1 0 6 5 / 1 / 1 5 .0 3 .5 OP
H ansen
e t a l , 60 1 9 9 5
U n iv e r s ity H ig h ly s e le c te d H o m e v is it f o llo w
- u p
h o s p ita l, p a tie n ts f r o m p ro g ra m f o r h ig h ly
D e n m a rk s u b a c u te g e r ia tr ic ta r g e te d e ld e r ly
w a rd n e e d in g p o p u la tio n
h o m e
r e h a b ilita tio n and
m e d ic a l a nd
s o c ia l s u p p o r t
D is c h a rg e
s u m m a ry s e n t
a n d s ta n d a rd
s u p p o r t
a rra n g e d
ACR, 1 m o 1 9 3 4 / 2 / 2 5 .0 3 .5 OP
M a slo ve
e t a t,61 2 0 0 9 h
S in g le G e n e ra l m e d ic a l
a c a d e m ic p a tie n ts ;

c e n te r, a p p r o x im a te ly
Canada 8 0 % d is c h a rg e d
h o m e
D e v e lo p m e n t o f m o re
u s e fu l a nd
s ta n d a rd iz e d
d is c h a rg e s u m m a ry
S ta n d a rd ,
a tte n d in g
p h y s ic ia n -
g e n e ra te d
d is c h a rg e
s u m m a rie s a nd
p la n n in g
ACRE, 1 m o 2 0 9 2 / 1 / 0 4 .0 3 .5 IP
F o rs te r
e t a l , 62 2 0 0 5
2 C am p u se s G e n e ra l m e d ic a l
o f a p a tie n ts ; m e an
te a c h in g a g e , 6 6 y
h o s p ita l,
Canada
In te g r a tio n o f
d e d ic a te d c lin ic a l
n u rs e s p e c ia lis t in to
c a re te a m t o f a c ilit a t e
d is c h a rg e p la n n in g
p roce ss

R e g u la r
d is c h a rg e c a re
p la n n in g
ACR+D, 1
m o
3 6 1 3 / 1 / 1 4 .0 3 .0 B o th
D udas
e t a l,63 2 0 0 1
S in g le G e n e ra l m e d ic a l
a c a d e m ic s e rv ic e p a tie n ts
c e n te r, US
P h a rm a c y s e rv ic e
f o l lo w - u p c a ll
R e g u la r
p h a rm a c y -
f a c ilita te d
d is c h a rg e
p roce ss
ACR, 1 m o 2 2 1 2 / 1 / 1 4 .0 3 .0 OP
P a rry
e t a l , 64 2 0 0 9
2 F e e - fo r - s e r v ic e Use o f t r a n s it io n
C o m m u n ity M e d ic a re p a tie n ts co a c h e s a nd p e
rs o n a l
h o s p ita ls , in s in g le h e a lth h e a lth r e c o rd t o e q
u ip
US s y s te m ; in c lu s io n p a tie n ts and

c r ite r ia d e s ire d t o c a re g iv e rs t o a s s e rt
c a tc h p a tie n ts m o re a c tiv e r o le in
d is c h a r g in g t o c a re tr a n s it io n
S N F - d id n o t
r e p o r t
d is p o s itio n s
N o t w e ll
re p o r te d
UR, 1 m o 9 8 5 / 1 / 5 5 .0 2 .5 B o th
A b b r e v ia tio n s : AC R , a ll-c a u s e r e a d m is s io n r
a te ; A C R +D , a ll-c a u s e r e a d m is s io n c N u m b e r
o f in d iv id u a ls m e a n in g f u lly in v o lv e d in d e liv
e r y o f t h e in t e r v e n tio n ,
a n d o u t - o f- h o s p ita l d e a t h ra te ; A C R E , a ll-c a u
s e r e a d m is s io n e v e n t c o u n t; B o th , a |y|jn j m u m
n u m b e r o f m e a n in g f u l h u m a n in t e r a c t io n s
in i n t e r v e n t io n d e liv e ry .
a c t i v it y o c c u r r e d in b o t h in p a t ie n t a n d o u t
p a t ie n t e n v ir o n m e n ts ; C O P D , c h r o n ic „ . , ,,
. . , ,. ,. . . . . . . . . e R a te d lik e lih o o d o f i n t e r v e n
t io n t o a f f e c t p a t ie n t c a p a c ity f o r s e lf- c a r e
o n a
o b s t r u c t iv e p u lm o n a r y d is e a s e ; DRG , d ia g n o
s is - r e la te d g r o u p ; HF, h e a r t f a ilu r e ; , , , , . „ . ,
.
,, .. .. . . . . . . . . „ .. .. ,. s c a l e o f l ( s u b s t a n t i a l ly d
e c r e a s e ) t o 4 ( n o e f f e c t ) t o 7 ( s u b s t a n t i a l l y
in c r e a s e ) .
IP, a ll a c t i v it y o c c u r r e d in i n p a t ie n t e n v ir o n

m e n t ; OP, a ll a c t iv it y o c c u r r e d in
o u t p a t ie n t e n v ir o n m e n t ; SNF, s k ille d n u r s in
g f a c ility ; U R, u n p la n n e d f R a te d lik e lih o o d o f
in t e r v e n t io n t o im p o s e w o r k o r b u r d e n o n p
a t ie n t o n a
r e a d m is s io n ra te ; U R + D E , u n p la n n e d r e a d m
is s io n a n d o u t - o f- h o s p ita l d e a th s s c a le o f 1 (
s u b s t a n t ia lly d e c re a s e ) t o 4 ( n o e f f e c t ) t o
7 ( s u b s t a n t ia lly in c re a s e ),
e v e n t c o u n t ; US, U n ite d S ta te s ; V A . V e te r a n s
A ffa ir s . s S e ttin g ( in p a tie n t , o u t p a t ie n t , o r b o
t h ) w h e r e in t e r v e n t io n a c t i v it y o c c u r r e d .
3 I n t e r v e n t io n a n d b a s e lin e /c o n tr o l a c tiv it ie
s w e r e s y s te m a tic a lly c o d e d in h C lu s te r - r a n
d o m iz e d s tu d y .
g r e a t e r d e ta il th a n c a n b e e x p r e s s e d in t h is
t a b le (s e e e T a b le 1 in S u p p le m e n t) .
b N u m b e r o f a c t iv it ie s in t h e i n t e r v e n t io n
as e v a lu a te d b y c o d in g s tr a te g y f r o m
T a b l e !
P o s t H o c M e t a r e g r e s s io n A n a ly s is
D e sp ite p o te n tia l c o lin e a rity o f th e c o n tr ib u tin
g v a ria b le s ,
m e ta re g re ssio n sh o w e d a sig n ifican t a n d in c re m
e n ta l effect
o f “c o m p r e h e n s i v e s u p p o r t ” o n r e d u c i n g r
e a d m is s io n s
(Table 4). C ategory 3 com prised 7 in terv en tio n

s.28,3037'47'56,58,64
C om pared w ith cate g o ry 1 in te rv e n tio n s, th e s e w
ere a sso c i-
a te d w ith a relativ e risk o f re a d m iss io n o f 0.63 (95%
Cl, 0.43-
0 .91; P = .02). C ategory 3 in te rv e n tio n s u s e d a c o n
siste n t an d
c o m p le x s tra te g y th a t e m p h a s iz e d th e a s s e s
s m e n t a n d a d -
d re ssin g o f facto rs re la te d to p a tie n t c o n te x t a n d
ca p a c ity for
self-care (including th e im p act o f com orbidities, fu nctional
s ta -
tu s , caregiver capabilities, socioeconom ic factors, p o te n tia
l for
self-m a n a g e m e n t, a n d p a tie n t a n d caregiver goals
for care).
T h ese in te rv e n tio n s co o rd in a te d care across th e in
p a tie n t-to -
o u tp a tie n t tr a n s itio n a n d in v o lv ed m u ltip le p a
tie n t in te ra c -
tio n s; all b u t l 28 inv o lv ed p a tie n t h o m e visits.
Discussion
O u r F in d in g s
T he b o d y o f ra n d o m iz e d trial ev id en c e show s a c o
n siste n t and
b en eficial effect o f te s te d in te rv e n tio n s o n th e risk
o f 30-day
read m issio n s. E x p lo rato ry su b g ro u p a n aly ses su g
g est th a t ef-

m
P r e v e n t in g 3 0 - D a y H o s p ita l R e a d m is s io n s O
r ig in a l I n v e s t ig a t io n Research
Figure 2. Results o f Prim ary Meta-analysis
Study RR (95% Cl)
Naylor e ta l,49 1990 0.33 (0 .0 4 -2 .9 4 )
Naylor e ta l,48 1994 0 .2 7 (0 .0 8 -0 .9 1 )
Naylor et a l 48 1994 0.69 (0 .2 3 -2 .0 8 )
Dunn et al,46 1995 1.13 (0 .6 1 -2 .08 )
Rich et a l,47 1995 0.69 (0 .4 2 -1 .1 3 )
Hansen e ta l,60 1995 0 .3 0 (0 .1 6 -0 .5 7 )
Jaarsma e ta l,43 1999 0.89 (0 .4 3 -1 .8 5 )
Naylor e ta l,44 1999 0 .3 5 (0 .1 9 -0 .6 5 )
Dudas e ta l,63 2 001 0.61 (0 .3 6 -1 .0 5 )
Doughty et al,42 2002 1 .1 4 (0 .6 4 -2 .0 4 )
Stowasser et al,54 2002 0 .8 4 (0 .3 7 -1 .9 3 )
Stromberg et a l,59 2003 0 .6 1 (0 .3 5 -1 .0 9 )
M ejhert et al,40 2004 0.91 (0 .4 5 -1 .8 3 )
Kwok et al,41 2004 1 .1 8 (0 .8 0 -1 .7 4 )
Atienza et a l,52 2 0 04 0.57 (0 .3 1 -1 .06 )
Riegel and Carlson,53 2004 1.53 (0 .5 4 -4 .31 )
Naylor et a l,58 2004 0.51 (0 .3 0 -0 .88 )
Koelling et a l,39 2 0 05 0 .7 0 (0 .4 3 -1 .1 5 )
Shyu e ta l,56 2005 0 .6 1 (0 .1 5 -2 .4 5 )
Forster e ta l,62 2 0 05 1.35 (0 .8 4 -2 .16 )

Coleman e ta l,35 2006 0.70 (0 .4 5 -1 .07 )
Linne and Liedholm ,36 2006 1.05 (0 .6 3 -1 .77 )
Casas et a l,37 2006 0 .5 9 (0 .2 4 -1 .4 6 )
Riegel et a l,38 2 0 06 0 .7 9 (0 .3 8 -1 .6 3 )
Balaban e t a l, 33 2008 1 .0 4 (0 .2 8 -3 .9 3 )
Wong et a l,34 2008 0 .9 8 (0 .7 3 -1 .3 1 )
Wakefield e ta l,32 2008 0.66 (0 .3 0 -1 .4 6 )
Koehler et a l,28 2009 0.42 (0 .0 9 -1 .9 2 )
Braun et a l,29 2009 0.92 (0 .4 1 -2 .0 3 )
Courtney e t a l, 30 2009 0 .3 0 (0 .0 9 -1 .0 4 )
Graumlich e ta l,51 2009 0.97 (0 .6 6 -1 .45 )
Parry et a l,64 2 0 09 0.44 (0 .1 5 -1 .3 5 )
R y tte r e ta l,27 2010 0 .7 1 (0 .4 5 -1 .1 3 )
Bowles et a l,23 2011 0.83 (0 .4 6 -1 .49 )
Finn e ta l,24 2011 1 .1 6 (0 .8 5 -1 .6 0 )
Wong e ta l,25 2011 0.78 (0 .5 3 -1 .16 )
Leventhal e ta l,26 2011 0 .5 6 (0 .0 6 -5 .6 3 )
Melton e ta l,19 2012 0 .7 8 (0 .6 2 -0 .9 9 )
A ltfeld et a l,212012 1.05 (0 .7 7 -1 .43 )
Davis et a l,22 2012 1.15 (0 .5 8 -2 .28 )
Angermann et al,57 2012 1.09 (0 .7 1 -1 .66 )
Marusic e ta l,20 2013 1 .2 0 (0 .3 8 -3 .7 7 )
Overall effect (P<.001) 0.82 (0 .7 3 -0 .9 1 )
Heterogeneity: l 2 = 31%; P = .03
Favors
Intervention
Favors
Control
j

0.1 1.0
RR (95% Cl)
Weight, %
0.24
0.71
0.88
2.30
3.08
2.14
1.75
2.28
2.77
2.49
1.44
2.57
1.88
4.17
2.31
0.97

2.75
3.11
0.57
3.33
3.72
2.93
1.24
1.77
0.62
5.46
1.54
0.48
1.54
0.70
4.09
0.86
3.38
2.47

5.06
4.16
0.22
6.30
5.18
1.95
3.77
0.81
100.00
T T 1
10
S ize o f t h e d a ta m a r k e r c o r r e s p o n d s
t o t h e r e la tiv e w e ig h t a s s ig n e d in t h e
p o o le d a n a ly s is u s in g r a n d o m - e ffe c ts
m o d e ls . RR in d ic a te s r e la tiv e ris k .
fective interventions are more complex and seek to enhance
patient capacity to reliably access and enact postdischarge care.
In addition, interventions tested more recently are, in gen-
eral, less efficacious when compared with controls.
Our findings are consistent with the CuCoM in their sug-
gestion that providing comprehensive and context-sensitive

support to patients reduces the risk of early hospital readmis-
sion; however, we could not identify an effect of rated inter-
vention workload on this risk.
Limitations and Strengths of This Review
Many studies in this review were conducted in single, aca-
demic centers; this raises questions about applicability. Also,
the scales that we used to evaluate intervention effects on pa-
tient workload and capacity relied on global judgments (rather
than criterion-based judgments) and are original to this work.
To our knowledge, no validated scale exists to assess the po-
tential of an intervention to impose patient workload or treat-
ment burden and/or affect a patient’s capacity for self-care. Al-
though our raters were consistent in their assessm ents of
interventions’ effect on patient capacity, their judgment of im
pact on patient workload was less reliable. Particularly, raters
believed that some burdensome interventions could be ben-
eficial if the patient had the capacity and resources to access
and enact the care. Because the experience of treatment bur-
den is not constant between patients, an ideal analysis of its
ja m a in t e r n a lm e d ic in e .c o m JAMA Internal Medicine
J u ly 2 0 1 4 V o lu m e 174, N u m b e r 7 1103
T a b le 3 . S u b g r o u p A n a ly s e s
S tu d y S u b g ro u p C h a r a c te r is tic (N o . o f S tu d ie
s in
S u b g r o u p ) 3

R e a d m is s io n , R e la tiv e R isk ( 9 5 % C l)
P V a lu e f o r
In te r a c tio nS u b g ro u p C o m p a ris o n G ro u p
P a tie n t c h a r a c te r is tic s
HF ( 1 6 ) 0 .8 2 ( 0 . 7 0 - 0 . 9 5 ) 0 . 8 0 ( 0 . 6 9 - 0 . 9 3 )
.8 3
A g e > 6 5 y ( 3 6 ) 0 .7 9 ( 0 . 6 9 - 0 . 9 0 ) 0 .9 1 ( 0 . 7 4 -
1 . 1 0 ) .2 4
F ro m g e n e r a l m e d ic a l w a r d ( 1 8 ) 0 . 8 0 ( 0 . 6 7 -
0 . 9 5 ) 0 . 8 3 ( 0 . 7 2 - 0 . 9 5 ) .7 9
I n te r v e n tio n c h a r a c te r is tic s
R a te d t o in c re a s e p a t ie n t c a p a c ity ( 1 6 ) 0 . 6 8
( 0 . 5 3 - 0 . 8 6 ) 0 . 8 8 ( 0 . 8 0 - 0 . 9 7 ) .0 4
R a te d t o in c re a s e p a t ie n t w o r k lo a d ( 5 ) b 0 .7
7 ( 0 . 5 7 - 1 . 0 3 ) 0 .8 2 ( 0 . 7 1 - 0 . 9 6 ) .6 8
R a te d t o d e c re a s e p a t ie n t w o r k lo a d ( 1 9 ) b 0
.8 1 ( 0 . 6 7 - 0 . 9 8 ) 0 .8 2 ( 0 . 7 1 - 0 . 9 6 ) .9 0 A b b r e
v ia tio n : HF, h e a r t fa ilu r e .
D e liv e re d b y 2 o r m o re in d iv id u a ls ( 1 3 ) c 0 . 6
9 ( 0 . 5 7 - 0 . 8 4 ) 0 .8 7 ( 0 . 7 7 - 0 . 9 8 ) .0 5 a C o m p a r
e d w it h t h e r e m a in d e r o f
a n a ly z e d s tu d ie s ( ie , 4 2 - N ) u n le s s
o th e r w is e n o te d .
in v o lv e d > 5 m e a n in g f u l p a t ie n t in t e r a c t io n s
( 1 3 ) c

0 . 7 7 ( 0 . 6 4 - 0 . 9 2 ) 0 . 8 4 ( 0 . 7 3 - 0 . 9 6 ) .4 3
C o m p ris e d > 5 u n iq u e a c t iv it ie s ( 1 6 ) c 0 .6 3 (
0 . 5 3 - 0 . 7 6 ) 0 .9 1 ( 0 . 8 1 - 1 . 0 1 ) .0 0 1
b C o m p a r e d w it h " n o c h a n g e ”
( n = 1 8).
c C u t o f fs c h o s e n b e c a u s e t h e y
H ad b o th a n in p a t ie n t a n d o u t p a t ie n t
c o m p o n e n t ( 2 2 )
0 .7 8 ( 0 . 6 5 - 0 . 9 2 ) 0 . 8 4 ( 0 . 7 4 - 0 . 9 7 ) .4 6
S tu d y p u b lis h e d 2 0 0 2 o r la t e r ( 3 3 ) d 0 .8 9 ( 0 .
8 1 - 0 . 9 7 ) 0 . 5 6 ( 0 . 4 0 - 0 . 7 9 ) .0 1
r e p r e s e n te d t h e 7 5 t h p e r c e n tile o f
O u tc o m e c h a r a c te r is tic s
O u tc o m e m e a s u re d w a s u n p la n n e d
r e a d m is s io n s ( 9 )
0 . 8 4 ( 0 . 6 9 - 1 . 0 2 ) 0 . 8 0 ( 0 . 7 0 - 0 . 9 1 ) .7 0 r e p r
e s e n te d t h e m i d - p o in t o f s tu d y
e lig ib ilit y f o r t h is r e v ie w .
T a b le 4 . E f f e c t s o f C o m p r e h e n s i v e S u p p o
r t in M e t a r e g r e s s i o n A n a ly s i s
S tu d y C h a r a c te r is tic S tu d ie s , N o. R e a d m is s io
n , R e la tiv e R isk ( 9 5 % C l)a P V a lu e
C o m p re h e n s iv e s u p p o r t c a te g o r y 5

1 ( 0 p o in ts ) 1 5 1 [R e fe r e n c e ]
2 (1 o r 2 p o in ts ) 2 0 0 .8 2 ( 0 . 6 6 - 1 . 0 2 ) .0 7
3 (3 o r 4 p o in ts ) 7 0 .6 3 ( 0 . 4 3 - 0 . 9 1 ) .0 2
P u b lic a tio n in 2 0 0 2 o r a fte r 3 3 1 .4 7 ( 1 . 1 0 - 1 .
9 6 ) .0 1
a T h is r e p r e s e n ts t h e a d ju s te d e f f e c t o f e a c
h c h a r a c te r is tic o n e a r ly r e a d m is s io n t h a t
(1) w e r e r a te d t o in c re a s e p a t ie n t c a p a c ity , (
2 ) h a d > 5 u n iq u e in t e r v e n t io n
in m e ta r e g r e s s io n . a c tiv it ie s , (3 ) h a d s 5 m e a n
in g fu l p a t ie n t in t e r a c t io n s , a n d ( 4 ) h a d > 2
b T h e c o m p r e h e n s iv e s u p p o r t v a r ia b le r e tu r
n e d 1 p o in t e a c h f o r in t e r v e n tio n s in d iv id u a
ls in v o lv e d in its d e liv e ry .
effects would be based on patient-reported assessm ents o f in -
te rv e n tio n w o rk lo ad . In d e e d , m an y eligible p a tie
n ts d e -
clined en ro llm en t in to som e s tu d ie s , 2 3 , 2 8 ,4 4 , 5 0
,5 3 o ften b e -
cause th ey did not w ish to take on th e perceived burden o f
the
intervention; evaluating th e effect o f intervention-im posed
w orkload in such sam ples is o f lim ited applicability. In gen-
eral, th e se assessm en ts should be regarded as h y p o th e sis-
generating and th e inferences m ade on th e basis o f subgroup
analyses m u st be view ed as tentative (given th e potential for
chance findings from testing multiple hypotheses and the pos-
sibility th a t some variables are correlated). Finally, despite ro

-
b u st efforts to obtain unpublished data, there was evidence
o f publication bias. The overall effect o f this on our findings
is n o t known.
This review also has m any strengths. First, it provides, to
our knowledge, th e largest a n d m ost com prehensive assess-
m ent o f discharge interventions and their effect on 30-day re-
adm issions, including 47 random ized trials at low risk o f bias.
This is a stronger and less heterogeneous body o f evidence than
previously assem bled , 11,65 and it includes u npublished data
from 18 trials. Our study used an activity-based coding m ethod
designed to en su re appropriate characterization o f each in -
te rv en tio n and th e n et difference in activity betw een in te
r-
v en tio n and control arm s. This m e th o d co n trib u tes to
th e
field an d can be applied to fu tu re assessm en ts o f com plex
interventions. To our knowledge, this is also th e first use of
th e CuCoM5 to analyze th e im pact o f health care delivery in
-
terv en tio n s on p atien ts as an explanation for th e ir relative
efficacy.
C o m p a r is o n W i t h O t h e r S t u d ie s
We identified 31 more random ized clinical trials th a n were
accu m u lated in th e m o st recen t review o f discharge in te
r-
ven tio n effects on 30-day readm ission ra te s , 11 an d w e p
ro -
vide th e first m eta-analysis on th is topic. Although previous
stu d ies an d review s have suggested th a t “b u n d le d ” in te
r-
v en tio n s are o f g rea ter v a lu e , 11,65 th is m e ta-an a ly

sis p ro -
vides objective support for this claim. In addition, our study
ad d s to an d en h an ces th e body o f evidence rela ted to th
e
im portance o f p atien t contextual factors in affecting health
outcom es. 6 5
Im p lic a t io n s f o r P o lic y a n d P r a c t ic e
In this analysis, interventions th a t used a com plex and su p -
portive strategy to assess and address contextual issues and
lim itations in patient capacity w ere m ost effective at reduc-
m
ing early hospital readm issions. Many o f these contacted th e
p atien t frequently, used hom e visits, and reported cost sav-
ings. This inform ation can be used to guide the design and te
st-
ing o f fu tu re interventions. The CuCoM may also have value
in helping to conceptualize th e effects o f health care in terv en
-
tions across diverse patient contexts, b u t we w ere unable to
characterize a co n sisten t effect o f rated in terv en tio n w
ork-
load on outcom es. Finally, we found th a t more recently tested
interventions were less effective. We hypothesize th at this may
rep rese n t (l) a general im provem ent over tim e in th e s ta n
-

dard o f care th a t was no t fully appreciated in control descrip-
tions, (2) an increased effort over tim e to test sim pler and less
comprehensive interventions, (3) a higher likelihood over tim e
o f more diverse interventions to m easure and report 30-day
readm ission rates (eg, including th o se less focused on red u c-
ing early readm issions), and/or (4) a general shift away from
interventions stressing hum an interaction tow ard those more
high tech in nature. Additional stu d y is need ed to d eterm
ine
th e im plications o f this finding.
Conclusions
Our results suggest th a t m ost interventions tested are effec-
tiv e in red u cin g th e risk o f early read m issio n s. Some fe
a -
tures, however, m ay enhance th e effect o f these programs. In
particular, we found value in interventions th a t supported p a-
tie n ts’ capacity for self-care in their transition from hospital
to hom e. F uture work in ten d ed to improve th e effectiveness
o f health care delivery may benefit from consideration o f the
dem ands th a t h ealth care interventions place on recently dis-
charged patients and th eir caregivers and th e extent to w hich
these dem ands are offset by comprehensive support for im ple-
m entation.
ARTICLE INFORMATION
Accepted for Publication: March 8,2014.
Published Online: May 12,2014.
doi:10.1001/jamainternmed.2014.1608.
Author Affiliations: Knowledge and Evaluation
Research Unit, Mayo Clinic, Rochester, Minnesota

(Leppin, Gionfriddo, Kessler, Brito, Wang, Boehmer,
Ting, Murad, M ontori); Mayo Graduate School.
Mayo Clinic, Rochester, Minnesota (Gionfriddo);
Departm ent o f Medicine, Mayo Clinic, Rochester,
Minnesota (Kessler, Brito, M ontori); Mayo Clinic
Center fo r the Science o f Healthcare Delivery, Mayo
Clinic, Rochester, Minnesota (Brito, Wang, Murad,
M ontori); General Practice and Primary Care,
Institute o f Health and Wellbeing, University o f
Glasgow, Glasgow, Scotland, United Kingdom (Mair,
Gallacher); Mayo Clinic Libraries, Mayo Clinic,
Rochester, Minnesota (Erwin); medical student at
St Louis University School o f Medicine, St Louis,
Missouri (Sylvester); graduate student at University
o f Minnesota School o f Public Health, Minneapolis
(Boehmer); Division o f Health Policy and
Management, School o f Public Health, University o f
Minnesota. Minneapolis (Shippee).
Author Contributions: Drs Leppin and M ontori had
full access to all o f th e data in the study and take
responsibility fo r th e integrity o f the data and the
accuracy o f th e data analysis.
Study concept and design: Leppin, Gionfriddo, Mair,
Gallacher, Erwin, Murad, Shippee, M ontori.
Acquisition, analysis, o r interpretation o f data:
Leppin, Gionfriddo, Kessler, Brito, Mair, Gallacher,
Wang, Sylvester, Boehmer, Ting, Murad, M ontori.
Drafting o f the manuscript: Leppin, Mair, Gallacher,
Boehmer, Murad, Montori.
Critical revision o f the manuscript fo r im portant
intellectual content: All authors.
Statistical analysis: Wang, Murad, Montori.
Administrative, technical, or m aterial support:
Leppin, Kessler, Brito, Mair, Gallacher, Erwin,
Sylvester, Boehmer, M ontori.

Study supervision: Leppin, M ontori.
Conflict o f Interest Disclosures: None reported.
Funding/Support: This publication was made
possible by Clinical and Translational Science Award
grant UL1TR000135 from th e National Center for
Advancing Translational Sciences, a com ponent o f
th e National Institutes o f Health.
Role o f the Sponsors: The funding source had no
role in the design and conduct o f th e study;
collection, management, analysis, and
interpretation o f the data; preparation, review, or
approval o f the manuscript; and decision to submit
the manuscript fo r publication.
Disclaimer: The contents are solely the
responsibility o f the authors and do n ot necessarily
represent the official view o f the National Institutes
o f Health.
Additional Contributions: The follow ing
individuals provided unpublished data, conducted
secondary analyses, assisted w ith study
identification, and/or provided guidance and
support: Agneta Bjorck Linne, MS, PhD, and Hans
Liedholm, MD, PhD (Malmo University Hospital,
Sweden); Marcia E. Leventhal, RN, MSN, Sabina De
Geest, PhD. RN. and Kris Denhaerynck, PhD, RN
(Institute o f Nursing Science, University o f Basel,
Switzerland); Lars Rytter, MD (Glostrup University
Hospital, Denmark); Gillian A. Whalley, PhD
(University o f Auckland, New Zealand); David
Maslove, MD, FRCPC (University o f Toronto,
Canada); Judith Garcia-Aymerich, MD, PhD

(Universitat Pomeu Fabra-Barcelona, Spain);
Bonnie J. Wakefield, PhD, RN (Iowa City Veterans
Affairs Healthcare System); Kathleen Finn, MD
(D epartm ent o f Medicine, Massachusetts General
Hospital, Boston); Jon C. Tilburt, MD, MPH (Mayo
Clinic); Christiane E. Angermann, MD
(Universitatsklinikum Wurzburg, Denmark); Felipe
Atienza, MD, PhD (Hospital General Universitario
Gregorio Maranon-Madrid, Spain); Dan Gronseth,
BS (Mayo Clinic); Michael W. Rich, MD (Washington
University, St Louis); A ndrew Masica, MD, MSCI
(Baylor Health Care System); Karen B. Hirschman,
PhD, and Mary D. Naylor, PhD (University o f
Pennsylvania School o f Nursing); James F.
Graumlich, MD (University o f Illinois College o f
Medicine at Peoria); Anna Stromberg, RN, PhD
(Linkoping University Hospital, Sweden). These
contributors were not compensated fo r th e ir
contributions.
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Copyright 2014 American Medical Association. All Rights
Reserved. Applicable
FARS/DFARS Restrictions Apply to Government Use.
This is a discussion post. PLEASE USE the textbook below for
reference and at least one SCHOLARLY PEER-Review
American Nurses Association. (2015). Nursing: Scope and
standards of practice (3rd ed.). Silver Spring, MD: Author.
Your capstone change project begins this week when you
identify a practice issue that you believe needs to change. The
practice issue must pertain to a systematic review that you must
choose from a List of Approved Systematic Reviews for the
capstone project, whose link may be found in the guidelines for
the Week 3 Capstone Project: Milestone 1 assignment page.
· 1st part Choose a systematic review from the list of approved
reviews based on your interests or your practice situation.
· Formulate a significant clinical question related to the topic of
the systematic review that will be the basis for your capstone
change project.
· Relate how you developed the question.
· Describe the importance of this question to your clinical
practice previously, currently, or in the future.

· Describe what a research-practice gap is.
2nd part Now that you have identified your capstone change
project, it is time to look at its feasibility.
· What tangible and intangible resources will be needed to
implement your project?
· What improved outcomes do you anticipate will occur that
could indicate the project produced a successful return on
investment (ROI) of these resources?
· How will you communicate your plan for change with key
decision makers so that they will support the allocation of the
resources you are seeking?
Overview
Write a five-page analysis of the American Civil War.
This assessment allows you to demonstrate your understanding
of a critical event in American history.
SHOW LESS
By successfully completing this assessment, you will
demonstrate your proficiency in the following course
competencies and assessment criteria:
· Competency 3: Examine how the Civil War was a catalyst for
economic change.
. Analyze the conflict between industry and agriculture in
America.
. Examine the economic shifts after the Civil War.
. Analyze the cultural shift after the Civil War.
. Investigate the emotional impact of the Civil War.
. Analyze whether slavery might have been profitable for the
South in 1860.
· Competency 6: Communicate effectively in a variety of
formats.
Context
America's Bloodiest War

America's bloodiest war was not fought overseas. The Civil War
had the highest number of American casualties. Almost three
quarters of a million men and women died. Many more than that
were wounded and disfigured. The war was fought and won by
more populous and fully developed states against those who
were less developed, much more agrarian, and prone to using
human beings as little more than animals. Slavery was an
abomination, but the upper classes in these states could not or
would not abolish it. The South aspired to be the major cotton
supplier to the world. In order to do so, the plantation owners
there clung to the notion that slavery remained necessary, all
the more so, if the plantation economy were to be introduced
into new territories destined for statehood lying further west.
Questions to consider
To deepen your understanding, you are encouraged to consider
the questions below and discuss them with a fellow learner, a
work associate, an interested friend, or a member of the
business community.Suggested Resources
The following optional resources are provided to support you in
completing the assessment or to provide a helpful context. For
additional resources, refer to the Research Resources and
Supplemental Resources in the left navigation menu of your
courseroom.Library Resources
The following e-books or articles from the Capella University
Library are linked directly in this course:
· Coclanis, P. A., & Engerman, S. L. (2013). Would slavery
have survived without the Civil War? Southern Cultures, 19(2),
66–90.
· Post, C. (2011). Social-property relations, class-conflict and
the origins of the U.S. Civil War: Towards a new social
interpretation. Historical Materialism, 19(4), 129–168.
· McCardell, J. M., Jr. (2014). Reflections on the Civil
War. Sewanee Review, 122(2), 295–303.
· Halpern, R., & Dal Lago, E. (Eds.). (2002). The growth of the
cotton kingdom. In Slavery and Emancipation (pp. 123–145).
Malden, MA: Blackwell Publishers.

SHOW LESSCourse Library Guide
A Capella University library guide has been created specifically
for your use in this course. You are encouraged to refer to the
resources in the HIS-FP4100 – Critical Aspects of American
History Library Guide to help direct your research.Bookstore
Resources
The resources listed below are relevant to the topics and
assessments in this course and are not required. Unless noted
otherwise, these materials are available for purchase from
the Capella University Bookstore. When searching the
bookstore, be sure to look for the Course ID with the specific –
FP (FlexPath) course designation.
· Keene, J. D., Cornell, S. T., & O'Donnell, E. T.
(2016). Visions of America: A history of the United
States (3rd ed.). Boston, MA: Pearson Education.
. Chapter 12, "Slavery and Sectionalism: The Political Crisis of
1848–1861."‹
. Chapter 13, "A Nation Torn Apart: The Civil War 1861–1865."
Assessment instructions
Write a five-page examination of the American Civil War.
Address the following in your examination:
· Analyze the concept that the war was one between industry
and agriculture, with industry coming out the winner.
· Examine ways in which the Civil War was a catalyst for
economic change.
· Analyze how the cultural shift after the Civil War was not
easily embraced.
· Examine how the Civil War still has an emotional impact on
people living today.
· Examine whether technology such as the cotton gin could have
affected the need for slavery in the South.
Additional Requirements
· Written communication: Written communication is free of
errors that detract from the overall message.

· APA formatting: Resources and citations are formatted
according to APA (6th edition) style and formatting.
· Number of resources: Minimum of one peer reviewed
resource.
· Length of paper: Five typed, double-spaced pages.
· Font and font size: Times New Roman, 12 point.

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