Transition of Care for

Acute Stroke and

Myocardial Infarction

Patients:

From Hospitalization to

Rehabilitation, Recovery, and

Secondary Prevention

Evidence-Based

Practice Advancing Excellence in Health Care • www.ahrq.gov

Agency for Healthcare Research and Quality

Evidence Report/Technology Assessment

Number 202
Evidence Report/Technology Assessment

Number 202

Transition of Care for Acute Stroke and Myocardial 

Infarction Patients: From Hospitalization to 

Rehabilitation, Recovery, and Secondary Prevention

Prepared for: 

Agency for Healthcare Research and Quality

U.S. Department of Health and Human Services

540 Gaither Road

Rockville, MD 20850

www.ahrq.gov

Contract No. 290-2007-10066-I 

Prepared by:

Duke Evidence-based Practice Center, Durham, North Carolina

Investigators: 

DaiWai M. Olson, Ph.D., R.N., Lead Investigator

Janet Prvu Bettger, Sc.D., Clinical Investigator

Karen P. Alexander, M.D., Clinical Investigator

Amy S. Kendrick, R.N., M.S.N., EPC Project Manager

Julian R. Irvine, M.C.M., EPC Project Coordinator

Liz Wing, M.A., EPC Editor

Remy R. Coeytaux, M.D., Ph.D., EPC Investigator

Rowena J. Dolor, M.D., M.H.S., EPC Associate Director

Pamela W. Duncan, Ph.D., Principal Investigator

Carmelo Graffagnino, M.D., Principal Investigator

AHRQ Publication No. 11(12)-E011

October 2011
ii

This report is based on research conducted by the Duke Evidence-based Practice Center (EPC) 

under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD 

(Contract No. 290-2007-10066-I). The findings and conclusions in this document are those of the 

authors, who are responsible for its contents; the findings and conclusions do not necessarily 

represent the views of AHRQ. Therefore, no statement in this report should be construed as an 

official position of AHRQ or of the U.S. Department of Health and Human Services. 

The information in this report is intended to help health care decisionmakers—patients and 

clinicians, health system leaders, and policymakers, among others—make well-informed 

decisions and thereby improve the quality of health care services. This report is not intended to 

be a substitute for the application of clinical judgment. Anyone who makes decisions concerning 

the provision of clinical care should consider this report in the same way as any medical 

reference and in conjunction with all other pertinent information, i.e., in the context of available 

resources and circumstances presented by individual patients. 

This report may be used, in whole or in part, as the basis for development of clinical practice 

guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage 

policies. AHRQ or U.S. Department of Health and Human Services endorsement of such 

derivative products may not be stated or implied. 

This document is in the public domain and may be used and reprinted without permission except 

those copyrighted materials that are clearly noted in the document. Further reproduction of those 

copyrighted materials is prohibited without the specific permission of copyright holders.

Persons using assistive technology may not be able to fully access information in this report. For 

assistance contact EffectiveHealthCare@ahrq.hhs.gov. 

Suggested Citation: Olson DM, Prvu Bettger J, Alexander KP, Kendrick AS, Irvine JR, Wing 

L, Coeytaux RR, Dolor RJ, Duncan PW, Graffagnino C. Transition of Care for Acute Stroke and 

Myocardial Infarction Patients: From Hospitalization to Rehabilitation, Recovery, and Secondary 

Prevention. Evidence Report No. 202. (Prepared by the Duke Evidence-based Practice Center 

under Contract No. 290-2007-10066-I.) AHRQ Publication No. 11(12)-E011. Rockville, MD. 

Agency for Healthcare Research and Quality. October 2011. 

None of the investigators has any affiliations or financial involvement that conflicts with the 

material presented in this report.
iii

Preface

The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based 

Practice Centers (EPCs), sponsors the development of evidence reports and technology 

assessments to assist public- and private-sector organizations in their efforts to improve the 

quality of health care in the United States. The reports and assessments provide organizations 

with comprehensive, science-based information on common, costly medical conditions, and new 

health care technologies and strategies. 

The EPCs systematically review the relevant scientific literature on topics assigned to them 

by AHRQ and conduct additional analyses when appropriate prior to developing their reports 

and assessments. To bring the broadest range of experts into the development of evidence reports 

and health technology assessments, AHRQ encourages the EPCs to form partnerships and enter 

into collaborations with other medical and research organizations. The EPCs work with these 

partner organizations to ensure that the evidence reports and technology assessments they 

produce will become building blocks for health care quality improvement projects throughout the 

Nation. The reports undergo peer review and public comment prior to their release as a final 

report. 

AHRQ expects that the EPC evidence reports and technology assessments will inform 

individual health plans, providers, and purchasers as well as the health care system as a whole by 

providing important information to help improve health care quality. 

We welcome comments on this evidence report. Comments may be sent by mail to the Task 

Order Officer named in this report to: Agency for Healthcare Research and Quality, 540 Gaither 

Road, Rockville, MD 20850, or by e-mail to epc@ahrq.hhs.gov. 

Carolyn M. Clancy, M.D.

Director, Agency for Healthcare Research 

and Quality

Jean Slutsky, P.A., M.S.P.H.

Director, Center for Outcomes and Evidence

Agency for Healthcare Research and Quality

Stephanie Chang M.D., M.P.H. 

Director, EPC Program

Center for Outcomes and Evidence

Agency for Healthcare Research and Quality

Shilpa Amin, M.D. MBsc., FAAFP

Task Order Officer

Center for Outcomes and Evidence

Agency for Healthcare Research and Quality
iv

Acknowledgments

The authors thank Connie Schardt, M.S.L.S., for help with the literature search and retrieval.

Technical Expert Panel

Gregory W. Arling, Ph.D.

Associate Professor of Medicine

Indiana University School of Medicine

Indianapolis, IN

Gregg C. Fonarow, M.D.

Division of Cardiology

University of California, Los Angeles

Los Angeles, CA

Larry B. Goldstein, M.D.

Professor of Medicine

Director, Center for Cerebrovascular 

Disease

Duke University

Durham, NC

Eugenie M. Komives, M.D.

Vice President and Senior Medical Director

Blue Cross Blue Shield of North Carolina

Durham, NC

Walter Koroshetz, M.D.

Deputy Director

National Institute of Neurologic Disease and 

Stroke

National Institutes of Health

Bethesda, MD

Eric D. Peterson, M.D., M.P.H.

Division of Cardiology

Duke University Medical Center

Duke Clinical Research Institute

Durham, NC

John Spertus, M.D., M.P.H.

Director of Cardiovascular and Education 

and Outcomes Research

Mid America Heart Institute

University of Missouri

Kansas City, MO

Norine C. Foley, M.Sc., R.D.

Aging, Rehabilitation and Geriatric Care 

Program

Lawson Health Research Institute

London, ON, Canada
v

Peer Reviewers

Cheryl Bushnell, M.D.

Department of Neurology

Wake Forest University Baptist Medical 

Center

Winston-Salem, NC

Mary George, M.D., M.S.P.H.

Division for Heart Disease and Stroke 

Prevention

Centers for Disease Control and Prevention

Atlanta, GA

Jennie C. Hansen, M.S., R.N.

Chief Executive Officer

American Geriatrics Society

New York, NY

Pamela R. Nonnenmacher, M.S.

Division for Heart Disease and Stroke 

Prevention

Centers for Disease Control and Prevention

Atlanta, GA

Debra Saliba, M.D., M.P.H.

Director, JH Borun Center for 

Gerontological Research

University of California, Los Angeles

Los Angeles, CA
vi

Transition of Care for Acute Stroke and Myocardial 

Infarction Patients: From Hospitalization to 

Rehabilitation, Recovery, and Secondary Prevention

Structured Abstract 

Objectives: To review the available published literature to assess whether evidence supports a 

beneficial role for coordinated transition of care services for the postacute care of patients 

hospitalized with first or recurrent stroke or myocardial infarction (MI). This review was framed 

around five areas of investigation: (1) key components of transition of care services, (2) evidence 

for improvement in functional outcomes, morbidity, mortality, and quality of life, (3) associated 

risks or potential harms, (4) evidence for improvement in systems of care, and (5) evidence that 

benefits and harms vary by patient-based or system-based characteristics. 

Data Sources: MEDLINE®, CINAHL®, Cochrane Database of Systematic Reviews, and 

Embase®.

Review Methods: We included studies published in English from 2000 to 2011 that specified 

postacute hospitalization transition of care services as well as prevention of recurrent stroke or 

MI.

Results: A total of 62 articles representing 44 studies were included for data abstraction.

Transition of care interventions were grouped into four categories: (1) hospital-initiated support 

for discharge was the initial stage in the transition of care process, (2) patient and family 

education interventions were started during hospitalization but were continued at the community 

level, (3) community-based models of support followed hospital discharge, and (4) chronic 

disease management models of care assumed the responsibility for long-term care. Early 

supported discharge after stroke was associated with reduced total hospital length of stay without 

adverse effects on functional recovery, and specialty care after MI was associated with reduced 

mortality. Because of several methodological shortcomings, most studies did not consistently 

demonstrate that any specific intervention resulted in improved patient- or system-based 

outcomes. Some studies included more than one intervention, which made it difficult to 

determine the effect of individual components on clinical outcomes. There was inconsistency in 

the definition of what constituted a component of transition of care compared to “standard care.” 

Standard care was poorly defined, and nearly all studies were underpowered to demonstrate a 

statistical benefit. The endpoints varied greatly from study to study. Nearly all the studies were 

single-site based, and most (26 of 44) were conducted in countries with national health care 

systems quite different from that of the U.S., therefore limiting their generalizability. 

Conclusions: Although a basis for the definition of transition of care exists, more consensus is 

needed on the definition of the interventions and the outcomes appropriate to those interventions. 

There was limited evidence that two components of hospital-initiated support for discharge 

(early supported discharge after stroke and specialty care followup after MI) were associated 

with beneficial effects. No other interventions had sufficient evidence of benefit based on the 

findings of this systematic review. The adoption of a standard set of definitions, a refinement in 

the methodology used to study transition of care, and appropriate selection of patient-centered 
vii

and policy-relevant outcomes should be employed to draw valid conclusions pertaining to 

specific components of transition of care. 
viii

Contents

Executive Summary.............................................................................................................. ES-1

Introduction..................................................................................................................................... 1

Background ................................................................................................................................ 1

Scope and Key Questions........................................................................................................... 2

Purpose of This Report............................................................................................................... 3

Role of the Technical Expert Panel............................................................................................ 4

Methods........................................................................................................................................... 5

Analytic Framework................................................................................................................... 5

Literature Search Strategy.......................................................................................................... 6

Sources Searched........................................................................................................................ 6

Screening for Inclusion and Exclusion....................................................................................... 6

Process for Study Selection........................................................................................................ 8

Data Extraction and Data Management...................................................................................... 9

Individual Study Quality Assessment ........................................................................................ 9

Data Synthesis............................................................................................................................ 9

Grading the Body of Evidence ................................................................................................. 10

Peer Review and Public Commentary...................................................................................... 10

Results........................................................................................................................................... 11

Literature Search and Screening............................................................................................... 11

Key Question 1......................................................................................................................... 13

Key Points............................................................................................................................. 13

Detailed Analysis.................................................................................................................. 13

Key Question 2......................................................................................................................... 29

Key Points............................................................................................................................. 29

Detailed Analysis.................................................................................................................. 29

Key Question 3......................................................................................................................... 55

Key Points............................................................................................................................. 56

Detailed Analysis.................................................................................................................. 56

Key Question 4......................................................................................................................... 58

Key Points............................................................................................................................. 58

Detailed Analysis.................................................................................................................. 59

Key Points............................................................................................................................. 63

Detailed Analysis.................................................................................................................. 63

Limitations of This Review...................................................................................................... 72

Conclusions.............................................................................................................................. 72

Future Research ............................................................................................................................ 78

References..................................................................................................................................... 81

List of Included Studies............................................................................................................ 86

Abbreviations................................................................................................................................ 91
ix

Tables

Table 1. Inclusion and Exclusion Criteria .................................................................................. 6

Table 2. Sources of Citations ................................................................................................... 11

Table 3. Transition of Care Interventions and Models for Stroke............................................ 16

Table 4. Transition of Care Interventions and Models for Myocardial Infarction................... 21

Table 5. Summary of Study Characteristics............................................................................. 30

Table 6. Relationship of Caregivers to Patients....................................................................... 42

Table 7. Transition of Care Interventions ................................................................................ 43

Table 8. Elements of Usual Care.............................................................................................. 45

Table 9. Outcome Assessment Measures................................................................................. 46

Table 10. Evidence Supporting Specific Components of Transition of Care Interventions.... 49

Table 11. Summary of Study Time Points Associated With Outcomes .................................. 55

Table 12. Measurement of Risks, Adverse Events, and Potential Harms by Study................. 56

Table 13. Resource Use and Transition of Care for Patients With MI .................................... 59

Table 14. Resource Use and Transition of Care for Patients With Stroke............................... 61

Table 15. Studies of How Benefits and Harms May Vary....................................................... 63

Table 16. Subgroup Characteristics.......................................................................................... 64

Table 17. Studies Showing Significant Findings for Transition Intervention.......................... 66

Table 18. Studies That Found a Benefit of Transition Intervention......................................... 68

Table 19. Summary of Findings............................................................................................... 74

Figures

Figure 1. Analytic Framework ................................................................................................... 5

Figure 2. Literature Flow Diagram........................................................................................... 12

Figure 3. Framework for Episodes of Care .............................................................................. 14

Figure 4. Taxonomy of Transition of Care Interventions for Stroke and MI........................... 28

Appendixes

Appendix A. Exact Search Strings

Appendix B. Data Abstraction Elements

Appendix C. List of Included Studies

Appendix D. Quality and Applicability of Included Studies

Appendix E. List of Excluded Studies
ES-1

Executive Summary

Background

The Centers for Medicare & Medicaid Services (www.cms.gov), the National Quality Forum 

(www.qualityforum.org), and the Institute of Medicine (www.iom.edu) have identified improved 

transitions in care as priorities for demonstration projects and research to reduce 

rehospitalizations and improve the quality of postdischarge care.

Despite advances in the quality of acute-care management of stroke and myocardial 

infarction (MI), there are gaps in knowledge about effective interventions to better manage the 

transition of care for patients with these complex health conditions. Transition of care is defined 

as “a set of actions designed to ensure the coordination and continuity of health care as patients 

transfer between different locations or different levels of care within the same location,”1 and is 

often provided by interdisciplinary teams of professionals.2 Indicators of potential transition 

problems include avoidable rehospitalizations and emergency room visits as well as poor 

functional status and quality of life. 

The Centers for Disease Control and Prevention (CDC) requested that the Agency for 

Healthcare Research and Quality’s (AHRQ’s) Evidence-based Practice Center Program 

systematically review the evidence for transition of care services and programs that improve the 

posthospitalization quality of care for individuals who have experienced strokes or MIs. The 

results of this review will inform the CDC about the current strength of evidence as it develops

future initiatives (e.g., research, clinical, public health and policy) to implement evidence-based 

recommendations for stroke and MI systems of care and postacute quality-of-care programs.

The median risk-standardized 30-day readmission rate for acute MI is approximately 20 

percent.3 Stroke patients are also at high risk for hospital readmissions, with 30 percent of acute 

stroke patients experiencing at least one readmission within 90 days after discharge.4 Acute-care 

hospitalization is a “point of influence” to improve outcomes and quality of care for recovery, 

risk-factor management, and better health. Better management of patients’ care will require 

management across multiple providers and settings. It will soon be expected that acute-care 

settings accept the responsibility to manage care transitions and avoid rehospitalizations. In 

2012, the Patient Protection and Affordable Care Act will financially penalize hospitals for high 

readmission rates. In 2015, acute MI will be one of the conditions targeted for improved quality 

of care, and stroke may be a condition identified in the future. These policies will increase the 

incentives for acute-care hospitals to develop effective transition of care programs and support 

integrated care. It will be important for health systems to develop and implement sustainable 

transition of care models in collaboration with primary care, other postacute health care systems 

(e.g., home health, rehabilitation centers, skilled nursing facilities), community-based services, 

and patients and their families.

Patients recovering from acute MI or stroke have complex medical and social needs and, as 

such, effective interventions are required to manage the transition of care from the acute hospital 

setting to one based in the community. This suggests that a broad and multidisciplinary review is 

required to adequately explore the key questions of transition of care for patients diagnosed with 

stroke or MI.
ES-2

Objectives

The goal of this evidence report was to review the literature that explores opportunities and 

limitations of existing models (such as patient resource management) available for patients as 

they navigate from acute hospital care to rehabilitation services and eventually to independent or 

dependent living. We reviewed the available published literature to assess whether evidence 

exists that coordinated transition of care services for postacute management have a beneficial 

effect on patient outcomes, processes of care, or health care utilization. 

The Key Questions (KQ) considered in this systematic review were: 

• Key Question 1. For patients hospitalized with first or recurrent stroke or myocardial 

infarction (MI), what are the key components of transition of care services? Can these 

components be grouped in a taxonomy, and are they based on a particular theory? 

• Key Question 2. For patients hospitalized with first or recurrent stroke or MI, do 

transition of care services improve functional status and quality of life and reduce 

hospital readmission, morbidity, and mortality (up to 1 year postevent)? 

• Key Question 3. For patients hospitalized with first or recurrent stroke or MI, what are 

the associated risks, adverse events, or potential harms—both system-based and patientbased—of transition of care services?

• Key Question 4. Do transition of care services improve aspects of systems of care for 

patients with stroke or MI (e.g., more efficient referrals, more timely appointments, better 

provider communication, reduced use of urgent care, or fewer emergency room visits as a 

result of transition of care services)? Is there improved coordination among multiple 

subspecialty care providers, and are new providers added to the care plan as a result of 

transition of care services?

• Key Question 5. For patients hospitalized with first or recurrent stroke or MI, do benefits 

and harms of transition of care services vary by characteristics—both patient-based and 

system-based—such as disease etiology and severity, comorbidities, sociodemographic 

factors, training of the health care providers, participants (patients, caregivers), 

geography (rural/urban, regional variations), and insurance status?
ES-3

Analytic Framework

The analytic framework (Figure A) shows how the components of transition of care services 

(e.g., multiple referrals, continuity and coordination of care, communication) for the 

postdischarge care of adult patients hospitalized with stroke or MI result in both patient-based 

and system-based outcomes (e.g., functional status, quality of life, hospital readmission, 

morbidity, and mortality). In addition, the components of transition of care services are analyzed 

by both patient-based and system-based characteristics as well as within the context of a 

theoretical framework. Adverse events, associated risks, or potential harms of transition of care 

services (both system-based and patient-based) are also addressed.

Figure A. Analytic framework

Abbreviations: ER = emergency room; KQ = Key Question; MI = myocardial infarction

Note: “Multiple referrals” indicates referrals to primary care and other health care providers.

Patient characteristics

Age/sex

Race/ethnicity

Marital status

Diagnosis etiology/severity

Comorbidities

System characteristics

Provider training

Geography

Insurance status

Components

Multiple referrals

Continuity of care 

Communication

Coordination of care

(and others)

KQ 3

Adverse events

Harms

Risks

Patient-based outcomes

Functional status

Quality of life

Hospital readmission

Morbidity/mortality

System-based outcomes

Referrals

Communication

ER utilization

Adult patients 

hospitalized with 

stroke or MI

KQ 1

Theoretical 

framework

KQ 5

KQ 2, KQ 4

Transition of care 

services

for postdischarge 

care

Patient characteristics

Age/sex

Race/ethnicity

Marital status

Diagnosis etiology/severity

Comorbidities

System characteristics

Provider training

Geography

Insurance status

Components

Multiple referrals

Continuity of care 

Communication

Coordination of care

(and others)

KQ 3

Adverse events

Harms

Risks

Patient-based outcomes

Functional status

Quality of life

Hospital readmission

Morbidity/mortality

System-based outcomes

Referrals

Communication

ER utilization

Adult patients 

hospitalized with 

stroke or MI

KQ 1

Theoretical 

framework

KQ 5

KQ 2, KQ 4

Transition of care 

services

for postdischarge 

care
ES-4

Methods

1. Input from Stakeholders. We identified experts in the field of transition of care services 

for patients with stroke and MI to serve as members of the project’s Technical Expert 

Panel (TEP). The TEP contributes to AHRQ’s broader goals of (1) creating and 

maintaining science partnerships and public–private partnerships and (2) meeting the 

needs of an array of potential customers and users of this report. To ensure accountability 

and scientifically relevant work, we asked the TEP for input at key stages of the project. 

More specifically, TEP members participated in conference calls and email exchanges to 

refine the analytic framework and key questions at the beginning of the project, refine the 

scope, discuss inclusion and exclusion criteria, and provide input on methodology. An 

additional group of peer reviewers was identified to provide comments on the report. Peer 

reviewers differed from the TEP members in that they were not involved during the 

development phase of the project. The report was also posted for public comment. A 

summary and disposition of the comments from peer and public reviewers has been 

prepared and submitted to AHRQ.

2. Data Sources and Selection. The comprehensive literature search included electronic 

searching of peer-reviewed literature databases from January 1, 2000, to April 21, 2011. 

These databases included the Cumulative Index to Nursing and Allied Health Literature 

(CINAHL®), MEDLINE® accessed via PubMed®, Cochrane Database of Systematic 

Reviews, and Embase®. Searches of these databases were supplemented with manual 

searching of reference lists contained in all included articles and in relevant review 

articles. Search strategies were specific to each database in order to retrieve the articles 

most relevant to the key questions. Our basic search strategy used the National Library of 

Medicine’s Medical Subject Headings (MeSH) keyword nomenclature developed for 

MEDLINE, limited to articles published in English, and a manual search of retrieved 

articles and published reviews. Search terms and strategies were developed in 

consultation with a medical librarian.
ES-5

Table A shows the inclusion and exclusion criteria for the KQs. 

Table A. Inclusion and exclusion criteria

Category Criteria

Study population KQs 1–5:

• Adults ≥ 18 years old who were discharged, or were preparing to be 

discharged, from a hospital for the following two conditions: 

o Acute myocardial infarction (ST elevation myocardial infarction or nonST elevation myocardial infarction) was defined by clinical signs or 

symptoms consistent with an acute coronary syndrome in addition to 

documented electrocardiographic or enzyme evidence of myocardial 

ischemia or injury. Patients with unstable angina were also included if 

evidence of ischemia was present. 

o Stroke (acute ischemic stroke or intracerebral hemorrhage) was defined 

as a focal neurologic deficit lasting more than 24 hours attributed to a 

cerebral vascular cause (either acute ischemic stroke or intracerebral 

hemorrhage). 

• Studies reporting mixed populations of discharge diagnoses were included if 

the results for the myocardial infarction or stroke population were reported 

separately. 

• Studies focused solely on patients with transient ischemic attack, 

subarachnoid hemorrhage, noncardiac chest pain, or congestive heart failure 

without myocardial infarction were excluded. 

Study design KQs 1–5:

• Original data published since 2000

• Randomized controlled trials

a

• Prospective or retrospective observational studies

• Registries

• Excluded if case report, editorial, letter to the editor, or pilot/exploratory study 

with small sample size and not powered to detect a statistically meaningful 

result as stated by the authors 
ES-6

 Table A. Inclusion and exclusion criteria, continued

Category Criteria

Interventions KQs 1–5: Components of transition of care services (peridischarge) included:

• Case management to oversee all care across multiple care environments 

(acute care, intermediate care, home health care, and community settings)

• Discharge planning including procurement of equipment and services, referrals 

for followup care (e.g., home health care, social services, rehabilitation), and 

education about community resources

• Self-management tools to alleviate patient and caregiver burden associated 

with managing transitions between care environments

• Care pathways developed to organize treatment and rehabilitation across care 

settings

• Systems for shared access to patient information to allow multiple health care 

providers across settings to access patient information and to coordinate care

• Referrals to specialty care providers (e.g., cardiologist, neurologist) based on 

patient needs, included as part of the transition of care service

• Referral back to primary care providers included as part of the transition of 

care service

Comparator KQs 1–5: Usual care—defined as care that did not

Study outcomes

include transition of care 

services that coordinated care among multiple providers (e.g., a simple 

recommendation for followup with primary care and other health care providers, or 

direct discharge to home or other health care facility)

• KQs 2, 3, and 4: Outcomes included death, hospital readmission, return to 

premorbid status, functional ability, quality of life, and hospital-free days. 

Predictors of these outcomes included the following:

o System-level of analysis: Academic versus community hospital, specialist 

versus general health care provider, urban versus rural setting

o Patient-level of analysis: Race, ethnicity, sex, comorbidities, 

socioeconomic and insurance status

• KQ 3: Outcomes included adverse events/harms/risks (e.g., readmissions, 

delayed discharge, increased utilization with no improved clinical outcomes, 

increased patient/caregiver burden, dropped from insurance)

• KQs 4 and 5: Outcomes included continuity of health care (with specialist and 

general health care provider), or the total number of health care 

providers/services for a patient

Timing KQs 1–5: Any time period (up to 1 year) following a hospital discharge from an 

acute myocardial infarction or stroke

Settings KQs 1–5: 

• Setting at baseline was an acute-care hospitalization

• Posthospitalization care setting included inpatient (e.g., inpatient rehabilitation 

facility, skilled nursing facility), outpatient (primary care physician, 

rehabilitation), and home care (including home modifications if needed)

• Geographical location, number of sites

Publication languages English only

a

The TEP approved a literature start date of 2000 because this date provided the most current publications and emphasized the 

current paradigms of care.

Abbreviation: KQ = Key Question 
ES-7

Interventions solely comprising cardiac rehabilitation or stroke rehabilitation were 

excluded since both are services that can be prescribed independently from a transition of 

care program. These articles were excluded at the full-text screening stage in the category 

of “not a system-level transitional intervention.” We did not identify any transition of care 

interventions that were developed to support patients transitioning from hospital to 

rehabilitation (either cardiac or stroke) or from rehabilitation to home.

Using the prespecified inclusion and exclusion criteria, titles and abstracts were examined 

independently by two reviewers for potential relevance to the key questions. Articles 

included by any reviewer underwent full-text screening. At the full-text screening stage, 

two independent reviewers read each article to determine if it met eligibility criteria. At 

the full-text review stage, paired researchers independently reviewed the articles and 

indicated a decision to “include” or “exclude” the article for data abstraction. When the 

paired reviewers arrived at different decisions about whether to include or exclude an 

article, they reconciled the difference through a third-party arbitrator. Articles meeting our 

eligibility criteria were included for data abstraction.

1. Data Extraction and Quality Assessment. Data from included reports were abstracted 

into the database by one reviewer and read by a second reviewer. Data elements abstracted 

included descriptors to assess applicability, quality elements, intervention details, and 

outcomes. Disagreements were resolved by consensus or by obtaining a third reviewer’s 

opinion when consensus could not be reached. 

We employed internal and external quality-monitoring checks through every phase of the 

project to reduce bias, enhance consistency, and verify accuracy. Examples of internal 

monitoring procedures were two progressively stricter screening opportunities for each 

article (abstract screening, full-text screening, and data abstraction), involvement of two 

individuals in each data abstraction, and agreement of the two investigators on all included 

studies. The peer review process was our principal external quality-monitoring device. 

The included studies were assessed on the basis of the quality of their reporting of relevant 

data. We evaluated the quality of individual studies using the approach described in 

AHRQ’s Methods Guide for Effectiveness and Comparative Effectiveness Reviews.

5 To 

assess methodological quality, we employed the strategy to (1) apply predefined criteria 

for quality and critical appraisal and (2) arrive at a summary judgment of the study’s 

quality. To indicate the summary judgment of the quality of the individual studies, we 

used the summary ratings of good, fair, or poor. 

To assess applicability, we used data abstracted on the population studied, the intervention 

and comparator, the outcomes measured, settings, and timing of assessments to identify 

specific issues that may limit the applicability of individual studies or a body of evidence 

as recommended in the Methods Guide.

5 We used these data to evaluate the applicability 
ES-8

to clinical practice, paying special attention to study eligibility criteria, baseline 

demographic features of the enrolled population (such as age, disease severity, and 

comorbid conditions) in comparison to the target population, characteristics of the 

transition of care intervention used in comparison with therapies currently in use in routine 

clinical practice, and clinical relevance and timing of the outcome measures. 

2. Data Synthesis and Analysis. The studies included in this review varied in the types of 

transition of care services, the delivery of the intervention tested, the comparator group, 

and the outcomes measured. Therefore, we were unable to group studies with similar 

transitions of care, interventions, and outcomes for a formal meta-analysis. Instead, we 

grouped studies with similar transition of care components and described the 

interventions, comparators, and outcomes. 

Results

The flow of articles through the literature search and screening process is depicted in Figure 

B. Of the 5,783 citations identified by our searches, 4,605 were excluded at the abstract 

screening stage. Of the 1,178 articles that passed the initial abstract screening, 22 were not 

original data (e.g., editorials), which were reviewed separately and excluded from further review, 

and 406 articles were excluded because they were non-English publications. The remaining 750 

articles went on to full-text screening. Of these, 688 were excluded, leaving a total of 62 

included articles (representing 44 studies). 
ES-9

Figure B. Literature flow diagram

Abbreviations: KQ = Key Question; MA = meta-analysis; MI = myocardial infarction; SR = systematic review

5,783 citations 

identified by 

literature search

4,605 abstracts excluded

1,178 articles passed 

abstract screening

22 articles not original data 

excluded from further review, and 

406 articles excluded because nonEnglish

688 articles excluded:

534 not system-level transitional intervention

48 not original peer-reviewed data

32 insufficient data/sample size

27 no acceptable comparator

16 SR or MA for background 

13 no outcomes of interest

13 not stroke or MI

2 methods paper

2 outside scope (before year 2000)

1 not human subjects or not < 18

62 articles representing 44 studies 

abstracted into database and 

included in review:

KQ 1: 62 articles (44 studies)

KQ 2: 53 articles (40 studies)

KQ 3: 8 articles (6 studies)

KQ 4: 18 articles (16 studies)

KQ 5: 14 articles (13 studies)

750 articles 

screened at full-text 

stage
ES-10

KQ 1. After a comprehensive review of the 62 articles (44 studies), we were able to group 

transition of care interventions into four types depending on which phase of an episode of illness 

the patient was in. Intervention type 1 included several components of care that were begun 

while patients were in hospital but being prepared for discharge. Intervention type 2 included all 

components of education, whether started during the hospitalization (type 2a) or after discharge 

(type 2b). Intervention type 3 included community-based support systems involving both lay and 

professional support and visitation (by physicians, nurses, therapists, etc.). Intervention type 4

included the transition of patients to chronic disease management models of care. 

KQ 2. Out of 53 articles (40 studies) reporting outcome measures relevant to KQ 2, we found 

moderate evidence to support the benefit of two components of hospital-initiated planning 

(intervention type 1): early supported discharge for stroke patients and referral for specialty 

followup after MI. Early supported discharge was associated with a reduction in hospital length 

of stay without adversely impacting survival, quality of life, or functional disability. In some 

cases, early supported discharge for stroke patients may also have reduced caregiver strain and 

improved some aspects of quality of life among patients as well as caregivers. Specialty 

followup after MI, as a component of hospital discharge planning (intervention type 1) was also 

associated with a reduction in mortality. There was insufficient evidence to support any specific 

hospital- or community-based educational or support programs in terms of their impact on the 

KQ 2 measures.

KQ 3. There was insufficient evidence to determine if there were differential rates of adverse 

events for transition of care interventions or components of transition of care services because 

rates for adverse events were similar for intervention and usual-care groups in the eight articles 

(six studies) that reported risks, adverse events, or harms. The six studies included only patients 

with stroke, and thus no conclusions could be made in terms of KQ 3 for patients with MI.

KQ 4. In KQ 4 we examined whether transition of care services improved coordination of 

care among multiple subspecialty care providers and whether new providers were added to the 

care plan as part of an improvement in care for patients with stroke or MI. Of the 18 articles (16 

studies) that reported system-level outcomes, there was insufficient evidence to support any of 

the four intervention types although there was a suggestion that some interventions may have a 

limited benefit. 

KQ 5. We did not find evidence that benefits or harms of transition of care services varied on 

the basis of patient characteristics (disease etiology, disease severity or comorbidities) or system 

characteristics (geography, insurance status, sociodemographic). Of 14 articles (13 studies) 

reviewed, the most commonly reported characteristics were disease severity, age, sex, and 

presence or absence of depressive symptoms. Only disease severity showed a trend, suggesting 

that patients with less severe strokes (lower on National Institutes of Health Stroke Scale) 

demonstrated a benefit from transition of care interventions compared with those with more 

severe deficits. 

Table B provides an aggregated view of the strength of evidence and brief conclusions from 

this review.
ES-11

Table B. Summary of findings

Key Question Strength of 

Evidence Summary

Key Question 1: For patients hospitalized with 

first or recurrent stroke or myocardial infarction 

(MI), what are the key components of transition 

of care services? Can these components be 

grouped in a taxonomy, and are they based on a 

particular theory?

Not relevant to 

this key 

question

44 studies (62 articles—10 good quality, 41 fair, 11 poor) described the key 

components of transition of care services.

Conclusion: Transition of care interventions were grouped into 4 intervention types 

that each began in a different phase of an episode of illness:

• Intervention type 1: hospital-initiated support for discharge to home (13 

studies)

• Intervention type 2: patient and family education interventions, both hospitalbased and community-based (7 studies)

• Intervention type 3: community-based models of support (20 studies)

• Intervention type 4: chronic disease management models of care (4 studies)

Key Question 2: Do transition of care services 

improve functional status and quality of life and 

reduce hospital readmission, morbidity, and 

mortality (up to 1 year postevent)?

Moderate to 

insufficient

40 studies (53 articles—8 good quality, 36 fair, 9 poor) reported functional status, 

quality of life, readmission, morbidity, and mortality outcomes. Eight studies used a 

hospital-initiated support intervention (intervention type 1). Early supported discharge 

was a component of 6 of these studies; improvement was reported in 8 articles 

representing 4 studies. 2 of these showed a reduction in mortality when MI patients 

were cared for using guideline-based practice and specialty followup (intervention type 

1). 

Conclusions:

• Early supported discharge as a component of hospital-initiated support 

(intervention type 1) after stroke was associated with a reduction in total 

hospital length of stay without adverse effects on death or functional recovery 

(moderate strength of evidence).

• Specialty followup, a component of hospital-initiated support (intervention type 

1), after MI and guideline-based practice were associated with a reduction in 

mortality (low strength of evidence).

• There was insufficient evidence to support a beneficial role for intervention 

types 3 or 4 in terms of improvement in functional status; quality of life; and 

reduction in hospital readmission, morbidity, and mortality. 

• There was little consistency in the transition of care interventions from one 

study to another. 

• There was much variability in the selection of outcome measures for 

evaluating the success of transition of care interventions. 
ES-12

Table B. Summary of findings (continued)

Key Question Strength of 

Evidence Summary

Key Question 3: What are the associated risks, 

adverse events, or potential harms—both system 

based and patient-based—of transition of care 

services?

Insufficient 6 studies (8 articles—2 good quality, 5 fair, 1 poor) reported risks, adverse events, or 

harms. Of the ones that did, all involved patients with stroke and none involved 

patients with MI. 

Conclusion: There was insufficient evidence to determine if there were differential 

rates of adverse events for transition of care interventions or components of transition 

of care services because rates for adverse events were similar for intervention and 

usual-care groups.

Key Question 4: Do transition of care services 

improve aspects of systems of care for patients 

with stroke or MI? Is there improved 

coordination among multiple subspecialty care 

providers, and are there new providers added to 

the care plan as a result of transition of care 

services?

Moderate to 

Insufficient

16 studies (18 articles—2 good quality, 13 fair, 3 poor) reported system-level 

outcomes. 

Given the available data, we found that:

• The use of emergency department services may be lessened by early 

education regarding stroke or MI symptoms (intervention type 2). 

• Disease-management programs may be more effective than remote phone 

calls for patients with MI (intervention type 3). 

• Early return to work after MI may be safe and may be cost effective from a 

societal perspective (intervention type 1). It did not seem to increase health 

care utilization, and it may save the cost of cardiac rehabilitation in low-risk 

patients. 

• Early supported discharge in low-risk stroke patients reduced hospital days 

and was thus cost effective (intervention type 1). It did not increase burden 

on family providers (moderate level of evidence). 

• Physician appointments or home visits by physical therapists may reduce 

readmission rates for stroke patients (intervention type 3). Visits by nurses 

did not produce the same effects (intervention type 3). 

• Family support and case management services may reduce visits to physical 

therapists and specialists (intervention type 3). 

Conclusion: From a system resource perspective, the evidence for transition of care 

services for patients with stroke or MI was insufficient to provide a full 

recommendation because of study designs, sample sizes, and non-U.S. populations. 
ES-13

Table B. Summary of findings (continued)

Key Question Strength of 

Evidence Summary

Key Question 5: Do benefits and harms of 

transition of care services vary by 

characteristics—both patient-based and systembased—such as disease etiology and severity, 

comorbidities, sociodemographic factors, 

training of the health care providers, participants 

(patients, caregivers), geography (rural/urban, 

regional variations), and insurance status?

Insufficient 13 studies (14 articles—2 good quality, 10 fair, 2 poor) described benefits and harms 

of transition of care services as they vary by patient- or system-based characteristics. 

The most commonly reported characteristics in transition of care studies were 

disease severity, age, sex, and presence or absence of depressive symptoms.

Conclusions:

• There was a lack of consistency by which characteristics were measured or 

reported.

• There was insufficient evidence to be able make conclusions regarding the 

impact of transition of care services on the basis of the patient’s insurance 

status. 

• There was no consistent evidence that demographic groups benefited or 

were harmed by transition of care services. 

• There was a trend suggesting that patients with less severe strokes (lower on 

NIH Stroke Scale) demonstrated a benefit from transition of care 

interventions compared with those with more severe deficits.

Abbreviations: MI = myocardial infarction; NIH = National Institutes of Health
ES-14

Discussion

We conducted a systematic review of the indexed medical literature to evaluate the evidence 

for transition of care services and programs that improve the posthospitalization quality of care 

for patients who have undergone strokes or MIs. A challenge in preparing this review was in 

defining the concept of “transition of care” following hospitalization with stroke or MI. We 

focused on the process that a patient underwent as they left the acute-care hospital and 

reintegrated into society. We found Coleman’s definition of transition of care most appropriate 

for our purposes: “the set of actions designed to ensure the coordination and continuity of health 

care as patients transfer between different locations or different levels of care within the same 

location.”1 We were guided by Donabedian’s framework of structure, process, and outcome in 

the development of a taxonomy of transition of care interventions for MI and stroke. 6-8

In this review, we found that the process of transitioning the care of a patient from the 

hospital to the community began in the hospital as part of the discharge planning process 

(intervention type 1). This phase included interventions such as predetermined integrated-care 

pathways, early supported discharge, extended stroke unit services, and rehabilitation 

coordination with community services. Referral for subsequent subspecialty care followup was 

also included as part of intervention type 1 if it was part of the discharge planning. Education of 

the patient and family prior discharge was also initiated during the acute hospitalization 

(intervention type 2). Educational programs varied from those that provided information 

packages to direct teaching by subspecialty trained nurses. 

Following hospital discharge, community-based support of the patient and family 

(intervention type 3) could be provided through advanced practice nurse care managers, primary 

care and specialty-based medical practitioners, and multidisciplinary care teams (including 

doctors; nurses; social workers; and physical, occupational, and speech therapists). This support 

could be provided in person at the patient’s home, by telephone, or at a clinical practice setting 

(physician’s office, outpatient rehabilitation setting or common meeting place for support 

groups). Ongoing patient and family education could also be maintained at the community level, 

such as the provision of medical-focused manuals, rehabilitation and lifestyle information, 

videotapes, and telephone-based educational programs. 

Chronic disease management (intervention type 4) was reviewed as part of the process of 

transition of care, and a few disease management models were identified that included the 

outcomes of interest in our review: one MI and three stroke intervention programs.

Despite a conceptual basis to support the transition of care, we found only limited evidence 

in favor of some components of hospital-initiated support (intervention type 1): transition of care 

after stroke and specialty followup after MI. Transition of care interventions seemed able to 

reduce the total number of hospitalized days without adversely impacting long-term functional 

recovery or death. Specialty care followup after MI was associated with reduced mortality. There 

were no transition of care interventions that consistently improved functional recovery after 

stroke or MI, and none seemed to consistently improve quality of life or psychosocial factors 

such as strain of care, anxiety, or depression. 
ES-15

Limitations of the Review Process

Across the 62 articles (44 studies) that met the inclusion criteria for this review, the major 

limitations were inadequate sample size, heterogeneity of outcome measures, lack of definition 

for the usual care group, and numerous studies conducted outside of U.S. settings. Few studies 

were designed with a single primary endpoint but rather simultaneously reported multiple 

outcome measures, frequently with an inadequate sample size to justify multiple statistical 

comparisons. The reported outcome measures included both validated and unvalidated outcome 

scales as well as combinations of the two. The treatment interventions were not always clearly 

described. Some studies included more than one intervention, which made it difficult to 

determine the effect of individual components on clinical outcomes. The most limiting aspect of 

the studies reviewed was that they did not define what constituted the control intervention, which 

in many cases was simply referred to as “usual care.” The latter made cross-study comparisons 

challenging. This heterogeneity in the intervention and control treatments precluded conducting a 

meta-analysis of the cohort of studies. A significant number of these studies (some of the better 

ones) were conducted outside the United States in countries with significantly different health 

care systems than ours (frequently in countries with single-payer systems), thus making 

translation of their results more challenging. 

Conclusions 

Although we were able to define a conceptual framework and a specific taxonomy for 

transition of care services that served as the foundation for evaluating the published literature, 

the evidence for efficacy in the setting of stroke and MI was insufficient. A number of the studies 

we reviewed were based on a solid conceptual framework with reasonable study designs but had 

too few patients to be able to reach statistically valid conclusions. Other studies did not follow 

their subjects long enough, and too many studies used inconsistent endpoints to be able to make 

comparisons. Although acute MI and stroke share many risk factors, the scope of medical needs 

that each of these two populations of patients experience is quite different. Even though we 

attempted to evaluate the individual components of transition of care services for each disease 

entity, we found that each medical condition presented unique care issues that required specific 

transition of care interventions. This was most true for the utilization of rehabilitation services 

following stroke. 

As the population of the United States gets older and the number of patients experiencing MI 

or stroke increases, it will be imperative to have transition of care interventions that have proven 

to be effective in improving functional outcomes and facilitating transfer of care from a hospitalbased system to a community-based medical system while at the same time effectively utilizing 

health care resources to maintain health. Based on the findings of this review, few studies 

support the adoption of any specific transition of care program as a matter of health care policy. 

Some components, such as early supported discharge following stroke, appear to shorten length 

of stay and improve short-term disease. A similar approach following MI with early return to 

work also seems to be safe and cost effective. Additional well-structured research performed in 

the United States is necessary before concluding that a specific approach is effective and worthy 
ES-16

of widespread adoption. These studies will need to be disease focused because stroke and MI 

involve quite different populations with unique challenges to overcome.

Implications for Future Research 

Although we defined a taxonomy for the purposes of our review, we believe that a consensus 

needs to be reached among investigators on a unified taxonomy and conceptual framework that 

defines the constituent components in the transition of care process following stroke and MI. We 

found that this process could be evaluated in the context of four different types of interventions, 

each with a multitude of components that could be evaluated individually for clinical and 

statistical effectiveness (i.e., the effects of an education program on medication compliance) or 

together as components of an integrated system (the effectiveness of “early supported discharge”

on functional recovery after stroke when compared to “standard rehabilitation”). Regardless of 

the method chosen, the intervention being tested needs to be clearly defined at the outset of the 

study as well as the expected outcome measures that will be used to evaluate the effectiveness of 

the intervention. 

The control treatment used for comparison against the intervention also needs to be clearly 

defined in terms of the standard prehospitalization and posthospitalization care offered because 

the standard of care in one health care system may be quite different in another. This is most 

relevant in the setting of multicenter trials. Having a manual of operations with clear definitions 

of interventions and control therapies would allow for standardization of treatments across 

centers. Given the heterogeneity of the interventions as well as the systems under which these 

studies are carried out, measures of intervention fidelity (adherence to the protocol) need to be 

built into each study in order to evaluate whether the interventions are feasible and effective.

In addition to consistency in the terms used to describe the components of transition, there 

also needs to be a set of validated and clinically relevant outcomes. The outcomes chosen for a 

study should, by definition, be ones that are responsive to the intervention being tested. After an 

appropriate primary outcome is selected for study, the expected treatment effect needs to be 

presented along with statistical justification for the sample size chosen for the study—thus 

reducing the likelihood of having an underpowered trial. Secondary outcomes could serve as the 

basis for hypothesis testing in future trials. A number of the studies we reviewed showed a 

promising trend toward benefit; however, they were underpowered, and outcomes were diluted 

by incorporating too many variables. There are interventions that would allow an investigator to 

focus on one component of the system at a time and potentially create, in a stepwise fashion, a 

set of clinically proven interventions in a transition of care pathway. 

We found that despite multiple strategies aimed at educating the patient and family about the 

patient’s medical condition, the long-term benefit of this effort seemed less clear. How to 

optimize health care education in order to modify behavior needs further study if it is going to be 

incorporated as a significant component of the transition process. It is already a cornerstone for 

the Joint Commission Primary Stroke Center designation for a hospital, yet there are few data on 

the optimal method for stroke education or whether it is associated with any benefit to the patient 

or family. 

We found little evidence regarding the optimal method of maintaining continuity of care 

following hospital discharge. Despite the rapid development of electronic medical records, there 

was limited evidence about the effectiveness of this tool as a component of transition of care. 
ES-17

The costs associated with widespread implementation are not insignificant, and yet an optimal 

method for implementation in a system of health care such as that in the United States has not 

been evaluated. 

Two examples of components suited for focused study are the role of health-related 

educational efforts in evaluating medication compliance and the implementation of an electronic 

medical record to facilitate communication among multiple providers (primary care, specialty 

care, care coordinators, rehabilitation specialists) after an acute hospitalization.

In other circumstances, it may not be possible to study subcomponents of an intervention; 

instead, a systems approach to care would need to be evaluated. Multidisciplinary dischargeplanning teams (composed of doctors, nurses, social workers, and physical, occupational, and 

speech therapists) are an example of the latter. In that case, the entire team program could be 

tested against “standard” single-provider discharge planning. 

For the results of an intervention to be generalizable to health care systems across the United 

States, the study should involve multiple centers across states as well as across health care 

systems (private practice groups, academic medical centers, health maintenance organizations, 

etc.). Many of the studies we reviewed were conducted in Europe, Australia, and Canada with 

single-payer systems that could affect the ability to extrapolate their study conclusions to the 

United States. More studies should be conducted under the health care system for which the 

intervention is intended to benefit. 

Finally, future studies on transition of care could assess whether there should be separate care 

coordination trajectories for stroke and MI, or whether there is sufficient overlap in these 

interventions such that these care paradigms can translate to the general hospitalized population 

as a whole. For example, the disease state most studied in transition of care research (and 

demonstration projects) is congestive heart failure.9 Programs developed for congestive heart 

failure in the future could be applied to acute MI or stroke and systematically evaluated. Future 

research that addresses whether transition of care interventions should be disease specific or be 

recommended for a general high-risk population would answer this important question. The 

challenges around transition of care are being recognized in all health care reform initiatives, and 

the Affordable Care Act of 2010, Section 3026, provides funding to test transition of care models 

for high-risk Medicare beneficiaries.

Glossary

AHRQ Agency for Healthcare Research and Quality

CDC Centers for Disease Control and Prevention

CINAHL Cumulative Index to Nursing and Allied Health Literature

EPC Evidence-based Practice Center

MeSH Medical Subject Heading

MI myocardial infarction

TEP Technical Expert Panel
ES-18

References

1. Coleman EA, Boult C. Improving the 

quality of transitional care for persons with 

complex care needs. J Am Geriatr Soc 

2003;51(4):556-7. 12657079

2. Naylor MD, Aiken LH, Kurtzman ET, et al. 

The importance of transitional care in 

achieving health reform. Health Aff 

(Millwood) 2011;30(4):746-54. 21471497

3. Bernheim SM, Grady JN, Lin Z, et al. 

National patterns of risk-standardized 

mortality and readmission for acute 

myocardial infarction and heart failure. 

Update on publicly reported outcomes 

measures based on the 2010 release. Circ 

Cardiovasc Qual Outcomes 2010;3(5):459-

67. 20736442

4. Fonarow GC, Smith EE, Reeves MJ, et al. 

Hospital-level variation in mortality and 

rehospitalization for medicare beneficiaries 

with acute ischemic stroke. Stroke 

2011;42(1):159-66. 21164109

5. Agency for Healthcare Research and 

Quality. Methods Guide for Effectiveness 

and Comparative Effectiveness Reviews. 

Rockville, MD: Agency for Healthcare 

Research and Quality. Available at: 

www.effectivehealthcare.ahrq.gov/index.cf

m/search-for-guides-reviews-andreports/?pageaction=displayproduct&produc

tid=318. Accessed March 15, 2011. 

6. McDonald KM, Sundaram V, Bravata DM, 

et al. Care Coordination. In: Shojania KG, 

McDonald KM, Wachter RM, Owens DK, 

eds. Closing the Quality Gap: A Critical 

Analysis of Quality Improvement Strategies. 

Technical Review 9 (Prepared by the 

Stanford University-UCSF Evidence-based 

Practice Center under contract 290-02-

0017). AHRQ Publication No. 04(07)-0051-

7. Vol. 7. Rockville, MD: Agency for 

Healthcare Research and Quality. 2007. 

7. Krumholz HM, Currie PM, Riegel B, et al. 

A taxonomy for disease management: a 

scientific statement from the American 

Heart Association Disease Management 

Taxonomy Writing Group. Circulation 

2006;114(13):1432-45. 16952985

8. Hoenig H, Sloane R, Horner RD, et al. A 

taxonomy for classification of stroke 

rehabilitation services. Arch Phys Med 

Rehabil 2000;81(7):853-62. 10895995

9. Naylor MD. Transitional care of older 

adults. Annu Rev Nurs Res 2002;20:127-47. 

12092508

Internet Citation

Olson DM, Prvu Bettger J, Alexander KP, et al. Transition of Care for Acute Stroke and 

Myocardial Infarction Patients: From Hospitalization to Rehabilitation, Recovery, and Secondary 

Prevention. Evidence Report No. 202. (Prepared by the Duke Evidence-based Practice Center 

under Contract No. 290-2007-10066-I.) AHRQ Publication No. 11(12)-E011. Rockville, MD. 

Agency for Healthcare Research and Quality. October 2011.
1

Introduction

Background

Despite advances in the quality of acute-care management of stroke and myocardial 

infarction (MI), there are gaps in knowledge about effective interventions to better manage the 

transition of care for patients with these complex health conditions. Transition of care is defined

as “a set of actions designed to ensure the coordination and continuity of health care as patients 

transfer between different locations or different levels of care within the same location,”1 and is 

often provided by interdisciplinary teams of professionals.

2 Indicators of potential transition 

problems include avoidable rehospitalizations and emergency room visits as well as poor 

functional status and quality of life. The Centers for Disease Control and Prevention (CDC) 

requested the Agency for Healthcare Research and Quality’s (AHRQ’s) Evidence-based Practice 

Center (EPC) Program to systematically review the evidence for transition of care services and 

programs that improve the posthospitalization quality of care for individuals who have 

experienced strokes or MIs. The results of this review will inform the CDC about the current 

strength of evidence as they develop future initiatives (e.g., research, clinical, public health and 

policy) to implement evidence-based recommendations for stroke and MI systems of care and 

postacute quality-of-care programs. State health departments are developing strategic and 

comprehensive plans for quality improvement programs for health systems, communities, and 

individuals to advance the transition of care. Their decisions should be informed by the current 

strength of evidence for transition of care models implemented during acute care, 

hospitalizations, and postacute settings of care (e.g., skilled nursing facilities, inpatient 

rehabilitation centers, community). Yet, the best practices for care transitions are not well 

established.

The mission of the Division for Heart Disease and Stroke Prevention (DHDSP) at the CDC is 

to provide public health leadership to improve cardiovascular health, reduce the burden, and 

eliminate disparities associated with heart disease and stroke. Cardiovascular disease and stroke 

account for 15 percent of the total health expenditures in 2007,3 and the total estimated costs for 

both are over $286 billion per year. Of the $286 billion, $40 billion is attributable to stroke.4

Advances in the management and quality of acute care have contributed to reduced mortality in 

both conditions.5 Yet some of the social and economic consequences of MI and stroke are their 

contribution to the burden of poor health, chronic disease, and disability rather than death. MIs 

and strokes contribute to, or become, chronic diseases due to the high risks of rehospitalization, 

functional decline, disability, and future cardiovascular events and second strokes. 

The median risk-standardized 30-day readmission rate for acute MI is approximately 20

percent.

6 Stroke patients are also at high risk for hospital readmissions, with 30 percent of acute 

stroke patients experiencing at least one readmission within 90 days after discharge.

7 Acute-care 

hospitalization is a “point of influence” to improve outcomes and quality of care for recovery, 

risk-factor management, and better health. Better management of patients’ care will require 

management across multiple providers and settings. It will soon be expected that acute-care 

settings accept the responsibility to manage care transitions and avoid rehospitalizations. In 

2012, the Patient Protection and Affordable Care Act will financially penalize hospitals for high 

readmission rates. In 2015, acute MI will be one of the conditions targeted for improved quality 

of care, and stroke may be a condition identified in the future. These policies will increase the 
2

incentives for acute-care hospitals to develop effective transition of care programs and support 

integrated care. It will be important for health systems to develop and implement sustainable 

transition of care models in collaboration with primary care, other postacute health care systems 

(e.g., home health, rehabilitations centers, skilled nursing facilities), community-based services, 

and patients and their families.

Most of the programs supporting transition of care have been developed for congestive heart 

failure8,9 and older adults with multiple comorbidities.1,10 Acute MI and stroke also are complex 

health conditions that require effective interventions to better manage transition of care. 

However, there are major gaps in knowledge about best practices for transition of care for MI 

and stroke. In 2007, an AHRQ technical review identified multiple quality gaps in the 

coordination of chronic disease care,11 and there was only one study of stroke and none of MI 

included in that review.

There are some inconsistencies in the early literature on transition of care models, depending 

on the focus of the study and the disciplines leading the interventions (nursing, medicine, 

rehabilitation).12 This suggests that a broad and multidisciplinary review is required to 

adequately explore the key questions of transition of care for patients diagnosed with stroke or 

MI. With the advent of transition of care models and methods to integrate service delivery, it is 

imperative that we synthesize the evidence to find promising models of transition of care or to 

identify gaps in the evidence and needed research and program development to improve the 

quality of management of two of the most common health problems. These efforts are consistent 

with the Institute of Medicine’s priorities to (1) compare the effectiveness of diverse models of 

transition support services for adults with complex health care needs (e.g., the elderly, homeless, 

mentally challenged) after hospital discharge and (2) compare the effectiveness of different 

quality improvement strategies in disease prevention, acute care, chronic disease care, and 

rehabilitation services for diverse populations of children and adults.13

Scope and Key Questions

The first challenge of this systematic review was to consider the pathways for the transition 

of care. Transitions may include those that are direct to the outpatient environment as well as 

those to and from intermediate care environments. In addition, the components of transition of 

care may occur separately or in aggregate, which makes it important to know how the 

components are categorized and described within a clear taxonomy. 

The second challenge was to dissect those data relevant to the disease states of interest. The 

incidence of stroke and MI increases with age, as does the presence of other chronic conditions 

that may be driving downstream outcomes. Also, stroke and MI are not exclusively diseases of 

the elderly, so it is fundamental to explore stroke and MI transitions within the population as a 

whole as well as in the older or chronically ill population. 

While both stroke and MI result from disorders of the vascular system—and as such share 

many common risk factors—each medical condition presents unique challenges regarding 

transitions across care settings. Stroke patients more often transition from hospital to inpatient 

rehabilitation facilities, nursing homes for rehabilitation or palliative care, or home health 

services. Also, patients with stroke have more long-term physical disability and cognitive 

impairments that may require rehabilitative services or long-term institutional support. In 
3

contrast, patients with MI are more likely to be discharged directly home and receive outpatient 

transition of care services. Additionally, patients with stroke are more likely to be older, female, 

and African American than are patients with MI.14

As part of this systematic review, we explored features of transition of care that are common 

to both vascular disorders as well as features that are unique to disease-specific needs. The key 

questions considered in this review were:

• Key Question 1. For patients hospitalized with first or recurrent stroke or myocardial 

infarction (MI), what are the key components of transition of care services? Can these 

components be grouped in a taxonomy, and are they based on a particular theory? 

• Key Question 2. For patients hospitalized with first or recurrent stroke or MI, do 

transition of care services improve functional status and quality of life and reduce 

hospital readmission, morbidity, and mortality (up to 1 year postevent)? 

• Key Question 3. For patients hospitalized with first or recurrent stroke or MI, what are

the associated risks, adverse events, or potential harms—both system-based and patientbased—of transition of care services?

• Key Question 4. Do transition of care services improve aspects of systems of care for 

patients with stroke or MI (e.g., more efficient referrals, more timely appointments, better 

provider communication, reduced use of urgent care, or fewer emergency room visits as a 

result of transition of care services)? Is there improved coordination among multiple 

subspecialty care providers, and are new providers added to the care plan as a result of 

transition of care services?

• Key Question 5. For patients hospitalized with first or recurrent stroke or MI, do benefits 

and harms of transition of care services vary by characteristics—both patient-based and 

system-based—such as disease etiology and severity, comorbidities, sociodemographic 

factors, training of the health care providers, participants (patients, caregivers), 

geography (rural/urban, regional variations), and insurance status?

Purpose of This Report

The goal of this evidence report was to review the literature that explored the opportunities 

and limitations of existing transition of care models, such as patient resource management, that 

are available for patients as they navigate from acute hospital care to rehabilitation services and 

eventually to independent or dependent living. Each step in the transition process was evaluated 

on its own merits as well as how it integrated the care of patients as they were discharged from 

the hospital and sought care with other providers, through different health care systems or in 

community programs. We reviewed the available published literature to assess whether evidence 

existed to support a beneficial role for coordinated transition of care for the postacute 

management period of medical, rehabilitative, and nursing services. Metrics of successful 

application of transition of care services included hospital readmission rates, second events 

(stroke or MI), resource utilization (cardiac or stroke rehabilitation, medical followup), 

functional status, medication adherence, and compliance with health care programs aimed at 

secondary prevention. 
4

Role of the Technical Expert Panel

We identified experts in the field of transitional care for patients with stroke and MI to serve 

as members of the project’s Technical Expert Panel (TEP). The TEP contributes to AHRQ’s 

broader goals of (1) creating and maintaining science partnerships and public–private 

partnerships and (2) meeting the needs of an array of potential customers and users of this report. 

To ensure accountability and scientifically relevant work, we asked the TEP for input at key 

stages of the project. More specifically, TEP members participated in conference calls and email 

exchanges to refine the analytic framework and key questions at the beginning of the project, 

refine the scope, discuss inclusion and exclusion criteria, and provide input on methodology. 

Members of our TEP represented a broad range of experience relevant to our topic because 

of their extensive knowledge of the literature. They included experts in cardiology, vascular 

neurology, community-based medicine and rehabilitation, and geriatric medicine. Additionally, 

the TEP included representatives from the National Institutes of Health as well as Blue Cross and 

Blue Shield. 
5

Methods

Analytic Framework

The analytic framework (Figure 1) shows how the components of transition of care services

(e.g., multiple referrals, continuity and coordination of care, communication) for the 

postdischarge care of adult patients hospitalized with stroke or MI result in both patient-based 

and system-based outcomes (e.g., functional status, quality of life, hospital readmission, 

morbidity, and mortality). In addition, the components of transition of care services are analyzed 

by both patient-based and system-based characteristics as well as within the context of a 

theoretical framework. Adverse events, associated risks, or potential harms of transition of care

services (both system-based and patient-based) are also addressed.

Figure 1. Analytic Framework

Note: “Multiple referrals” indicates referrals to primary care and other health care providers.

Abbreviations: ER = emergency room, KQ = key question, MI = myocardial infarction

Patient characteristics

Age/sex

Race/ethnicity

Marital status

Diagnosis etiology/severity

Comorbidities

System characteristics

Provider training

Geography

Insurance status

Components

Multiple referrals

Continuity of care 

Communication

Coordination of care

(and others)

KQ 3

Adverse events

Harms

Risks

Patient-based outcomes

Functional status

Quality of life

Hospital readmission

Morbidity/mortality

System-based outcomes

Referrals

Communication

ER utilization

Adult patients 

hospitalized with 

stroke or MI

KQ 1

Theoretical 

framework

KQ 5

KQ 2, KQ 4

Transition of care 

services

for postdischarge 

care

Patient characteristics

Age/sex

Race/ethnicity

Marital status

Diagnosis etiology/severity

Comorbidities

System characteristics

Provider training

Geography

Insurance status

Components

Multiple referrals

Continuity of care 

Communication

Coordination of care

(and others)

KQ 3

Adverse events

Harms

Risks

Patient-based outcomes

Functional status

Quality of life

Hospital readmission

Morbidity/mortality

System-based outcomes

Referrals

Communication

ER utilization

Adult patients 

hospitalized with 

stroke or MI

KQ 1

Theoretical 

framework

KQ 5

KQ 2, KQ 4

Transition of care 

services

for postdischarge 

care
6

Literature Search Strategy

Sources Searched

The comprehensive literature search involved electronic searching of peer-reviewed literature 

databases from January 1, 2000, to April 21, 2011. These databases included the Cumulative 

Index to Nursing and Allied Health Literature (CINAHL®), MEDLINE® accessed via PubMed®, 

the Cochrane Database of Systematic Reviews, and Embase®. Searches of these databases were 

supplemented with manual searching of reference lists contained in all included articles and in 

relevant review articles.

Screening for Inclusion and Exclusion

We developed a list of article inclusion and exclusion criteria for the key questions (Table 1) 

and modified the list after discussion with the TEP. 

Table 1. Inclusion and exclusion criteria

Category Criteria

Study population KQs 1—5:

• Adults ≥ 18 years of age who were discharged, or were preparing to be 

discharged, from a hospitalization for the following two conditions: 

o Acute myocardial infarction (ST elevation myocardial infarction or non–

ST elevation myocardial infarction) was defined by clinical signs or 

symptoms consistent with an acute coronary syndrome in addition to 

documented electrocardiographic or enzyme evidence of myocardial 

ischemia or injury. Patients with unstable angina were also included if 

evidence of ischemia was present. 

o Stroke (acute ischemic stroke or intracerebral hemorrhage) was defined 

as a focal neurologic deficit lasting more than 24 hours that is attributed to 

a cerebral vascular cause (either acute ischemic stroke or intracerebral 

hemorrhage). 

• Studies reporting mixed populations of discharge diagnoses were included if 

the results for the myocardial infarction or stroke population were reported 

separately. 

• Studies focused solely on patients with transient ischemic attack, 

subarachnoid hemorrhage, noncardiac chest pain, or congestive heart failure 

without myocardial infarction were excluded. 
7

Table 1. Inclusion and exclusion criteria (continued)

Category Criteria

Study design KQs 1–5:

• Original data published since 2000a

• Randomized controlled trials

• Prospective or retrospective observational studies

• Registries

• Excluded if case report, editorial, letter to the editor, or pilot/exploratory study 

with small sample size and not powered to detect a statistically meaningful 

result as stated by the authors 

Interventions KQs 1–5: Components of transition of care services (peridischarge) included:

• Case management to oversee all care across multiple care environments 

(acute care, intermediate care, home health care, and community settings)

• Discharge planning including procurement of equipment and services, referrals 

for followup care (e.g., home health care, social services, rehabilitation), and 

education about community resources

• Self-management tools to alleviate patient and caregiver burden associated 

with managing transitions between care environments

• Care pathways developed to organize treatment and rehabilitation across care 

settings

• Systems for shared access to patient information to allow multiple health care 

providers across settings to access patient information and to coordinate care

• Referrals to specialty care providers (e.g., cardiologist, neurologist) based on 

patient needs, included as part of the transition of care service

• Referral back to primary care providers included as part of the transition of 

care service

Comparator KQs 1–5: Usual care—defined as care that did not

Study outcomes

include transition of care 

services that coordinated care among multiple providers (e.g., a simple 

recommendation for followup with primary care and other health care providers, or 

direct discharge to home or other health care facility)

• KQs 2, 3, and 4: Outcomes included death, hospital readmission, return to 

premorbid status, functional ability, quality of life, and hospital-free days. 

Predictors of these outcomes included the following:

o System-level of analysis: Academic versus community hospital, specialist 

versus general health care provider, urban versus rural setting

o Patient-level of analysis: Race, ethnicity, sex, comorbidities, 

socioeconomic and insurance status

• KQ 3: Outcomes included adverse events/harms/risks (e.g., readmissions, 

delayed discharge, increased utilization with no improved clinical outcomes, 

increased patient/caregiver burden, dropped from insurance)

• KQs 4 and 5: Outcomes included continuity of health care (with specialist and 

general health care provider), or the total number of health care 

providers/services for a patient
8

Table 1. Inclusion and exclusion criteria (continued)

Category Criteria

Timing KQs 1–5: Any time period (up to 1 year) following a hospital discharge from an 

acute myocardial infarction or stroke

Settings KQs 1–5: 

• Setting at baseline was an acute-care hospitalization

• Posthospitalization care setting included inpatient (e.g., inpatient rehabilitation 

facility, skilled nursing facility), outpatient (primary care physician, 

rehabilitation), and home care (including home modifications if needed)

• Geographical location, number of sites

Publication languages English only

a

The TEP approved a literature start date of 2000 because this date provided the most current publications and emphasized the 

current paradigms of care.

Abbreviation: KQ = key question

Process for Study Selection

Search strategies were specific to each database in order to retrieve the articles most relevant 

to the key questions. Our basic search strategy used the National Library of Medicine’s Medical 

Subject Headings (MeSH) key word nomenclature developed for MEDLINE®, limited to 

articles published in English, and a manual search of retrieved articles and published reviews. 

Search terms and strategies were developed in consultation with a medical librarian. 

We incorporated transition of care studies that specified postacute hospitalization transition 

of care services as well as prevention of recurrent MI or stroke. Naylor8 identified keywords used 

in our search strategy (transitional care, discharge planning, care coordination, case management, 

continuity of care, referrals, postdischarge followup, patient assessment, patient needs, 

interventions, and evaluations), and we incorporated and built on this foundation. The exact 

search strings used in our strategy are given in Appendix A.

Interventions solely comprised of cardiac rehabilitation or stroke rehabilitation were 

excluded since both are services that can be prescribed independently from a transition of care 

program. These articles were excluded at the full-text screening stage in the category of “not a 

system-level transitional intervention.” We did not identify any transition of care interventions 

that were developed to support patients transitioning from hospital to rehabilitation (either 

cardiac or stroke) or from rehabilitation to home.

Using the prespecified inclusion and exclusion criteria, titles and abstracts were examined 

independently by two reviewers for potential relevance to the key questions. Articles included by 

any reviewer underwent full-text screening. At the full-text screening stage, two independent 

reviewers read each article to determine if it met eligibility criteria. At the full-text review stage, 

paired researchers independently reviewed the articles and indicated a decision to “include” or 

“exclude” the article for data abstraction. When the paired reviewers arrived at different 

decisions about whether to include or exclude an article, they reconciled the difference through a 

third-party arbitrator. Articles meeting our eligibility criteria were included for data abstraction. 
9

Data Extraction and Data Management

Data from included reports were abstracted into the database by one reviewer and read over 

by a second reviewer. Data elements abstracted included study design, setting, geographic 

location, patient characteristics, transition of care components, outcomes, length of followup, 

adverse events, and descriptors to assess applicability, quality elements, intervention details, and

outcomes. Disagreements were resolved by consensus or by obtaining a third reviewer’s opinion 

when consensus could not be reached. Appendix B lists the elements used in the data abstraction 

form. Appendix C contains a bibliography of all included studies organized alphabetically by 

author.

Individual Study Quality Assessment

We employed internal and external quality-monitoring checks through every phase of the 

project to reduce bias, enhance consistency, and verify accuracy. Examples of internal 

monitoring procedures were two progressively stricter screening opportunities for each article 

(abstract screening, full-text screening, and data abstraction), involvement of two individuals in 

each data abstraction, and agreement of the two investigators on all included studies. The peer 

review process was our principal external quality-monitoring device.

The included studies were assessed on the basis of the quality of their reporting of relevant 

data. We evaluated the quality of individual studies using the approach described in AHRQ’s 

Methods Guide for Effectiveness and Comparative Effectiveness Reviews (hereafter referred to as 

the Methods Guide).

15 To assess methodological quality, we employed the strategy to (1) apply 

predefined criteria for quality and critical appraisal and (2) arrive at a summary judgment of the 

study’s quality. To indicate the summary judgment of the quality of the individual studies, we 

used the summary ratings of good, fair, or poor. Appendix B describes our quality assessment 

process, and Appendix D lists our quality assessment for each included study.

To assess applicability, we used data abstracted on the population studied, the intervention 

and comparator, the outcomes measured, settings, and timing of assessments to identify specific 

issues that may limit the applicability of individual studies or a body of evidence as 

recommended in the Methods Guide.

15 Appendix B describes our applicability assessment 

process, and Appendix D lists our applicability assessment for each included study. We used 

these data to evaluate the applicability to clinical practice, paying special attention to study 

eligibility criteria, baseline demographic features of the enrolled population (such as age, disease 

severity, and comorbid conditions) in comparison to the target population, characteristics of the 

transition of care intervention used in comparison with therapies currently in use in routine 

clinical practice, and clinical relevance and timing of the outcome measures. 

Data Synthesis

The studies included in this review varied in the types of transition of care service, the 

delivery of the intervention tested, the comparator group, and the outcomes measured. Therefore, 
10

we were unable to group studies with similar transitions of care, interventions, and outcomes for

a formal meta-analysis. Instead, we grouped studies with similar transition of care components 

and described the interventions, comparators, and outcomes. 

Grading the Body of Evidence for Each Key Question

The strength of evidence for each key question was assessed using the approach described in 

the Methods Guide.

15 The evidence was evaluated using the four required domains: risk of bias 

(low, medium, or high), consistency (consistent, inconsistent, or unknown/not applicable), 

directness (direct or indirect), and precision (precise or imprecise). Additionally, when 

appropriate, the studies were evaluated for coherence, dose-response association, residual 

confounding, strength of association (magnitude of effect), publication bias, and applicability. 

The strength of evidence was assigned an overall grade of High, Moderate, Low, or 

Insufficient according to the following four-level scale:

• High—High confidence that the evidence reflects the true effect. Further research is very 

unlikely to change our confidence in the estimate of effect.

• Moderate—Moderate confidence that the evidence reflects the true effect. Further 

research may change our confidence in the estimate of effect and may change the 

estimate.

• Low—Low confidence that the evidence reflects the true effect. Further research is likely 

to change the confidence in the estimate of effect and is likely to change the estimate.

• Insufficient—Evidence either is unavailable or does not permit estimation of effect.

Peer Review and Public Commentary

Nominations for peer reviewers were solicited from several sources, including the TEP and 

interested Federal agencies. The list of nominees was forwarded to AHRQ for vetting and 

approval. A list of reviewers submitting comments on the draft version of this report is included 

in the Preface of this document.
11

Results

Literature Search and Screening

Searches of all sources identified a total of 5783 potentially relevant citations. Table 2 details 

the number of citations identified from each source.

Table 2. Sources of citations

Source Number unique of citations

MEDLINE 5355

CINAHL 22

Cochrane Database of Systematic Reviews 1

Embase 376

References of review articles and primary studies 16

Other (recommendations from staff at AHRQ or TEP or from project 

investigators)

13

Total 5783

Figure 2 describes the flow of literature through the screening process. Of the 5783 unique 

citations identified by our searches, 4605 were excluded at the abstract screening stage. Of the 

1178 articles that passed the initial abstract screening, 22 were not original data (e.g., editorials),

which were reviewed separately and excluded from further review, and 406 articles were 

excluded because they were non-English publications. The remaining 750 articles went on to 

full-text screening. Of these, 688 were excluded, leaving a total of 62 included articles

(representing 44 studies). Appendix D provides a table of studies included in this review along

with their quality rating, limitations to applicability, and relevant key questions. Appendix E 

provides a complete list of articles excluded at the full-text screening stage, with reasons for 

exclusion.
12

Figure 2. Literature Flow Diagram

Abbreviations: KQ = key question; MA = meta-analysis; MI = myocardial infarction; SR = systematic review

5783 citations 

identified by 

literature search

4605 abstracts excluded

1178 articles passed 

abstract screening

22 articles not original data 

excluded from further review, and 

406 articles excluded because nonEnglish

688 articles excluded:

534 not system-level transitional intervention

48 not original peer-reviewed data

32 insufficient data/sample size

27 no acceptable comparator

16 SR or MA for background 

13 no outcomes of interest

13 not stroke or MI

2 methods paper

2 outside scope (before year 2000)

1 not human subjects or not < 18

62 articles representing 44 studies 

abstracted into database and 

included in review:

KQ 1: 62 articles (44 studies)

KQ 2: 53 articles (40 studies)

KQ 3: 8 articles (6 studies)

KQ 4: 18 articles (16 studies)

KQ 5: 14 articles (13 studies)

750 articles 

screened at full-text 

stage
13

Key Question 1: For patients hospitalized with first or recurrent stroke or 

myocardial infarction (MI), what are the key components of transition of 

care services? Can these components be grouped in a taxonomy, and are 

they based on a particular theory? 

Key Points

• Theory was rarely reported in clinical trial papers reporting study outcomes.

• Transition of care interventions for patients with MI or stroke were grouped into four 

categories of intervention, and each category began in a different phase of an episode of 

illness. 

• The components of the different interventions were grouped into a taxonomy that 

addressed the type of transition relative to the phase of illness and care, type of 

intervention, recipient of the intervention, content of the intervention, facilitator of the 

intervention, method of recipient-to-facilitator contact, intensity and complexity, and 

outcomes.

Detailed Analysis

A patient experiencing an acute MI or stroke undergoes a number of transitions, from the 

onset of symptoms and hospital admission through the various settings of acute and subacute 

care before returning to the community or a final place of residence. This report focuses on the 

process of transitioning from an acute inpatient setting to an out-of-hospital setting. The 

transition may include (1) a return to home, (2) a transient stay in a setting that provides 

rehabilitation, or (3) relocation to a long-term care facility. As the individual moves through 

these various settings, a number of different health care providers may be involved in various 

configurations of care models to transition patients “home.”

Before the effectiveness of the various approaches to transitioning patients home can be 

examined, the approaches need to be categorized and the components defined. We present the 

transition of care interventions and models categorized as they would be delivered in an episode 

of care and then describe the supporting theories and the structure and process of the different 

types that were identified. This presentation of the structural components and processes of 

transition of care services supports the KQs that are focused on outcomes.

Framework. We have adapted the National Quality Forum’s episode of care framework for 

aligning the interventions and models identified in this literature review, modifying it only 

slightly to include stroke as well as MI (Figure 3). This framework, developed to guide 

measurement, essentially depicts the care pathway experienced by patients for an episode of 

illness such as an acute MI or stroke. Although the framework captures individuals prior to the 

acute event as they transition through the acute hospitalization and into followup care, our focus 

for this review is concentrated only on the transition out of the acute hospital stay. While we 

recognize that transitions of care as defined by Coleman et al.1 occur even during the acute 
14

hospitalization, we focused on the transfer across settings. Thus, the acute-care hospital, and in 

some cases the acute hospital or the next setting for inpatient care, became our point of interest 

as the primary point of influence on recovery and maintenance of health for patients transitioning 

home. We did not identify any studies that focused solely on the transition from an alternative 

inpatient setting such as a skilled nursing facility to home. 

Figure 3. Framework for episodes of care

Literature identified. Four types of transition of care interventions were identified in this 

review of 62 articles (10 good quality, 41 fair, 11 poor) describing 44 studies: 

(1) Hospital-initiated support for discharge to home or intermediary care units such as 

inpatient rehabilitation or skilled nursing facilities. 

(2) 2a. Hospital-based patient and family education interventions

2b. Community-based patient and family education interventions

(3) Community-based models of support interventions

(4) Chronic disease management models of care

Each intervention type, as tested in the studies reviewed, was intended to transition the 

patient back to the community and promote recovery and positive outcomes. While all studies in 

this review measured 3-, 6-, or 12-month outcomes, the emphasis of the intervention weighted 

more heavily in either the acute hospital, as with types 1 and 2a, or the community, as with 2b, 3, 

(Adapted from Patient-Focused Episodes of Care Framework, National Quality Forum 2010)

Population

At Risk Acute Care

Postacute

Rehabilitation 

Care

Living in the 

community

Living in longterm care

Postevent

Episode of care 

begins with onset

of symptoms

Important

outcomes at 3, 6, or 

12 months postevent

Patient-level 

outcomes

System-level

outcomes

Adverse events

Transition to

postacute 

care

General population 
15

and 4. The following tables describe the 44 interventions organized by type, first for stroke 

(Table 3, 27 stroke interventions published in 41 articles) and then for MI (Table 4, 17 MI 

interventions published in 21 articles).
16

Table 3. Transition of care interventions and models for stroke

Study/Country Components Theory

Intervention type 1: Hospital-initiated support

Askim et al., 200416

Askim et al., 200617

Norway

Early supported discharge: Ordinary stroke unit service with rehabilitation and primary care 

services after discharge plus mobile stroke team from the stroke unit to focus on early and 

intensive task-specific exercise therapy in the patients’ home; shared goal setting with team, 

physician, patient, and family if possible; and coordination with primary care.

None reported

Bautz-Holtert et al., 200218

Norway

Early supported discharge: Project team did in-hospital assessment, discharge planning, and 

coordination of the continued rehabilitation provided by community services. Each patient 

had a multidisciplinary team, ongoing support and supervision, an outpatient clinic visit at 4 

weeks, and the option for continued inpatient or outpatient rehabilitation.

None reported

Fjaertoft et al., 200319

Fjaertoft et al., 200420

Fjaertoft et al., 200521

Indredavik et al., 200022

Norway

Extended stroke unit service, essentially the same as early supported discharge. Same as 

Askim et al.16,17 (originally developed by Indredavik et al., 200022).

None reported

Grasel et al., 200523

Grasel et al., 200624

Germany

Intensified transition:(1) Psychoeducational seminar for caregivers, (2) individual training 

course at bedside for caregivers about care at home and how to reduce caregiver burden, (3) 

therapeutic weekend for patient at home before discharge with home evaluation, (4) 3-month 

telephone followup for counseling based on need.

None reported

Holmqvist et al., 200025

von Koch et al., 200026

von Koch et al., 200127

Sweden

Early supported discharge: Short-term admission to a hospital, followed by (where 

appropriate) early supported discharge with continuity of rehabilitation in the community 

(physical therapist, occupational therapist, speech and language pathologist, social worker 

consultation as needed).

None reported

Mayo et al., 200028

Teng et al., 200329

Canada

Early supported discharge: prompt discharge from hospital with the immediate followup 

services for 4 weeks by a multidisciplinary team offering nursing, physical therapy, 

occupational therapy, speech therapy, and dietary consultation. Nursing or physical therapy 

took the lead for most patients.

None reported

Sulch et al., 200030

Sulch et al., 200231

Sulch et al., 200232

England

Predetermined inpatient rehabilitation integrated-care pathway led by a stroke nurse which 

specified recommendations for medicine, nursing, physiotherapy, occupational therapy, 

speech, and nutrition for 5 weeks following discharge.

None reported
17

Table 3. Transition of care interventions and models for stroke (continued)

Study/Country Components Theory

Torp et al., 200633

Denmark

Hospital-supported discharge: independent interdisciplinary stroke team consisting of an 

occupational therapist, a physiotherapist, and a physician from the rehabilitation unit who 

followed the patient until the last 7 days of the hospitalization. Team then took over the 

training and carried out home visits during the last 7 days of the hospital stay to establish 

personal contact. 

Postdischarge care included a comprehensive rehabilitation program for the patients for up 

to 30 days with a maximum of 10 home visits. They supervised patient, relatives, and home 

care professionals and handed over the care of the patient to local home care services 

through personal contact to the relevant health staff.

None reported

Intervention type 2a: Patient and family education (hospital-based)

Hoffmann et al., 200734

Australia

“What you need to know about stroke” system: stroke education based on and formatted for 

patients and delivered by research nurse.

None reported

Intervention type 2b: Patient and family education (home-based)

Clark et al., 200335

Australia

Information package at discharge about stroke and its consequences, measures for 

reducing the risk of further stroke, practical coping suggestions, and information about 

community services and support structures. Home visits by social worker trained in family 

counseling techniques and provided based on family need.

Family systems theory 

Johnston et al., 200736

UK

Workbook with education about stroke and recovery, guidance on coping skills, and selfmanagement instruction plus telephone followup; led by a nurse.Cognitive behavioral theory

Mant et al., 200037

Mant et al., 200538

UK

Family support organizer provided information, emotional support, and was the liaison with

other services. Facilitated through a combination of home and hospital visits and telephone 

calls tailored by need.

None reported

Sahebalzamani et al., 200939

Iran

Education on activities of daily living in six to eight 2-hour sessions over 45 days (however, 

same booklet of information was given to control group); led by a nurse.

None reported
18

Table 3. Transition of care interventions and models for stroke (continued)

Study/Country Components Theory

Intervention type 3: Community-based support

Allen et al., 200240

Allen et al., 200941

US

Postdischarge care management including (1) care with an equal emphasis on physical and 

psychosocial health, (2) an advanced practice nurse care manager to assess patients’ 

problems and coordinate care, (3) standardized assessments, education and interventions 

to ensure consistency in care targeting poststroke complications, (4) an interdisciplinary 

poststroke consultation team of stroke experts to devise and advise individual care plans, 

and (5) communication of assessments and care plan to each primary care physician and 

collaboration on with advanced practice nurse to support the team’s evidence-based 

recommendations and patient goals. 

Wagner's model of chronic 

illness care42

Andersen et al., 200043

Andersen et al., 200244

Denmark

Arm 1: Physician intervention consisting of three 1-hour home visits over 12 weeks focused 

on early detection and treatment of complications, maintenance of functional capacity, and 

psychological and social adjustment to a new life with stroke-related disability. Patients 

could call the project physician whenever they wished. 

Arm 2: Physiotherapist instruction and reeducation for 6 weeks after discharge in the 

patient’s home to evaluate and address problems with indoor and outdoor mobility and 

some activities of daily living. Instruction and education for family and professional 

caregivers on how to maximize patient's function.

None reported

Ayana et al., 200145

UK

Patient-held record with telephone numbers of all relevant staff with space for therapist, 

patient, or family to record assessment and management decisions postdischarge (did not 

replace usual documentation) kept by each professional group. 

None reported 

Boter et al., 200446

Netherlands

Nurse followup with standardized checklist on risk factors for stroke, consequences of 

stroke, and unmet needs for stroke services. Also a checklist for caregivers with special 

attention to the consequences the stroke has on caregivers’ well-being. Interaction directed 

by needs. Patients/caregivers coached on self-management. Problems referred to general 

practitioner as needed.

None reported 

Claiborne et al., 200647

US

Integration of biopsychosocial interventions within a coordinated delivery of care (evidencebased health practices, proactive preventive treatment, and followup); monitor patient care 

and progress related to his or her biopsychosocial issues, service needs, and adherence to 

self-care practices; assess, assist, problem solve and coordinate service needs, for 

example, additional medical and related appointments, transportation issues, financial 

issues, housing needs, heating and repair assistance, equipment modification and 

assistance, employment issues, entitled services, and so forth; education, counsel and refer 

caregivers for support as needed.

None reported
19

Table 3. Transition of care interventions and models for stroke (continued)

Study/Country Components Theory

Donnelly et al., 200448

UK

Early discharge after home evaluation and assistive equipment in place. Team meetings at 

home with patient and family to discuss progress and goals.

None reported

Ertel et al., 200749

Glass et al., 200450

US

Beginning early after onset of stroke, psychosocial intervention to mobilize the social 

networks of the stroke patient (including the primary caregiver, family, friends, and formal 

caregivers) during the postdischarge period to provide effective emotional and instrumental 

support, increase the patient’s sense of self-efficacy regarding ability to regain function, 

maximize stress reduction, enhance effectiveness of problem solving. Home visits included 

intervention provider, patient, family and paid caregivers. Checklist used to confirm 16

content areas of psychosocial adaptation to stroke were identified.

Family systems theory and 

cognitive behavioral theory

Geddes et al., 200151

UK

Five intervention types met transition of care definition and all had a coordinator: the 

availability of multidisciplinary assessment and treatment; a patient-oriented approach to 

rehabilitation; the provision of help to caregivers; and the ability to address physical, 

psychological, and social aspects of rehabilitation.

None reported

Mayo et al., 200852

Canada

Case management: for 6 weeks after discharge, a nurse stroke care manager was in 

contact with patients through home visits and telephone calls to coordinate care with the 

patient’s personal physician and link the stroke survivor into community-based stroke 

services.

None reported 

Ricauda et al., 200453

Italy

Geriatric home hospitalization service included referral by general practitioners or 

physicians of hospital units, 24-hour rapid access to equipment needed for home nursing, 

multidisciplinary care, and admission if required in the hospital catchment area. Availability 

of a caregiver was necessary for participation in the program.

None reported

Torres-Arreola Ldel et al., 200954

Mexico

Nurse-led physical therapy plus education; started rehabilitation in the hospital and 

continued it at home after discharge and trained the caregiver and patient in general 

aspects of stroke and rehabilitation.

None reported
20

Table 3. Transition of care interventions for models and stroke (continued)

Study/Country Components Theory

Intervention type 4: Chronic disease management

Joubert et al., 200655

Australia

Support GPs to manage risk factors and detect and treat depression; personal contact 

between the specialist service (study neurologist) and the GP; telephone-tracking system 

provided ongoing information to the GP and gave patient and caregiver support; flowchart 

continuous surveillance and feedback while facilitating risk-factor management and 

providing feedback to the stroke service.

None reported

Joubert et al., 200856

Australia

Structured nurse-led telephone and physician office visit followup over 12 months; support 

to GPs to manage risk factors and detect and treat depression; personal contact between 

the specialist service (study neurologist) and the GP; telephone-tracking system provided 

ongoing information to the GP and gave patient and caregiver support; flowchart continuous 

surveillance and feedback while facilitating risk factor management and providing feedback 

to the stroke service.

None reported

Joubert et al., 200957

Australia

Same as Joubert et al., 200856 None reported

Abbreviations: GP = general practitioner; UK = United Kingdom; US = United States
21

Table 4. Transition of care interventions and models for myocardial infarction

Study/Country Components Theory

Intervention type 1: Hospital-initiated support

Eagle et al., 200558

Rogers et al., 200759

US

Embedded the key priorities of the national guidelines into acute MI care. None reported

Ho et al., 200760

US

Inpatient and followup cardiology care in the Veterans Affairs hospital. None reported

Kotowycz et al., 201061

Canada

Early hospital discharge (48 to 72 hours) plus outpatient followup with an advanced practice 

nurse within 3 days of discharge and had ≥ 2 additional followups within 30 days of discharge; 

advanced practice nurse was to educate patients about the nature and management of their 

disease, with a focus on medications, and facilitation of discharge planning by ensuring patients

were aware of all followup appointments and outpatient tests.

None reported

Petrie et al., 200262

New Zealand

Brief psychological intervention to change inaccurate and negative illness perceptions of MI. None reported

Young et al., 200363

Canada

Four components of the disease management program were (1) the standardized pathway, 

labeled “the nursing checklist,” (2) the referral criteria for specialty care management, (3) the 

communication systems, including the discharge summary and the nurses’ visit report and (4) 

patient education. Patients were eligible to receive a minimum of six home care visits from a 

cardiac-trained nurse.

None reported

Intervention type 2a: Patient and family education (hospital-based)

Mayou et al., 200264

UK

Individualized educational and behavioral, nurse-delivered cardiac rehabilitation program. None reported

Intervention type 2b: Patient and family education (home-based)

Lacey et al., 200465

UK

Heart manual: rehabilitation and lifestyle information and advice, relaxation exercises and advice 

for patients and partners using audiotape, and an exercise plan to be followed according to 

individual ability. Support by a facilitator who provides contact by telephone or by face-to-face 

meeting during the first 6 weeks after acute MI.

None reported
22

Table 4. Transition of care interventions and models for myocardial infarction (continued)

Study/Country Components Theory

Intervention type 3: Community-based support

Bambauer et al., 200566

US

Six 30-minute telephone counseling sessions over a period of 8 weeks led by a doctoral-level 

clinician (psychiatrist, clinical psychologist, and/or internist) to address eight specific issues or 

fears, including loss of control, loss of self-image, dependency, stigma, abandonment, anger, 

isolation, and fear of death.

None reported

Costa e Silva et al., 200867

Brazil

Transdisciplinary care, multidisciplinary across specialties and settings with followup by 

cardiologist, endocrinologist, nurse and dietitian for up to 6 months.

None reported

Gallagher et al., 200368

Australia

Support and information by a cardiac nurse to promote self-managed recovery and psychosocial 

adjustment beginning 1 to 2 days before hospital discharge, followed by 4 telephone calls at 2 to 

3 days and 1, 3, and 6 weeks after discharge. Followup calls were scheduled to assist women 

coping with various stages of adjustment during recovery.

None reported

Hall et al., 200269

Kovoor et al., 200670

Australia

Early return to work at 2 weeks with phone contact once a week for 5 weeks by the nurse 

coordinator (and from economics center); 6 weeks in cardiac rehabilitation and no intervention 

contact until 6 months.

None reported

Hanssen et al., 200771

Hanssen et al., 200972

Norway

Weekly nurse-initiated telephone calls were arranged for the first 4 weeks; subsequent calls 

were arranged 6, 8, 12, and 24 weeks after discharge to address individual needs and support of 

patients’ own coping efforts with respect to lifestyle changes and risk-factor reduction.

Lazarus and Folkman73

theory on stress, 

appraisal, and coping; 

also principles about 

patient education

Luszczynska et al., 200674

Poland

Implementation intention intervention program given on an individual basis and lasted10 to 15 

minutes: Patients (1) received instructions about what implementation intention should include, 

(2) completed the intervention form, (3) screened the intervention form together with an 

interviewer and received supportive feedback from an interviewer regarding their implementation 

intentions, and (4) were complimented by an interviewer regarding successful implementation of 

their intentions.

None reported

Oranta et al., 200975

Finland

Psychiatric nurse led interpersonal counseling program over six sessions (all by phone except 

last) including starting, encouragement, and ending phases.

None reported
23

Table 4. Transition of care interventions and models for myocardial infarction (continued)

Study/Country Components Theory

Robertson et al., 200176

Robertson et al., 200377

Canada

Weekly home visit for 4 weeks after discharge by an experienced emergency and critical care 

nurse.

None reported

Sinclair et al., 200578

UK

Home visits at 1 to 2 weeks and 6 to 8 weeks after hospital discharge by a nurse who 

encouraged compliance with and knowledge of their treatment regimen, offered support and 

guidance about resuming daily activities, and involved other community services as appropriate.

None reported

Intervention type 4: Chronic disease management

Barlow et al., 200979

UK

Expert Patients Programme None reported

Abbreviations: MI = myocardial infarction; UK = United Kingdom; US= United States
24

Intervention type 1: Hospital-initiated support for discharge to home. While the hospitalinitiated models designed to prepare patients for discharge and the transition to home were 

generally described in detail, none of the six stroke models or the four MI models reported any 

theoretical foundation supporting the design of the intervention.

The components of four of the six interventions designed for stroke patients were similar.16-

22,33 These “extended stroke unit services” or “hospital-supported discharge” models each 

included a multidisciplinary team of professionals that followed the stroke patients as they 

transitioned home—and provided continued support, supervision, and coordination with 

community-level services. The timing and length of followup postdischarge varied, but the 

therapeutic foci on rehabilitation and continuity of care were similar across studies. The 

intervention described in Grasel et al.23,24 differed in that it focused on the caregivers who 

provided psychoeducational education, training, and counseling prior to and after discharge from 

acute care for up to 3 months. The study by Sulch et al.30-32 was the only stroke-specific 

intervention in this category that identified a single facilitator or lead interventionist—a stroke 

nurse, who in this study implemented an integrated-care pathway to improve coordination and 

discharge planning and reduce the length of stay. Although the integrated-care pathway was 

developed by a multidisciplinary team, the study investigators strategically chose a single lead 

interventionist so that the study would not be a burden for other disciplines. Unique to this 

category of hospital-initiated transition of care interventions for stroke patients, the study by 

Sulch et al. did not provide any postdischarge followup. 

Each of the four MI models was distinctly different, but each shared at least one similarity 

with one of the hospital-initiated stroke interventions. Like Sulch et al., the study by Eagle et al. 

and Rogers et al.58,59 tested a hospital-initiated program that in part aimed to improve care 

coordination and discharge planning but did not provide any posthospital followup as part of the 

intervention. Like the intervention in Grasel et al., the Petrie et al.62 study was a psychological 

intervention, but it focused on patients’ perceptions rather than on caregivers’ perceptions. 

Interventions described by Ho et al.60 and Young et al.63 both straddled inpatient and outpatient 

or community-level care, but neither intervention was designed to support the handoff to 

community-based physicians or services. Also dissimilar from the stroke interventions in this 

category was the absence of a lead facilitator or specified team of professionals for any of the MI 

interventions. These components are depicted in Figure 4 as part of the taxonomy of MI and 

stroke transition of care interventions.

Intervention type 2: Patient and family education interventions, both hospital-based and 

community-based. Seven patient and family education interventions were identified, with five for 

stroke patients and two for MI patients. Of these seven, three were based in the hospital (one MI, 

two stroke) and four were based in the community (one MI and three stroke). While the 

distinction was made between home-based and community-based to support the possibility of 

translation to practice for interventions found effective, it seemed less important to separate the 

two MI interventions from the five stroke interventions because the foundation of each was 

similar. Furthermore, the content of education included a myriad of topics but usually 

concentrated more heavily on either condition-specific information or psychosocial adaptation.

Collectively, the seven interventions can be stratified into three levels of complexity. At the 

most basic level, both Hoffman et al.34 and Mayou et al.64 tested structured education programs 

individualized for the patient and delivered by nurses. While Clark et al.,35 Johnston et al.,36
25

Sahebalzamani et al.,39 and Lacey et al.65 also tested education programs, each also included 

patient followup by a nurse,36,39 social worker,35, or a “facilitator” that was not identified by 

discipline or training.65 The study by Mant et al.37,38 was the only intervention in this category 

that centered on information, support, and followup by a “family support organizer” and also 

extended the responsibilities of this role to serve as a liaison with other services. Very little detail 

was available on this intervention, and thus it could not be considered as a more advanced model 

of community-based support (intervention type 3). 

Although the theoretical underpinnings of education programs are much more advanced and 

more commonly referred to than the theories supporting transition of care interventions, only two 

studies reported a theory guiding the intervention. Johnston et al.36 reported a cognitive 

behavioral theory that applied more to the followup provided by nurses for guidance on coping 

skills and self-management. Clark et al.35 described the applicability of family systems theory 

and how the family is a system both influenced by and influencing society and the individuals 

within or around the family unit. This theory seemed relevant for other interventions focused on 

the caregivers or the patient-caregiver dyad, but no other studies in this category of patient and 

family education reported its use.

Intervention type 3: Community-based models of support. Of the 4 types of transition of care 

interventions, community-based models were most common (10 MI models and 13 stroke 

models). However, the variation among community-based models resulted in the creation of 

three subcategories: (1) provider-driven interventions, (2) psychosocial- or behavioral-focused 

interventions, and (3) technical support structures. Only 3 of 23 studies reported any theoretical 

or conceptual foundation.40,41,49,50,71,72 Allen’s advanced-practice nurse (APN) model was 

designed using Wagner’s model of chronic illness care.42 Family systems and cognitive 

behavioral theories were reported to support the stroke psychosocial intervention,49,50 but no 

citation was provided for either theory. The nurse-led MI intervention by Hanssen et al.71 used 

the theory on stress, appraisal, and coping.73

For conditions other than MI and stroke, provider-driven community-based models were 

most common and had the strongest evidence base.10 They were also most common in this 

review of the literature, with half of the MI community-based models and 10 of 13 stroke 

models. These models generally identified one provider to serve as the care manager or 

coordinator facilitating a multifaceted intervention to support holistic health—targeting both 

physical and psychosocial needs and the transition in health status and physical location of care 

delivery. Followup or contact with the provider facilitating the intervention was, in some cases, 

structured and predetermined or was conducted as needed. Followup usually extended over only 

the short term, such as 1 to 3 months posthospitalization. Access to a larger multidisciplinary 

team was not uncommon, but purposeful coordination between acute and community-level care 

was not always a core component of the intervention. 

Ten provider-driven structures were tested for stroke patients. Allen et al.40,41 tested an APN 

model, and Mayo et al.52 tested a nurse-led model. Boter et al.46 also tested a nurse model but 

targeted both patients and their caregivers. Three models described in the article by Geddes et 

al.51 were each led by a nurse; one was led by a physical therapist and an occupational therapist; 

and one was coordinated by both a nurse and a physical therapist. Torres-Arreola et al.54

described a model that, instead of including nurses and physical therapists, included nurses 

trained to provide physical therapy. A team effort of nurses and physical therapists was used in 

the multidisciplinary early supported discharge model tested in Canada by Teng et al.29
26

The European early supported discharge models more commonly used a team approach 

without a designated lead coordinator or facilitator. The study by Holmqvist et al.25 was an 

example of this team-led model. The hospital-at-home model by Ricauda et al.53 also included a 

multidisciplinary team of professionals, but ultimately the intervention was led and managed by 

a physician, nurse, and physical therapist. Andersen et al.43,44 tested a physician model and a less 

intense and rehabilitation-focused physiotherapist model. Donnelly et al.48 also tested a simpler 

model focused on assistive equipment and goal setting facilitated by a team of professionals. The 

five MI provider-driven models varied little from the stroke models. Costa e Silva et al.67 used a 

multidisciplinary team but followed patients for up to 6 months. Kotowycz et al.61 used a more 

traditional APN model. Other studies by Hall et al.,69 Kovoor et al.,70 Robertson et al.,76,77 and 

Sinclair et al.78 used a nurse coordinator. The foci and intervention components were similar to 

the stroke models.

The psychosocial- and behavioral-focused community-based models were also provider 

driven. Of the two stroke studies, Ertel et al.49 and Glass et al.50 used a team approach to 

mobilize the patient’s social network to facilitate adaptation after stroke, and Claiborne et al.47

used a social worker–led model to facilitate both coordination of services and biopsychosocial 

needs. The psychosocial and behavioral interventions for MI were all single-provider driven and 

similar in length to the provider-driven models described above. The study by Bambauer et al.66

was led over 8 weeks by a specialist—psychiatrist, psychologist, or internist. The study by 

Gallagher et al.68 began in the hospital, extended 6 weeks after discharge, and was led by a 

cardiac nurse. The intervention in Oranta et al.75 was held over six sessions and led by a 

psychiatric nurse, and the Hanssen et al.71,72 study was also nurse-led but over 24 weeks if the 

patient needed the support. 

The interviewer’s background and training were not specified for the Luszczynska et al.74

study, but the intervention was well described and was distinct and unique from the others. The 

behavior-change intervention was called “implementation intention” and was used to promote 

the adherence to guidelines for physical activity after MI. Proactive followup of study 

participants was not part of this specific model but instead added to evaluate change at 8 months.

Only one technical structure was included in this review. Ayana et al.45 tested a patient-held 

record that was ultimately the responsibility of the patient to use to improve communication 

across providers. No contact was made with the patient after the device was distributed through 

the completion of the study at 6 months, and other aspects of the transition of care were not 

evaluated. It is possible that other studies of this nature—testing a technical structure or a 

specific component of an intervention supporting the transition from hospital to home—were not 

identified in the literature review because of the keywords used in the literature search (see 

Appendix A).

Intervention type 4: Chronic disease management models of care. Few chronic disease 

management models of care were identified for this review. This may be the case because 

chronic disease management models are more commonly designed for ambulatory conditions 

such as heart failure, diabetes, and depression, with the goal of managing risk factors and 

comorbid conditions, promoting self-management, and positively affecting change in specific 

laboratory values or adherence to medication regimens. However, one MI and three stroke 

models were included in this review because they had outcomes of interest and components of 

the model specifically addressed patient transitions. These models should be considered

community-level interventions. 
27

The MI model as described by Barlow et al.79 tested an established chronic disease 

management program called the Expert Patient Programme—a “lay-led” community-based 

program—and compared this to cardiac rehabilitation. The three stroke studies,55-57 on the other 

hand, were clinically designed to address areas similar to traditional chronic disease management 

models, but the structure of the intervention was more similar to a provider-driven communitybased model of care. The studies of integrated care by Joubert et al.55-57 were each nurse-led and 

had a lot of emphasis on the components facilitating continuity and coordination across providers 

and over the 12-month intervention. These components are again highlighted in the taxonomy 

below.

Taxonomy. Donabedian’s framework of structure, process, and outcome—originally developed 

to examine health care quality—and other published taxonomies or frameworks for related 

interventions were used to guide the development of this taxonomy describing MI and stroke 

transition of care interventions.11,80,81 Donabedian’s framework is now more commonly used to 

define the characteristics of an intervention or model of care delivery (structure), the content and 

activities (process), and how these relate to and interact to influence outcomes. In Figure 4, we 

have similarly described the structure by depicting common subdomains of the type of transition, 

type of model, recipient of the intervention, and facilitator or lead personnel delivering the 

intervention. The process is described by highlighted key processes common across model types, 

the method of contact between the recipient and the facilitator, and the intensity and complexity 

of the intervention. The outcomes listed in the taxonomy are evaluated in KQs 2–5.
28

Figure 4. Taxonomy of transition of care interventions for stroke and MI

*For this report, transitions from the acute hospital to another setting are included with the acute hospital-to-home interventions because the patient's setting for initial contact and 

discharge were the same (acute hospital and home). The transition between settings (e.g., hospital to skilled nursing facility) was not the primary focus of any of the studies 

included in this report.

Abbreviations: APN = advanced practice nurse, MI = myocardial infarction, PT = physical therapist, OT = occupational therapist

Transition of Care Taxonomy

Transition type

Acute hospital 

to home*

Other inpatient 

setting to 

home

Model type

Hospital-based 

Patient, family 

education

Community-based

Disease 

management

Recipient

Patient

Caregiver

Physician

Key processes

Education

Counseling

Monitoring

Goal setting

Coordinating care

Managing risk 

factors

Facilitator

Nurse

APN

Social worker

PT/OT

Physician

Multidisciplinary 

team

Method of 

contact

In-person home 

visit

In-person clinic 

visit

Telephone

Intensity and 

complexity

Frequency 

Duration

Complexity

Outcomes

Patient measures

Caregiver 

measures

Process 

measures

System measures
29

Key Question 2: For patients hospitalized with first or recurrent stroke or 

MI, do transition of care services improve functional status and quality of 

life and reduce hospital readmission, morbidity, and mortality (up to 1 year 

postevent)?

Key Points

• The summary of evidence for KQ 2 was built on results from the past 11 years of 34 

articles in stroke and 19 articles in MI that involved 4146 patients with hemorrhagic or 

ischemic stroke and 11,070 patients with some form of cardiac disease. 

• A variety of interventions considered transition of care for patients following stroke and 

MI; however, there was little consistency from study to study, making cross-study 

comparisons challenging.

• The most studied transition of care intervention was that of “early supported discharge” 

(intervention type 1). Early supported discharge after stroke was shown to be effective in 

reducing the total number of days spent in hospital while at the same time demonstrating 

that patient-related outcomes such as mortality, disability, and quality of life were no 

different than among patients treated with standard medical care. Early supported 

discharge after stroke was associated with increased patient and caregiver satisfaction.

• Guideline-based practice, disease management programs, and specialty followup after MI 

(intervention type 1) were associated with reduced length of stay, lower rehospitalization 

rates, and reduced mortality. 

• There were no transition of care interventions that consistently improved functional 

outcomes after stroke.

• Early return to normal activities in low-risk post-MI patients was shown to be safe 

(intervention type 3).

• The most frequently cited comparator—usual care—was not well defined in the studies.

• There was much variability in the selection of outcome measures for evaluating the 

success of transitions. 

Detailed Analysis

Literature identified. We identified 53 peer-reviewed articles (8 good quality, 36 fair, 9 poor)

between 2000 and 2011 that were relevant to KQ 2. These 53 articles presented data from 40 

studies that enrolled 15,216 patients: 4146 in the stroke subpopulation and 11,070 in the MI 

subpopulation (Table 5/5b).
30

Table 5. Summary of study characteristics for stroke studies

Study/Country Populationa N Intervention Comparator Outcomes

(intervention group versus “other”)b Timing Transitionfrom setting

Transition 

to setting

Intervention type 1: Hospital-initiated support

Askim et al., 

200416

Norway

Mixed stroke 62 Early supported 

discharge

Usual care Barthel Index: p = .450

Caregiver strain: p = .832

mRS: p = .444

NHP: p = .918

Mortality: p = .534

1.5 mo

6 mo

12 mo

Hospital Home

Askim et al., 

200617

Norway

Mixed stroke 

(study 

population16)

62 Early supported 

discharge

Usual care BBS: p = .440

Timed walk: p = .130

1.5 mo

6 mo

12 mo

Hospital Home

Bautz-Holtert et 

al., 200218

Norway

AIS only 82 Early supported 

discharge

Usual care Death: OR = 2.2 (.3-25.7)

EADL: p = .93

GHQ: p = .74 at 6 mo

MADR: p = .30

3 mo

6 mo

Hospital Home

Fjaertoft et al., 

200319

Norway

AIS only 

(study 

population22)

320 Early supported 

discharge

Usual care mRS: ≤ 2, 56.3% vs 45%, p = .045

Barthel Index: ≥ 95, 52.5% vs 46.3%,

p = .264

Mortality: 13.1% vs 16.3%, p = .429

12 mo Hospital Home

Fjaertoft et al., 

200420

Norway

AIS only 

(study 

population22)

320 Early supported 

discharge

Usual care NHP: improved 78.9 vs 75.2, p = .048

Caregiver strain: improved 23.3 vs 22.6,

p = .089

FAI: NS, p = .435

MADR: NS, p = .757

MMSE: NS, p = .498

NHP: improved

12 mo Hospital Home

Fjaertoft et al., 

200521

Norway

AIS only 

(study 

population22)

320 Early supported 

discharge

Usual care Length of stay: improved, p = .012 12 mo Hospital Home
31

Table 5. Summary of study characteristics for stroke studies (continued)

Study/Country Populationa N Intervention Comparator Outcomes

(intervention group versus “other”)b Timing Transitionfrom setting

Transition 

to setting

Indredavik et al., 

200022

Norway

AIS only 320 Early supported 

discharge

Usual care Barthel Index: ≥ 95, 60% vs 49%, p = .056 

(OR = 1.54; 95% CI, .99 to 2.39)

mRS: ≤ 2, 65% vs 52%, p = .017 (OR = 1.72; 

95% CI, 1.10 to 2.70)

Total hospital length of stay: 18.6 days vs 

31.1 days, p = .0324

Mortality: 2.5% vs 4.4%, p = .3573

6 mo Hospital Home

Grasel et al., 

200523

US

Mixed stroke 

and 

caregivers

62

patients

62 

caregivers

Intensified 

transition

Usual care Patient:

AshSS: NS, p = .270

Barthel Index: NS, p = .968

FIM: NS, p = .129

SF-36 physical: NS, p = .270

SR 36 emotional: NS, p = .663

TUG: NS, p = .261

Caregiver:

BSFC: NS, p = .980

6 mo Inpatient

rehabilitation

Home

Grasel et al., 

200624

US

Mixed stroke 

and 

caregivers 

(study 

population23)

71 Intensified 

transition

Usual care Institutionalized (2 vs 5) or deceased (4 vs 

11) p = .010

31 mo Inpatient

rehabilitation

Home

Holmqvist et al., 

200025

Sweden

Mixed stroke 

and 

caregivers

81

patients

63 

caregivers

Early supported 

discharge 

Home 

rehabilitation 

Usual care Patient:

Inpatient length of stay: 53% reduction (16 

days) p < 0.001

Patient satisfaction: improved, p = 0.021

Rehospitalization: no difference, p = .392

6 mo Hospital Home

von Koch et al., 

200127

Sweden

Mixed stroke 

(study 

population25)

83 Early supported 

discharge 

Usual care Barthel Index: NS

FAI: NS

IADL: NS

LMC: NS 

NPT: NS

RAT: NS

SIP: NS

Timed walk: NS

Hospitalization = improved (mean 18 vs 33 

days, p = 0.002)

12 mo Hospital Home
32

Table 5. Summary of study characteristics for stroke studies (continued)

Study/Country Populationa N Intervention Comparator Outcomes

(intervention group versus “other”)b Timing Transitionfrom setting

Transition 

to setting

Mayo et al., 

200028

Canada

Mixed stroke 114 Early supported 

discharge

Usual care Barthel Index: NS

IADL: improved

Length of stay: improved

SF-36 MCS: NS

SF-36 PCS: improved

TUG: NS

1 mo

3 mo

Hospital Home

Sulch et al., 

200030

England

AIS only 152 Integrated-care 

pathway

Usual care Barthel Index: no difference, p >.05

Death: no difference, p >.05

Home: no difference, p >.05

Length of stay: no difference, p >.05

Quality of life (EuroQOL): worse 63 vs 72, 

p < .005

6 mo Inpatient 

rehabilitation

Home

Sulch et al., 

200232

England

AIS only 152 Integrated-care 

pathway

Usual care EQ-5D worse (72 vs 63), p < .005 6 mo Inpatient 

rehabilitation 

Home

Torp et al., 

200633

Denmark

Mixed stroke 198 Early supported 

discharge

Usual care Barthel Index: p = .89

Length of stay: p > .05

MD visit: p > .05

MMSE: p =.08

Patient satisfaction: p > .05

Rehospitalization: p > .05

SF-36: .43-.52

6 mo

12 mo

Hospital Home

Intervention type 2a: Patient and family education (hospital-based)

Hoffmann et al., 

200734

US

Mixed stroke 138 Computer-tailored 

stroke education

Usual care COOP: no difference, p = .15-.97

HADS: anxiety worse -1.4, p = 0.03

Knowledge: no difference, p = .79

Patient satisfaction: improved, p = .003

Self-efficacy: no difference, p = .20-.64

3 mo Hospital Home
33

 Table 5. Summary of study characteristics for stroke studies (continued)

Study/Country Populationa N Intervention Comparator

Outcomes

(intervention group versus “other”)b Timing

Transition

from setting

Transition 

to setting

Intervention type 2b: Patient and family education (home-based)

Clark et al., 

200335

US

AIS only and 

caregivers

62 Stroke 

information 

packet and family 

counseling after 

discharge

Usual care Patient:

AAP: improved, p = .05

Barthel Index: improved, p = .05

GDS: NS

HADS: NS

Mastery scale: NS

SF-36 patient: NS, p = .65

Caregiver:

FAD: improved, p = .001

SF-36 spouse: NS, p = -.16

6 mo Hospital Home

Johnston et al., 

200736

US

Mixed stroke 

and 

caregivers

203

patients

217 

caregivers

Postdischarge 

education and 

followup

Usual care Patient:

Barthel Index: no difference F = .04, p > .05

HADS: no difference; F = .40, p > .05

OAD: -.17 vs .19; F 5.61, p = .019

Patient satisfaction: no difference F = .15,

p > .05

Patient’s confidence in recovery: improved 

p = .001

Caregiver:

Caregiver satisfaction: no difference, p > .05

6 mo Hospital Home
34

Table 2. Summary of study characteristics for stroke studies (continued)

Study/Country Populationa N Intervention Comparator

Outcomes

(intervention group versus “other”)b Timing

Transition

from setting

Transition 

to setting

Mant et 

al., 200037

UK

Mixed 

stroke and 

caregivers

323 

patie

nts

267 

caregivers

Family 

support

Usual 

care

Patient:

Barthel Index: no difference, p = .23

COOP: no difference, p = .08-.85

FAI: no difference, p = .66

HADS anxiety and depression: no 

difference, p = .12 and .46

Knowledge: no difference, p = .72

LHS: no difference, p = .98

Patient satisfaction: no difference, p 

= .60

RMI: no difference, p = .15

Caregiver:

COOP:

Quality of life better, p = .01

All other categories no difference,

p = .12-.66

Caregiver satisfaction: NS 

Caregiver strain: no difference, p = 

.91

FAI: improved, p = .03

GHQ: no difference, p = .55

Knowledge: no difference, p = .61

SF-36

Energy and vitality better, p = .02

Mental health better, p = .004

Pain better, p = .03

Physical function better, p = .025

General health perception better,

p = .02

Social function and role limitation 

no difference, p = .17-.67

6 

mo

Hospit

al

Hom

e
35

Table 5. Summary of study characteristics for stroke studies (continued)

Study/Country Populationa N Intervention Comparator

Outcomes

(intervention group versus “other”)b Timing

Transition

from setting

Transition 

to setting

Mant et al., 

200538

UK

Mixed stroke 

and 

caregivers 

(study 

population37)

323

patients

267 

caregivers

Family support Usual care Patient

Barthel Index: no difference, p= .06

COOP: no difference, p = .32-.92

FAI: no difference, p = .92

HADS anxiety and depression: no difference, 

p = .51, p = .92 

LHS: no difference, p = .98

RMI: no difference, p = .17

Caregiver

COOP: no difference, p =.06-.54 

Caregiver strain: no difference, p =.37 

FAI: no difference, p = .97

GHQ: no difference, p = .38

SF-36: 

Energy and vitality improved, p =.05

All other measures no difference, 

p =.07-.25 

12 mo Hospital Home

Intervention type 3: Community-based support

Allen et al., 

200240

US

Mixed stroke 96 APN followup Usual care Barthel Index: NS

CES-D: NS

Death: NS

Falls: NS

NIHSS: NS

SIP: improved

Knowledge: improved

3 mo Hospital or 

rehabilitation

Home

Allen et al., 

200941

US

AIS only 380 Post discharge 

care 

management

Usual care CES-D: NS

Death: NS

Knowledge and lifestyle modification: 

improved, p = .003

Length of stay: NS

NIHSS: NS

Quality of life: NS

TUG: NS

6 mo Hospital Home
36

 Table 5. Summary of study characteristics for stroke studies (continued)

Study/Country Populationa N Intervention Comparator

Outcomes

(intervention group versus “other”)b Timing

Transition

from setting

Transition 

to setting

Andersen et al., 

200244

Denmark

Mixed stroke 155 Followup services 

(physician or 

physical therapist

home visits)

Usual care Barthel Index: NS, p = .165

Death: NS

FAI: NS, p = .355

FQM: NS, p = .111

IADL: NS, p = .200

6 mo Hospital Home

Boter et al., 

200446

Netherlands

Mixed stroke 536 Telephone 

followup and 

home followup

Usual care Barthel Index: N Diff. in means (95%CI) 0 (0 

to 0)

mRS: no difference in means (95%CI) 0

(-0.32 to 0.39)

SASC (dissatisfaction with hospital care) RR

1.17 (0.82 to 1.68)

SASC (dissatisfaction with home care) RR

1.07 (0.89 to 1.28)

6 mo Hospital Home

Claiborne et al., 

200647

US

AIS only 28 Social worker 

coordination 

services

Usual care Compliance (self-care): improved, p < .05

GDS: improved, p < .001

SF-36 PCS: NS, p values NR

SF-36 MCS: improved, p < .001

3 mo Hospital Home

Donnelly et al., 

200448

US

AIS only 113 Communitybased stroke 

team

Usual care Barthel Index: NS, p = .179

EADL: NS, p = .244

EQ-5D: NS, p = .604

Length of stay: NS

Patient satisfaction: p = .017

Quality of life: NS, p = .581

SF-36 MCS: NS, p:.68

SF-36 PCS: NS, p = .799

Timed walk: NS, p = .335

Caregiver strain: NS, p = .927

12 mo Hospital Home

Ertel et al., 

200749

US

Mixed stroke 291 Home care 

cognitive 

behavioral 

therapy 

Usual care CSS: NS, p = .43

Death: NS, p = .91

IADL: NS, p = .89

PPT: NS, p = .86

6 mo Hospital

Inpatient 

rehabilitation

Home

Glass et al., 

200450

US

Mixed stroke 

(study 

population49)

291 Psychosocial 

interventions

Usual care Barthel Index: NS 6 mo Hospital Home
37

 Table 5. Summary of study characteristics for stroke studies (continued)

Study/Country Populationa N Intervention Comparator

Outcomes

(intervention group versus “other”)b Timing

Transition

from setting

Transition 

to setting

Mayo et al., 

200852

Canada

Mixed stroke 190 Case 

management

Followup and 

care coordination

Usual care Barthel Index: NS

EQ-5D: NS

GDS: NS

PBSI: NS

RNLI: NS

SF-36: NS

TUG: NS

Timed walk: NS

6 mo Hospital Home

Ricauda et al., 

200453

Italy

AIS only 120 Emergency 

department to 

home 

Emergency 

department

to ward

CNS: NS

Death: NS

FIM: NS

GDS: improved (median 10 vs 17, p < 0.001)

NIHSS: NS

6 mo Emergency 

department

Home/ward

Torres-Arreola 

Ldel et al., 

200954

Mexico

AIS only 110 Physical therapy 

and caregiver 

education

Caregiver 

education 

only

Barthel Index: NS

FAI: NS

MMSE: NS

1 mo

3 mo

6 mo

Hospital Home

Intervention type 4: Chronic disease management

Joubert et al., 

200655

Australia

Mixed stroke 97 Integrated care Usual care Depression. 20% vs 40%, p = .06

Activity (change in number of walks per 

week) p = .048

12 mo Hospital Home

Joubert et al., 

200856

Australia

Mixed stroke 233 Integrated care Usual care PHQ-9 (depression): improved 33% vs 55%,

p = .003

12 mo Hospital Home

Joubert et al., 

200957

Australia

Mixed stroke 

(study 

population56)

186 Integrated care Usual care Change in walks per week: .8 vs -.7, p < .001

mRS: >2 (disabled) improved 14% vs 33%,

p = .003

Barthel Index: no difference 19.1 vs 17.8,

p = .64

MMSE: no difference 21 vs 19, p = .97

Quality of life: improved 26.4 vs 29.7,

p = .012 

12 mo Hospital Home
38

Table 5b. Summary of study characteristics for myocardial infarction studies (continued)

Study/Country Populationa N Intervention Comparator Outcomes

(intervention group versus “other”)b Timing Transitionfrom setting

Transition 

to setting

Intervention type 1: Hospital-initiated support

Eagle et al., 

200558

US

MI only 2857 Guidelines 

applied in 

practice

Usual care Mortality

Hospital: 10.4%, p = .02

30 days: 16.7% vs 21.6%, p = .02

1 year: 33.2% vs 38.3%, p = .02

Hospital 

30 day

1 year

Hospital Home

Rogers et al., 

200759

US

MI only 1368 Guidelines 

applied in 

practice

Usual care Death: “significantly decreased 1-year 

mortality” in tertile 2 (OR 0.43, 95% CI: 

0.22, 0.84) and tertile 3 (OR 0.45, 95% CI: 

0.27,0.76)

12 mo Hospital Home

Ho et al., 200760

US

Mixed MI 4933 Specialty followup Usual care Death: 18.8 vs 22.1%, p = .009

Hazard ratio 0.73 (95%CI 0.62 to .87)

1 mo

3 mo

Hospital Outpatient

Kotowycz et al., 

201061

Canada

MI only 54 Early supported 

discharge

Usual care Compliance (rehab): no difference 55% vs 

52%, p = .31

Compliance (meds): no difference,

p > .30-.82

Death: no deaths

Quality of life (SF-36): no difference, p >.05

Rehospitalization: no difference 8% vs 4%,

p = .56

3 days

1 mo

Hospital Home

Petrie et al., 

200262

New Zealand

MI only 65 Illness perception 

education

Usual care ACS: improved (14% vs 39%, p < 0.05)

IPQ: improved, p < 0.01

Patient satisfaction: improved, p < 0.05

Work: improved, p = 0.05

3 mo Hospital Home

Young et al., 

200363

US

MI only 146 Disease 

Management 

Program

Usual care Rehospitalization: apparently improved (40 vs 

80, statistical significance NR)

Readmission days, all causes: improved (814 

vs 483, p < 0.001)

Emergency department visits: improved (147 

vs 64, p < 0.001)

1 year Hospital Home
39

Table 5b. Summary of study characteristics for myocardial infarction studies (continued)

Study/Country Populationa N Intervention Comparator Outcomes

(intervention group versus “other”)b Timing Transitionfrom setting

Transition 

to setting

Intervention type 2a: Patient and family education (hospital-based)

Mayou et al., 

200264

UK

MI only 114 Guideline-based 

educational and 

behavioral 

cardiac 

rehabilitation

Usual care COOP: NS at 1 mo

HADS: NS at 1 mo

COOP: improved at 3 mo (median difference, 

-3.09, p = 0.004)

HADS: improved at 3 mo (median difference, 

-3.27, p = 0.002)

COOP: NS at 12 mo

HADS: NS at 12 mo

1 mo

3 mo

12 mo

Hospital Home

Intervention type 2b: Patient and family education (home-based)

Lacey et al., 

200465

UK

MI only 152 Self-help manual 

supported by 

facilitator

Usual care Quality of life (EQ-5D): no difference .69 vs 

.65, p = .13

HADS depression: improved 4.26 vs 5.37, 

p = .01

HADS anxiety: improved 4.87 vs 6.60 p <

.001

1.5 mo

6 mo

Hospital Home

Intervention type 3: Community-based support

Bambauer et al., 

200566

US

Mixed MI 100 Telephone 

counseling

Usual care CGI-I: improved at 3 mo, p = .01

CGI-I: NS at 6 mo, p = .13

3 mo

6 mo

Hospital Home

Costa e Silva et 

al., 200867

Brazil

MI only 153 Transdisciplinary 

care

Usual care CII: NS p = 1.0

Compliance (diet): improved, p = .007

Compliance (meds): NS, p = 1.0

Compliance (followup): improved, p = .001

Death: NS, p = .250

Emergency department visits: NS, p = .742

PPT: NS

Rehospitalization: NS, p = .168

6 mo Hospital Outpatient

Hall et al., 

200269

Australia

MI only 142 Early return to 

normal activities

Usual care No harm associated with early return to 

normal activities 

Quality of life: NS

Work: NS

1.5 mo

3 mo

6 mo

12 mo

Hospital Home
40

 Table 5b. Summary of study characteristics for myocardial infarction studies (continued)

Study/Country Populationa N Intervention Comparator Outcomes

(intervention group versus “other”)b Timing Transitionfrom setting

Transition 

to setting

Hanssen et al., 

200771

Norway

MI only 288 Telephone 

followup

Usual care PPT: frequency of exercise improved,

p = .004 

SF-36 MCS: p = .447 

SF-36 PCS: improved by 2.33, p = .039

6 mo Hospital Home

Hanssen et al., 

200972

Norway

MI only 

(study 

population71)

288 Telephone 

followup

Usual care PPT: no difference in frequency of exercise at 

12 mo, p = .593; or at 18 mo, p = .159 

SF-36 MCS: no difference p = .280

SF-36 PCS: no difference p = .250

12 mo

18 mo

Outpatient Home

Kovoor et al., 

200670

Australia

MI only 

(study 

population69)

142 Early return to 

normal activities 

with nurse 

coordinator 

weekly phone 

calls x 5 wk

Cardiac 

rehabilitation 

x 5 wk then 

return to work 

at 6 wk postMI

Death: no deaths

Reinfarction: no difference 2% vs 6%, p = .1

CABG: no difference 10% vs 3%, p = .08

Exercise: no difference, p = .12

1.5 mo

6 mo

Hospital Home

Lusczynska et 

al., 200674

Poland

MI only 114 Followup with 

implementation 

intervention 

program

Usual care Physical activity levels maintained higher at 8 

mo in patients using the program, p < .001

8 mo Rehabilitation Home

Robertson et al., 

200176

Canada

MI only 68 Home followup 

and education

Usual care Rehospitalization: trend toward improvement 

(3 vs 7 patients), but statistical significance 

NR

Cost: trend toward improvement, but 

statistical significance NR

1.5 mo Hospital Home

Robertson et al., 

200377

Canada

MI only 

(study 

population76)

68 Home followup 

and education

Usual care Rehospitalization: “major difference in rehospitalisations ... during the first 6 weeks, 

and a smaller but still substantial difference

... during the 6 week to 6 month period” 

(statistical significance NR)

1.5 mo

6 mo

Hospital Home

Sinclair et al., 

200578

UK

Mixed MI 324 Home followup 

and education

Usual care Death: NS

IADL: NS

Quality of life: NS

Rehospitalization: improved (35 vs 51, RR 

0.68, p < 0.05)

Days of hospitalization after discharge: 

improved (mean difference -1.7, p < 0.05)

3 mo Emergency Home
41

Table 5b. Summary of study characteristics for myocardial infarction studies (continued)

Study/Country Populationa N Intervention Comparator Outcomes

(intervention group versus “other”)b Timing Transitionfrom setting

Transition 

to setting

Intervention type 4: Chronic disease management

Barlow et al., 

200979

UK

MI only 192 Expert Patient 

Program

Usual care HADS anxiety: p = .016

HADS depression: p = .079

MIDAS: NS p ranges for all domains .153 to 

.808

SF-36 physical: p = .111

SF 36 mental: p = .497

4 mo Home Outpatient

a“Study population” cites the patient population from an earlier study.

bInstruments reported in the Outcomes column are full score or partial score as reported by the author.

Abbreviations: AAP = Adelaide Activities Profile, ACS = acute coronary symptoms, AIS = acute ischemic stroke, AshSS = Ashworth Spastic Scale, BBS = Berg Balance Scale, BSFC = 

Burden Scale for Family Caregivers, CABG = coronary artery bypass grafting, CGI-I = Clinical Global Impressions, CNS = Canadian Neurological Scale, CES-D = Center for 

Epidemiological Studies-Depression, CII = clinical improvement index, COOP = Dartmouth COOP, CSS = Cognitive Summary Score, EADL = Nottingham Extended Activities of Daily 

Living, EQ-5D = EuroQol 5 Dimensions, FAD = McMaster Family Assessment Device, FAI = Frenchay Activity Index, FIM = Functional Impairment Measure, FQM = Function Quality of 

Movement, GDS = Geriatric Depression Scale, GHQ = General Health Questionnaire, HADS = Hospital Anxiety and Depression Scale, IADL = Index of Activities of Daily Living, IPQ = 

Illness Perception Questionnaire, LHS = London Handicap Scale, LMC = Lindmark Motor Capacity, MADR = Montgomery Asberg Depression rating, MI = myocardial infarction, MIDAS =

Myocardial Infarction Dimensional Assessment Scale, MMSE = Mini-Mental State Examination, mo = month/months, mRS = modified Rankin Scale, NHP = Nottingham Health Profile, 

NIHSS = National Institutes of Health Stroke Scale, NPT = Nine-Hole Peg Test, NS = no statistically significant difference, OAD = Observer-Assessed Disability, OT = occupational 

therapy/therapist, PBSI = Preference-Based Stroke Index, PHQ = Patient Health Questionnaire Depression Model, PPT = physical performance test, PT = physical therapy/therapist, RAT = 

Reinvang Aphasia Test, RNLI = Reintegration to Normal Living Index, RMI = Rivermead Mobility Index, SAH = subarachnoid hemorrhage, SASC = Satisfaction with Stroke Care, Self = 

self-efficacy, SF-36 = Short Form-36, SF-36 MCS = Short Form-36 Mental Component Summary, SF-36 PCS = Short Form-36 Physical Component Summary, SIP = Sickness Impact 

Profile, SNA = service needs assessment, SRH = Self-Rated Health, TUG = Timed Up and Go, UK = United Kingdom; US = United States; ZDS = Zerssen Depression Scale
42

Population. The population of interest was the set of patients with vascular disease resulting in 

AIS, intracerebral hemorrhage (ICH), or MI. Study populations were categorized into four 

population cohorts (shown in Table 5/5b) as follows. The AIS-only cohort included studies in 

which the sample was limited to patients with ischemic stroke. The mixed-stroke cohort included

studies that enrolled patients with both ischemic and hemorrhagic stroke. Studies limited to 

patients presenting with transient ischemic attacks (TIAs) were not included in this review as 

most patients with TIA are not hospitalized, and establishing a definitive diagnosis of TIA is 

often problematic, thus introducing potential ascertainment bias into the conclusions drawn from 

the study. The MI-only cohort included studies in which the sample was limited to acute MI or 

unstable angina. The mixed-MI cohort included studies that enrolled patients with multiple 

cardiac diagnoses, where at least one diagnostic category was acute MI or unstable angina. 

From the original 53 articles, 13 studies18-22,30,32,35,41,47,48,53,54 included only patients with 

acute ischemic stroke (AIS only), 16 studies58,59,61-65,67,69-72,74,76,77,79 included only patients with 

MI (MI only), 21 studies16,17,23-25,27,28,33,34,36-38,40,44,46,49,50,52,55-57 included patients with AIS, ICH, 

and subarachnoid hemorrhage or did not define stroke as ischemic/hemorrhagic (mixed stroke), 

and 3 studies60,66,78 included patients with MI or ACS and other cardiac diseases (mixed MI). 

There were no studies that explored transition interventions for patients diagnosed only with 

ICH/SAH. The final sample of 15,216 patients included 1367 patients in the AIS-only cohort, 

5713 patients in the MI-only cohort, 2779 patients in the mixed-stroke cohort, and 5375 patients 

in the mixed-MI cohort. 

Six articles23,25,35-38 reporting on five distinct studies enrolled the patient and the caregiver. In 

these studies, there was no attempt to describe a dyadic relationship; rather, they described the 

effect of the intervention on separate outcomes for patient and caregiver. The caregiver 

population was predominately female (70.6%) and most often described as spouse or partner 

(89.6%) (Table 6). The patient population for each study was stroke—none of the MI studies 

included in this analysis enrolled caregivers.

Table 6. Relationship of caregivers to patients

Study Population Na Spouse Partner Child Other Female

Clark et al., 200335 AIS only 62 100% 61.3%

Grasel et al., 200523 Mixed stroke 62 71% 22.6% 6.5% 74.2%

Holmqvist et al., 200025 Mixed stroke 81 77.8% 69.1% 8.6%b 46.9%

Johnston et al., 200736 Mixed stroke 217 79.3%

Mant et al., 200037 and 

200538 Mixed stroke 267 65.2% 24% 10.9% 67.4%

Sulch et al., 200232 AIS only 152

a

N reflects number of patients in the primary study; not all patients in a study had caregiver support. b

Sex not reported.

Abbreviation: AIS = acute ischemic stroke.

Interventions and comparators. There was a wide range of interventions described in these 

studies. By far, the most common type of intervention could be broadly described as early 
43

supported discharge (ESD) (see KQ 1 for the taxonomy of intervention programs). Key elements 

that emerged in the interventions included the use of inpatient or outpatient rehabilitation, patient 

and caregiver followup, patient and caregiver education, providing patients with specialty 

physician consults, and coordination of care delivery services. These elements were typically 

addressed in studies that defined the intervention as ESD.16,18,25,28,33,48,52 In addition to ESD, 

studies described intervention programs developed under umbrella titles such as extended stroke 

unit services (ESUS),22 and guidelines applied in practice (GAP).58,59

Table 7 shows that—with the exception of those studies described above (each of which used 

a developed program)—there was a range of intervention approaches. A modification to the 

usual approach for rehabilitation (including inpatient, outpatient, or variations in delivery) was 

used as a component of eight different studies.32,41,44,53,54,64,65,69 Some form of patient followup 

was utilized in 24 (60%) studies.23,28,35,36,40,41,44,46,47,49,53,55,56,60-64,66,67,71,74,76,78 Education was used 

in 27 (67.5%) studies.23,32,34-37,40,41,44,46,47,49,54-56,61,62,64,65,69,71,74,76,78,79 Eleven (27.5%) 

studies23,32,40,41,47,53,55,56,61,63,70 reported that coordinating some aspect of care delivery was part of 

the intervention, and five (12.5%) studies23,40,41,55,56 reported that consulting (providing consult 

to) a specialist was a component of the intervention.

Table 7. Transition of care interventions

Studya Population Programb Rehabc Followupd Educatione Coordinatef Consultg

Allen et al., 200240 Mixed 

stroke X X X X

Allen et al., 200941 AIS only X X X X X

Andersen et al., 

200244 Mixed stroke X X X

Askim et al., 200416 Mixed 

stroke ESD

Bambauer et al., 

200566 Mixed MI X

Barlow et al., 200979 MI only X

Bautz-Holtert et al., 

200218 AIS only ESD

Boter et al., 200446 Mixed 

stroke X X

Claiborne et al., 

200647 AIS only X X X

Clark et al., 200335 AIS only X X

Costa e Silva et al., 

200867 MI only X

Donnelly et al., 

200448 AIS only ESD

Eagle et al., 200558 MI only GAP

Ertel et al., 200749 Mixed 

stroke X X

Grasel et al., 200523 Mixed 

stroke X X X X

Hall et al., 200269 MI only X X

Hanssen et al., 

200771 MI only X X
44

Table 7. Transition of care interventions (continued)

Studya Population Programb Rehabc Followupd Educatione Coordinatef Consultg

Ho et al., 200760 Mixed MI X

Hoffmann et al., 

200734 Mixed stroke X

Holmqvist et al., 

200025 Mixed stroke ESD

Indredavik et al., 

200022 AIS only ESUS

Johnston et al., 

200736 Mixed stroke X X

Joubert et al., 

200655 Mixed stroke X X X X

Joubert et al., 

200856 Mixed stroke X X X X

Kotowycz et al., 

201061 MI only X X X

Kovoor et al., 200670 MI only X

Lacey et al., 200465 MI only X X

Lusczynska et al., 

200674 MI only X X

Mant et al., 200037 Mixed 

stroke X X

Mayo et al., 200028 Mixed 

stroke ESD

Mayo et al., 200852 Mixed 

stroke ESD

Mayou et al., 200264 MI only X X X

Petrie et al., 200262 MI only X X

Ricauda et al., 

200453 AIS only X X X

Robertson et al., 

200176 MI only X X

Rogers et al., 200759 MI only GAP

Sinclair et al., 200578 Mixed MI X X

Sulch et al., 200030 AIS only X X X

Torp et al., 200633 Mixed 

stroke ESD

Torres-Arreola Ldel 

et al., 200954 AIS only X X

Young et al., 200363 MI only X X a

Articles cited in the table Study Characteristics (Table 5/5b) that are secondary or followup data analyses of an earlier study are 

not included in this table.

b

Program options indicate a developed or systems-based intervention. c

Rehab indicates that patients received some form of rehabilitation as part of the intervention.

d

Followup refers to any activity where medical staff provides followup care after discharge. e

Education indicates that there was ample evidence that patient or caregiver education was part of the intervention.

f

Coordinate indicates that at least one component of the intervention was the coordination of care services for patient after 

discharge.

g

Consult indicates that as part of the intervention, staff were instructed to facilitate a consult to general practitioners or specialists.

Abbreviations: Abbreviation: AIS = acute ischemic stroke, ESD = early supported discharge, ESUS = extended stroke unit 

services, GAP = guidelines applied in practice, MI = myocardial infarction

The intervention group was most often defined as receiving some intervention in addition to 

receiving the usual care. In all but two studies, the comparator was defined as usual care.53,54

Table 8 shows, however, that when usual care was the default comparator, the description of 

usual care was generally confined to a few aspects of care. The majority of studies (52.5%) 
45

22,23,25,28,35-37,40,46,47,49,52,55,56,58-60,62,74,78,79 gave either no real description of usual care or did not 

addressed key elements of usual care. There were 5 studies16,18,41,48,67 that listed some form of 

acute care as usual care, and 10 studies16,32,33,41,44,48,63,65,69,70 added rehabilitation. Some form of 

patient followup was cited as usual care in seven studies.33,44,61,63,64,71,76 Five studies34,41,64,66,69

documented education as usual care, whereas seven studies16,32,33,41,61,63,67 included coordination 

of care delivery as a component of usual care. 

Table 8. Elements of usual care 

Studya Not 

reportedb Acute 

carec Rehabilitationd Followupe Educationf Coordinationg

Allen et al., 200240 X

Allen et al., 200941 X X X X

Andersen et al., 200244 X X

Askim et al., 200416 X X X

Bambauer et al., 

200566 X

Barlow et al., 200979 X

Bautz-Holtert et al., 

200218 X

Boter et al., 200446 X

Claiborne et al., 200647 X

Clark et al., 200335 X

Costa e Silva et al., 

200867 X X

Donnelly et al., 200448 X X

Eagle et al., 200558 X

Ertel et al., 200749 X

Grasel et al., 200523 X

Hall et al., 200269 X X

Hanssen et al., 200771 X

Ho et al., 200760 X

Hoffmann et al., 200734 X

Holmqvist et al., 200025 X

Indredavik et al., 

200022 X

Johnston et al., 200736 X

Joubert et al., 200655 X

Joubert et al., 200856 X

Kotowycz et al., 201061 X X

Kovoor et al., 200670 X

Lacey et al., 200465 X

Lusczynska et al., 

200674 X

Mant et al., 200037 X

Mayo et al., 200028 X

Mayo et al., 200852 X

Mayou et al., 200264 X X

Petrie et al., 200262 X

Robertson et al., 

200176 X

Rogers et al., 200759 X

Sinclair et al., 200578 X

Sulch et al., 200030 X X

Torp et al., 200633 X X X

Young et al., 200363 X X X
46

a

Articles cited in the Study Characteristics (Table 5/5b) that are secondary or followup data analyses of an earlier study are not 

included in this table.

b

The authors did not report a definition of “usual care.”

c

Acute care refers to any level of specialty care (e.g., stroke unit, cardiac care unit).

d

Rehabilitation includes inpatient and outpatient rehabilitation. e

Followup includes patient followup (telephone, in-person, office visit) and any form of care delivered in the home setting (e.g., 

nursing care, rehabilitation).

f

Education refers to any form of formal education plan focused on facilitation the transition of care. g

Coordination refers to any form of care coordination (e.g., discharge planning, physician referral).

Two studies53,54 that did not use the comparator of usual care were stroke studies. The study 

by Ricauda et al.53 explored transitioning stroke patients from the emergency department (ED) to 

home after 24 hours and used the “ED-to-ward” comparator. It was unclear if ED-to-ward 

equated with usual care given that it is not unexpected that a proportion of patients having a 

stroke would be discharged home directly from the ED following a 24-hour observation period. 

Here, the distinction was important given that there were three major options for rehabilitation 

(inpatient, outpatient, and home care) and neither is considered the gold standard. Torres-Areola 

Ldel et al.54 explored an education intervention in conjunction with physical therapy and 

compared this against an education-only cohort. 

Outcomes. We identified more than 70 distinctly different outcome measures that were used to 

evaluate the relationship between transition of care services and impairments, functional status, 

quality of life, mortality, health care utilization, and family/caregiver burden. The majority of 

measures (n = 60) were measures that were validated or reported in prior studies or that could be 

classified as objective or physiological measures. Table 9 lists the reported outcome assessment

measures grouped by category.

Table 9. Outcome assessment measures

Outcome assessments and abbreviations

Impairments

Any measure of acute coronary symptoms (ACS)

Ashworth Spastic Scale (AshSS)

Canadian Neurological Scale (CNS)

Center for Epidemiological Studies of Depression scale (CES-D)

Cognitive Summary Score (CSS)

Geriatric Depression Scale (GDS)

Hospital Anxiety and Depression Scale (HADS)

Mini-Mental State Examination (MMSE)

Montgomery Asberg Depression Rating (MADR)

National Institutes of Health Stroke Scale (NIHSS)

Patient Health Questionnaire Depression (PHQ)

Psychosocial assessment

Reinvang Aphasia Test (RAT)

Zerssen Depression Scale (ZDS)

Functional status

Adelaide Activities Profile (AAP)

Any measure of compliance

Any measure of physical performance test (PPT)

Any measure of return to work

Barthel Index
47

Table 9. Outcome assessment measures (continued)

Outcome assessments and abbreviations

Berg Balance Scale (BBS)

Clinical improvement index (CII)

Dartmouth COOP charts (COOP)

Frenchay Activity Index (FAI)

Functional Impairment Measure (FIM)

Function Quality of Movement (FQM)

Instrumental of Activities of Daily Living (IADL)

Lindmark Motor Capacity (LMC)

Myocardial Infarction Dimensional Assessment Scale (MIDAS)

Nine-Hole Peg Test (NHP)

Observer-Assessed Disability (OAD)

Nottingham Extended Activities of Daily Living (EADL)

Rivermead Mobility Index (RMI)

Timed walk

Timed Up and Go (TUG)

Quality of life

Clinical Global Impressions (Improvement subscale) (CGI-I)

EuroQol 5 Dimensions (EQ-5D)

General health questionnaire (GHQ)

Illness Perception Scale (IPQ)

London Handicap Scale (LHS)

Nottingham Health Profile (NHP)

Reintegration to Normal Living Index (RNLI)

Self-Rated Health (SRH)

Short Form-36 (SF-36)

Short Form-36 Mental Component Summary (SF-36 MCS)

Short Form-36 Physical Component Summary (SF-36 PCS)

Sickness Impact Profile (SIP)

Mortality

Deaths 

Health care utilization

Any measure of cost of care

Any measure of length of hospital stay

Any patient-physician scheduled appointment

Any measure of patient location

Any readmission or rehospitalization

Emergency department visits

MD visit

Family or caregiver

Burden Scale for Family Caregivers (BSFC)

Caregiver satisfaction

Caregiver strain index 

McMaster Family Assessment Device (FAD)

Patient satisfaction

Satisfaction with care

Other

Any measure of illness-related knowledge

There were no universally beneficial or universally harmful transition interventions (Table 

10). Most interventions had mixed effects on outcomes, with some outcomes demonstrating 

benefit and others showing no change or worsening. Based on the preponderance of the evidence 

reviewed we were able to draw a number of conclusions about the effectiveness of each 
48

intervention when applied during one of the 4 phases of transition of care as defined in our 

model. 

At the stage of hospital-initiated support for discharge, “early supported discharge” was 

shown in 8 studies18-22,24,25,27 to reduce total hospital length of stay and improve patient 

satisfaction while there did not appear to be any adverse effects associated with it such as altered 

mortality, functional disability, or quality of life.16-20,22,23,27,28,33 We were able to find only a 

single study that evaluated “early supported discharge” following MI,61 and that trial did not 

demonstrate any benefits to the patients or their caregivers. Guideline-based practice and disease 

management programs following MI were shown to decrease death and rehospitalization; 

however, this conclusion is based on only three moderate-sized studies.58,59,63

Hospital-based as well as community-based patient and family education programs were able 

to increase patient satisfaction,34 reduce anxiety and depression in some cases62,64,65 as well as 

increase patient confidence in gaining recovery;36 however, the findings were not always 

consistent.35,36,64,65 There was no community-based support program that consistently improved 

either patient or family well-being, whether that program was staffed by nurses, physical 

therapists, social workers or physicians (Table 10). 

One program that seemed to show promise was that of allowing patients with MI and a lowrisk profile to return to normal activities early while being followed by weekly phone calls, 

without having to go through the standard 5-week cardiac rehabilitation program.69,70 This 

program was not associated with any increase in mortality, reinfarction, or requirement for future 

coronary bypass surgery. Patients in that program were able to return to work at the same rate as 

the control subjects. Risk factor control was also the same between the two groups. Telephonebased supportive followup did not demonstrate consistent benefits when evaluated after MI.71,72

Guideline-based practice58,59 and specialty care followup after MI were associated with reduced 

mortality.60 We did not find any chronic disease transition of care interventions that produced 

consistent improvement in outcomes or risk factor modification.55-57,67
49

 Table 10. Evidence supporting specific components of transition of care interventions

Population

Specific transition of 

care

intervention

Total # of studies 

demonstrating 

benefit

Endpoints with

improvement

Total # of studies 

demonstrating

no benefit

Endpoints without

improvement

Intervention type 1: Hospital-initiated support

Stroke patients Early supported 

discharge 818-22,24,25,27 Death

mRS

NHP

Length of stay

Patient satisfaction

Institutionalization

IADL

1016-20,22,23,27,28,33 Barthel Index

mRS

NHP

Death

BBS

Timed walk

EADL

GHQ

MADR

FAI

MMSE

AshSS

FIM

SF-36

TUG

Rehospitalization

MD visits

Integrated-care pathway 0 230,32 Barthel Index

Death

Length of stay

EQ-5D

Stroke 

patients’ 

caregivers

Early supported 

discharge 120 Caregiver strain 316,20,23 Caregiver strainBSFC

MI patients Early supported 

discharge 0 161 Medication compliance

Death

SF-36

Readmission

Guideline-based 

practice 258,59 Death 0

Disease management 

program 163 Rehospitalization

Emergency department visits

Readmission length of stay

0

Specialty followup 160 Death 0
50

Table 10. Evidence supporting specific components of transition of care interventions (continued)

Population

Specific transition of 

care

intervention

Total # of studies 

demonstrating 

benefit

Endpoints with

improvement

Total # of studies 

demonstrating

no benefit

Endpoints without

improvement

MI patients’ 

caregivers

No studies

Intervention type 2a: Patient and family education (hospital-based)

Stroke patient Computer-tailored 

stroke education 134 Patient satisfaction 134 COOPKnowledge

Self-efficacy

HADS anxiety (worsened)

Stroke 

patients’ 

caregivers

No studies

MI patients Illness perception 

education 162 ACS

IPQ

Patient satisfaction

Work

0

Guideline-based 

education 164 COOP:3 moHADS: 3 mo 164 HADS: 12 moCOOP: 12 mo

Self-help manual 165 HADS depression 

HADS anxiety 165 EQ-5D

Intervention type 2b: Patient and family education (home-based)

Stroke Stroke information 

packet and family 

counseling

135 AAP

Barthel Index

FAD

135 GDS

HADS

Mastery scale

SF-36 patient

SF-36 spouse 

Postdischarge 

education and followup 136 OADPatient confidence in 

recovery

136 Barthel Index

HADS

Patient satisfaction

Caregiver satisfaction
51

Table 10. Evidence supporting specific components of transition of care interventions (continued)

Population

Specific transition of 

care

intervention

Total # of studies 

demonstrating 

benefit

Endpoints with

improvement

Total # of studies 

demonstrating

no benefit

Endpoints without

improvement

Intervention type 3: Community-based support

Stroke Postdischarge care 

management or home 

followup

240,41 SIP

Knowledge 340,41,52 Barthel Index,CES-D

Death

Falls

NIHSS

Length of stay

TUG

Quality of life

FAI

FQM

IADL

Family support, 

community-based stroke 

team

328,38,48 SF-36 energy and vitality

SF-36 quality of life improved 

in caregiver

Patient satisfaction

328,38,48 Barthel Index

COOP-patient

COOP-caregiver

FAI-caregiver

HADS

LHS

RMI

GHQ-caregiver

Caregiver strain

EQ-5D

Length of stay

SF-36 MCS

SF-36 PCS

Timed walk

Telephone counseling 166 CGI-I: 3 mo 246,66 CGI-I: 6 mo

Barthel Index

mRS

HADS

SASC

SF-36 
52

Table 10. Evidence supporting specific components of transition of care interventions (continued)

Population Specific transition of 

care intervention

Total # of studies 

demonstrating 

benefit

Endpoints with

improvement

Total # of studies 

demonstrating

no benefit

Endpoints without

improvement

Stroke, cont. Expert Patient 

Programme 0 179 HADS anxiety

HADS depression

MIDAS

SF-36 MCS

SF-36 PCS

Social worker, 

psychosocial 

interventions

147 Self-care compliance

GDS

SF-36 MCS

247,50 Barthel Index

SF-36 PCS

Home care cognitive 

therapy 0 149 CSS

Death

IADL

Physical exercise

MI Early return to normal 

activity 269,70 No harm experienced (no difference in mortality, 

reinfarction, bypass surgery, 

quality of life and work)

170 Exercise

Telephone followup 171 Improved exercise

SF-36 PCS 271,72 ExerciseSF-36 MCS

SF-36 PCS

Implementation 

intervention program 174 Increased physical activity 0

Home followup and 

education 256,78 RehospitalizationDepression (PHQ-9) 376-78 RehospitalizationDeath

IADL

Intervention type 4: Chronic disease management

Stroke Integrated care 355-57 Depression (PHQ-9)

Activity

mRS

Quality of life

255,57 Barthel Index

Depression

MMSE

MI Transdisciplinary care 167 Diet compliance

Medical followup compliance 167 Medication complianceCII

Death

Exercise

Rehospitalization

Emergency department visits
53

Abbreviations: AAP = Adelaide Activities Profile, ACS = acute coronary symptoms, AIS = acute ischemic stroke, AshSS = Ashworth Spastic Scale, BBS = Berg Balance Scale, 

BSFC = Burden Scale for Family Caregivers, CGI-I = Clinical Global Impressions, CES-D = Center for Epidemiological Studies-Depression, CII = clinical improvement index, 

COOP = Dartmouth COOP, CSS = Cognitive Summary Score, EADL = Nottingham Extended Activities of Daily Living, EQ-5D = EuroQol 5 Dimensions, FAD = McMaster 

Family Assessment Device, FAI = Frenchay Activity Index, FIM = Functional Impairment Measure, FQM = Function Quality of Movement, GDS = Geriatric Depression Scale, 

GHQ = General Health Questionnaire, HADS = Hospital Anxiety and Depression Scale, IADL = Index of Activities of Daily Living, IPQ = Illness Perception Questionnaire, LHS 

= London Handicap Scale, LMC = Lindmark Motor Capacity, MADR = Montgomery Asberg Depression rating, MI = myocardial infarction, MIDAS = Myocardial Infarction 

Dimensional Assessment Scale, MMSE = Mini-Mental State Examination, mo = month/months, mRS = modified Rankin Scale, NHP = Nottingham Health Profile, NIHSS = 

National Institutes of Health Stroke Scale, NS = no statistically significant difference, OAD = Observer-Assessed Disability, PBSI = Preference-Based Stroke Index, PHQ = 

Patient Health Questionnaire Depression Model, PPT = physical performance test, RMI = Rivermead Mobility Index, SASC = Satisfaction with Stroke Care, SF-36 = Short Form36, SF-36 MCS = Short Form-36 Mental Component Summary, SF-36 PCS = Short Form-36 Physical Component Summary, SIP = Sickness Impact Profile, TUG = Timed Up and 

Go
54

Of the 53 articles included in the analysis for KQ 2, six reported universal benefit to patients 

who received the intervention (Table 10)—one in the stroke cohort,56 and five in the MI 

cohort.60,62,63,65,74 The single study56 in the stroke cohort included 29 patients and concluded that 

integrated care reduced depressive symptoms. In total, the 5 MI cohort studies included 5410 

patients. In a study of 4933 MI patients, Ho et al.

60 found that a reduction in mortality was 

associated with transition to specialty care followup. The remaining MI cohort studies explored 

education interventions;

62,65 followup interventions;74 a disease-management protocol;63 and 

benefits to patients in reducing depression (Hospital Anxiety and Depression Scale [HADS], 

EuroQOL 5 Dimensions [EQ-5D]),65 improving health,62,74 and increasing satisfaction and 

returning to work earlier with fewer physical symptoms associated with their illness.

62,63

A majority of the studies in the stroke cohort16-25,28,35,36,40,41,47,55,57,64,66,71,72 found mixed 

results and reported some area of benefit to patients who received the intervention but also found 

areas of no difference in outcomes for patients who received the intervention versus those who 

did not. In the stroke cohort, five articles18,64,66,71,72 from four studies reported mixed positive and 

null results at different time points (Table 10). Three of these studies18,64,66 initially showed a 

benefit to the transition intervention at 3 months after discharge that did not remain statistically 

significant at the 6-month or 12-month measure. However, Bambauer et al.66 found that the 

intervention had sustained improvement in depression (HADS) and self-rated health scores. 

Hanssen et al.71,72 found early benefit to a followup intervention at 6 months (improved qualityof-life and SF-36 physical component summary [PCS] scores) that did not remain significant at 

12 and 18 months after discharge.

Including all 53 articles relevant to KQ 2, a beneficial effect from the intervention was noted 

in 35 of the 71 outcomes reported. While nine outcome measures—knowledge, Geriatric 

Depression Scale, HADS, length of stay, modified Rankin Scale, patient satisfaction, physical 

performance test, quality of life, and SF-36 PCS—were found by more than one study to benefit 

from the intervention, each of these measures was also reported as not being significantly 

impacted by the intervention.16,19,21,22,25,28,33-38,41,46-49,52,53,55,57,61,62,64-67,70-72,74,78,79 The most 

commonly reported measure was the SF-36 (or SF-36 components), which was reported in 12 

studies.23,28,33,35,46-48,52,59,71,72,79 Three studies reported any level of improved SF-36 component 

scores,28,47,71 and no study reported an overall improvement in SF-36 scores. One study71 found 

that the intervention resulted in improved SF-36 mental component summary (MCS) scores at 3 

months following stroke discharge. One study72 reported improved SF-36 PCS scores at 6 

months after stroke but not at 12 or 18 months after stroke. Mayo et al.28 reported improved SF36 PCS scores at 1 and 3 months after stroke but no change in SF-36 MCS scores for this period.

There were 15 studies in which the authors found neither benefit nor harm for patients 

assigned to receive the transition intervention—10 in the stroke cohort,27,30,33,37,38,44,46,48,49,52,54

and 5 in the MI cohort.58,59,61,70,76,77,79 The 10 stroke cohort studies explored 8 different 

interventions and 35 different outcome measures with no significant differences in groups (Table 

10). 

There were three articles from two studies30,32,34 that concluded some form of harm as a 

result of the intervention. In a study of 138 stroke patients, Hoffmann et al.34 found that a 

computer-tailored stroke education intervention resulted in worse depression (HADS) but 

improved patient satisfaction for the intervention group; there was no difference in Dartmouth 

COOP scores, knowledge of stroke, or self-efficacy. Sulch et al.30,32 also found that depression 

scores were worse for the intervention group in their study of 152 stroke patients. Patients who 

were treated with an integrated-care pathway were also found have lower quality-of-life and 
55

Barthel Index scores compared to their counterparts.30 There were no major negative outcomes 

reported in the MI cohort studies.

The impact of the intervention on the caregiver was explored in a small portion of the stroke 

studies and none of the MI studies. There was insufficient evidence in these studies to 

demonstrate an adverse response or benefit to the quality of life and functional status of the 

caregiver. Two studies35,37 demonstrated a relationship between the transition intervention and 

caregiver outcomes. Clark et al.35 found that an intervention of education and family counseling 

improved family functioning at 6 months but that that there was no change in SF-36 scores for 

the caregiver. The first study by Mant et al.37 reported a significant improvement in the 

instrumental activities of daily living for caregivers (reported as improved scores in Frenchay 

Activity Index [FAI]) but found no change in caregiver satisfaction, strain, GHQ, COOP, or SF36 scores. In a followup study, Mant et al.38 found no change in FAI scores or in caregiver 

satisfaction, strain, GHQ, COOP, or SF-36 scores. In the remaining studies, the interventions had 

no significant impact on caregiver burden,23,30 satisfaction,30,36 symptoms (e.g., Giessen 

Symptom List23 and SIP25), or depression (ZDS).23

Timing. The primary aim of this report was to explore outcomes at 3 months, 6 months, and 12

months after discharge for patients with acute stroke and MI. However, many studies reported 

outcomes for more than one time point. Despite a tendency for some studies to measure 

outcomes in weeks and others in months, it was most common for outcomes to be measured 6 

months and 12 months after discharge (Table 11). The most common timing of outcome 

measures fell between 6 and 11 months after discharge. Using this timeframe, there were 21 

articles16-18,22-25,30,32,33,35-37,41,44,46,49,50,53,54 that reported outcomes for the stroke cohort and 10 

studies that reported outcomes for the MI cohort.58,65-67,69-71,74 Three studies (four articles)4,5,23,50

measured outcomes at 1 month or 1.5 months after discharge.16,17,54,69 In each case, outcome 

measurements were repeated at later time intervals—either at 3 and 6 months after discharge54,69

or at 6 and 12 months after discharge.16,17,69 Approximately half of the studies evaluated 

outcomes only one time—6 studies34,40,47,62,78,79 at 3 months after discharge, 19 studies22-25,30,32,35-

37,41,44,46,49,50,52,53,67,71,74 at 6 months after discharge, and 11 studies19-21,27,38,48,55-57,59 evaluated 

outcomes at 12 months after discharge. 

Table 11. Summary of study time points associated with outcomesa

Population Less than 3 

months 3 to 5 months 6 to 11 months 12 months Over 12 monthsb

AIS only 1 study54 3 studies18,47,54 8 studies18,22,30,32,35,4

1,53,54 4 studies19-21,48 0 studies

MI only

9 

studies58,60,61,64,6

5,69,70,76,77 4 studies62,64,69,79 8 studies58,65,67,69-

71,74,77

5 

studies59,63,64,69,7

2 1 study72

Mixed stroke 3 studies16,17,28 3 studies28,34,40 13 studies16,17,23-

25,33,36,37,44,46,49,50,52

8 

studies16,17,27,33,3

8,55-57 0 studies

Mixed MI 1 study60 3 studies60,66,78 2 studies66,71 0 studies 0 studies

a

Studies may be listed multiple times if outcomes were measured at different time points. 

b

Studies reporting outcomes beyond 12 months were included only if they also reported outcomes before 1 year after discharge.

Abbreviations: AIS = acute ischemic stroke, MI = myocardial infarction Key Question 3
56

KQ 3: For patients hospitalized with first or recurrent stroke or MI, what are 

the associated risks, adverse events, or potential harms—both systembased and patient-based—of transition of care services?

Key Points

• Six studies reported risks, adverse events, or harms, and of those that did, none involved

interventions for MI patients.

• There was insufficient evidence to determine if there were differential rates of adverse 

events for transition of care interventions or components of transition of care services. 

• Reported rates of adverse events were similar for intervention and usual-care groups.

• The available data must be interpreted with caution because data on risks, adverse events, 

and harms have not been systematically collected or reported across studies.

Detailed Analysis

The definition of risks, adverse events, or harms for a transition of care intervention was any 

event that caused a failure to improve (i.e., complications such as death, rehospitalization, 

prolonged length of stay, lost to followup) or that increased burden or anxiety of the patient or 

caregiver. While some of these events may also be viewed as an outcome of interest for KQ 2, 

they also represent an adverse event for KQ 3 and thus are included in both sections. 

Literature identified. Only 8 articles (2 good quality, 5 fair, 1 poor)

16,27,28,40,41,45,46 representing 

6 studies reported data relevant to KQ 3 (Table 12), and all were studies of stroke patients 

transitioning from hospital to home. With one exception,45 all were randomized controlled trials 

with four single-site and three multisite studies. Sample size ranged from 83 to 535 patients, and 

the comparator in every case was usual care. The interventions included a diverse collection of 

providers and strategies.

Table 12. Measurement of risks, adverse events, and potential harms by study

Study Timing of followup Failure to improve Burden or anxiety

Allen et al., 200240

Allen et al., 200941 3 and 6 months Severe complications (death, rehospitalization or nursing 

home admission); composite 

measure of length of stay (at 

facility) and death 

Askim, et al., 200416 6 weeks, 

6 and 12 months

Caregiver Strain Index

Ayana, et al., 200145 6 months Patient’s opinion of intervention
57

Table 3. Measurement of risks, adverse events, and potential harms by study (continued)

Study Timing of followup Failure to improve Burden or anxiety

Boter et al., 200446 6 months Caregiver Strain Index, Sense of 

Competence Questionnaire 

(caregiver), Social Support List–

Discrepancies (caregiver)

Mayo et al., 200028 1 and 3 months Impact of losses to followup on 

functional performance

von Koch et al., 200026

von Koch et al., 200127 6 and 12 months Death or dependency

Rather than being provider-focused, all interventions were patient-centered, increasing the 

potential risk for patient or caregiver burden or anxiety. While only Boter et al.46 reported 

descriptive data on the presence of a support system, two studies16,46 reported caregiver burden 

as measured by the Caregiver Strain Index. Neither found a difference between the intervention 

and control groups. Caregivers in the Boter et al. study46 were also assessed with the Sense of 

Competence Questionnaire as well as on the discrepancies in social support with the Social 

Support List-Discrepancies measure, but no differences were found between groups at 6 months. 

von Koch 2000, 2001 reported living arrangements after discharge (alone or with others), but no 

measures of burden are reported. Ayana et al.45 tested the use of a patient-held record and 

reported that the patients felt the intervention was burdensome. Almost half of the stroke patients 

discharged with a patient-held record reported that they never received one, 15 percent lost the 

record before the 6-month assessment, and 23 percent never read or referred to it during the 6-

month intervention period. The majority of patients had difficulty engaging providers to add 

information to the record, and only 15 percent felt the record kept them informed about the 

treatment over time. There was insufficient evidence to a make a conclusion on patient or 

caregiver burden related to transition of care interventions for stroke patients.

The impact of the intervention on insurance coverage that was selected as a focus for this 

review was not reported for any study; however, it may not have been an appropriate focal point 

for the majority of studies because in this subsample, five of six studies were conducted 

internationally in countries with national health insurance models. Only the study by Allen et 

al.40,41 was conducted in the U.S. and did not report the insurance status of stroke patients. This 

study did, on the other hand, report a composite outcome of severe complications at 3 months40

and institutional time and death at 6 months.41 Both were measures summarizing death, 

rehospitalization, and nursing home admission, with the latter reporting the number of days and 

the former reporting a dichotomous outcome (yes/no). Although the intervention was found to 

produce a positive effect on severe complications at 3 months (moderate effect size of 0.43, 90% 

confidence interval 0.09 to 0.78), the 6-month outcome was not significantly different between 

groups. Von Koch et al.26,27 examined a similar negative outcome of death or dependency on the 

Barthel Index and had similar findings concluding no difference. There was no significant 

difference between groups at 6 or 12 months. These two interventions and the structure of the 

outcome are too dissimilar to draw any conclusions from these findings.

Finally, only Mayo et al.28 examined those patients lost to followup for whether poor 

performance influenced attrition. Although it was concluded that the intervention-group patients 

who did not complete the final evaluation could not have been predicted, persons lost to 

followup from the usual-care group had significantly lower performance for mobility and 

activities of daily living. Other studies did not report specific analyses of those lost to followup. 
58

Key Question 4: Do transition of care services improve aspects of systems 

of care for patients with stroke or MI (e.g., more efficient referrals, more 

timely appointments, better provider communication, reduced use of urgent 

care, or fewer emergency room visits as a result of transition of care 

services)? Is there improved coordination among multiple subspecialty care 

providers, and are new providers added to the care plan as a result of 

transition of care services?

Key Points

• From a system resource perspective, the evidence for transition of care services for 

patients with stroke or MI was insufficient because of study designs, sample sizes, and 

non-U.S. populations. 

• Resource use was complex; however, the use of services, particularly emergency 

department services, is lessened by early education regarding stroke or MI symptoms. 

• The greatest impact for education efforts appeared to be early and attenuated over time 

(during the first 3 months).

MI-specific key points

• Disease management programs may be more effective than remote phone calls only. 

• Early return to work after an MI was safe and may be cost-effective from a societal 

perspective. Returning to work did not increase health care utilization, and it saved the 

cost of cardiac rehabilitation in patients without complications or comorbidity.

Stroke-specific key points

• Early supported discharge, particularly in patients without complications or comorbidity, 

was either cost-neutral or cost-effective as it substantially reduced overall hospital days. 

This difference in hospital days was driven by the early discharge strategy, with no 

difference observed in rehospitalization rates in either arm. Early supported discharge did

not increase burden on family providers, and it reduced days in the hospital and 

outpatient physical therapy and occupational therapy visits.

• Rehabilitation in a day hospital or at home resulted in similar overall system resource 

use.

• Integrated-care pathways may facilitate communication transfer to other providers.

• Physician appointments or home visits by physical therapists may reduce readmission 

rate for stroke patients, particularly those with prolonged rehabilitation and stroke-related 

impairment prior to the intervention. Visits by nurses did not produce a similar effect.

• Family support and case management services reduced visits to physical therapists and 

specialists, the cause of which was unknown.
59

Detailed Analysis

In addition to improving outcomes, transition of care services can facilitate coordination and 

continuity of care, thereby improving quality and efficiency at a system level. For KQ 4, we 

addressed the data pertaining to the impact of transition of care services on systems of care for 

patients with stroke or MI. This question explored resource use and cost implications as well as 

coordination and use of important services. Less than half of the 44 studies (N = 18) identified in 

this report addressed the effect of transition of care services on systems of care. Also, the 

majority of these studies looked at rehospitalization and costs of care, rather than at 

communication or followup appointments. The MI population data focused on cardiac 

rehabilitation, postdischarge support and education, and specialist care. The stroke population 

focused on the transition from hospitalization to home, in terms of early discharge as well as 

supporting services. Little was found in regard to patient referrals, timely appointments, provider 

communication, coordination of care, use of urgent care, and emergency department visits. Many 

of the studies were single center, with non-U.S. populations of fewer than 200 patients. Most 

studies had few event rates and small population sizes, which limited their ability to provide 

meaningful comparisons or conclusions.

Literature identified—MI studies. The eight MI studies60,61,63,69,70,72,76,78 all lacked sufficient 

numbers of patients or events to determine the impact on resource use as a result of transition of 

care services (Table 13). Most observations did not show statistical significance because of

sample size and low occurrence of the outcomes. All studies except Ho et al.60 were outside the 

U.S., which limits the generalizability of practices to U.S. health care.

Table 13. Resource use and transition of care for patients with MI

System 

improvements

Studies Observations

Rehospitalization Hanssen et al., 200972

Kotowycz et al., 201061

Robertson et al., 200176

Sinclair et al., 200578

Young et al., 200363

Home or phone followup interventions after discharge 

showed lower rehospitalization, but none are statistically 

significant (small samples).

Disease management program demonstrated reduced 

rehospitalization days out of 1000 patient followup days 

(p < 0.0001), both overall and cardiac.

Health care 

utilizationa Young et al., 200363

Hall et al., 200269

Disease management program demonstrated lower 

costs of care for emergency room visits, tests, 

laboratory services.

Early return to work did not increase in health care 

utilization.

Costs Hall et al., 200269 Early return to work was cost effective by saving on 

initial cardiac rehabilitation cost in low-risk patients.

MD outpatient visits Ho et al., 200760

Kovoor et al., 200670

Specialist care resulted in better use of evidence-based 

medicine and more followup appointments with primary

care physicians.

Early return to work showed no differences in followup 

appointments with specialist or primary care physicians. a

Health care utilization includes emergency department visits, rehospitalization, laboratory and diagnostic testing, and 

revascularization.

Abbreviation: MI = myocardial infarction
60

Of the eight MI studies, five61,63,72,76,78 examined postdischarge support programs, two69,70

looked at timing for return to work, and one60 looked at specialty versus primary care in 

Veterans Affairs (VA) systems. The five studies looking at postdischarge support described 

phone or nurse visits for 6 to 12 weeks after discharge from an MI.61,63,72,76,78 These studies were 

following patients for quality of life, satisfaction, and emotional health as well as adverse events 

and resource use. The reported rehospitalization rates were not significantly different because of 

the rare occurrence of rehospitalization. Only the study by Young et al.,63 which utilized a 

disease management program with four components after an MI discharge, demonstrated lower 

use of emergency department visits, diagnostic and therapeutic tests, and hospitalization days in 

the disease management group compared to the control group. 

Two studies looked at the impact of returning to work and specialty care on physician visits 

after discharge. The study by Ho et al.60 noted that when both inpatient and outpatient services to 

acute MI patients were provided by cardiologists (specialists), there was an increased likelihood 

of visits with primary care physicians in 90 days after discharge. The study by Kovoor et al.70

determined that early return to work after MI—defined as 2 weeks as opposed to 6 to 8 weeks—

had no effect on the resulting use of primary care or specialist clinic visits. In addition, there 

were no additional increases in health care utilization of laboratory tests or imaging.69 This also 

established the safety of early return to work for patients with uncomplicated MI, yielding 

overall economic benefits due to saving on cardiac rehabilitation costs and returning to 

productive work.

Literature identified—stroke studies. The 10 stroke studies18,21,25,27,30,33,37,43,48,52 that examined 

resource utilization were similarly small in size, often single center, and all were non-U.S. (Table 

14). This limits their statistical power and relevance to U.S. practice regarding the impact of 

transition of care services on cost and care coordination. However, readmission is common in 

stroke patients, occurring in up to one-third of all patients, and is likely due to stroke-related 

complications. Accordingly, data in the stroke population are better in terms of rehospitalizations 

as compared with the MI population. Of the 10 stroke studies, five18,21,25,27,48 studied early 

supported discharge, four33,37,43,52 studied transition of care services following standard 

discharge, and one studied an integrated-care pathway.31
61

Table 14. Resource use and transition of care for patients with stroke

System Improvements Studies Observations

Rehospitalization; total 

hospital days

Andersen et al., 200043

Bautz-Holtert et al., 200218

Donnelly et al., 200448

Fjaertoft et al., 200521

Holmqvist et al., 200025

von Koch et al., 200127

Sulch et al., 200030

MD or PT home visits after discharge from inpatient 

rehabilitation significantly reduced readmissions at 6 

months (26% or 34% versus 44% control; p = 0.028).

Early supported discharge to multidisciplinary team 

resulted in fewer hospital days than standard care (22 

days versus 31 days, p = 0.09).

Early supported discharge to multidisciplinary 

community team care resulted in a nonsignificant 

reduction in overall hospital days and significantly less 

use of day hospitals.

Early supported discharge resulted in fewer hospital 

days (66.7 versus 85, p = 0.012).

Early supported discharge resulted in fewer overall 

hospital days, mostly due to the shortened initial 

hospitalization (15 versus 30, p < 0.0001).

No difference in overall length of stay of integrated-care 

pathway versus standard care.

Health care utilizationa Mayo et al., 200852

Sulch et al., 200231

Torp et al., 200633

Case management did not alter health care utilization.

Integrated pathway did not alter health care utilization.

Supported discharge did not alter health care utilization.

Costs Donnelly et al., 200448

Fjaertoft et al., 200521

Torp et al., 200633

Early discharge with community team supports trend to 

cost savings but is not significant.

Early supported discharge was cost-neutral.

Supported discharge was cost-neutral compared to 

usual care.

Outpatient visits/ 

communications

Fjaertoft et al., 200521

Holmqvist et al., 200025

von Koch et al., 200127

Mant et al., 200037

Mayo et al., 200852

Sulch et al., 200231

Torp et al., 200633

Early supported discharge had increase in clinic visits 

(11.4 versus 8.9, p = 0.027).

Early supported discharge resulted in fewer day 

hospital and outpatient PT/OT visits compared to the 

usual care arm.

Family support services resulted in fewer visits to PT 

compared to control. (44% versus 56%, p = 0.04).

Case management group has fewer visits to specialists 

after discharge (2.2 versus 3.4, p = 0.01).

Integrated-care pathways improved communications 

with primary MDs (80% versus 45%, p > 0.0001).

Supported discharge did not alter visits to primary care 

or specialists. a

Health care utilization includes emergency department visits, rehospitalization, laboratory and diagnostic testing, and 

revascularization.

Abbreviations: OT = occupational therapy/therapist, PT = physical therapy/therapist
62

The studies of early supported discharge varied in process; however, reductions in initial 

hospitalization seemed feasible and potentially cost-saving. Bautz-Holtert et al.18 found that 

combining a multidisciplinary team with early discharge to home resulted in fewer overall 

hospital days (including baseline hospitalization) without adverse events; however, this was on a 

selected group of high-functioning stroke patients. Donnelly et al.48 also noted, on a smaller 

sample of stroke patients, a trend to fewer hospital days and lower costs with the strategy of early 

discharge and community multidisciplinary support teams. Similar findings among 320 patients 

were noted in another study21 of early supported discharge, with fewer overall hospital days (p = 

0.012) and no difference in overall costs. In this study, a slight increase in clinic visits in the 

early discharge group (11.4 versus 8.9, p = 0.027) was counterbalanced by fewer overall 

inpatient rehabilitation days (11.1 versus 23.4, p = 0.0001). A study by Holmqvist et al.25 showed 

that early discharge resulted in fewer hospital days overall (15 versus 30, p < 0.0001), mostly 

due to the shortened initial hospitalization. The early discharge to home rehabilitation group had 

no significant differences in other services such as transportation, home health, or assistance 

from family caregivers. The costs were neutral.25 Those studies that looked at providing 

rehabilitation at home versus in a rehabilitation hospital following standard discharge found no 

significant resource differences. Further differences were an increase in day hospital attendance 

(p < 0.001) and outpatient visits to occupational therapy and physical therapy.27

In the four studies33,37,43,52 of transition of care services following standard discharge, Torp et 

al.33 studied discharge supported by an interdisciplinary stroke team versus standard aftercare 

and found no differences in resource use, GP visits, or health care services. Mant et al.37 found 

that family support group patients had a lower use of outpatient PT visits (44 versus 56%, p = 

0.04), but otherwise there were no differences in use of services. Mayo et al.52 studied case 

management involving nursing phone calls and visits to coordinate care 6 weeks after discharge 

and found no differences in health care utilization between case management patients and 

controls. There was, however, a slight increase in specialist visits in the usual care group (3.4 

versus 2.2, p < 0.01). Andersen et al.43 found that physician or physiotherapist visits to patients 

with stroke following discharge from an inpatient rehabilitation facility significantly reduced 

readmissions over and above contact with nursing services only (control) (26% and 33% versus 

44%, p < 0.028). Therefore, from a cost and resource use perspective, it appears that support is 

most useful when used in combination with a shortening of the initial hospitalization in selected 

patients and when delivered in person by skilled staff.

Two studies by Sulch et al.30,31 studied the role of integrated-care pathways. Integrated-care 

pathways did not shorten length of stay.30 In addition, integrated pathways were tested for their 

ability to improve communications with the outpatient setting. The integrated pathway tested by 

Sulch et al.31 did increase notification of primary physicians related to discharge and 

documentation of information, but there were no significant differences in the process of care 

between the integrated-care pathway group and the control group. 
63

Key Question 5: For patients hospitalized with first or recurrent stroke or 

MI, do benefits and harms of transition of care services vary by 

characteristics—both patient-based and system-based—such as disease 

etiology and severity, comorbidities, sociodemographic factors, training of 

the health care providers, participants (patients, caregivers), geography 

(rural/urban, regional variations), and insurance status?

Key Points

• Thirteen studies of transition of care explored the benefits and harms as they varied by 

characteristics.

• The most commonly reported characteristics in transition of care studies were severity, 

age, sex and presence/absence of depressive symptoms.

• There was a lack of consistency by which characteristics are measured or reported.

Detailed Analysis

Literature identified. We identified 14 peer-reviewed articles (2 good quality, 10 fair, 2 poor)

between 2000 and 2011 that were specifically relevant to KQ 5. These 14 articles presented data 

from 13 studies that enrolled 3420 patients. 

Population. The population of interest is the set of patients with vascular disease resulting in 

AIS or MI who received transition of care services for which there was a difference in benefit or 

harm that can be related to patient characteristics (Table 15). Study populations were categorized 

into the followed four cohorts: (1) AIS only, (2) MI only, (3) mixed stroke, and (4) mixed MI. To 

be included in the sample, studies with a mixed population must also have included patients with 

ICH stroke, ischemic stroke, MI, or unstable angina with evidence of ischemia. 

Table 15. Studies of how benefits and harms may vary by patient or system characteristics

Study Population N Intervention Country Centers

Allen et al., 200941 AIS only 296 Discharge care management US Single

Andersen et al., 

200043 Mixed stroke 155 Organized aftercare Denmark Multi (3)

Askim et al., 200617 Mixed stroke 62 Early supported discharge Norway Single

Barlow et al., 200979 MI only 192 Expert Patient Programme UK Single

Ertel et al., 200749 Mixed stroke 291 Home care cognitive behavioral 

therapy 

US Multi (4)

Fjaertoft et al., 200521 AIS only 320 Extended stroke unit services Norway Single

Gallagher et al., 

200368 Mixed MI 196 Education and followup Australia Single

Geddes et al., 200151 Mixed stroke 1076 Coordinated care UK Multi (6)

Indredavik et al., 

200022 AIS only 320 Extended stroke unit services Norway Single
64

Table 4. Studies of how benefits and harms may vary by patient or system characteristics 

(continued)

Study Population N Intervention Country Centers

Lusczynska et al., 

200674 MI only 114 Followup with implementation intervention program

Poland Single

Mant et al., 200037 Mixed stroke 323 Family support UK Not clear

Teng et al., 200329 Mixed stroke 114 Early supported discharge Canada Single

Torp et al., 200633 Mixed stroke 198 Early supported discharge Denmark Single

von Koch et al., 

200127 Mixed stroke 83 Early supported discharge Sweden Single

Abbreviations: AIS = acute ischemic stroke, MI = myocardial infarction; UK = United Kingdom; US = United States

From these 14 original articles, three studies21,22,41 included only patients with AIS (AIS 

only); two studies74,79 included only patients with MI (MI only); seven studies17,29,33,37,43,49,51 had 

a mixed-stroke population that included patients with stroke, and either did not define stroke as 

ischemic/hemorrhagic or included AIS and other stroke (ICH and/or SAH); and one study68

included a mixed-MI population defined as acute coronary syndrome or patients with MI as well 

as other patients (but not stroke). There were no studies that included only patients with 

combined stroke and MI, and no studies that explored transition interventions for patients 

diagnosed only with ICH.

The 14 articles described single-center and multicenter studies around the world. Singlecenter studies were performed in the U.S.,

41 Norway,17,21,22 U.K.,79 Australia,68 Poland,74

Canada,29 Denmark,33 and Sweden.27 Multicenter studies were conducted in Denmark,43 U.S.,49

and U.K.51

Subgroups. There was a lack of consistency with regard to which characteristics were explored 

for their relationship to benefits and harms of transition of care interventions. Table 16 provides 

details about the most frequently reported subgroup characteristics in transition intervention 

studies. 

Table 16. Subgroup characteristics

Studya

SeverityAgeSexDepressionKnowledge/educationRace/ethnicityComorbidityPremorbid statusHealth care providerMMSERehospitalizationPrior stroke/MILength of staySocial tiesDuration since dischargeFrailty/stressbGeographyWork status

Allen et al., 200941 X X X X X X X X

Andersen et al., 

200043 X X X X X X

Askim et al., 

200617 X

Barlow et al., 

200979 X X X X

Ertel et al., 200749 X X X X X X X X
65

Table 5. Subgroup characteristics (continued)

Studya

SeverityAgeSexDepressionKnowledge/educationRace/ethnicityComorbidityPremorbid statusHealth care providerMMSERehospitalizationPrior stroke/MILength of staySocial tiesDuration since dischargeFrailty/stressbGeographyWork status

Fjaertoft et al., 

200521 X

Gallagher et al., 

200368 X X X X X

Geddes et al., 

200151 X X X X

Indredavik et al., 

200022 X

Lusczynska et al., 

200674 X

Mant et al., 200037 X

Teng et al., 200329 X

Torp et al., 200633 X

von Koch et al., 

200127 X

a

Articles cited in the Study Characteristics (Table 5/5b) that are secondary or followup data analyses of an earlier study are not 

included in this table.

b

Frailty/stress is any measure of the patient’s condition of frailty or experiencing a stressful event.

Abbreviations: MMSE = Mini-Mental State Examination

The relationship between outcomes and severity of illness was the most frequently reported 

characteristic.17,21,22,29,33,41,49,51 The measures of severity that were reported included National 

Institutes of Health Stroke Scale (NIHSS), Scandinavian Stroke Scale (SSS), Barthel Index, and 

modified Rankin Scale (mRS). Other common subgroup analyses were performed for 

age,

41,43,49,51,68,79 and sex,41,43,49,68,79 while only one study41 explored the relationship of 

race/ethnicity to outcomes. Depression was an outcome of interest in 18 articles,32,34-38,41,46-

48,52,53,55,56,64-66,79 but depression was also explored as a characteristic in four studies.27,41,43,49

Three studies43,49,51 explored some form of patient baseline knowledge/education. The patient’s 

premorbid status or number of comorbidities was explored in four studies.41,49,74,79 Only two 

studies43,51 explored system-level characteristics by describing the relationship of health care 

provider to patient outcomes. 

Benefits and harms. Each of the studies reported at least one significant finding attributed to 

one or more patient-based or system-based characteristic (Table 17). Functional status at 

discharge, while measured using different tools, was found to be a significant predictor of 

outcome in 8 studies.16,17,19-22,26,27,29,33,49,51 The outcome for these 8 studies varied from balance to 

depression and morbidity; there was no universal outcome associated with functional status. The 

most common characteristics analyzed were age and sex, which were reported in all but two 

studies.74,78 Only two studies37,38,51 reported systems-based characteristics with significant 

findings. Geddes et al.51 found that patients who were deceased or transferred to a nursing home 
66

1 year after home-based rehabilitation were more likely to have been referred by a general 

practitioner compared to having been referred by hospital-based personnel. In a study of MI 

patients, Mant37,38 found that admission to a specialty rehabilitation after discharge was 

associated with improved functional status at 6 months.

Table 17. Studies showing significant findings for transition intervention

Study Characteristic Significant finding

Allen et al., 200941 History of prior stroke, TIA, atrial fibrillation Greater benefit from care management 

of neuromotor function 

Andersen et al., 200043 Longer length of stay (usual care group), 

Unskilled status, older age, history of 

depression

Higher readmission for usual care group

Increased risk of readmission

Askim et al., 200617 Severe or moderate paresis Worse balance after 1 year

Barlow et al., 200979 Femalesa Reduced depression and anxiety in 

intervention group

Ertel et al., 200749 Malesa

Not fraila

Less severe strokea

High MMSE

Lower depression scoresa

High depression scorea

Fewer comorbidities

Higher cognitive score

Higher ADL and lower mortality 

Higher cognition scores

Trend to higher ADL (p = 0.08)

Trend to lower mortality (p = 0.07)

Trend to higher mortality (p = 0.08)

Higher instrumental ADL scores

Fjaertoft et al., 200521 High functiona Higher cost

Gallagher et al., 200368 Younger females (compared to age 55 to 

70)

Rehospitalized, not working, experiencing a 

stressful event, poor perception of control

History of depression

Worse adjustment to illness scores

Higher anxiety and depression

Higher depression

Geddes et al., 200151 GP referral (compared to hospital personnel 

referral), older age, poor cognitive function, 

more severe stroke

Deceased or transferred to nursing home 

after rehabilitation

Indredavik et al., 

200022 Moderate to severe strokea More improvement in mRS and Barthel Index scores

Lusczynska et al., 

200674 Physical activity before MI Physical activity after MI

Mant et al., 200037 Admission to specialty rehabilitationa Higher SF-36 scores

Teng et al., 200329 Functional status at discharge No difference in cost

Torp et al., 200633 Functional status at discharge No difference in length of stay or 

rehospitalization

von Koch et al., 200127 Higher coping capacity Greater independence a

Difference was seen or analyzed in the intervention group.

Abbreviations: ADL = activities of daily living, GP = general practitioner, MI = myocardial infarction, MMSE = Mini-Mental 

State Examination, mRS = modified Rankin Scale, SF-36 = Short Form-36, TIA = transient ischemic attack
67

Secondary analysis for KQ 5. After exploring the data from the 14 transition articles identified 

above that analyzed differences in outcome for various characteristics within a single study, we 

sought to explore for patterns of benefit or harm between the transition studies. To accomplish 

this, we examined the relationships of key characteristics between studies that reported benefit or 

harm associated with a transition of care intervention. 

From the 62 articles included in this systematic review, there were 22 articles17,19-22,25,34-

36,41,47,53,55-57,60,62,65-67,74,78 that identified some benefit to a transition intervention. To fully explore 

for patterns in characteristics associated with patients who benefited from the intervention, the 

four main subgroup characteristics identified in Table 16 (severity of stroke/MI, age, sex, and 

depression) were abstracted for each outcome measure that reported a benefit of a transition 

intervention (Table 18). Across the studies that reported benefit, the mean age was between 56 

and 82 years. The percentage of male patients in the stroke studies that reported benefit was 42 to 

61 percent.17,19-22,25,34-36,41,47,53,55-57

Of studies that found a benefit to the intervention and reported sex in the MI population, one 

study conducted in a VA population60 reported that 97 percent of subjects were male; in the 

remaining MI population studies, the percentage of male subjects ranged from 46 to 70 

percent.62,65-67 Severity of illness/injury was reported in 11 studies.17,19,22,25,36,41,53,56,57,60,67 Studies 

that reported baseline mRS values and found benefit from the transition intervention generally 

reported baseline mRS of greater than 2 as a characteristic,17,22,56,57 whereas Fjaertoft et al.19

reported that 6.3 percent of patients who benefited from ESUS had mRS less than 3. Studies that 

included NIHSS scores found benefit from the transition intervention when the mean NIHSS was 

less than 5.

36,41,53 Baseline depression was explored using CES-D,41 EQ-5D,65 GDS,47,53 and 

HADS.

36,65,66 With the exception that depression scores at baseline predicted later depression 

scores,47,65,66 there was no consistent relationship between depression and a transition 

intervention. 

Characteristics from studies that found a benefit to the intervention. There were 17 studies 

(22 articles)

17,19-22,25,34-36,41,47,53,55-57,60,62,65-67,74,78 that reported a positive effect from the transition 

intervention and included data for patient characteristics. The four most frequently reported 

subgroup characteristics were severity of stroke/MI, age, sex, and depression. As noted in Table 

18, there was insufficient evidence to support the hypothesis that response to any given transition

of care intervention varies by patient characteristics. There was only a modest variation in age 

and sex reported. The mean age reported varied from a low of 56 in one MI study62 of 65 patients 

to a high of 82 in a stroke study.53 Given the exception of a study performed in a VA population 

where the sample was 97 percent male,60 the percentage of male patients ranged from 42 percent 

in a study of 138 stroke patients34 to 70 percent in a study of 65 patients with MI.62
68

Table 18. Studies that found a benefit of transition intervention

Studya Populationb N

Outcomes 

improved by 

interventionc

Mean 

aged % 

malee Severity Depression

Allen et al., 

200941 AIS only 296 Knowledge 68 50 NIHSS = 2 CES-D = 2.8

Askim et al., 

200617

Mixed stroke 

(study 

population16)

62 BBS 

Timed walk 77 52

SSS = 45.4

Barthel Index = 

57.7

mRS = 3.7

NR

Bambauer et 

al., 200566 Mixed MI 100 HADS SRH 61 65 NR HADS = 8.5

Claiborne et 

al., 200647 AIS only 28

Compliance (selfcare) 

GDS 

SF-36 MCS 

70 44 NR GDS = 10.8

Clark et al., 

200335 AIS only and 

Caregiver 62

AAP 

Barthel Index

FAD 

73 59 NR NR

Costa e Silva 

et al., 200867 MI only 153

Compliance

(diet) 

Compliance

(followup)

59 48 STEMI = 83.3% NR

Fjaertoft et al., 

200319

AIS only 

(study 

population22)

320 mRS 74 54

mRS < 3 = 6.3%

Barthel Index > 94 

= 52.5%

NR

Fjaertoft et al., 

200420

AIS only 

(study 

population22)

320 NHP 74 54 NR NR

Fjaertoft et al., 

200521

AIS only 

(study 

population22)

320 Length of stay 74 54 NR NR

Ho et al., 

200760 Mixed MI 4933 Death 66 97 TIMI risk = 3.2 NR

Hoffmann et 

al., 200734 Mixed stroke 138 Patient satisfaction 67 42 NR NR

Holmqvist et 

al., 200025

Mixed stroke 

and 

Caregiver

81 Patient 

satisfaction 68 55 CT scan, coping, 

comorbidity NR

Indredavik et 

al., 200022 AIS only 320 Length of stay

mRS 74 54

Barthel Index = 

60.4

mRS = 3.3

SSS = 43.6

NR

Johnston et 

al., 200736

Mixed stroke 

and 

Caregiver

203

OAD 69 61

Barthel Index = 

18.0

NIHSS = 4.6

HADS = 6.9

Joubert et al., 

200655 Mixed stroke 97 PPT 65 51 NR NR

Joubert et al., 

200856 Mixed stroke 233 PHQ-9 63 58 mRS > 2 = 26% NR

Joubert et al., 

200957

Mixed stroke 

(study 

population56)

186 mRS 

Quality of life 63 58 mRS > 2 = 26% NR

Lacey et al., 

200465 MI only 152 EQ-5D HADS 67 67 NR HADS = 5.3EQ-5D = 0.5
69

Table 18. Studies that found a benefit of transition intervention (continued)

Studya Populationb N

Outcomes 

improved by 

interventionc

Mean 

aged % malee Severity Depression

Lusczynska et 

al., 200674 MI only 114 PPT NR NR NR NR

Petrie et al., 

200262 MI only 65

ACS 

IPQ 

Patient 

satisfaction 

Work 

56 70 NR NR

Ricauda et al., 

200453 AIS only 120 GDS 82 45

CNS = 6

FIM = 41.5

NIHSS = 24

GDS = 17.5

Sinclair et al., 

200578 Mixed MI 324 Rehospitalization NR NR NR NR

a

The Grasel et al.,23 Hanssen et al.71 and Mayo et al.28 studies are excluded from this table because they did not have any 

measures with positive impact across all time points. The Mant et al.37 study had no patient outcomes. b

Caregiver measures are not included in this table.

c

Measures that reported improvement at first time point but not at a later assessment were not included (e.g., SF-36 improved at 6 

months but was unchanged at 12 months). d

Mean age is the mean age of intervention group (mean age of entire sample if not given for each group).

e

% male is the percentage of males in the intervention group (percent male of entire sample if not given for each group).

Abbreviations: AAP = Adelaide Activities Profile, ACS = acute coronary symptoms, AIS = acute ischemic stroke, BBS = Berg 

Balance Scale, CES-D = Center for Epidemiological Studies-Depression, EQ-5D = EuroQol 5 Dimensions, FAD = McMaster 

Family Assessment Device, GDS = Geriatric Depression Scale, HADS = Hospital Anxiety and Depression Scale, IPQ = illness 

Perception Questionnaire, MI = myocardial infarction, mRS = modified Rankin Scale, NHP = Nine-Hole Peg Test, NIHSS = 

National Institutes of Health Stroke Scale, OAD = Observer-Assessed Disability, PPT = physical performance test, SF-36 = Short 

Form-36, SF-36 MCS = Short Form-36 Mental Component Summary, SRH = Self-Rated Health, TIMI = thrombolysis in 

myocardial infarction.

There was a lack of consistency in the use of instruments for reporting illness severity. There 

were only 11 studies that reported severity of illness at the time of admission in the subset of 

studies that found a benefit to the intervention and reported characteristics associated with 

outcomes. Studies including patients with stroke reported severity using NIHSS,36,41,53 SSS,17

Barthel Index,

17,19,22,36 CNS,53 FIM,53 and mRS;17,19,22,56,57 and one study25 reported CT scan 

results along with coping and comorbidities. For the studies including cardiac patients, only two 

reports60,67 included illness severity scales. Ho et al.60 found a mean thrombolysis in myocardial 

infarction (TIMI) risk score of 2.2 in their study of 4922 cardiac patients, wherein the finding of 

lower mortality was associated with a hospital-initiated support model of transition intervention. 

A smaller study67 of 153 MI patients reported that STEMI versus non-STEMI as a measure of 

severity in a community-based support intervention was associated with improved compliance 

with dietary recommendations and improved rates of physician followup. 

The presence and rating of depression was reported in four stroke studies36,41,47,53 and two MI 

studies.65,66 Six studies reported findings using four different depression rating scales: 

HADS,36,65,66 GDS,47,53 EQ-5D,65 and CES-D.41 Notably, four47,53,65,66 of the six studies that 

reported depression scores as a characteristic also reported that the transition intervention 

improved depression; hence, these studies suggest that while the transition intervention improved 

depression, the effect of the transition was moderated by the presence/absence of baseline 

depression. 
70

Characteristics of studies for which the intervention was associated with a negative 

outcome. Only 2 articles32,34 of the 62 articles reported any form of harm for subjects who 

received a transition intervention. Sulch et al.32 used an integrated-care pathway for 76 patients 

in the intervention group and compared results to 76 patients who received usual care (no 

integrated-care pathway). Groups were similar at baseline, but depression scores at 3 months 

were worse for those who received the intervention compared to those who did not; mRS at 

discharge was independently associated with depression. Hoffman et al.34 provided 69 patients 

with a computer-generated educational intervention that was tailored to their needs. The 

intervention group, when compared to the 69 subjects who received usual education, was 

reported to have higher levels of anxiety. In this study, the intervention group had a significantly 

higher male-to-female ratio than did the control group; there was no report of independent 

association of anxiety scores and sex. 
71

Summary and Discussion

For this report, we conducted a systematic review of the indexed medical literature to 

evaluate the evidence for transition of care services and programs that improve the 

posthospitalization quality of care for patients who have undergone strokes or MIs. A challenge 

in preparing this review was in defining the concept of “transition of care” following 

hospitalization with stroke or MI. We focused on the process that a patient underwent as they left 

the acute-care hospital and reintegrated into society. For some patients, that process involved a 

transient stay in an acute rehabilitation setting followed by discharge to home, while for others 

the transition involved relocation to a skilled nursing home or assisted living environment. We 

found Coleman’s definition of transition of care most appropriate for our purposes: “the set of 

actions designed to ensure the coordination and continuity of health care as patients transfer 

between different locations or different levels of care within the same location.”1

The conceptual model we worked with was one that began with hospital-initiated support for 

discharge to home or to intermediary care units and subsequently involved community-based 

resources such as multidisciplinary care teams, group support services, and patient- and familyfocused educational programs. The process of hospital-initiated discharge preparation often 

included education of the patient and/or their family or health care providers as well as initiating 

followup care with primary and specialty care providers. Community-based support services 

were often initiated at this time as well. Educational programs based in the community were also 

evaluated, as were community-based systems of support. Although the majority of patients with 

stroke or MI also had a number of concurrent chronic medical conditions such as diabetes, 

hypertension, and hyperlipidemia that had contributed to the sentinel presenting event (stroke or 

MI), we did not incorporate chronic disease management models as a component of transition of 

care.

In this review, we found that the process of transitioning the care of a patient from the 

hospital to the community began in the hospital as part of the discharge planning process 

(intervention type 1). This phase included interventions such predetermined integrated-care

pathways, early supported discharge, extended stroke unit services, and rehabilitation 

coordination with community services. Education of the patient and family prior discharge was 

also initiated during the acute hospitalization (intervention type 2). Educational programs varied 

from those that provided information packages to direct teaching by subspecialty trained nurses. 

Following hospital discharge, community-based support of the patient and family

(intervention type 3) could be provided through advanced practice nurse care managers, primary 

care and specialty-based medical practitioners, and multidisciplinary care teams (including 

doctors; nurses; social workers; and physical, occupational, and speech therapists). This support 

could be provided in person at the patient’s home, by telephone, or at a clinical practice setting 

(physician’s office, outpatient rehabilitation setting or common meeting place for support 

groups). Ongoing patient and family education could also be maintained at the community level,

such as the provision of medical-focused manuals, rehabilitation and lifestyle information, 

videotapes, and telephone-based educational programs. 

Chronic disease management (intervention type 4) was reviewed as part of the process of 

transition of care, and a few disease management models were identified that included the 

outcomes of interest in our review: one MI and three stroke intervention programs. 

Despite a conceptual basis to support the transition of care, we found limited evidence in 

favor of some components of hospital-initiated discharge planning (transition of care after stroke 
72

and specialty followup after MI). Transition of care interventions seemed able to reduce the total 

number of hospitalized days without adversely impacting long term functional recovery or death. 

Specialty care followup after MI was associated with reduced mortality. There were no transition 

of care interventions that consistently improved functional recovery after stroke or MI, and none 

seemed to consistently improve quality of life or psychosocial factors such as strain of care, 

anxiety, or depression. 

Limitations of This Review

Across the 62 articles (44 studies) that met the inclusion criteria for this review, the major 

limitations were inadequate sample size, heterogeneity of outcome measures, lack of definition 

for the usual care group, and numerous studies conducted outside of U.S. settings. Few studies 

were designed with a single primary endpoint, but rather simultaneously reported multiple 

outcome measures, frequently with an inadequate sample size to justify multiple statistical 

comparisons. The reported outcome measures included both validated and unvalidated outcome 

scales as well as combinations of the two. The treatment interventions were not always clearly 

described. Some studies included more than one intervention, which made it difficult to 

determine the effect of individual components on clinical outcomes. 

The interventions reported did not include postdischarge medication management. Poor 

medication management is one of the recognized reasons for hospital readmissions in chronic 

care. There were no studies that addressed racial, ethnic, or cultural factors that could influence 

access or response to transitional care.

The most limiting aspect of the studies reviewed was that they did not define what 

constituted the control intervention, which in many cases was simply referred to as “usual care.” 

The latter made cross-study comparisons challenging. This heterogeneity in the intervention and

control treatments precluded conducting a meta-analysis of the cohort of studies. A significant 

number of these studies (some of the better ones) were conducted outside the U.S. in countries 

with significantly different health care systems than ours (frequently in countries with singlepayer systems), thus making translation of their results more challenging. 

Conclusions

This systematic review showed limited evidence for making definitive conclusions about the 

effectiveness of transition of care services following stroke or MI. Although we were able to 

define a conceptual framework and a specific taxonomy for transition of care services that served 

as the foundation for evaluating the published literature, the evidence for efficacy in the setting 

of stroke and MI was insufficient. A number of studies that we reviewed were based on a solid 

conceptual framework with reasonable study designs but had too few patients to be able to reach 

statistically valid conclusions. Other studies did not follow their subjects long enough, and too 

many studies used inconsistent endpoints to be able to make comparisons. Although acute MI 

and stroke share many risk factors, the scope of medical needs for each of these two populations 

is quite different. Even though we attempted to evaluate the individual components of transition
73

of care services for each disease entity, we found that each medical condition presented unique 

care issues that required specific transition of care interventions. This was most true for the 

utilization of rehabilitation services following stroke. 

As the population of the U.S. gets older and the number of patients experiencing MI or stroke 

increases, it will be imperative to have transition of care interventions that have proven to be 

effective in improving functional outcomes, facilitating transfer of care from a hospital-based 

system to a community-based medical system while at the same time effectively utilizing health 

care resources to maintain health. Based on the findings of this review, few studies support the 

adoption of any specific transition of care program as a matter of health care policy. Some 

components, such as early supported discharge following stroke, appear to shorten length of stay 

and improve short-term disease. A similar approach following MI with early return to work also 

seems to be safe and cost-effective. Additional well-structured research performed in the U.S. is 

necessary before concluding that a specific approach is effective and worthy of widespread 

adoption. These studies will need to be disease focused because stroke and MI involve quite 

different populations with unique challenges to overcome. 

Table 19 summarizes the findings for each key question.
74

Table 19. Summary of findings

Key Question Strength of 

Evidence

Summary

Key Question 1: For patients hospitalized with 

first or recurrent stroke or myocardial infarction 

(MI), what are the key components of transition 

of care services? Can these components be 

grouped in a taxonomy, and are they based on a 

particular theory?

Not relevant to 

this key 

question

44 studies (62 articles—10 good quality, 41 fair, 11 poor) described the key 

components of transition of care services.

Conclusion: Transition of care interventions were grouped into 4 intervention types 

that each began in a different phase of an episode of illness:

• Intervention type 1: hospital-initiated support for discharge to home (13 

studies)

• Intervention type 2: patient and family education interventions, both hospitalbased and community-based (7 studies)

• Intervention type 3: community-based models of support (20 studies)

• Intervention type 4: chronic disease management models of care (4 studies)
75

Table 19. Summary of findings (continued)

Key Question Strength of 

Evidence

Summary

Key Question 2: Do transition of care services 

improve functional status and quality of life and 

reduce hospital readmission, morbidity, and 

mortality (up to 1 year postevent)?

Moderate to 

insufficient

40 studies (53 articles—8 good quality, 36 fair, 9 poor) reported functional status, 

quality of life, readmission, morbidity, and mortality outcomes. 8 studies used a 

hospital-initiated support intervention (intervention type 1). Early supported discharge 

was a component of 6 of these studies; improvement was reported in 8 articles 

representing 4 studies. 2 of these showed a reduction in mortality when MI patients 

were cared for using guideline-based practice and specialty followup (intervention type 

1).

Conclusions:

• Early supported discharge as a component of hospital-initiated discharge 

planning (intervention type 1) after stroke was associated with a reduction in 

total hospital length of stay without adverse effects on death or functional 

recovery (moderate strength of evidence).

• Specialty followup, a component of hospital-initiated support (intervention type 

1), after MI and guideline-based practice were associated with a reduction in 

mortality (low strength of evidence).

• There was insufficient evidence to support a beneficial role for intervention 

types 3 or 4 in terms of improvement in functional status; quality of life; and 

reduction in hospital readmission, morbidity, and mortality. 

• There was little consistency in the transition of care interventions from one 

study to another. 

• There was much variability in the selection of outcome measures for 

evaluating the success of transition of care interventions. 

Key Question 3: What are the associated risks, 

adverse events, or potential harms—both system 

based and patient-based—of transition of care 

services?

Insufficient 6 studies (8 articles—2 good quality, 5 fair, 1 poor) reported risks, adverse events, or 

harms. Of the ones that did, all involved patients with stroke and none involved 

patients with MI. 

Conclusion: There was insufficient evidence to determine if there were differential 

rates of adverse events for transition of care interventions or components of transition 

of care services because rates for adverse events were similar for intervention and 

usual-care groups.
76

Table 19. Summary of findings (continued)

Key Question Strength of 

Evidence

Summary

Key Question 4: Do transition of care services 

improve aspects of systems of care for patients 

with stroke or MI? Is there improved 

coordination among multiple subspecialty care 

providers, and are there new providers added to 

the care plan as a result of transition of care 

services?

Moderate to 

Insufficient

16 studies (18 articles—2 good quality, 13 fair, 3 poor) reported system-level 

outcomes. 

Given the available data, we found that:

• The use of emergency department services may be lessened by early 

education regarding stroke or MI symptoms (intervention type 2). 

• Disease management programs may be more effective than remote phone 

calls for patients with MI (intervention type 3). 

• Early return to work after MI may be safe and may be cost-effective from a 

societal perspective (intervention type 1). It did not seem to increase health 

care utilization, and it may save the cost of cardiac rehabilitation in low-risk 

patients. 

• Early supported discharge in low-risk stroke patients reduced hospital days 

and was thus cost-effective (intervention type 1). It did not increase burden 

on family providers (moderate level of evidence). 

• Physician appointments or home visits by physical therapists may reduce 

readmission rates for stroke patients (intervention type 3). Visits by nurses 

did not produce the same effects (intervention type 3). 

• Family support and case management services may reduce visits to physical 

therapists and specialists (intervention type 3).

Conclusion: From a system resource perspective, the evidence for transition of care 

services for patients with stroke or MI was insufficient to provide a full 

recommendation because of study designs, sample sizes, and non-U.S. populations. 
77

Table 19. Summary of findings (continued)

Key Question Strength of 

Evidence

Summary

Key Question 5: Do benefits and harms of 

transition of care services vary by 

characteristics—both patient-based and systembased—such as disease etiology and severity, 

comorbidities, sociodemographic factors, 

training of the health care providers, participants 

(patients, caregivers), geography (rural/urban, 

regional variations), and insurance status?

Insufficient 13 studies (14 articles—2 good quality, 10 fair, 2 poor) described benefits and harms 

of transition of care services as they vary by patient- or system-based characteristics. 

The most commonly reported characteristics in transition of care studies were 

disease severity, age, sex, and presence or absence of depressive symptoms.

Conclusions:

• There was a lack of consistency by which characteristics were measured or 

reported.

• There was insufficient evidence to be able make conclusions regarding the 

impact of transition of care services on the basis of the patient’s insurance 

status. 

• There was no consistent evidence that demographic groups benefited or 

were harmed by transition of care services. 

• There was a trend suggesting that patients with less severe strokes (lower 

NIH Stroke Scale) demonstrated a benefit from transition of care 

interventions compared to those with more severe deficits.

Abbreviations: MI = myocardial infarction; NIH = National Institutes of Health
78

Future Research

In this section, we propose activities through which identified gaps could be filled by future 

research studies that investigate issues related to transition of care for patients following stroke 

and MI. We began our review process by creating a model that described the transition of care as 

a process that starts during hospitalization at the stage of planning for discharge (intervention 

type 1); includes education of the patient and caregivers during hospitalization (intervention type 

2a) as well as in the community (intervention type 2b); and is followed up by community support 

services (intervention type 3) and transitioning to long-term, chronic models of care (intervention 

type 4). 

Although we defined a taxonomy for the purposes of our review, we believe that a consensus 

needs to be reached among investigators on a unified taxonomy and conceptual framework that 

defines the constituent components in the transition of care process. A clearer set of guidelines 

and terms that would be used to define interventions to be studied is needed for each component 

of the transition of care process (intervention types 1–4). We found significant heterogeneity in 

the definition of discharge planning among studies. Even the term “early supported discharge” 

was used to define a process that varied from center to center in terms of its constituent parts. 

This form of heterogeneity makes cross-study comparisons difficult and multicenter studies 

challenging. 

We found that transition of care following stroke and MI could be evaluated in the context of 

four different types of interventions, each with a multitude of components. These components 

could be evaluated individually for clinical and statistical effectiveness (i.e., the effects of an 

education program on medication compliance) or together as components of an integrated system 

(the effectiveness of “early supported discharge” on functional recovery after stroke when 

compared to “standard rehabilitation”). Regardless of the method chosen, the intervention being 

tested needs to be clearly defined at the outset of the study as well as the expected outcome 

measures that will be used to evaluate the effectiveness of the intervention. 

The control treatment used for comparison against the intervention also needs to be clearly 

defined in terms of the standard prehospitalization and posthospitalization care offered because

the standard of care in one health care system may be quite different in another. This is most 

relevant in the setting of multicenter trials. Having a manual of operations with clear definitions 

of interventions and control therapies would allow for standardization of treatments across 

centers. Given the heterogeneity of the interventions as well as the systems under which these 

studies are carried out, measures of intervention fidelity (adherence to the protocol) need to be 

built into each study in order to evaluate whether the interventions were feasible and effective.

In addition to consistency in the terms used to describe the components of transition, there 

also needs to be a set of validated and clinically relevant outcomes. The outcomes chosen for a 

study should, by definition, be ones that are responsive to the intervention being tested. For 

example, using an outcome such as the severity of neurological deficit as measured by the NIH 

Stroke Scale at 6 months after an acute stroke cannot be considered an appropriate measure of 

the effectiveness of an educational program focusing on medication compliance. After an 

appropriate primary outcome is selected for study, the expected treatment effect needs to be 

presented along with statistical justification for the sample size chosen for the study—thus 

reducing the likelihood of having an underpowered trial. Secondary outcomes could serve as the 

basis for hypothesis testing in future trials. A number of the studies we reviewed showed a 
79

promising trend toward benefit; however, they were underpowered, and outcomes were diluted 

by incorporating too many variables. There are interventions that would allow an investigator to 

focus on one component of the system at a time and potentially create, in a stepwise fashion, a 

set of clinically proven interventions in a transition of care pathway. Furthermore, many of the 

stroke articles enrolled and reported outcomes in a mixed stroke population. Stratifying 

randomization and/or separating out the outcomes of ischemic and hemorrhagic stroke in future 

publications would be helpful to differentiating the effects on these stroke subpopulations.

We found that despite multiple different strategies aimed at educating the patient and family

about the patient’s medical condition (intervention type 2), the long-term benefit of this effort 

seemed less clear. How to optimize health care education in order to modify behavior needs 

further study if it is going to be incorporated as a significant component of the transition process. 

It is already a cornerstone for the Joint Commission Primary Stroke Center designation for a 

hospital, yet there are few data on the optimal method for stroke education or whether it is 

associated with any benefit to the patient or family. 

We found little evidence regarding the optimal method of maintaining continuity of care 

following hospital discharge (intervention types 3 and 4). Despite the rapid development of 

electronic medical records, there was limited evidence about the effectiveness of this tool as a 

component of transition of care. The costs associated with widespread implementation are not 

insignificant, and yet an optimal method for implementation in a system of health care such as 

that in the U.S. has not been evaluated. 

Two examples of components that are suited for focused study are the role of health-related 

educational efforts in evaluating medication compliance (intervention type 2) and the optimal 

implementation of an electronic medical record to facilitate communication among multiple 

providers (primary care, specialty care, care coordinators, rehabilitation specialists) after an acute 

hospitalization (intervention type 4). Potential study designs could include patient-level 

randomized trials, cluster randomized trials, quasi-experimental methods, interrupted time series, 

or best practices research depending on whether the aim of the project is an evaluation of 

efficacy in controlled settings or effectiveness in real-world settings.

In other circumstances, it may not be possible to study subcomponents of an intervention; 

instead, a systems approach to care would need to be evaluated. Multidisciplinary dischargeplanning teams (composed of doctors; nurses; social workers; and physical, occupational, and 

speech therapists) are an example of the latter. In that case, the entire team program could be 

tested against “standard” single-provider discharge planning. 

For the results of an intervention to be generalizable to health care systems across the U.S., 

the study should involve multiple centers across states as well as across health care systems 

(private practice groups, academic medical centers, health maintenance organizations, etc.). 

Many of the studies we reviewed were conducted in Europe, Australia, and Canada with singlepayer systems that could affect the ability to extrapolate their study conclusions to the U.S. More 

studies should be conducted under the health care system for which the intervention is intended 

to benefit. 

Finally, future studies on transition of care could assess whether there should be separate care 

coordination trajectories for stroke and MI, or whether there is sufficient overlap in these 

interventions such that these care paradigms can translate to the general hospitalized population 

as a whole. For example, the disease state most studied in transition of care research (and 

demonstration projects) is congestive heart failure.8 Programs developed for congestive heart 

failure in the future could be applied to acute MI or stroke and systematically evaluated. Future 
80

research that addresses whether transition of care interventions should be disease-specific or be 

recommended for a general high-risk population would answer this important question. The 

challenges around transition of care are being recognized in all health care reform initiatives, and 

the Affordable Care Act of 2010, Section 3026, provides funding to test transition of care models 

for high-risk Medicare beneficiaries.
81

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Abbreviations

AAP Adelaide Activities Profile

ACS acute coronary syndrome

ADL activities of daily living

AE adverse event

AHRQ Agency for Healthcare Research and Quality

AIS acute ischemic stroke

AshSS Ashworth Spastic Scale

BBS Berg Balance Scale

BSFC Burden Scale for Family Caregivers

CABG coronary artery bypass grafting

CDC Centers for Disease Control and Prevention

CES-D Center for Epidemiological Studies-Depression

CGI-I Clinical Global Impressions-Improvement

CI confidence interval

CII clinical improvement index

COOP Dartmouth-Northern New England Primary Care Cooperative Information 

Project (COOP)

CNS Canadian Neurological Scale

CSS cognitive summary score

DHDSP Division for Heart Disease and Stroke Prevention

EADL Nottingham Extended Activities of Daily Living

ED emergency department

EPC Evidence-based Practice Center

EQ-5D EuroQOL 5 Dimensions (descriptive system)

ESD early supported discharge

ESUS extended stroke unit services

FAD McMaster Family Assessment Device

FAI Frenchay Activities Index

FIM functional impairment measure

FQM functional quality of movement measure

GAP guidelines applied in practice

GDS Geriatric Depression Scale

GHQ General Health Questionnaire

GP general practitioner

IADL Index of Activities of Daily Living

ICH intracerebral hemorrhage

IPQ Illness Perception Questionnaire

IRF inpatient rehabilitation facility

LHS London Handicap Scale

LMC Lindmark Motor Capacity

MADRS Montgomery-Asberg Depression Rating Scale

MeSH medical subject headings

MI myocardial infarction
92

MIDAS Myocardial Infarction Dimensional Assessment Scale

MMSE Mini-Mental State Examination

mo month or months

mRS modified Rankin Scale

N or n number (subjects/population)

NA not applicable

NHP Nottingham Health Profile

NIH National Institutes of Health

NIHSS NIH Stroke Scale

NPT Nine-Hole Peg Test

NR not reported

ns or NS not significant

NSTEMI non–ST elevation myocardial infarction

OAD observer-assessed disability

p probability

PA psychosocial assessment

PBSI Preference-Based Stroke Index

PCP primary care physician

PHQ-9 Patient Health Questionnaire (depression model)

PICOTS population, intervention, comparator, outcome, timing, setting

RAT Reinvang aphasia test

RCT randomized controlled trial

RMI Rivermead Mobility Index

RNLI Reintegration to Normal Living Index

RR risk ratio

SAH subarachnoid hemorrhage

SASC Satisfaction With Stroke Care questionnaire

SF-36 Short Form health scale (36 questions)

SF-36 MCS SF-36 mental component summary scale

SF-36 PCS SF-36 physical component summary scale

SIP Sickness Impact Profile

SNA service needs assessment

SNF skilled nursing facility

SRH self-rated health

STEMI ST elevation myocardial infarction

TEP Technical Expert Panel

TIA transient ischemic attack

TUG Timed Up-and-Go test

ZDS Zerssen Depression Scale
A-1

Appendix A: Exact Search Strings

PubMed® search strategy (last search run April 21, 2011): ---------------------------------------------------------------------------------------------------------------------

(((myocardial infarction[mesh] OR stroke[mesh] AND ("last 10 years"[PDat]))) AND ((("critical 

pathways"[mesh] AND ("last 10 years"[PDat]))) OR ("physical therapy modalities"[mesh] OR 

"case management"[mesh] OR "rehabilitation"[mesh] OR "continuity of patient care"[mesh] OR 

"patient discharge"[mesh] OR "patient transfer"[mesh] OR "skilled nursing facilities"[mesh] OR 

"assisted living facilities"[mesh] OR transition* OR postdischarge OR post-discharge OR 

coordination OR coordinate OR transfer OR post-acute care OR postacute care OR skilled 

nursing OR post-hospital* OR posthospital* OR subacute care OR sub-acute care OR discharge 

OR referral OR continuity AND ("last 10 years"[PDat])) AND ("last 10 years"[PDat]))) AND 

("case-control studies"[mesh] OR "clinical trial"[publication type] OR "clinical trials as 

topic"[mesh] OR "meta-analysis as topic"[mesh] OR "comparative study"[publication type] OR 

"multicenter study"[publication type] OR "cohort studies"[mesh] OR "cross-over studies"[mesh] 

OR "follow-up studies"[mesh] OR "cross-sectional studies"[mesh] OR "evaluation 

studies"[publication type] OR "consensus development conference"[publication type] OR metaanalysis[ptyp] OR systematic[sb] OR (randomized[title/abstract] AND controlled[title/abstract] 

AND trial[title/abstract]) OR cohort[title/abstract] AND ("last 10 years"[PDat])) 

Limits: published in the last 10 years

Critical path search:

((((((myocardial infarction[mesh] OR stroke[mesh])) AND ("physical therapy modalities"[mesh] 

OR "case management"[mesh] OR "rehabilitation"[mesh] OR "continuity of patient care"[mesh] 

OR "patient discharge"[mesh] OR "patient transfer"[mesh] OR "skilled nursing facilities"[mesh] 

OR "assisted living facilities"[mesh] OR transition* OR postdischarge OR post-discharge OR 

coordination OR coordinate OR transfer OR post-acute care OR postacute care OR skilled 

nursing OR post-hospital* OR posthospital* OR subacute care OR sub-acute care OR discharge 

OR referral OR continuity))) AND ("case-control studies"[mesh] OR "clinical trial"[publication 

type] OR "clinical trials as topic"[mesh] OR "meta-analysis as topic"[mesh] OR "comparative 

study"[publication type] OR "multicenter study"[publication type] OR "cohort studies"[mesh] 

OR "cross-over studies"[mesh] OR "follow-up studies"[mesh] OR "cross-sectional 

studies"[mesh] OR "evaluation studies"[publication type] OR "consensus development 

conference"[publication type] OR meta-analysis[ptyp] OR systematic[sb] OR 

(randomized[title/abstract] AND controlled[title/abstract] AND trial[title/abstract]) OR 

cohort[title/abstract]))) AND ("last 10 years"[PDat]) 

Limits: published in the last 10 years
A-2

CINAHL® search strategy (last search run April 21, 2011): ---------------------------------------------------------------------------------------------------------------------

((Myocardial infarction OR (MH “Myocardial Infarction”)) OR heart attack) OR (stroke OR 

(MH “Stroke”)) AND ((Physical therapy modalities OR (MH “Physical Therapy+”)) OR (Case 

management OR (MH “Case Management”)) OR (Rehabilitation OR (MH “Rehabilitation”)) OR 

(Continuity of patient care OR (MH “Continuity of Patient Care+”)) OR ((Patient discharge OR 

(MH “Patient Discharge+”)) OR patient transfer) OR (Skilled nursing facilities OR (MH “Skilled 

Nursing Facilities”)) OR (Assisted Living Facilities OR (MH “Assisted Living”)) OR 

(Transition* OR (MH “Health Transition”)) OR ((Postdischarge OR post-discharge) OR (MH 

“After Care”)) OR (Coordination OR Coordinate OR transfer OR post-acute care OR postacute 

care OR skilled nursing OR post-hospital* OR posthospital* OR subacute care OR sub-acute 

care OR discharge OR referral OR continuity)) OR (Readmission OR (MH “Readmission”)) OR 

(Recurrence OR (MH “Recurrence”)) OR (Patient readmission)

AND

Limiters – Human; Publication Type: Clinical Trial, Systematic Review; Language: English

Embase® search strategy (last search run April 21, 2011): ---------------------------------------------------------------------------------------------------------------------

'heart infarction'/exp OR 'myocardial infarction'/exp OR 'stroke'/exp OR 'heart attack'/exp AND 

('controlled study'/exp OR 'comparative study'/exp OR 'observational study'/exp OR 'randomized 

controlled trial'/exp OR 'clinical study'/exp OR 'cohort analysis'/exp OR 'cross-sectional 

study'/exp OR 'practice guideline'/exp OR 'multicenter study'/exp OR 'systematic review'/exp OR 

'meta analysis'/exp OR (randomized AND controlled AND trial) OR cohort) AND 

('readmission'/exp OR 'rehospitalization'/exp OR 'recurrence'/exp OR 'quality of care' OR 

'secondary prevention'/exp) AND ('physiotherapy'/exp OR 'case management'/exp OR 

'rehabilitation'/exp OR 'rehabilitation care'/exp OR 'hospital discharge'/exp OR 'patient 

transport'/exp OR 'residential home'/exp OR 'assisted living facility'/exp OR 'nursing home'/exp 

OR 'rehabilitation center'/exp OR transition OR transitional OR postdischarge OR 'post 

discharge' OR 'coordination'/exp OR coordinate OR transfer OR 'post-acute care' OR 'postacute 

care' OR 'skilled nursing' OR 'post-hospital' OR 'posthospital' OR 'subacute care'/exp OR 

discharge OR 'referral'/exp OR continuity) AND [humans]/lim AND [english]/lim NOT 

[medline]/lim NOT ('case report'/exp OR 'editorial'/exp OR 'letter'/exp OR 'note'/exp) AND 

[embase]/lim AND [2000-2011]/py
A-3

Critical path search:

'myocardial infarction'/exp OR 'myocardial infarction' OR 'stroke'/exp OR stroke OR 'heart 

attack'/exp OR 'heart attack' OR 'cerebrovascular accident'/exp OR 'cerebrovascular accident'

AND ('controlled study'/exp OR 'comparative study'/exp OR 'observational study'/exp OR 

'randomized controlled trial'/exp OR 'clinical study'/exp OR 'cohort analysis'/exp OR 'crosssectional study'/exp OR 'practice guideline'/exp OR 'multicenter study'/exp OR 'systematic 

review'/exp OR 'meta analysis'/exp OR (randomized AND controlled AND trial) OR cohort) 

AND ('readmission'/exp OR readmission OR 'rehospitalization'/exp OR rehospitalization OR 

'recurrence'/exp OR recurrence) AND ('physiotherapy'/exp OR 'case management'/exp OR 

'rehabilitation'/exp OR 'rehabilitation care'/exp OR 'hospital discharge'/exp OR 'patient 

transport'/exp OR 'residential home'/exp OR 'assisted living facility'/exp OR 'nursing home'/exp 

OR 'rehabilitation center'/exp OR transition OR transitional OR postdischarge OR 'post 

discharge' OR 'coordination'/exp OR coordination OR coordinate OR transfer OR 'post-acute 

care' OR 'postacute care' OR 'skilled nursing' OR 'post-hospital' OR 'posthospital' OR 'subacute 

care'/exp OR 'subacute care' OR discharge OR 'referral'/exp OR referral OR continuity)
B-1

Appendix B: Data Abstraction Elements

I. Citation identifiers

• Total number of subjects across all arms

• Study design

• Funding source

II. Study sites

• Geographical location

• Number of sites

• General setting

III. Study population characteristics

• Stroke

• Myocardial infarction

• Both stroke and MI

• Other mix (specify)

• Severity description provided? (Y/N/NR)

o If Y, admission, discharge, NR

o How measured?

• Age (mean, median, range)

• Sex (%)

• Ethnicity

• Race

• Living arrangement (alone, with someone)

• Has support system?

• Work status

o Home by choice

o Home not by choice

o Working

o NR

o Other (specify)

IV. Insurance status

• Medicare

• Medicaid

• Private insurance

• VA

• National healthcare system

• None

• NR

• Other (specify)
B-2

V. Followup assessments

• 3 months

• 6 months

• 1 year

• NR

• Other (specify)

VI. Intervention characteristics

• FROM specific setting—Defined as the specific setting or environment FROM which the 

patient or population is transitioning:

o Hospital (includes stroke unit and CCU)

o Inpatient rehabilitation

o Outpatient rehabilitation

o Skilled nursing facility

o ED

o Other setting (specify)

• TO specific setting—Defined as the specific setting or environment TO which the patient 

or population is transitioning:

o Inpatient rehabilitation

o Outpatient rehabilitation

o Skilled nursing facility

o Home

o Home care

o Long-term care

o Other setting (specify)

VII. Components of transitional services

• Education and training of provider

• Education and training of caregiver

• Discharge planning (including procurement of equipment and services, referrals for 

followup care, and education about community resources)

• Self-management tools (alleviate patient and caregiver burden managing transitions 

between care environments)

• Care pathways (to organize treatment and rehabilitation across care settings)

• Systems for shared access to patient information to allow multiple health care providers 

across settings to access patient information and to coordinate care

• Referrals to specialty care providers based on patient needs

• Referral back to primary care providers

• Home caregiver support

• Post discharge followup (phone, mail, etc.)

• Other service (specify)
B-3

VIII. Intervention provider

• Generalist (MD/DO)

• Specialist (MD/DO) (specify specialty)

• Advance practice nurse (APN)

• Nurse

• Nurse practitioner/physician assistant

• Pharmacist

• Physical therapist

• Occupational therapist

• Case manager

• Lay practitioner

• Other provider (specify)

IX. Comparator

• Has comparator of usual care (care that does not include transitional services that 

coordinate care among multiple providers; for example, a simple recommendation for 

followup with primary care and other HCPs, or direct discharge to home or other health 

care facility)

• Other comparator (specify)

X. Study arm characteristics

• # of arms

• N per arm

• Mean age per arm

• Median age per arm

• Age range per arm

• Sex distribution per arm

• Ethnicity per arm

• Race per arm

• Other (specify)

XI. Intervention impact

• Intervention improved outcome

• Intervention worsened outcome

• Intervention had no impact

• Not reported

XII. KQ applicability

• KQ 1 (Y/N)

• KQ 2 (Y/N)

• KQ 3 (Y/N)

• KQ 4 (Y/N)

• KQ 5 (Y/N)
B-4

XIII. KQ outcomes and results

• KQ 1: Theoretical framework? If Y, specify

• KQs 2–5 (primary outcomes):

o Death at 3 months, 6 months, or 1 year following the event

o Hospital readmission at 3 months, 6 months, or 1 year following the event

o Continuity of health care with specialist

o Continuity of health care with general HCPs

• KQs 2–5 (secondary outcomes):

o Hospital-free days

o Increase total # of services for a patient

o Return to premorbid status

o Return to premorbid functional ability

o Return to premorbid quality of life (if Y, how measured?)

 Barthel index

 SF-36, SF-12, etc.

 Modified Rankin score

 PHQ depression scale

 FIM

 NR

 Other (specify)

XIV. Adverse events/harms/risks

• Hospital readmission

• Delayed discharge

• Failure to improve from baseline

• Increased utilization with failure to improve

• Increased patient/caregiver burden

• Lost to followup

• Overreferred

• Dropped from insurance

• Other harm [specify]

XV. Improvements (specify results for all that apply)

• Efficiency of referrals for followup care

• Timely appointments

• Communication among HCPs

• Coordination of patient care across HCPs

• Care pathways

• Shared access to patient information

• Other (specify)

XVI. Reductions (specify results for all that apply)

• ER visits

• Hospital readmissions

• Morbidity

• Mortality

• Delayed discharge

• Caregiver burden
B-5

• Insurance issues

• Other (specify)

XVII. Quality and applicability assessments

A. Study-level quality assessment: Please assign each study an overall quality rating of 

“Good,” “Fair,” or “Poor” based on the following definitions: 

• A Good study has the least bias and results are considered valid. A good study has a 

clear description of the population, setting, interventions, and comparison groups; 

uses a valid approach to allocate patients to alternative treatments; has a low 

dropout rate; and uses appropriate means to prevent bias; measure outcomes; 

analyze and report results. 

• A Fair study is susceptible to some bias, but probably not sufficient to invalidate the 

results. The study may be missing information, making it difficult to assess limitations 

and potential problems. As the fair-quality category is broad, studies with this rating 

vary in their strengths and weaknesses. The results of some fair-quality studies are 

possibly valid, while others are probably valid. 

• A Poor rating indicates significant bias that may invalidate the results. These studies 

have serious errors in design, analysis, or reporting; have large amounts of missing 

information; or have discrepancies in reporting. The results of a poor-quality study 

are at least as likely to reflect flaws in the study design as to indicate true differences 

between the compared interventions.

If a study is rated as “Fair” or “Poor,” please note any important limitations on internal 

validity based on the USPSTF criteria, as adapted here: 

• Initial assembly of comparable groups: 

o For RCTs: adequate randomization, including concealment and whether 

potential confounders were distributed equally among groups.

o For cohort studies: consideration of potential confounders with either 

restriction or measurement for adjustment in the analysis; consideration 

of inception cohorts. 

• Maintenance of comparable groups (includes attrition, crossovers, adherence, 

contamination)

• Important differential loss to followup or overall high loss to followup.

• Measurements: equal, reliable, and valid (includes masking of outcome 

assessment).

• Clear definition of interventions.

• All important outcomes considered.

• Analysis: adjustment for potential confounders for cohort studies, or intention-totreat analysis for RCTs.

B. Applicability assessment: Do not assign an overall applicability score. Instead, list the 

most important (up to 3) limitations affecting applicability, if any, based on the following list. 

(Bolded criteria are prioritized for this project.) 

1) Setting of the study

• In which country (or countries) was the study conducted?

• In what health care system (or systems) was the study conducted?

• Were patients recruited from the primary, secondary, or tertiary care settings?
B-6

• How were study centers selected for participation?

• How were study clinicians selected for participation?

2) Selection of participants

• How were participants diagnosed and identified for eligibility screening before 

random allocation?

• What were the study eligibility criteria?

• What were the study exclusion criteria?

• Did the study require a run-in period with the control or placebo intervention?

• Did the study require a run-in period with the active intervention?

• Did the study selectively recruit participants who demonstrated a history of 

favorable or unfavorable response to drug or other interventions for the 

condition? 

• Did the study report the ratio of randomly allocated participants to nonallocated 

participants (who were eligible)?

• Did the study report the proportion of eligible participants who declined random 

allocation?

3) Characteristics of study participants

• Did the study report participants’ baseline characteristics?

• Did the study report participants’ race?

• Did the study report participants’ underlying pathology?

• Did the study report participants’ stage in the natural history of the disease?

• Did the study report participants’ severity of disease? 

• Did the study report participants’ comorbid conditions?

• Did the study report participants’ absolute risk of a poor outcome in the control 

arm?

4) Differences between the study protocol and routine clinical practice

• Were the study interventions (active arm) similar to interventions used in 

routine clinical practice?

• Was the timing of the intervention similar to the timing in routine clinical 

practice?

• Was the study’s control arm appropriate and relevant in relation to routine 

clinical practice?

• Were the study’s cointerventions—which were not randomly allocated—

adequate to reflect routine clinical practice?

• Were any interventions prohibited by the study routinely used in clinical 

practice?

• Have there been diagnostic or therapeutic advances used in routine 

practice since the study was conducted?

5) Outcome measures and followup

• If applicable, did the study use a clinically relevant surrogate outcome?

• If applicable, did the study use a scale that is clinically relevant, valid, and 

reproducible?

• If applicable, was the intervention beneficial on the most relevant 

components of the composite outcome?

• Which clinician measured the outcome (e.g., treating physician or surgeon)?
B-7

• Did the study use patient-centered outcomes?

• How frequently were participants followed in the study?

• Was the duration of participant followup adequate?

6) Adverse effects of treatment

• How completely did the study report the occurrence of relevant adverse effects? 

• Did the study report the rates of treatment discontinuations?

• Were the study centers and/or clinicians selected on the basis of their skill or 

experience?

• Did the study exclude participants at elevated risk of intervention complications?

• Did the study exclude participants who suffered adverse effects during the run-in 

period? 

• Did the study monitor participants intensively for early signs of adverse effects?
C-1

Appendix C: List of Included Studies

Allen K, Hazelett S, Jarjoura D, et al. A randomized trial testing the superiority of a 

postdischarge care management model for stroke survivors. J Stroke Cerebrovasc Dis 

2009;18(6):443-52.

Allen KR, Hazelett S, Jarjoura D, et al. Effectiveness of a postdischarge care management model 

for stroke and transient ischemic attack: a randomized trial. J Stroke Cerebrovasc Dis 

2002;11(2):88-98.

Andersen HE, Eriksen K, Brown A, et al. Follow-up services for stroke survivors after hospital 

discharge--a randomized control study. Clin Rehabil 2002;16(6):593-603.

Andersen HE, Schultz-Larsen K, Kreiner S, et al. Can readmission after stroke be prevented? 

Results of a randomized clinical study: a postdischarge follow-up service for stroke survivors. 

Stroke 2000;31(5):1038-45.

Askim T, Morkved S, Indredavik B. Does an extended stroke unit service with early supported 

discharge have any effect on balance or walking speed? J Rehabil Med 2006;38(6):368-74.

Askim T, Rohweder G, Lydersen S, et al. Evaluation of an extended stroke unit service with 

early supported discharge for patients living in a rural community. A randomized controlled trial. 

Clin Rehabil 2004;18(3):238-48.

Ayana M, Pound P, Lampe F, et al. Improving stroke patients' care: a patient held record is not 

enough. BMC Health Serv Res 2001;1(1):1.

Bambauer KZ, Aupont O, Stone PH, et al. The effect of a telephone counseling intervention on 

self-rated health of cardiac patients. Psychosom Med 2005;67(4):539-45.

Barlow JH, Turner AP, Gilchrist M. A randomised controlled trial of lay-led self-management 

for myocardial infarction patients who have completed cardiac rehabilitation. Eur J Cardiovasc 

Nurs 2009;8(4):293-301.

Bautz-Holtert E, Sveen U, Rygh J, et al. Early supported discharge of patients with acute stroke: 

a randomized controlled trial. Disabil Rehabil 2002;24(7):348-55.

Boter H. Multicenter randomized controlled trial of an outreach nursing support program for 

recently discharged stroke patients. Stroke 2004;35(12):2867-72.

Claiborne N. Effectiveness of a care coordination model for stroke survivors: a randomized 

study. Health Soc Work 2006;31(2):87-96.

Clark MS, Rubenach S, Winsor A. A randomized controlled trial of an education and counselling 

intervention for families after stroke. Clin Rehabil 2003;17(7):703-12.

Costa e Silva R, Pellanda L, Portal V, et al. Transdisciplinary approach to the follow-up of 

patients after myocardial infarction. Clinics (Sao Paulo) 2008;63(4):489-96.

Donnelly M, Power M, Russell M, et al. Randomized controlled trial of an early discharge 

rehabilitation service: the Belfast Community Stroke Trial. Stroke 2004;35(1):127-33.
C-2

Eagle KA, Montoye CK, Riba AL, et al. Guideline-based standardized care is associated with 

substantially lower mortality in medicare patients with acute myocardial infarction: the 

American College of Cardiology's Guidelines Applied in Practice (GAP) Projects in Michigan. J 

Am Coll Cardiol 2005;46(7):1242-8.

Ertel KA, Glymour MM, Glass TA, et al. Frailty modifies effectiveness of psychosocial 

intervention in recovery from stroke. Clin Rehabil 2007;21(6):511-22.

Fjaertoft H, Indredavik B, Johnsen R, et al. Acute stroke unit care combined with early supported 

discharge. Long-term effects on quality of life. A randomized controlled trial. Clin Rehabil 

2004;18(5):580-6.

Fjaertoft H, Indredavik B, Lydersen S. Stroke unit care combined with early supported 

discharge: long-term follow-up of a randomized controlled trial. Stroke 2003;34(11):2687-91.

Fjaertoft H, Indredavik B, Magnussen J, et al. Early supported discharge for stroke patients 

improves clinical outcome. Does it also reduce use of health services and costs? One-year 

follow-up of a randomized controlled trial. Cerebrovasc Dis 2005;19(6):376-83.

Gallagher R, McKinley S, Dracup K. Effects of a telephone counseling intervention on 

psychosocial adjustment in women following a cardiac event. Heart Lung 2003;32(2):79-87.

Geddes JM, Chamberlain MA. Home-based rehabilitation for people with stroke: a comparative 

study of six community services providing co-ordinated, multidisciplinary treatment. Clin 

Rehabil 2001;15(6):589-99.

Glass TA, Berkman LF, Hiltunen EF, et al. The Families In Recovery From Stroke Trial 

(FIRST): primary study results. Psychosom Med 2004;66(6):889-97.

Grasel E, Biehler J, Schmidt R, et al. Intensification of the transition between inpatient 

neurological rehabilitation and home care of stroke patients. Controlled clinical trial with followup assessment six months after discharge. Clin Rehabil 2005;19(7):725-36.

Grasel E, Schmidt R, Biehler J, et al. Long-term effects of the intensification of the transition 

between inpatient neurological rehabilitation and home care of stroke patients. Clin Rehabil 

2006;20(7):577-83.

Hall JP, Wiseman VL, King MT, et al. Economic evaluation of a randomised trial of early return 

to normal activities versus cardiac rehabilitation after acute myocardial infarction. Heart Lung 

Circ 2002;11(1):10-8.

Hanssen TA, Nordrehaug JE, Eide GE, et al. Improving outcomes after myocardial infarction: a 

randomized controlled trial evaluating effects of a telephone follow-up intervention. Eur J 

Cardiovasc Prev Rehabil 2007;14(3):429-37.

Hanssen TA, Nordrehaug JE, Eide GE, et al. Does a telephone follow-up intervention for 

patients discharged with acute myocardial infarction have long-term effects on health-related 

quality of life? A randomised controlled trial. J Clin Nurs 2009;18(9):1334-45.

Ho PM, Luther SA, Masoudi FA, et al. Inpatient and follow-up cardiology care and mortality for 

acute coronary syndrome patients in the Veterans Health Administration. Am Heart J 

2007;154(3):489-94.
C-3

Hoffmann T, McKenna K, Worrall L, et al. Randomised trial of a computer-generated tailored 

written education package for patients following stroke. Age Ageing 2007;36(3):280-6.

Holmqvist LW, von Koch L, de Pedro-Cuesta J. Use of healthcare, impact on family caregivers 

and patient satisfaction of rehabilitation at home after stroke in southwest Stockholm. Scand J 

Rehabil Med 2000;32(4):173-9.

Indredavik B, Fjaertoft H, Ekeberg G, et al. Benefit of an extended stroke unit service with early 

supported discharge: A randomized, controlled trial. Stroke 2000;31(12):2989-94.

Johnston M, Bonetti D, Joice S, et al. Recovery from disability after stroke as a target for a 

behavioural intervention: results of a randomized controlled trial. Disabil Rehabil 

2007;29(14):1117-27.

Joubert J, Joubert L, Reid C, et al. The positive effect of integrated care on depressive symptoms 

in stroke survivors. Cerebrovasc Dis 2008;26(2):199-205.

Joubert J, Reid C, Barton D, et al. Integrated care improves risk-factor modification after stroke: 

initial results of the Integrated Care for the Reduction of Secondary Stroke model. J Neurol 

Neurosurg Psychiatry 2009;80(3):279-84.

Joubert J, Reid C, Joubert L, et al. Risk factor management and depression post-stroke: the value 

of an integrated model of care. J Clin Neurosci 2006;13(1):84-90.

Kotowycz MA, Cosman TL, Tartaglia C, et al. Safety and feasibility of early hospital discharge 

in ST-segment elevation myocardial infarction--a prospective and randomized trial in low-risk 

primary percutaneous coronary intervention patients (the Safe-Depart Trial). Am Heart J 

2010;159(1):117 e1-6.

Kovoor P, Lee AK, Carrozzi F, et al. Return to full normal activities including work at two 

weeks after acute myocardial infarction. Am J Cardiol 2006;97(7):952-8.

Lacey EA, Musgrave RJ, Freeman JV, et al. Psychological morbidity after myocardial infarction 

in an area of deprivation in the UK: evaluation of a self-help package. Eur J Cardiovasc Nurs 

2004;3(3):219-24.

Luszczynska A. An implementation intentions intervention, the use of a planning strategy, and 

physical activity after myocardial infarction. Soc Sci Med 2006;62(4):900-8.

Mant J, Carter J, Wade DT, et al. Family support for stroke: a randomised controlled trial. Lancet 

2000;356(9232):808-13.

Mant J, Winner S, Roche J, et al. Family support for stroke: one year follow up of a randomised 

controlled trial. J Neurol Neurosurg Psychiatry 2005;76(7):1006-8.

Mayo NE, Nadeau L, Ahmed S, et al. Bridging the gap: the effectiveness of teaming a stroke 

coordinator with patient's personal physician on the outcome of stroke. Age Ageing 

2008;37(1):32-8.

Mayo NE, Wood-Dauphinee S, Cote R, et al. There's no place like home : an evaluation of early 

supported discharge for stroke. Stroke 2000;31(5):1016-23.
C-4

Mayou RA, Thompson DR, Clements A, et al. Guideline-based early rehabilitation after 

myocardial infarction. A pragmatic randomised controlled trial. J Psychosom Res 2002;52(2):89-

95.

Oranta O, Luutonen S, Salokangas RK, et al. The outcomes of interpersonal counselling on 

depressive symptoms and distress after myocardial infarction. Nord J Psychiatry 2010;64(2):78-

86.

Petrie KJ, Cameron LD, Ellis CJ, et al. Changing illness perceptions after myocardial infarction: 

an early intervention randomized controlled trial. Psychosom Med 2002;64(4):580-6.

Ricauda NA, Bo M, Molaschi M, et al. Home hospitalization service for acute uncomplicated 

first ischemic stroke in elderly patients: a randomized trial. J Am Geriatr Soc 2004;52(2):278-83.

Robertson K, Kayhko K, Kekki P. A supportive-education home follow-up programme for post 

MI patients. J Community Nurs 2003;17(6):4.

Robertson KA, Kayhko K. Cost analysis of an intensive home follow-up program for first-time 

post-myocardial infarction patients and their families. Dynamics 2001;12(4):25-31.

Rogers AM, Ramanath VS, Grzybowski M, et al. The association between guideline-based 

treatment instructions at the point of discharge and lower 1-year mortality in Medicare patients 

after acute myocardial infarction: the American College of Cardiology's Guidelines Applied in 

Practice (GAP) initiative in Michigan. Am Heart J 2007;154(3):461-9.

Sahebalzamani M, Aliloo L, Shakibi A. The efficacy of self-care education on rehabilitation of 

stroke patients. Saudi Med J 2009;30(4):550-4.

Sinclair AJ, Conroy SP, Davies M, et al. Post-discharge home-based support for older cardiac 

patients: a randomised controlled trial. Age Ageing 2005;34(4):338-43.

Sulch D, Evans A, Melbourn A, et al. Does an integrated care pathway improve processes of care 

in stroke rehabilitation? A randomized controlled trial. Age Ageing 2002;31(3):175-9.

Sulch D, Melbourn A, Perez I, et al. Integrated care pathways and quality of life on a stroke 

rehabilitation unit. Stroke 2002;33(6):1600-4.

Sulch D, Perez I, Melbourn A, et al. Randomized controlled trial of integrated (managed) care 

pathway for stroke rehabilitation. Stroke 2000;31(8):1929-34.

Teng J, Mayo NE, Latimer E, et al. Costs and caregiver consequences of early supported 

discharge for stroke patients. Stroke 2003;34(2):528-36.

Torp CR, Vinkler S, Pedersen KD, et al. Model of hospital-supported discharge after stroke. 

Stroke 2006;37(6):1514-20.

Torres-Arreola Ldel P, Doubova Dubova SV, Hernandez SF, et al. Effectiveness of two 

rehabilitation strategies provided by nurses for stroke patients in Mexico. J Clin Nurs 

2009;18(21):2993-3002.

von Koch L, de Pedro-Cuesta J, Kostulas V, et al. Randomized controlled trial of rehabilitation 

at home after stroke: one-year follow-up of patient outcome, resource use and cost. Cerebrovasc 

Dis 2001;12(2):131-8.
C-5

von Koch L, Holmqvist LW, Wottrich AW, et al. Rehabilitation at home after stroke: a 

descriptive study of an individualized intervention. Clin Rehabil 2000;14(6):574-83.

Young W, Rewa G, Goodman SG, et al. Evaluation of a community-based inner-city disease 

management program for postmyocardial infarction patients: a randomized controlled trial. 

CMAJ 2003;169(9):905-10.
D-1

Appendix D: Quality and Applicability of Included Studies

Table D-1. Quality, applicability, and relevant key questions (KQs) for stroke studies

Study/Country Quality Limitations to applicability KQ 1 KQ 2 KQ 3 KQ4 KQ5

Intervention type 1: Hospital-initiated support

Askim et al., 20041

Askim et al., 20062

Norway

Fair

Fair

• Setting – non-US (Norway) 

• Comparator – usual care with more followup 

services than US

• Population – no description of race or ethnicity

X

X

X

X

X

X

Bautz-Holtert et al., 20023

Norway

Fair • Setting – non-US (Norway)

• Comparator – usual care with more followup 

services than US

X X X

Fjaertoft et al., 20034

Fjaertoft et al., 20045

Fjaertoft et al., 2005,6

Indredavik et al., 20007

Norway

Fair

Fair

Fair

Fair

• Setting – non-US (Norway)

• Intervention – broad, nonspecific intervention

• Population – characteristics of participants at 

baseline and disease severity not described

X

X

X

X

X

X

X

X

X X

X

Grasel et al., 20058

Grasel et al., 20069

Germany

Poor

Poor

• Methods – small sample size, nonrandomized, 

incomplete followup, not intention-to-treat analysis

X

X

X

X

Holmqvist et al., 200010

von Koch et al., 200011

von Koch et al., 200112

Sweden

Poor

Good

Fair

• Setting – non-U.S (Sweden)

• Intervention – not fully described

• Comparator – usual care with more followup 

services than US

• Population – characteristics of participants not 

described

X

X

X

X

X

X

X

X

X X
D-2

Table D-1. Quality, applicability, and relevant key questions (KQs) for stroke studies (continued)

Study/Country Quality Limitations to applicability KQ 1 KQ 2 KQ 3 KQ4 KQ5

Mayo et al., 200013

Teng et al., 200314

Canada

Good

Fair

• Setting – non-US (Canada)

• Population – excluded patients not ready for 

discharge by 28 days, those who needed 2 people 

to assist with walking, and those without a caregiver

X

X

X X

X

Sulch et al., 200015

Sulch et al., 200216

Sulch et al., 200217

England

Fair

Fair

Fair

• Setting – non-US (England)

• Population – few demographic details provided

• Method – small sample size, no mention of 

statistical correction for multiple analyses

X

X

X

X

X

X

Torp et al., 200618

Denmark

Fair • Setting – non-US (Denmark)

• Population – few details about participant 

demographics; e.g., race/ethnicity

X X X X

Intervention type 2a: Patient and family education (hospital-based)

Hoffmann et al., 200719

Australia

Fair • Population – hemorrhagic and ischemic stroke 

included

X X

Intervention type 2b: Patient and family education (home-based)

Clark et al., 200320

Australia

Fair • Population – participants had to have living spouse

• Intervention – nonspecific, generalized social 

worker support

X X

Johnston et al., 200721

UK

Fair • Population – stroke type not specified X X

Mant et al., 200022

Mant et al., 200523

UK

Fair

Fair

• Setting – non-US (United Kingdom)

• Intervention – not clearly described

• Population – participants not fully described

• Method – not intention-to-treat analysis, incomplete 

followup

X

X

X

X

X

X

Sahebalzamani et al., 200924

Iran

Poor • Population – participant demographics not fully 

described

• Method – outcomes measured at 45 days 

posthospitalization

X
D-3

Table D-1. Quality, applicability, and relevant key questions (KQs) for stroke studies (continued)

Study/Country Quality Limitations to applicability KQ 1 KQ 2 KQ 3 KQ4 KQ5

Intervention type 3: Community-based support

Allen et al., 200225

Allen et al., 200926

US

Fair

Fair

• Population – participant demographics not fully 

described

• Methods – groups not balanced, small sample size

X

X

X

X

X

X X

Andersen et al., 200027

Andersen et al., 200228

Denmark

Fair

Fair

• Setting – non-US (Denmark)

• Population – different race/ethnicity distribution

• Methods – combined two intervention groups in 

analysis, no adjustment for multiple analyses

X

X X

X

X

Ayana et al., 200129

UK

Fair • Comparator – description of usual care group was 

limited

• Methods – time series design

X X

Boter et al., 200430

Netherlands

Fair • Setting – non-US (Netherlands)

• Population – participant demographics not fully 

described

X X X

Claiborne et al., 200631

US

Poor • Intervention – multiple persons delivered 

intervention without description of what they actually 

did

• Population – not balanced by age, sex, and race

X X

Donnelly et al., 200432

UK

Fair • Population – participant demographics not fully 

described

X X X

Ertel et al., 200733

Glass et al., 200434

US

Good

Good

• Intervention – delivered by multiple types of 

practitioners (psychologist and social work)

• Population – hemorrhagic and ischemic stroke 

included

X

X

X

X

X

Geddes et al., 200135

UK

Poor • Population – participants from six systems of care

• Intervention – not a discrete intervention, evaluated

models of care

• Comparator – cross comparisons due to multiple 

overlapping components

X X
D-4

Table D-1. Quality, applicability, and relevant key questions (KQs) for stroke studies (continued)

Study/Country Quality Limitations to applicability KQ 1 KQ 2 KQ 3 KQ4 KQ5

Mayo et al., 200836

Canada

Good • None X X X

Ricauda et al., 200437

Italy

Good • Setting – non-US (Italy)

• Population – participant demographics not fully 

described

X X

Torres-Arreola Ldel et al., 

200938

Mexico

Fair • Setting – non-US (Mexico) X X

Intervention type 4: Chronic disease management

Joubert et al., 200639

Australia

Fair • Setting – non-US (Australia)

• Population – excluded participants with cognitive 

impairment

• Methods – imbalance in treatment allocation

X X

Joubert et al., 200840

Australia

Fair • Setting – non-US (Australia)

• (Intervention – not fully described

• Population – included ischemic and hemorrhagic 

stroke, and TIA

X X

Joubert et al., 200941

Australia

Fair • Setting – non-US (Australia)

• Methods – imbalance in treatment allocation

X X
D-5

Table D-2. Quality, applicability, and Key Questions (KQs) for Myocardial Infarction Studies

Study and Country Quality Limitations to applicability KQ 1 KQ 2 KQ 3 KQ4 KQ5

Intervention type 1: Hospital-initiated support

Eagle et al., 200542

Rogers et al., 200743

US

Fair

Fair

• Population – Medicare population only

• Method – not randomized clinical trial

X

X

X

X

Ho et al., 200744

US

Good • Setting – Veterans Affairs 

• Comparator – not fully described

X X X

Kotowycz et al., 201045

Canada

Fair • Setting – non-US (Canada)

• Method – small sample size; pilot study to 

demonstrate feasibility and safety

X X X

Petrie et al., 200246

New Zealand

Good • Setting – non-US (New Zealand)

• Method – small sample size

• Comparator – description of usual care not 

provided

X X

Young et al., 200347

Canada

Fair • Methods – small sample size, unblinded 

outcomes

X X X

Intervention type 2a: Patient and family education (hospital-based)

Mayou et al., 200248

UK

Poor • Setting – non-US (United Kingdom)

• Comparator – usual care not fully described

• Methods – small sample size

X X

Intervention type 2b: Patient and family education (home-based)

Lacey et al., 200449

UK

Fair • Setting – non-US (United Kingdom)

• Methods – small sample size, outcomes not fully 

described

X X
D-6

Table D-2. Quality, applicability, and Key Questions (KQs) for Myocardial Infarction Studies (continued)

Study and Country Quality Limitations to applicability KQ 1 KQ 2 KQ 3 KQ4 KQ5

Intervention type 3: Community-based support

Bambauer et al., 200550

US

Fair • Population – included chronic ischemic heart 

disease with myocardial infarction population

X X

Costa e Silva et al., 200851

Brazil

Fair • Setting – non-US (Brazil)

• Population – no race/ethnicity data

• Methods – small sample size, short followup

period

X X

Gallagher et al., 200352

Australia

Good • Population – female only X X

Hall et al., 200253

Kovoor et al., 200654

Australia

Poor

Fair

• Setting – non-US (Australia)

• Methods – nonrandom allocation

• Population – small sample with hemorrhagic and 

ischemic stroke

X

X

X

X

X

X

Hanssen et al., 200755

Hanssen et al., 200956

Norway

Good

Fair

• Setting – non-US (Norway)

• Methods – small sample size, short followup

period

X

X

X

X X

Luszczynska et al., 200657

Poland

Fair • Setting – non-US (Poland)

• Population – control population not fully 

described

X X X

Oranta et al., 200958

Finland

Fair • Setting – non-US (Finland)

• Design – nonrandomized

• Methods – outcomes of depressed and 

nondepressed patients not analyzed

X

Robertson et al., 200159

Robertson et al., 200360

Canada

Fair

Poor

• Setting – non-US (Canada)

• Population – participant demographics not fully 

described

• Methods – statistical analysis not described

• Comparator – not fully described

X

X

X

X

X

Sinclair et al., 200561

UK

Poor • Setting – non-US (United Kingdom)

• Comparator – not fully described

• Methods – small sample size, not powered to 

show statistical differences

X X X
D-7

Table D-2. Quality, applicability, and Key Questions (KQs) for Myocardial Infarction Studies (continued)

Study and Country Quality Limitations to applicability KQ 1 KQ 2 KQ 3 KQ4 KQ5

Intervention type 4: Chronic disease management

Barlow et al., 200962

UK

Fair • Setting – non-US (United Kingdom)

• Population – recruitment from tertiary care 

cardiac rehabilitation units

X X X
D-8

References Cited in Appendix D

1. Askim T, Rohweder G, Lydersen S, et al. 

Evaluation of an extended stroke unit 

service with early supported discharge for 

patients living in a rural community. A 

randomized controlled trial. Clin Rehabil 

2004;18(3):238-48. 15137554

2. Askim T, Morkved S, Indredavik B. Does an 

extended stroke unit service with early 

supported discharge have any effect on 

balance or walking speed? J Rehabil Med 

2006;38(6):368-74. 17067970

3. Bautz-Holtert E, Sveen U, Rygh J, et al. 

Early supported discharge of patients with 

acute stroke: a randomized controlled trial. 

Disabil Rehabil 2002;24(7):348-55. 

12022784

4. Fjaertoft H, Indredavik B, Lydersen S. 

Stroke unit care combined with early 

supported discharge: long-term follow-up of 

a randomized controlled trial. Stroke 

2003;34(11):2687-91. 14576376

5. Fjaertoft H, Indredavik B, Johnsen R, et al. 

Acute stroke unit care combined with early 

supported discharge. Long-term effects on 

quality of life. A randomized controlled 

trial. Clin Rehabil 2004;18(5):580-6. 

15293492

6. Fjaertoft H, Indredavik B, Magnussen J, et 

al. Early supported discharge for stroke 

patients improves clinical outcome. Does it 

also reduce use of health services and costs? 

One-year follow-up of a randomized 

controlled trial. Cerebrovasc Dis 

2005;19(6):376-83. 15860914

7. Indredavik B, Fjaertoft H, Ekeberg G, et al. 

Benefit of an extended stroke unit service 

with early supported discharge: A 

randomized, controlled trial. Stroke 

2000;31(12):2989-94. 11108761

8. Grasel E, Biehler J, Schmidt R, et al. 

Intensification of the transition between 

inpatient neurological rehabilitation and 

home care of stroke patients. Controlled 

clinical trial with follow-up assessment six 

months after discharge. Clin Rehabil 

2005;19(7):725-36. 16250191

9. Grasel E, Schmidt R, Biehler J, et al. Longterm effects of the intensification of the 

transition between inpatient neurological 

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16894800

10. Holmqvist LW, von Koch L, de PedroCuesta J. Use of healthcare, impact on 

family caregivers and patient satisfaction of 

rehabilitation at home after stroke in 

southwest Stockholm. Scand J Rehabil Med 

2000;32(4):173-9. 11201624

11. von Koch L, Holmqvist LW, Wottrich AW, 

et al. Rehabilitation at home after stroke: a 

descriptive study of an individualized 

intervention. Clin Rehabil 2000;14(6):574-

83. 11128731

12. von Koch L, de Pedro-Cuesta J, Kostulas V, 

et al. Randomized controlled trial of 

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follow-up of patient outcome, resource use 

and cost. Cerebrovasc Dis 2001;12(2):131-8. 

11490107

13. Mayo NE, Wood-Dauphinee S, Cote R, et 

al. There's no place like home : an 

evaluation of early supported discharge for 

stroke. Stroke 2000;31(5):1016-23. 

10797160

14. Teng J, Mayo NE, Latimer E, et al. Costs 

and caregiver consequences of early 

supported discharge for stroke patients. 

Stroke 2003;34(2):528-36. 12574571

15. Sulch D, Perez I, Melbourn A, et al. 

Randomized controlled trial of integrated 

(managed) care pathway for stroke 

rehabilitation. Stroke 2000;31(8):1929-34. 

10926959

16. Sulch D, Evans A, Melbourn A, et al. Does 

an integrated care pathway improve 

processes of care in stroke rehabilitation? A 

randomized controlled trial. Age Ageing 

2002;31(3):175-9. 12006305

17. Sulch D, Melbourn A, Perez I, et al. 

Integrated care pathways and quality of life 

on a stroke rehabilitation unit. Stroke 

2002;33(6):1600-4. 12052998
D-9

18. Torp CR, Vinkler S, Pedersen KD, et al. 

Model of hospital-supported discharge after 

stroke. Stroke 2006;37(6):1514-20. 

16645132

19. Hoffmann T, McKenna K, Worrall L, et al. 

Randomised trial of a computer-generated 

tailored written education package for 

patients following stroke. Age Ageing 

2007;36(3):280-6. 17360794

20. Clark MS, Rubenach S, Winsor A. A 

randomized controlled trial of an education 

and counselling intervention for families 

after stroke. Clin Rehabil 2003;17(7):703-

12. 14606735

21. Johnston M, Bonetti D, Joice S, et al. 

Recovery from disability after stroke as a 

target for a behavioural intervention: results 

of a randomized controlled trial. Disabil 

Rehabil 2007;29(14):1117-27. 17612998

22. Mant J, Carter J, Wade DT, et al. Family 

support for stroke: a randomised controlled 

trial. Lancet 2000;356(9232):808-13. 

11022928

23. Mant J, Winner S, Roche J, et al. Family 

support for stroke: one year follow up of a 

randomised controlled trial. J Neurol 

Neurosurg Psychiatry 2005;76(7):1006-8. 

15965213

24. Sahebalzamani M, Aliloo L, Shakibi A. The 

efficacy of self-care education on 

rehabilitation of stroke patients. Saudi Med J 

2009;30(4):550-4. 19370286

25. Allen KR, Hazelett S, Jarjoura D, et al. 

Effectiveness of a postdischarge care 

management model for stroke and transient 

ischemic attack: a randomized trial. J Stroke 

Cerebrovasc Dis 2002;11(2):88-98. 

17903862

26. Allen K, Hazelett S, Jarjoura D, et al. A 

randomized trial testing the superiority of a 

postdischarge care management model for 

stroke survivors. J Stroke Cerebrovasc Dis 

2009;18(6):443-52. 19900646

27. Andersen HE, Schultz-Larsen K, Kreiner S, 

et al. Can readmission after stroke be 

prevented? Results of a randomized clinical 

study: a postdischarge follow-up service for 

stroke survivors. Stroke 2000;31(5):1038-

45. 10797163

28. Andersen HE, Eriksen K, Brown A, et al. 

Follow-up services for stroke survivors after 

hospital discharge--a randomized control 

study. Clin Rehabil 2002;16(6):593-603. 

12392333

29. Ayana M, Pound P, Lampe F, et al. 

Improving stroke patients' care: a patient 

held record is not enough. BMC Health Serv 

Res 2001;1(1):1. 11257719

30. Boter H. Multicenter randomized controlled 

trial of an outreach nursing support program 

for recently discharged stroke patients. 

Stroke 2004;35(12):2867-72. 15514186

31. Claiborne N. Effectiveness of a care 

coordination model for stroke survivors: a 

randomized study. Health Soc Work 

2006;31(2):87-96. 16776026

32. Donnelly M, Power M, Russell M, et al. 

Randomized controlled trial of an early 

discharge rehabilitation service: the Belfast 

Community Stroke Trial. Stroke 

2004;35(1):127-33. 14671238

33. Ertel KA, Glymour MM, Glass TA, et al. 

Frailty modifies effectiveness of 

psychosocial intervention in recovery from 

stroke. Clin Rehabil 2007;21(6):511-22. 

17613582

34. Glass TA, Berkman LF, Hiltunen EF, et al. 

The Families In Recovery From Stroke Trial 

(FIRST): primary study results. Psychosom 

Med 2004;66(6):889-97. 15564354

35. Geddes JM, Chamberlain MA. Home-based 

rehabilitation for people with stroke: a 

comparative study of six community 

services providing co-ordinated, 

multidisciplinary treatment. Clin Rehabil 

2001;15(6):589-99. 11777089

36. Mayo NE, Nadeau L, Ahmed S, et al. 

Bridging the gap: the effectiveness of 

teaming a stroke coordinator with patient's 

personal physician on the outcome of stroke. 

Age Ageing 2008;37(1):32-8. 18006510

37. Ricauda NA, Bo M, Molaschi M, et al. 

Home hospitalization service for acute 

uncomplicated first ischemic stroke in 

elderly patients: a randomized trial. J Am 

Geriatr Soc 2004;52(2):278-83. 14728641
D-10

38. Torres-Arreola Ldel P, Doubova Dubova 

SV, Hernandez SF, et al. Effectiveness of 

two rehabilitation strategies provided by 

nurses for stroke patients in Mexico. J Clin 

Nurs 2009;18(21):2993-3002. 19821873

39. Joubert J, Reid C, Joubert L, et al. Risk 

factor management and depression poststroke: the value of an integrated model of

care. J Clin Neurosci 2006;13(1):84-90. 

16410202

40. Joubert J, Joubert L, Reid C, et al. The 

positive effect of integrated care on 

depressive symptoms in stroke survivors. 

Cerebrovasc Dis 2008;26(2):199-205. 

18628619

41. Joubert J, Reid C, Barton D, et al. Integrated 

care improves risk-factor modification after 

stroke: initial results of the Integrated Care 

for the Reduction of Secondary Stroke 

model. J Neurol Neurosurg Psychiatry 

2009;80(3):279-84. 19010943

42. Eagle KA, Montoye CK, Riba AL, et al. 

Guideline-based standardized care is 

associated with substantially lower mortality 

in medicare patients with acute myocardial 

infarction: the American College of 

Cardiology's Guidelines Applied in Practice 

(GAP) Projects in Michigan. J Am Coll 

Cardiol 2005;46(7):1242-8. 16198838

43. Rogers AM, Ramanath VS, Grzybowski M, 

et al. The association between guidelinebased treatment instructions at the point of 

discharge and lower 1-year mortality in 

Medicare patients after acute myocardial 

infarction: the American College of 

Cardiology's Guidelines Applied in Practice 

(GAP) initiative in Michigan. Am Heart J 

2007;154(3):461-9. 17719291

44. Ho PM, Luther SA, Masoudi FA, et al. 

Inpatient and follow-up cardiology care and 

mortality for acute coronary syndrome 

patients in the Veterans Health 

Administration. Am Heart J 

2007;154(3):489-94. 17719295

45. Kotowycz MA, Cosman TL, Tartaglia C, et 

al. Safety and feasibility of early hospital 

discharge in ST-segment elevation 

myocardial infarction--a prospective and 

randomized trial in low-risk primary 

percutaneous coronary intervention patients 

(the Safe-Depart Trial). Am Heart J 

2010;159(1):117 e1-6. 20102876

46. Petrie KJ, Cameron LD, Ellis CJ, et al. 

Changing illness perceptions after 

myocardial infarction: an early intervention 

randomized controlled trial. Psychosom 

Med 2002;64(4):580-6. 12140347

47. Young W, Rewa G, Goodman SG, et al. 

Evaluation of a community-based inner-city 

disease management program for 

postmyocardial infarction patients: a 

randomized controlled trial. CMAJ 

2003;169(9):905-10. 14581307

48. Mayou RA, Thompson DR, Clements A, et 

al. Guideline-based early rehabilitation after 

myocardial infarction. A pragmatic 

randomised controlled trial. J Psychosom 

Res 2002;52(2):89-95. 11832254

49. Lacey EA, Musgrave RJ, Freeman JV, et al. 

Psychological morbidity after myocardial 

infarction in an area of deprivation in the 

UK: evaluation of a self-help package. Eur J 

Cardiovasc Nurs 2004;3(3):219-24. 

15350231

50. Bambauer KZ, Aupont O, Stone PH, et al. 

The effect of a telephone counseling 

intervention on self-rated health of cardiac 

patients. Psychosom Med 2005;67(4):539-

45. 16046365

51. Costa e Silva R, Pellanda L, Portal V, et al. 

Transdisciplinary approach to the follow-up 

of patients after myocardial infarction. 

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18719760

52. Gallagher R, McKinley S, Dracup K. Effects 

of a telephone counseling intervention on 

psychosocial adjustment in women 

following a cardiac event. Heart Lung 

2003;32(2):79-87. 2003095558. Language: 

English. Entry Date: 20030718. Revision 

Date: 20091218. Publication Type: journal 

article

53. Hall JP, Wiseman VL, King MT, et al. 

Economic evaluation of a randomised trial 

of early return to normal activities versus 

cardiac rehabilitation after acute myocardial 

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16352063

54. Kovoor P, Lee AK, Carrozzi F, et al. Return 

to full normal activities including work at 

two weeks after acute myocardial infarction. 

Am J Cardiol 2006;97(7):952-8. 16563893
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55. Hanssen TA, Nordrehaug JE, Eide GE, et al. 

Improving outcomes after myocardial 

infarction: a randomized controlled trial 

evaluating effects of a telephone follow-up 

intervention. Eur J Cardiovasc Prev Rehabil 

2007;14(3):429-37. 17568244

56. Hanssen TA, Nordrehaug JE, Eide GE, et al. 

Does a telephone follow-up intervention for 

patients discharged with acute myocardial 

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controlled trial. J Clin Nurs 

2009;18(9):1334-45. 19220616

57. Luszczynska A. An implementation 

intentions intervention, the use of a planning 

strategy, and physical activity after 

myocardial infarction. Soc Sci Med 

2006;62(4):900-8. 16095786

58. Oranta O, Luutonen S, Salokangas RK, et al. 

The outcomes of interpersonal counselling 

on depressive symptoms and distress after 

myocardial infarction. Nord J Psychiatry 

2010;64(2):78-86. 19919291

59. Robertson KA, Kayhko K. Cost analysis of 

an intensive home follow-up program for 

first-time post-myocardial infarction patients 

and their families. Dynamics 2001;12(4):25-

31. 11845484

60. Robertson K, Kayhko K, Kekki P. A 

supportive-education home follow-up 

programme for post MI patients. Journal of 

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2004038638. Language: English. Entry 

Date: 20040227. Revision Date: 20091218. 

Publication Type: journal article

61. Sinclair AJ, Conroy SP, Davies M, et al. 

Post-discharge home-based support for older 

cardiac patients: a randomised controlled 

trial. Age Ageing 2005;34(4):338-43. 

15955757

62. Barlow JH, Turner AP, Gilchrist M. A 

randomised controlled trial of lay-led selfmanagement for myocardial infarction 

patients who have completed cardiac 

rehabilitation. Eur J Cardiovasc Nurs 

2009;8(4):293-301. 19261545
E-2

Appendix E: List of Excluded Studies

All studies listed below were reviewed in their full-text version and excluded. Following each 

reference, in italics, is the reason for exclusion. Reasons for exclusion signify only the usefulness 

of the articles for this study and are not intended as criticisms of the articles. 

Abbott KC, Bohen EM, Yuan CM, et al. Use of beta-blockers and aspirin after myocardial 

infarction by patient renal function in the Department of Defense health care system. Am J 

Kidney Dis 2006;47(4):593-603. Exclude - not system-level transitional intervention

Abdallah M, Karrowni W, Dakik HA. Utilization of glycoprotein IIb/IIIa inhibitors in non-STelevation acute myocardial infarction in a tertiary referral medical center in a developing 

country. Int J Cardiol 2007;114(2):282-3. Exclude - not system-level transitional intervention 

Aben L, Busschbach JJ, Ponds RW, et al. Memory self-efficacy and psychosocial factors in 

stroke. J Rehabil Med 2008;40(8):681-3. Exclude - not system-level transitional intervention

Abete P, Ferrara N, Cacciatore F, et al. High level of physical activity preserves the 

cardioprotective effect of preinfarction angina in elderly patients. J Am Coll Cardiol 

2001;38(5):1357-65. Exclude - not system-level transitional intervention 

Abraham WT. Switching to evidence-based once-daily beta-blockers for improved adherence to 

medication across the continuum of post-myocardial infarction left ventricular dysfunction and 

heart failure. Congest Heart Fail 2008;14(5):272-80. Exclude - not original peer-reviewed data

Acevedo M, Sprecher DL, Lauer MS, et al. Routine statin treatment after acute coronary 

syndromes? Am Heart J 2002;143(6):940-2. Exclude - not original peer-reviewed data

Ada L, Dean CM, Hall JM, et al. A treadmill and overground walking program improves 

walking in persons residing in the community after stroke: a placebo-controlled, randomized 

trial. Arch Phys Med Rehabil 2003;84(10):1486-91. Exclude - not system-level transitional 

intervention

Ada L, Dean CM, Lindley R, et al. Improving community ambulation after stroke: the 

AMBULATE Trial. BMC Neurol 2009;9:8. Exclude - not system-level transitional intervention

Ada L, Dean CM, Morris ME, et al. Randomized trial of treadmill walking with body weight 

support to establish walking in subacute stroke: the MOBILISE trial. Stroke 2010;41(6):1237-42. 

Exclude - not system-level transitional intervention

Ada L, Foongchomcheay A. Efficacy of electrical stimulation in preventing or reducing 

subluxation of the shoulder after stroke: a meta-analysis. Aust J Physiother 2002;48(4):257-67. 

Exclude - not system-level transitional intervention

Adamczyk K, Lorencowicz R, Turowski K. Evaluation of motor efficiency with respect to selfcare of neurological patients. Ann Univ Mariae Curie Sklodowska Med 2004;59(2):219-23. 

Exclude - not system-level transitional intervention

Adams HP, Jr., Leira EC, Torner JC, et al. Treating patients with 'wake-up' stroke: the 

experience of the AbESTT-II trial. Stroke 2008;39(12):3277-82. Exclude - not system-level 

transitional intervention 
E-3

Adlbrecht C, Distelmaier K, Bonderman D, et al. Long-term outcome after thrombectomy in 

acute myocardial infarction. Eur J Clin Invest 2010;40(3):233-41. Exclude - not system-level 

transitional intervention

Adunsky A, Levenkron S, Fleissig Y, et al. In-hospital referral source and rehabilitation outcome 

of elderly stroke patients. Aging (Milano) 2001;13(6):430-6. Exclude - not system-level 

transitional intervention

Afolabi BA, Novaro GM, Pinski SL, et al. Use of the prehospital ECG improves door-to-balloon 

times in ST segment elevation myocardial infarction irrespective of time of day or day of week. 

Emerg Med J 2007;24(8):588-91. Exclude - not system-level transitional intervention

Agarwal P, Kumar S, Hariharan S, et al. Hyperdense middle cerebral artery sign: can it be used 

to select intra-arterial versus intravenous thrombolysis in acute ischemic stroke? Cerebrovasc Dis 

2004;17(2-3):182-90. Exclude - not system-level transitional intervention

Agarwal V, McRae MP, Bhardwaj A, et al. A model to aid in the prediction of discharge location 

for stroke rehabilitation patients. Arch Phys Med Rehabil 2003;84(11):1703-9. Exclude - not 

system-level transitional intervention

Ahmed N, Wahlgren N, Brainin M, et al. Relationship of blood pressure, antihypertensive 

therapy, and outcome in ischemic stroke treated with intravenous thrombolysis: retrospective 

analysis from Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis 

Register (SITS-ISTR). Stroke 2009;40(7):2442-9. Exclude - not system-level transitional 

intervention

Ahmed R, Zuberi BF, Afsar S. Stroke scale score and early prediction of outcome after stroke. J 

Coll Physicians Surg Pak 2004;14(5):267-9. Exclude - not system-level transitional intervention 

Ahrens J. Italian study concludes "home hospitalization" benefits stroke patients. Caring 

2004;23(8):40-2; quiz 44-5. Exclude - not original peer-reviewed data

Albright KC, Raman R, Ernstrom K, et al. Can comprehensive stroke centers erase the 'weekend 

effect'? Cerebrovasc Dis 2009;27(2):107-13. Exclude - not system-level transitional intervention 

Aldana SG, Whitmer WR, Greenlaw R, et al. Cardiovascular risk reductions associated with 

aggressive lifestyle modification and cardiac rehabilitation. Heart Lung 2003;32(6):374-82. 

Exclude - not system-level transitional intervention

Alexander H, Bugge C, Hagen S. What is the association between the different components of 

stroke rehabilitation and health outcomes? Clin Rehabil 2001;15(2):207-15. Exclude - not 

system-level transitional intervention

Allen K, Hazelett S, Jarjoura D, et al. Improving stroke outcomes: Implementation of a 

postdischarge care management model. Journal of Clinical Outcomes Management 

2004;11(11):707-714. Exclude - methods paper

Allen KR, Hazelett SE, Palmer RR, et al. Developing a stroke unit using the acute care for elders 

intervention and model of care. J Am Geriatr Soc 2003;51(11):1660-7. Exclude - not original 

peer-reviewed data

Alter DA, Khaykin Y, Austin PC, et al. Processes and outcomes of care for diabetic acute 

myocardial infarction patients in Ontario: do physicians undertreat? Diabetes Care 

2003;26(5):1427-34. Exclude - not system-level transitional intervention
E-4

Amar J, Chamontin B, Ferrieres J, et al. Hypertension control at hospital discharge after acute 

coronary event: influence on cardiovascular prognosis--the PREVENIR study. Heart 

2002;88(6):587-91. Exclude - not system-level transitional intervention

Amato CP. Still going, growing.....Twenty-three years after a stroke. Top Stroke Rehabil 

2005;12(4):61-7. Exclude - insufficient detail/sample size

Amin A. Improving the management of patients after myocardial infarction, from admission to 

discharge. Clin Ther 2006;28(10):1509-39. Exclude - not system-level transitional intervention

Amin AP, Mukhopadhyay E, Nathan S, et al. Association of medical noncompliance and longterm adverse outcomes, after myocardial infarction in a minority and uninsured population. 

Transl Res 2009;154(2):78-89. Exclude - not original peer-reviewed data

Anderson C, Ni Mhurchu C, Brown PM, et al. Stroke rehabilitation services to accelerate 

hospital discharge and provide home-based care: an overview and cost analysis. 

Pharmacoeconomics 2002;20(8):537-52. Exclude - Systematic Review for background

Andersson A, Levin LA, Oberg B, et al. Health care and social welfare costs in home-based and 

hospital-based rehabilitation after stroke. Scand J Caring Sci 2002;16(4):386-92. Exclude - not 

system-level transitional intervention

Anonymous. NRMI (National Registry of Myocardial Infarction) data impacts care on many 

different levels. Healthc Benchmarks 2002;9(3):27, 29-31. Exclude - not original peer-reviewed 

data

Anonymous. Services for reducing duration of hospital care for acute stroke patients. Cochrane 

Database Syst Rev 2002(1):CD000443. Exclude - meta-analysis for background

Anonymous. New research establishes importance of specialty care after discharge for an MI. 

Dis Manag Advis 2003;9(4):61-3, 50. Exclude - not original peer-reviewed data

Anonymous. Therapy-based rehabilitation services for stroke patients at home. Cochrane 

Database Syst Rev 2003(1):CD002925. Exclude - Systematic Review for background

Anonymous. The impact of standardized stroke orders on adherence to best practices. Neurology 

2005;65(3):360-5. Exclude - not system-level transitional intervention

Anonymous. Services for reducing duration of hospital care for acute stroke patients. Cochrane 

Database Syst Rev 2005(2):CD000443. Exclude - Systematic Review for background

Anonymous. Assessing care of vulnerable elders-3 quality indicators. J Am Geriatr Soc 2007;55 

Suppl 2:S464-87. Exclude - not original peer-reviewed data 

Appelros P, Nydevik I, Terent A. Living setting and utilisation of ADL assistance one year after 

a stroke with special reference to gender differences. Disabil Rehabil 2006;28(1):43-9. Exclude -

not system-level transitional intervention

Aprile I, Di Stasio E, Romitelli F, et al. Effects of rehabilitation on quality of life in patients with 

chronic stroke. Brain Inj 2008;22(6):451-6. Exclude - not original peer-reviewed data

Arif H, Aijaz B, Islam M, et al. Drug compliance after stroke and myocardial infarction: a 

comparative study. Neurol India 2007;55(2):130-5. Exclude - not original peer-reviewed data
E-5

Aronow HD, Topol EJ, Roe MT, et al. Effect of lipid-lowering therapy on early mortality after 

acute coronary syndromes: an observational study. Lancet 2001;357(9262):1063-8. Exclude - not 

system-level transitional intervention 

Astin F, Atkin K, Darr A. Family support and cardiac rehabilitation: a comparative study of the 

experiences of South Asian and White-European patients and their carer's living in the United 

Kingdom. Eur J Cardiovasc Nurs 2008;7(1):43-51. Exclude - insufficient detail/sample size

Austin PC, Mamdani MM, Juurlink DN, et al. Missed opportunities in the secondary prevention 

of myocardial infarction: an assessment of the effects of statin underprescribing on mortality. 

Am Heart J 2006;151(5):969-75. Exclude - not system-level transitional intervention

Austin PC, Tu JV, Ko DT, et al. Factors associated with the use of evidence-based therapies after 

discharge among elderly patients with myocardial infarction. CMAJ 2008;179(9):901-8. Exclude 

- not system-level transitional intervention

Ayanian JZ, Landrum MB, Guadagnoli E, et al. Specialty of ambulatory care physicians and 

mortality among elderly patients after myocardial infarction. N Engl J Med 2002;347(21):1678-

86. Exclude - not system-level transitional intervention

Bagg SD, Pombo AP, Hopman WM. Toward benchmarks for stroke rehabilitation in Ontario, 

Canada. Am J Phys Med Rehabil 2006;85(12):971-6. Exclude - not system-level transitional 

intervention

Bailey TC, Noirot LA, Blickensderfer A, et al. An intervention to improve secondary prevention 

of coronary heart disease. Arch Intern Med 2007;167(6):586-90. Exclude - no outcomes of 

interest

Baillargeon JP, Lepage S, Larrivee L, et al. Intensive surveillance and treatment of dyslipidemia 

in the postinfarct patient: evaluation of a nurse-oriented management approach. Can J Cardiol 

2001;17(2):169-75. Exclude - not stroke/MI

Barth J, Critchley J, Bengel J. Psychosocial interventions for smoking cessation in patients with 

coronary heart disease. Cochrane Database Syst Rev 2008(1):CD006886. Exclude - not original 

peer-reviewed data

Batchelor FA, Hill KD, Mackintosh SF, et al. The FLASSH study: protocol for a randomised 

controlled trial evaluating falls prevention after stroke and two sub-studies. BMC Neurol 

2009;9:14. Exclude - not original peer-reviewed data

Bates B, Choi JY, Duncan PW, et al. Veterans Affairs/Department of Defense Clinical Practice 

Guideline for the Management of Adult Stroke Rehabilitation Care: executive summary. Stroke 

2005;36(9):2049-56. Exclude - not system-level transitional intervention

Bates BE, Stineman MG. Outcome indicators for stroke: application of an algorithm treatment 

across the continuum of postacute rehabilitation services. Arch Phys Med Rehabil 

2000;81(11):1468-78. Exclude - not system-level transitional intervention

Battersby M, Hoffmann S, Cadilhac D, et al. 'Getting your life back on track after stroke': a 

Phase II multi-centered, single-blind, randomized, controlled trial of the Stroke SelfManagement Program vs. the Stanford Chronic Condition Self-Management Program or 

standard care in stroke survivors. Int J Stroke 2009;4(2):137-44. Exclude - insufficient 

detail/sample size
E-6

Beck CA, Lauzon C, Eisenberg MJ, et al. Discharge prescriptions following admission for acute 

myocardial infarction at tertiary care and community hospitals in Quebec. Can J Cardiol 

2001;17(1):33-40. Exclude - not system-level transitional intervention

Bernhardt J, Dewey H, Collier J, et al. A Very Early Rehabilitation Trial (AVERT). Int J Stroke 

2006;1(3):169-71. Exclude - insufficient detail/sample size

Bernhardt J, Dewey H, Thrift A, et al. A very early rehabilitation trial for stroke (AVERT): 

phase II safety and feasibility. Stroke 2008;39(2):390-6. Exclude - not system-level transitional 

intervention 

Bernhardt J, Thuy MN, Collier JM, et al. Very early versus delayed mobilisation after stroke. 

Cochrane Database Syst Rev 2009(1):CD006187. Exclude - not system-level transitional 

intervention 

Bestul MB, McCollum M, Stringer KA, et al. Impact of a critical pathway on acute myocardial 

infarction quality indicators. Pharmacotherapy 2004;24(2):173-8. Exclude - not system-level 

transitional intervention 

Bhandari VK, Kushel M, Price L, et al. Racial disparities in outcomes of inpatient stroke 

rehabilitation. Arch Phys Med Rehabil 2005;86(11):2081-6. Exclude - not system-level 

transitional intervention 

Birnie DH, Cobbe SM. Risk of sudden death after discharge following myocardial infarction. 

Eur Heart J 2001;22(14):1153-5. Exclude - not system-level transitional intervention

Bisaillon S, Kelloway L, LeBlanc K, et al. Best practices in stroke care. Can Nurse 

2005;101(8):25-9. Exclude - not system-level transitional intervention

Biviano AB, Rabbani LE, Paultre F, et al. Usefulness of an acute coronary syndrome pathway to 

improve adherence to secondary prevention guidelines. Am J Cardiol 2003;91(10):1248-50. 

Exclude - not system-level transitional intervention 

Bjorkdahl A, Nilsson AL, Grimby G, et al. Does a short period of rehabilitation in the home 

setting facilitate functioning after stroke? A randomized controlled trial. Clin Rehabil 

2006;20(12):1038-49. Exclude - not system-level transitional intervention

Bjorkdahl A, Nilsson AL, Sunnerhagen KS. Can rehabilitation in the home setting reduce the 

burden of care for the next-of-kin of stroke victims? J Rehabil Med 2007;39(1):27-32. Exclude -

not system-level transitional intervention

Bjorkdahl A, Sunnerhagen KS. Process skill rather than motor skill seems to be a predictor of 

costs for rehabilitation after a stroke in working age; a longitudinal study with a 1 year follow up 

post discharge. BMC Health Serv Res 2007;7:209. Exclude - not system-level transitional 

intervention 

Black-Schaffer RM, Winston C. Age and functional outcome after stroke. Top Stroke Rehabil 

2004;11(2):23-32. Exclude - not system-level transitional intervention 

Blight A, Pereira AC, Brown MM. A single consultation cerebrovascular disease clinic is cost 

effective in the management of transient ischaemic attack and minor stroke. J R Coll Physicians 

Lond 2000;34(5):452-5. Exclude - not system-level transitional intervention
E-7

Blumenthal JA, Babyak MA, Carney RM, et al. Exercise, depression, and mortality after 

myocardial infarction in the ENRICHD trial. Med Sci Sports Exerc 2004;36(5):746-55. Exclude 

- not system-level transitional intervention 

Blustein J, Valentine M, Mead H, et al. Race/Ethnicity and patient confidence to self-manage 

cardiovascular disease. Med Care 2008;46(9):924-9. Exclude - not system-level transitional 

intervention

Bohannon RW, Lee N. Association of physical functioning with same-hospital readmission after 

stroke. Am J Phys Med Rehabil 2004;83(6):434-8. Exclude - not system-level transitional 

intervention

Bonetti D, Johnston M. Perceived control predicting the recovery of individual-specific walking 

behaviours following stroke: testing psychological models and constructs. Br J Health Psychol 

2008;13(Pt 3):463-78. Exclude - not system-level transitional intervention 

Bosch M, Faber MJ, Cruijsberg J, et al. Review article: Effectiveness of patient care teams and 

the role of clinical expertise and coordination: A literature review. Med Care Res Rev 2009;66(6 

SUPPL.):5S-35S. Exclude - not system-level transitional intervention

Boter H, Rinkel GJ, de Haan RJ. Outreach nurse support after stroke: a descriptive study on 

patients' and carers' needs, and applied nursing interventions. Clin Rehabil 2004;18(2):156-63. 

Exclude - not system-level transitional intervention

Boudrez H, De Backer G. Recent findings on return to work after an acute myocardial infarction 

or coronary artery bypass grafting. Acta Cardiol 2000;55(6):341-9. Exclude - not system-level 

transitional intervention 

Bowen A, Knapp P, Hoffman A, et al. Psychological services for people with stroke: compliance 

with the U.K. National Clinical Guidelines. Clin Rehabil 2005;19(3):323-30. Exclude - not 

system-level transitional intervention 

Bowker TJ, Turner RM, Wood DA, et al. A national Survey of Acute Myocardial Infarction and 

Ischaemia (SAMII) in the U.K.: characteristics, management and in-hospital outcome in women 

compared to men in patients under 70 years. Eur Heart J 2000;21(17):1458-63. Exclude - not 

system-level transitional intervention 

Boysen G, Krarup LH, Zeng X, et al. ExStroke Pilot Trial of the effect of repeated instructions to 

improve physical activity after ischaemic stroke: a multinational randomised controlled clinical 

trial. BMJ 2009;339:b2810. Exclude - not system-level transitional intervention 

Bradley EH, Holmboe ES, Wang Y, et al. What are hospitals doing to increase beta-blocker use? 

Jt Comm J Qual Saf 2003;29(8):409-15. Exclude - not system-level transitional intervention

Brainin M, Olsen TS, Chamorro A, et al. Organization of stroke care: education, referral, 

emergency management and imaging, stroke units and rehabilitation. European Stroke Initiative. 

Cerebrovasc Dis 2004;17 Suppl 2:1-14. Exclude - not original peer-reviewed data

Brajkovic L, Godan A, Godan L. Quality of life after stroke in old age: comparison of persons 

living in nursing home and those living in their own home. Croat Med J 2009;50(2):182-8. 

Exclude - not system-level transitional intervention 
E-8

Bramlage P, Messer C, Bitterlich N, et al. The effect of optimal medical therapy on 1-year 

mortality after acute myocardial infarction. Heart 2010;96(8):604-9. Exclude - not system-level 

transitional intervention 

Branca G, Capodanno D, Capranzano P, et al. Early discharge in acute myocardial infarction 

after clinical and angiographic risk assessment. J Cardiovasc Med (Hagerstown) 2008;9(8):858-

61. Exclude - not system-level transitional intervention

Briffa TG, Eckermann SD, Griffiths AD, et al. Cost-effectiveness of rehabilitation after an acute 

coronary event: a randomised controlled trial. Med J Aust 2005;183(9):450-5. Exclude - not 

system-level transitional intervention 

Broadbent E, Ellis CJ, Thomas J, et al. Further development of an illness perception intervention 

for myocardial infarction patients: a randomized controlled trial. J Psychosom Res 

2009;67(1):17-23. Exclude - not system-level transitional intervention 

Brock KA, Vale SJ, Cotton SM. The effect of the introduction of a case-mix-based funding 

model of rehabilitation for severe stroke: an Australian experience. Arch Phys Med Rehabil 

2007;88(7):827-32. Exclude - not system-level transitional intervention

Bronskill SE, Normand SL, McNeil BJ. Post-acute service use following acute myocardial 

infarction in the elderly. Health Care Financ Rev 2002;24(2):77-93. Exclude - insufficient 

detail/sample size

Brownstein JN, Bone LR, Dennison CR, et al. Community health workers as interventionists in 

the prevention and control of heart disease and stroke. Am J Prev Med 2005;29(5 Suppl 1):128-

33. Exclude - not original peer-reviewed data

Bugnicourt JM, Chillon JM, Canaple S, et al. Stroke secondary prevention and blood pressure 

reduction: an observational study of the use of PROGRESS therapy. Fundam Clin Pharmacol 

2008;22(2):217-22. Exclude - not system-level transitional intervention 

Buntin MB, Colla CH, Escarce JJ. Effects of payment changes on trends in post-acute care. 

Health Serv Res 2009;44(4):1188-210. Exclude - not system-level transitional intervention 

Buntin MB, Garten AD, Paddock S, et al. How much is postacute care use affected by its 

availability? Health Serv Res 2005;40(2):413-34. Exclude - not system-level transitional 

intervention 

Butler J, Arbogast PG, BeLue R, et al. Outpatient adherence to beta-blocker therapy after acute 

myocardial infarction. J Am Coll Cardiol 2002;40(9):1589-95. Exclude - not system-level 

transitional intervention

Butler J, Speroff T, Arbogast PG, et al. Improved compliance with quality measures at hospital 

discharge with a computerized physician order entry system. Am Heart J 2006;151(3):643-53. 

Exclude - not system-level transitional intervention 

Campos TF, Galvao Silveira AB, Miranda Barroso MT. Regularity of daily activities in stroke. 

Chronobiol Int 2008;25(4):611-24. Exclude - not system-level transitional intervention 

Carlsson E, Ehnfors M, Ehrenberg A. Multidisciplinary recording and continuity of care for 

stroke patients with eating difficulties. J Interprof Care 2010;24(3):298-310. Exclude - no 

acceptable comparator
E-9

Carroll DL, Rankin SH. Comparing interventions in older unpartnered adults after myocardial 

infarction. Eur J Cardiovasc Nurs 2006;5(1):83-9. Exclude - not system-level transitional 

intervention

Carroll DL, Rankin SH, Cooper BA. The effects of a collaborative peer advisor/advanced 

practice nurse intervention: cardiac rehabilitation participation and rehospitalization in older 

adults after a cardiac event. J Cardiovasc Nurs 2007;22(4):313-9. Exclude - not system-level 

transitional intervention

Carswell JL, Beard KA, Chevrette MM, et al. Tracking trends in secondary stroke prevention 

strategies. Ann Pharmacother 2004;38(2):215-9. Exclude - not system-level transitional 

intervention 

Censullo J, Chiu D. Comprehensive stroke center quality metrics. Crit Pathw Cardiol 

2008;7(3):178-84. Exclude - not system-level transitional intervention 

Chan L, Wang H, Terdiman J, et al. Disparities in outpatient and home health service utilization 

following stroke: results of a 9-year cohort study in Northern California. PM R 2009;1(11):997-

1003. Exclude - not system-level transitional intervention

Chan ML. Description of a return-to-work occupational therapy programme for stroke 

rehabilitation in Singapore. Occup Ther Int 2008;15(2):87-99. Exclude - insufficient 

detail/sample size

Chan V, Cooke CE. Pharmacotherapy after myocardial infarction: disease management versus 

usual care. Am J Manag Care 2008;14(6):352-8. Exclude - not system-level transitional 

intervention

Chapman M. The technological edge. Med Device Technol 2002;13(10):21-2. Exclude -

insufficient detail/sample size

Cheng EM, Birbeck G, Vickrey B. VA Stroke Study: neurologist care is associated with 

increased testing but improved outcomes. Neurology 2004;62(10):1914; author reply 1914-5. 

Exclude - insufficient detail/sample size

Cheung CM, Tsoi TH, Hon SF, et al. Outcomes after first-ever stroke. Hong Kong Med J 

2007;13(2):95-9. Exclude - not system-level transitional intervention

Chew DP, Huynh LT, Liew D, et al. Potential survival gains in the treatment of myocardial 

infarction. Heart 2009;95(22):1844-50. Exclude - not system-level transitional intervention 

Chiantera A, Scalvini S, Pulignano G, et al. Role of telecardiology in the assessment of angina in 

patients with recent acute coronary syndrome. J Telemed Telecare 2005;11 Suppl 1:93-4. 

Exclude - no system-level transitional intervention

Chien MY, Tsai MW, Wu YT. Does cardiac rehabilitation improve quality of life for a man with 

coronary artery disease who received percutaneous transluminal coronary angioplasty with 

insertion of a stent? Phys Ther 2006;86(12):1703-10. Exclude - not system-level transitional 

intervention

Chiu A, Shen Q, Cheuk G, et al. Establishment of a stroke unit in a district hospital: review of 

experience. Intern Med J 2007;37(2):73-8. Exclude - not system-level transitional intervention
E-10

Chiu CC, Wu SS, Lee PY, et al. Control of modifiable risk factors in ischemic stroke outpatients 

by pharmacist intervention: an equal allocation stratified randomized study. J Clin Pharm Ther 

2008;33(5):529-35. Exclude - not system-level transitional intervention

Chiu L, Shyu WC, Liu YH. Comparisons of the cost-effectiveness among hospital chronic care, 

nursing home placement, home nursing care and family care for severe stroke patients. J Adv 

Nurs 2001;33(3):380-6. Exclude - not system-level transitional intervention 

Choo J, Burke LE, Pyo Hong K. Improved quality of life with cardiac rehabilitation for postmyocardial infarction patients in Korea. Eur J Cardiovasc Nurs 2007;6(3):166-71. Exclude - not 

system-level transitional intervention

Choudhry NK, Brennan T, Toscano M, et al. Rationale and design of the Post-MI FREEE trial: a 

randomized evaluation of first-dollar drug coverage for post-myocardial infarction secondary 

preventive therapies. Am Heart J 2008;156(1):31-6. Exclude - not system-level transitional 

intervention 

Choudhry NK, Setoguchi S, Levin R, et al. Trends in adherence to secondary prevention 

medications in elderly post-myocardial infarction patients. Pharmacoepidemiol Drug Saf 

2008;17(12):1189-96. Exclude - insufficient detail/sample size

Chuang KY, Wu SC, Dai YT, et al. Post-hospital care of stroke patients in Taipei: use of services 

and policy implications. Health Policy 2007;82(1):28-36. Exclude - not system-level transitional 

intervention 

Chuang KY, Wu SC, Ma AH, et al. Identifying factors associated with hospital readmissions 

among stroke patients in Taipei. J Nurs Res 2005;13(2):117-28. Exclude - not system-level 

transitional intervention

Chuang KY, Wu SC, Yeh MC, et al. Exploring the associations between long-term care and 

mortality rates among stroke patients. J Nurs Res 2005;13(1):66-74. Exclude - not system-level 

transitional intervention 

Claesson L, Gosman-Hedstrom G, Fagerberg B, et al. Hospital re-admissions in relation to acute 

stroke unit care versus conventional care in elderly patients the first year after stroke: the 

Goteborg 70+ Stroke study. Age Ageing 2003;32(1):109-13. Exclude - not system-level 

transitional intervention 

Cobb SL, Brown DJ, Davis LL. Effective interventions for lifestyle change after myocardial 

infarction or coronary artery revascularization. J Am Acad Nurse Pract 2006;18(1):31-9. Exclude 

- systematic review for background

Cohen MG, Fonarow GC, Peterson ED, et al. Racial and ethnic differences in the treatment of 

acute myocardial infarction: findings from the Get With the Guidelines-Coronary Artery Disease 

program. Circulation 2010;121(21):2294-301. Exclude - not system-level transitional 

intervention 

Colivicchi F, Bassi A, Santini M, et al. Discontinuation of statin therapy and clinical outcome 

after ischemic stroke. Stroke 2007;38(10):2652-7. Exclude - not system-level transitional 

intervention
E-11

Conaglen P, Sebastian C, Jayaraman C, et al. Management of unstable angina and non-STelevation myocardial infarction: do cardiologists do it better? A comparison of secondary and 

tertiary centre management in New Zealand. N Z Med J 2004;117(1194):U890. Exclude - not 

system-level transitional intervention 

Cook C, Stickley L, Ramey K, et al. A variables associated with occupational and physical 

therapy stroke rehabilitation utilization and outcomes. J Allied Health 2005;34(1):3-10. Exclude 

- not system-level transitional intervention

Cortes O, Arthur HM. Determinants of referral to cardiac rehabilitation programs in patients with 

coronary artery disease: a systematic review. Am Heart J 2006;151(2):249-56. Exclude - not 

system-level transitional intervention

Cottin Y, Cambou JP, Casillas JM, et al. Specific profile and referral bias of rehabilitated 

patients after an acute coronary syndrome. J Cardiopulm Rehabil 2004;24(1):38-44. Exclude -

not system-level transitional intervention

Coyle MK. Over time: reflections after a myocardial infarction. Holist Nurs Pract 2009;23(1):49-

56. Exclude - not system-level transitional intervention 

Craciun L, Avram A, Iurciuc S, et al. Smoking prevalence in coronary patients from EuroAspire 

III Romania. Pneumologia 2009;58(3):190-4. Exclude - not system-level transitional intervention 

Cramer SC. The VECTORS study: When too much of a good thing is harmful. Neurology 

2009;73(3):170-1. Exclude - insufficient detail/sample size

Crawford VL, Dinsmore JG, Stout RW, et al. Stroke presentation and hospital management: 

comparison of neighboring healthcare systems with differing health policies. Stroke 

2009;40(6):2143-8. Exclude - not system-level transitional intervention 

Crotty M, Giles LC, Halbert J, et al. Home versus day rehabilitation: a randomised controlled 

trial. Age Ageing 2008;37(6):628-33. Exclude - not system-level transitional intervention

Crowe C. Development and implementation of a 'nurse run' post acute stroke clinic. Aust Nurs J 

2009;16(8):28-31. Exclude - no acceptable comparator

Crowther MR, Scogin F, Johnson Norton M. Treating the aged in rural communities: the 

application of cognitive-behavioral therapy for depression. J Clin Psychol 2010;66(5):502-12. 

Exclude - insufficient detail/sample size

Culler SD, Schieb L, Casper M, et al. Is there an association between quality of in-hospital 

cardiac care and proportion of low-income patients? Med Care 2010;48(3):273-8. Exclude - not 

system-level transitional intervention 

Dai YT, Chang Y, Hsieh CY, et al. Effectiveness of a pilot project of discharge planning in 

Taiwan. Res Nurs Health 2003;26(1):53-63. Exclude - no outcomes of interest

Dalal HM, Evans PH, Campbell JL, et al. Home-based versus hospital-based rehabilitation after 

myocardial infarction: A randomized trial with preference arms--Cornwall Heart Attack 

Rehabilitation Management Study (CHARMS). Int J Cardiol 2007;119(2):202-11. Exclude - not 

system-level transitional intervention
E-12

Daly J, Sindone AP, Thompson DR, et al. Barriers to participation in and adherence to cardiac 

rehabilitation programs: a critical literature review. Prog Cardiovasc Nurs 2002;17(1):8-17. 

Exclude - not system-level transitional intervention

Daugherty SL, Ho PM, Spertus JA, et al. Association of early follow-up after acute myocardial 

infarction with higher rates of medication use. Arch Intern Med 2008;168(5):485-91; discussion 

492. Exclude - not system-level transitional intervention

Dawood N, Vaccarino V, Reid KJ, et al. Predictors of smoking cessation after a myocardial 

infarction: the role of institutional smoking cessation programs in improving success. Arch 

Intern Med 2008;168(18):1961-7. Exclude - not system-level transitional intervention 

de Gevigney G, Cao D, Macfadden E, et al. Do differences in baseline characteristics or in 

management account for the poorer in-hospital and subsequent outcome after myocardial 

infarction in diabetics? Data from a large unselected cohort. Acta Cardiol 2002;57(3):187-96. 

Exclude - not system-level transitional intervention 

de Koning JS, Klazinga NS, Koudstaal PJ, et al. Quality of care in stroke prevention: results of 

an audit study among general practitioners. Prev Med 2004;38(2):129-36. Exclude - not systemlevel transitional intervention

De Luca G, de Boer MJ, Ottervanger JP, et al. Impact of beta-blocker therapy at discharge on 

long-term mortality after primary angioplasty for ST-segment elevation myocardial infarction. 

Am J Cardiol 2005;96(6):806-9. Exclude - not system-level transitional intervention 

De Luca G, Suryapranata H, Ottervanger JP, et al. Impact of statin therapy at discharge on 1-year 

mortality in patients with ST-segment elevation myocardial infarction treated with primary 

angioplasty. Atherosclerosis 2006;189(1):186-92. Exclude - not system-level transitional 

intervention 

De Luca G, Suryapranata H, van 't Hof AW, et al. Prognostic assessment of patients with acute 

myocardial infarction treated with primary angioplasty: implications for early discharge. 

Circulation 2004;109(22):2737-43. Exclude - not system-level transitional intervention 

De Silva DA, Wong TY, Chang HM, et al. Is routine retinal examination useful in patients with 

acute ischemic stroke? Stroke 2008;39(4):1352-4. Exclude - not system-level transitional 

intervention 

Degli Esposti L, Di Martino M, Saragoni S, et al. Pharmacoutilization of statin therapy after 

acute myocardial infarction. A real practice analysis based on administrative data. Ital Heart J 

2004;5(2):120-6. Exclude - not system-level transitional intervention

Demain S, Wiles R, Roberts L, et al. Recovery plateau following stroke: fact or fiction? Disabil 

Rehabil 2006;28(13-14):815-21. Exclude - not system-level transitional intervention

Deplanque D, Leys D, Parnetti L, et al. Secondary prevention of stroke in patients with atrial 

fibrillation: factors influencing the prescription of oral anticoagulation at discharge. Cerebrovasc 

Dis 2006;21(5-6):372-9. Exclude - not system-level transitional intervention

Detry JR, Vierendeel IA, Vanbutsele RJ, et al. Early short-term intensive cardiac rehabilitation 

induces positive results as long as one year after the acute coronary event: a prospective one-year 

controlled study. J Cardiovasc Risk 2001;8(6):355-61. Exclude - not system-level transitional 

intervention
E-13

Devlin G, Anderson FA, Heald S, et al. Management and outcomes of lower risk patients 

presenting with acute coronary syndromes in a multinational observational registry. Heart 

2005;91(11):1394-9. Exclude - not system-level transitional intervention 

Di Matteo M, Anderson C, Ratnasabapathy Y, et al. The Acute Stroke Unit at Middlemore 

Hospital: an evaluation in its first year of operation. N Z Med J 2004;117(1190):U798. Exclude -

not system-level transitional intervention

Diamond PT. Rehabilitative management of post-stroke visuospatial inattention. Disabil Rehabil 

2001;23(10):407-12. Exclude - not system-level transitional intervention

Dickstein R. Rehabilitation of gait speed after stroke: a critical review of intervention 

approaches. Neurorehabil Neural Repair 2008;22(6):649-60. Exclude - not system-level 

transitional intervention

Diserens K, Michel P, Bogousslavsky J. Early mobilisation after stroke: Review of the literature. 

Cerebrovasc Dis 2006;22(2-3):183-90. Exclude - not original peer-reviewed data

Domes T, Szafran O, Bilous C, et al. Acute myocardial infarction: quality of care in rural 

Alberta. Can Fam Physician 2006;52:68-9. Exclude - not system-level transitional intervention 

Donohue MA. Best-practice protocols: evidence-based care for acute myocardial infarction. Nurs 

Manage 2005;36(8):23-4, 26-7. Exclude - not system-level transitional intervention

Donovan K, Lord SE, McNaughton HK, et al. Mobility beyond the clinic: the effect of 

environment on gait and its measurement in community-ambulant stroke survivors. Clin Rehabil 

2008;22(6):556-63. Exclude - not system-level transitional intervention

Dorn J, Naughton J, Imamura D, et al. Correlates of compliance in a randomized exercise trial in 

myocardial infarction patients. Med Sci Sports Exerc 2001;33(7):1081-9. Exclude - no 

acceptable comparator

Dorsch MF, Lawrance RA, Sapsford RJ, et al. An evaluation of the relationship between 

specialist training in cardiology and implementation of evidence-based care of patients following 

acute myocardial infarction. Int J Cardiol 2004;96(3):335-40. Exclude - not system-level 

transitional intervention

Doshi VS, Say JH, Young SH, et al. Complications in stroke patients: a study carried out at the 

Rehabilitation Medicine Service, Changi General Hospital. Singapore Med J 2003;44(12):643-

52. Exclude - not system-level transitional intervention 

Doughty M, Mehta R, Bruckman D, et al. Acute myocardial infarction in the young--The 

University of Michigan experience. Am Heart J 2002;143(1):56-62. Exclude - not system-level 

transitional intervention

Drummond AE, Pearson B, Lincoln NB, et al. Ten year follow-up of a randomised controlled 

trial of care in a stroke rehabilitation unit. BMJ 2005;331(7515):491-2. Exclude - not systemlevel transitional intervention 

Duits A, Munnecom T, van Heugten C, et al. Cognitive complaints in the early phase after stroke 

are not indicative of cognitive impairment. J Neurol Neurosurg Psychiatry 2008;79(2):143-6. 

Exclude - not system-level transitional intervention 
E-14

Duncan PW, Horner RD, Reker DM, et al. Adherence to postacute rehabilitation guidelines is 

associated with functional recovery in stroke. Stroke 2002;33(1):167-77. Exclude - not systemlevel transitional intervention

Dunlay SM, Witt BJ, Allison TG, et al. Barriers to participation in cardiac rehabilitation. Am 

Heart J 2009;158(5):852-9. Exclude - not system-level transitional intervention 

Dziewierz A, Siudak Z, Rakowski T, et al. Prognostic significance of new onset atrial fibrillation 

in acute coronary syndrome patients treated conservatively. Cardiol J 2010;17(1):57-64. Exclude 

- not system-level transitional intervention 

Eagle KA, Kline-Rogers E, Goodman SG, et al. Adherence to evidence-based therapies after 

discharge for acute coronary syndromes: an ongoing prospective, observational study. Am J Med 

2004;117(2):73-81. Exclude - not system-level transitional intervention 

Echeverry D, Dike M, Jovanovic L, et al. Efforts to improve subsequent treatment of 

cardiovascular risk factors in older patients with diabetes hospitalized for a cardiac event. Am J 

Manag Care 2005;11(12):758-64. Exclude - no outcomes of interest

Economides Munoz C, Singh BN. Antithrombotic therapies for stroke prevention in atrial 

fibrillation. Minerva Cardioangiol 2004;52(2):125-39. Exclude - not system-level transitional 

intervention 

Edwards SG, Thompson AJ, Playford ED. Integrated care pathways: disease-specific or processspecific? Clin Med 2004;4(2):132-5. Exclude - insufficient detail/sample size

Ekstam L, Uppgard B, von Koch L, et al. Functioning in everyday life after stroke: a longitudinal 

study of elderly people receiving rehabilitation at home. Scand J Caring Sci 2007;21(4):434-46. 

Exclude - not system-level transitional intervention 

Ekstrand E, Ringsberg KA, Pessah-Rasmussen H. The physiotherapy clinical outcome variables 

scale predicts length of hospital stay, discharge destination and future home facility in the acute 

comprehensive stroke unit. J Rehabil Med 2008;40(7):524-8. Exclude - not system-level 

transitional intervention 

Eldar R, Ring H, Tshuwa M, et al. Quality of care for urinary incontinence in a rehabilitation 

setting for patients with stroke. Simultaneous monitoring of process and outcome. Int J Qual 

Health Care 2001;13(1):57-61. Exclude - not system-level transitional intervention 

Ellerbeck EF, Bhimaraj A, Hall S. Impact of organizational infrastructure on beta-blocker and 

aspirin therapy for acute myocardial infarction. Am Heart J 2006;152(3):579-84. Exclude - not 

system-level transitional intervention 

Ellis C, Breland HL, Egede LE. Racial/ethnic differences in utilization of post-stroke 

rehabilitation services: a systematic review. Ethn Dis 2008;18(3):365-72. Exclude - not original 

peer-reviewed data

Ellis G, Mant J, Langhorne P, et al. Stroke liaison workers for stroke patients and carers: an 

individual patient data meta-analysis. Cochrane Database Syst Rev 2010;5:CD005066. Exclude -

not original peer-reviewed data

English C, Hillier SL. Circuit class therapy for improving mobility after stroke. Cochrane 

Database Syst Rev 2010(7):CD007513. FTExcl - not system-level transitional intervention
E-15

Excoffier S, De Gevigney G, Ecochard R, et al. Treatment at discharge after myocardial 

infarction in 2,102 patients. The PRIMA study. Prise en charge de l'Infarctus du Myocarde Aigu. 

Acta Cardiol 2001;56(1):17-26. Exclude - not system-level transitional intervention 

Fagerberg B, Claesson L, Gosman-Hedstrom G, et al. Effect of acute stroke unit care integrated 

with care continuum versus conventional treatment: A randomized 1-year study of elderly 

patients: the Goteborg 70+ Stroke Study. Stroke 2000;31(11):2578-84. Exclude - not systemlevel transitional intervention

Fan CW, Farrelly E, Murphy S. Acute stroke care in an Irish general hospital. Ir Med J 

2005;98(1):11-2. Exclude - not system-level transitional intervention

Fearnley D, McLean J, Wilkins G, et al. Audit of a collaborative care model suggests patients 

with acute myocardial infarction are not disadvantaged by treatment in a rural hospital. N Z Med 

J 2002;115(1165):U239. Exclude - not system-level transitional intervention

Fernandes AW, Madhavan SS, Amonkar MM, et al. Outcomes of inappropriate prescribing of 

beta-blockers after an acute myocardial infarction in a Medicaid population. Ann Pharmacother 

2005;39(9):1416-22. Exclude - not system-level transitional intervention

Ferrieres J, Bataille V, Leclercq F, et al. Patterns of statin prescription in acute myocardial 

infarction: the French registry of Acute ST-elevation or non-ST-elevation Myocardial Infarction 

(FAST-MI). Atherosclerosis 2009;204(2):491-6. Exclude - not system-level transitional 

intervention

Ferriero G, Franchignoni F, Benevolo E, et al. The influence of comorbidities and complications 

on discharge function in stroke rehabilitation inpatients. Eura Medicophys 2006;42(2):91-6. 

Exclude - not system-level transitional intervention

Feuerstadt P, Chai A, Kligfield P. Submaximal effort tolerance as a predictor of all-cause 

mortality in patients undergoing cardiac rehabilitation. Clin Cardiol 2007;30(5):234-8. Exclude -

not system-level transitional intervention

Fiellin DA, O'Connor PG, Wang Y, et al. Quality of care for acute myocardial infarction in 

elderly patients with alcohol-related diagnoses. Alcohol Clin Exp Res 2006;30(1):70-5. Exclude 

- not system-level transitional intervention

Filippi A, D'Ambrosio G, Giustini SE, et al. Pharmacological treatment after acute myocardial 

infarction from 2001 to 2006: a survey in Italian primary care. J Cardiovasc Med (Hagerstown) 

2009;10(9):714-8. Exclude - not system-level transitional intervention

Foley N, Salter K, Teasell R. Specialized stroke services: a meta-analysis comparing three 

models of care. Cerebrovasc Dis 2007;23(2-3):194-202. Exclude - not original peer-reviewed 

data

Fonarow GC. Hospital protocols and evidence-based therapies: the importance of integrating 

aldosterone blockade into the management of patients with post-acute myocardial infarction 

heart failure. Clin Cardiol 2006;29(1):4-8. Exclude - not original peer-reviewed data 

Fonarow GC, French WJ, Parsons LS, et al. Use of lipid-lowering medications at discharge in 

patients with acute myocardial infarction: data from the National Registry of Myocardial 

Infarction 3. Circulation 2001;103(1):38-44. Exclude - not original peer-reviewed data
E-16

Foo K, Cooper J, Deaner A, et al. A single serum glucose measurement predicts adverse 

outcomes across the whole range of acute coronary syndromes. Heart 2003;89(5):512-6. Exclude 

- not system-level transitional intervention

Forster A, Young J, Green J, et al. Structured re-assessment system at 6 months after a disabling 

stroke: a randomised controlled trial with resource use and cost study. Age Ageing 

2009;38(5):576-83. Exclude - not system-level transitional intervention

Frank M, Conzelmann M, Engelter S. Prediction of discharge destination after neurological 

rehabilitation in stroke patients. Eur Neurol 2010;63(4):227-33. Exclude - not system-level 

transitional intervention 

Fransen M, Anderson C, Chalmers J, et al. Effects of a perindopril-based blood pressurelowering regimen on disability and dependency in 6105 patients with cerebrovascular disease: a 

randomized controlled trial. Stroke 2003;34(10):2333-8. Exclude - not system-level transitional 

intervention

Fremont AM, Cleary PD, Hargraves JL, et al. Patient-centered processes of care and long-term 

outcomes of myocardial infarction. J Gen Intern Med 2001;16(12):800-8. Exclude - not systemlevel transitional intervention

Fridlund B. Self-rated health in women after their first myocardial infarction: a 12-month 

comparison between participation and nonparticipation in a cardiac rehabilitation progamme. 

Health Care Women Int 2000;21(8):727-38. Exclude - not system-level transitional intervention

Frilling B, Schiele R, Gitt AK, et al. Too little aspirin for secondary prevention after acute 

myocardial infarction in patients at high risk for cardiovascular events: Results from the MITRA 

study. Am Heart J 2004;148(2):306-11. Exclude - not system-level transitional intervention

Fuentes B, Diez-Tejedor E, Ortega-Casarrubios MA, et al. Consistency of the benefits of stroke 

units over years of operation: an 8-year effectiveness analysis. Cerebrovasc Dis 2006;21(3):173-

9. Exclude - not system-level transitional intervention 

Fukuda M, Kanda T, Kamide N, et al. Gender differences in long-term functional outcome after 

first-ever ischemic stroke. Intern Med 2009;48(12):967-73. Exclude - not system-level 

transitional intervention

Gagnon D, Nadeau S, Tam V. Clinical and administrative outcomes during publicly-funded 

inpatient stroke rehabilitation based on a case-mix group classification model. J Rehabil Med 

2005;37(1):45-52. Exclude - not system-level transitional intervention

Gagnon D, Nadeau S, Tam V. Ideal timing to transfer from an acute care hospital to an 

interdisciplinary inpatient rehabilitation program following a stroke: an exploratory study. BMC 

Health Serv Res 2006;6:151. Exclude - not system-level transitional intervention

Garbusinski JM, van der Sande MA, Bartholome EJ, et al. Stroke presentation and outcome in 

developing countries: a prospective study in the Gambia. Stroke 2005;36(7):1388-93. Exclude -

not system-level transitional intervention 

Gargano JW, Reeves MJ. Sex differences in stroke recovery and stroke-specific quality of life: 

results from a statewide stroke registry. Stroke 2007;38(9):2541-8. Exclude - not system-level 

transitional intervention 
E-17

Gassaway J, Horn SD, DeJong G, et al. Applying the clinical practice improvement approach to 

stroke rehabilitation: methods used and baseline results. Arch Phys Med Rehabil 2005;86(12 

Suppl 2):S16-S33. Exclude - not system-level transitional intervention 

Gasse C, Jacobsen J, Larsen AC, et al. Secondary medical prevention among Danish patients 

hospitalised with either peripheral arterial disease or myocardial infarction. Eur J Vasc Endovasc 

Surg 2008;35(1):51-8. Exclude - not system-level transitional intervention 

Gemmell I, Heller RF, McElduff P, et al. Population impact of stricter adherence to 

recommendations for pharmacological and lifestyle interventions over one year in patients with 

coronary heart disease. J Epidemiol Community Health 2005;59(12):1041-6. Exclude - not 

system-level transitional intervention

Geusgens CA, van Heugten CM, Cooijmans JP, et al. Transfer effects of a cognitive strategy 

training for stroke patients with apraxia. J Clin Exp Neuropsychol 2007;29(8):831-41. Exclude -

not system-level transitional intervention 

Giannuzzi P, Temporelli PL, Maggioni AP, et al. GlObal Secondary Prevention strategiEs to 

Limit event recurrence after myocardial infarction: the GOSPEL study. A trial from the Italian 

Cardiac Rehabilitation Network: rationale and design. Eur J Cardiovasc Prev Rehabil 

2005;12(6):555-61. Exclude - insufficient detail/sample size

Gibbs RG, Newson R, Lawrenson R, et al. Diagnosis and initial management of stroke and 

transient ischemic attack across UK health regions from 1992 to 1996: experience of a national 

primary care database. Stroke 2001;32(5):1085-90. Exclude - not system-level transitional 

intervention 

Giladi N, Mordechovich M, Gruendlinger L, et al. "Brain Screen": A self-referral, screening 

program for strokes, falls and dementia risk factors. J Neurol 2006;253(3):307-15. Exclude - not 

system-level transitional intervention 

Ginn MB, Cox G, Heath J. Evidence-based approach to an inpatient tobacco cessation protocol. 

AACN Adv Crit Care 2008;19(3):268-78; quiz 279-80. Exclude - not system-level transitional 

intervention 

Gislason GH, Abildstrom SZ, Rasmussen JN, et al. Nationwide trends in the prescription of betablockers and angiotensin-converting enzyme inhibitors after myocardial infarction in Denmark, 

1995-2002. Scand Cardiovasc J 2005;39(1-2):42-9. Exclude - not system-level transitional 

intervention 

Gislason GH, Rasmussen JN, Abildstrom SZ, et al. Long-term compliance with beta-blockers, 

angiotensin-converting enzyme inhibitors, and statins after acute myocardial infarction. Eur 

Heart J 2006;27(10):1153-8. Exclude - not system-level transitional intervention 

Glader EL, Sjolander M, Eriksson M, et al. Persistent use of secondary preventive drugs declines 

rapidly during the first 2 years after stroke. Stroke 2010;41(2):397-401. Exclude - not systemlevel transitional intervention

Glader EL, Stegmayr B, Johansson L, et al. Differences in long-term outcome between patients 

treated in stroke units and in general wards: a 2-year follow-up of stroke patients in sweden. 

Stroke 2001;32(9):2124-30. Exclude - not system-level transitional intervention 
E-18

Glader EL, Stegmayr B, Norrving B, et al. Large variations in the use of oral anticoagulants in 

stroke patients with atrial fibrillation: a Swedish national perspective. J Intern Med 

2004;255(1):22-32. Exclude - not system-level transitional intervention 

Goldberg RJ, Currie K, White K, et al. Six-month outcomes in a multinational registry of 

patients hospitalized with an acute coronary syndrome (the Global Registry of Acute Coronary 

Events [GRACE]). Am J Cardiol 2004;93(3):288-93. Exclude - not system-level transitional 

intervention 

Goldstein LB, Matchar DB, Hoff-Lindquist J, et al. VA Stroke Study: neurologist care is 

associated with increased testing but improved outcomes. Neurology 2003;61(6):792-6. Exclude 

- not system-level transitional intervention 

Goldstein LB, Matchar DB, Hoff-Lindquist J, et al. Veterans Administration Acute Stroke 

(VASt) Study: lack of race/ethnic-based differences in utilization of stroke-related procedures or 

services. Stroke 2003;34(4):999-1004. Exclude - not system-level transitional intervention 

Gosman-Hedstrom G, Claesson L, Blomstrand C. Consequences of severity at stroke onset for 

health-related quality of life (HRQL) and informal care: a 1-year follow-up in elderly stroke 

survivors. Arch Gerontol Geriatr 2008;47(1):79-91. Exclude - not system-level transitional 

intervention 

Gottlieb S, Behar S, Hod H, et al. Trends in management, hospital and long-term outcomes of 

elderly patients with acute myocardial infarction. Am J Med 2007;120(1):90-7. Exclude - not 

system-level transitional intervention 

Gouya G, Reichardt B, Ohrenberger G, et al. Survival of patients discharged after acute 

myocardial infarction and evidence-based drug therapy. Eur J Epidemiol 2007;22(3):145-9. 

Exclude - not system-level transitional intervention 

Graham JE, Ripsin CM, Deutsch A, et al. Relationship between diabetes codes that affect

Medicare reimbursement (tier comorbidities) and outcomes in stroke rehabilitation. Arch Phys 

Med Rehabil 2009;90(7):1110-6. Exclude - not system-level transitional intervention 

Granger CB, Steg PG, Peterson E, et al. Medication performance measures and mortality 

following acute coronary syndromes. Am J Med 2005;118(8):858-65. Exclude - not system-level 

transitional intervention 

Green T, Haley E, Eliasziw M, et al. Education in stroke prevention: efficacy of an educational 

counselling intervention to increase knowledge in stroke survivors. Can J Neurosci Nurs 

2007;29(2):13-20. Exclude - not system-level transitional intervention 

Greenberg E, Treger J, Ring H. Post-stroke follow-up in a rehabilitation center outpatient clinic. 

Isr Med Assoc J 2004;6(10):603-6. Exclude - no acceptable comparator

Gregory PC, Han E, Morozova O, et al. Do racial disparities exist in access to inpatient stroke 

rehabilitation in the state of Maryland? Am J Phys Med Rehabil 2006;85(10):814-9. Exclude -

not system-level transitional intervention

Guadagnoli E, Normand SL, DiSalvo TG, et al. Effects of treatment recommendations and 

specialist intervention on care provided by primary care physicians to patients with myocardial 

infarction or heart failure. Am J Med 2004;117(6):371-9. Exclude - no outcomes of interest
E-19

Gupta M, Doobay AV, Singh N, et al. Risk factors, hospital management and outcomes after 

acute myocardial infarction in South Asian Canadians and matched control subjects. CMAJ 

2002;166(6):717-22. Exclude - not system-level transitional intervention 

Gutierrez ME, Labovitz AJ. Underutilization of beta-adrenoceptor antagonists post-myocardial 

infarction. Am J Cardiovasc Drugs 2005;5(1):23-9. Exclude - not system-level transitional 

intervention 

Hackam DG, Spence JD. Combining multiple approaches for the secondary prevention of 

vascular events after stroke: a quantitative modeling study. Stroke 2007;38(6):1881-5. Exclude -

not system-level transitional intervention 

Hackett ML, Vandal AC, Anderson CS, et al. Long-term outcome in stroke patients and 

caregivers following accelerated hospital discharge and home-based rehabilitation. Stroke 

2002;33(2):643-5. Exclude - insufficient detail/sample size

Haddad H, Searles G, Gillis A. The management of patients who have suffered an acute 

myocardial infarction in a tertiary care centre. Can J Cardiol 2001;17(2):179-83. Exclude - not 

system-level transitional intervention 

Hage C, Mattsson E, Stahle A. Long-term effects of exercise training on physical activity level 

and quality of life in elderly coronary patients--a three- to six-year follow-up. Physiother Res Int 

2003;8(1):13-22. Exclude - not system-level transitional intervention

Hama S, Yamashita H, Kato T, et al. 'Insistence on recovery' as a positive prognostic factor in 

Japanese stroke patients. Psychiatry Clin Neurosci 2008;62(4):386-95. Exclude - not system-level 

transitional intervention 

Hao SC, Chai A, Kligfield P. Heart rate recovery response to symptom-limited treadmill exercise 

after cardiac rehabilitation in patients with coronary artery disease with and without recent 

events. Am J Cardiol 2002;90(7):763-5. Exclude - not system-level transitional intervention 

Harats D, Leibovitz E, Maislos M, et al. Cardiovascular risk assessment and treatment to target 

low density lipoprotein levels in hospitalized ischemic heart disease patients: results of the 

HOLEM study. Isr Med Assoc J 2005;7(6):355-9. Exclude - no outcomes of interest

Harrington R, Taylor G, Hollinghurst S, et al. A community-based exercise and education 

scheme for stroke survivors: a randomized controlled trial and economic evaluation. Clin 

Rehabil 2010;24(1):3-15. Exclude - not system-level transitional intervention

Hart J, Kanner H, Gilboa-Mayo R, et al. Tai Chi Chuan practice in community-dwelling persons 

after stroke. Int J Rehabil Res 2004;27(4):303-4. Exclude - not system-level transitional 

intervention

Hartman-Maeir A, Eliad Y, Kizoni R, et al. Evaluation of a long-term community based 

rehabilitation program for adult stroke survivors. NeuroRehabilitation 2007;22(4):295-301. 

Exclude - not system-level transitional intervention

Hawkes AL, Atherton J, Taylor CB, et al. Randomised controlled trial of a secondary prevention 

program for myocardial infarction patients ('ProActive Heart'): study protocol. Secondary 

prevention program for myocardial infarction patients. BMC Cardiovasc Disord 2009;9:16. 

Exclude - no outcomes of interest
E-20

Hayes J, Vogel B, Reker DM. Factors associated with VHA costs of care for first 12 months 

after first stroke. J Rehabil Res Dev 2008;45(9):1375-84. Exclude - not system-level transitional 

intervention

Heckert KD, Komaroff E, Adler U, et al. Postacute reevaluation may prevent Dysphagiaassociated morbidity. Stroke 2009;40(4):1381-5. Exclude - not system-level transitional 

intervention

Heggunje PS, Harjai KJ, Stone GW, et al. Procedural success versus clinical risk status in 

determining discharge of patients after primary angioplasty for acute myocardial infarction. J 

Am Coll Cardiol 2004;44(7):1400-7. Exclude - not system-level transitional intervention 

Heijnen IC, Franken RJ, Bevaart BJ, et al. Long-term outcome of superficialis-to-profundus 

tendon transfer in patients with clenched fist due to spastic hemiplegia. Disabil Rehabil 

2008;30(9):675-8. Exclude - not system-level transitional intervention

Helin-Salmivaara A, Virtanen A, Vesalainen R, et al. NSAID use and the risk of hospitalization 

for first myocardial infarction in the general population: a nationwide case-control study from 

Finland. Eur Heart J 2006;27(14):1657-63. Exclude - not system-level transitional intervention 

Hellstrom K, Lindmark B, Wahlberg B, et al. Self-efficacy in relation to impairments and 

activities of daily living disability in elderly patients with stroke: a prospective investigation. J 

Rehabil Med 2003;35(5):202-7. Exclude - not system-level transitional intervention 

Henderson LR, Scott A. The costs of caring for stroke patients in a GP-led community hospital: 

an application of programme budgeting and marginal analysis. Health Soc Care Community 

2001;9(4):244-54. Exclude - not original peer-reviewed data

Hendricks HT, van Limbeek J, Geurts AC, et al. Motor recovery after stroke: a systematic 

review of the literature. Arch Phys Med Rehabil 2002;83(11):1629-37. Exclude - not systemlevel transitional intervention

Hershkovitz A, Beloosesky Y, Brill S, et al. Is a day hospital rehabilitation programme 

associated with reduction of handicap in stroke patients? Clin Rehabil 2004;18(3):261-6. Exclude 

- no acceptable comparator

Heung TH, Ng SS. Effect of seat height and turning direction on the timed up and go test scores 

of people after stroke. J Rehabil Med 2009;41(9):719-22. Exclude - not system-level transitional 

intervention

Hevey D, Brown A, Cahill A, et al. Four-week multidisciplinary cardiac rehabilitation produces 

similar improvements in exercise capacity and quality of life to a 10-week program. J 

Cardiopulm Rehabil 2003;23(1):17-21. Exclude - not system-level transitional intervention

Hildingh C, Fridlund B. Participation in peer support groups after a cardiac event: a 12-month 

follow-up. Rehabil Nurs 2003;28(4):123-8. Exclude methods paper for background

Hildingh C, Fridlund B, Baigi A. Sense of coherence and experiences of social support and 

mastery in the early discharge period after an acute cardiac event. J Clin Nurs 2008;17(10):1303-

11. Exclude - not system-level transitional intervention 

Hillen T, Coshall C, Tilling K, et al. Cause of stroke recurrence is multifactorial: patterns, risk 

factors, and outcomes of stroke recurrence in the South London Stroke Register. Stroke 

2003;34(6):1457-63. Exclude - not system-level transitional intervention 
E-21

Hiltunen EF, Winder PA, Rait MA, et al. Implementation of efficacy enhancement nursing 

interventions with cardiac elders. Rehabil Nurs 2005;30(6):221-9. Exclude - no acceptable 

comparator

Hitzeman N, Reiss M. Occupational therapy improves activities of daily living after stroke. Am 

Fam Physician 2007;75(11):1651-2. Exclude - not original peer-reviewed data 

Hjemdahl P, Eriksson SV, Held C, et al. Favourable long term prognosis in stable angina 

pectoris: an extended follow up of the angina prognosis study in Stockholm (APSIS). Heart 

2006;92(2):177-82. Exclude - not stroke/MI

Ho PM, Spertus JA, Masoudi FA, et al. Impact of medication therapy discontinuation on 

mortality after myocardial infarction. Arch Intern Med 2006;166(17):1842-7. Exclude - not 

system-level transitional intervention

Hoenig H, Duncan PW, Horner RD, et al. Structure, process, and outcomes in stroke 

rehabilitation. Med Care 2002;40(11):1036-47. Exclude - not system-level transitional 

intervention

Hoenig H, Sloane R, Horner RD, et al. Differences in rehabilitation services and outcomes 

among stroke patients cared for in veterans hospitals. Health Serv Res 2001;35(6):1293-318. 

Exclude - not system-level transitional intervention

Horn SD, DeJong G, Smout RJ, et al. Stroke rehabilitation patients, practice, and outcomes: is 

earlier and more aggressive therapy better? Arch Phys Med Rehabil 2005;86(12 Suppl 2):S101-

S114. Exclude - not system-level transitional intervention 

Hoverman C, Shugarman LR, Saliba D, et al. Use of postacute care by nursing home residents 

hospitalized for stroke or hip fracture: how prevalent and to what end? J Am Geriatr Soc 

2008;56(8):1490-6. Exclude - not system-level transitional intervention 

Hu X, Tong KY, Song R, et al. Variation of muscle coactivation patterns in chronic stroke during 

robot-assisted elbow training. Arch Phys Med Rehabil 2007;88(8):1022-9. Exclude - insufficient 

detail/sample size

Hudson M, Richard H, Pilote L. Parabolas of medication use and discontinuation after 

myocardial infarction--are we closing the treatment gap? Pharmacoepidemiol Drug Saf 

2007;16(7):773-85. Exclude - not system-level transitional intervention 

Hui PN, Wan M, Chan WK, et al. An evaluation of two behavioral rehabilitation programs, 

qigong versus progressive relaxation, in improving the quality of life in cardiac patients. J Altern 

Complement Med 2006;12(4):373-8. Exclude - not system-level transitional intervention 

Hui-Chan CW, Ng SS, Mak MK. Effectiveness of a home-based rehabilitation programme on 

lower limb functions after stroke. Hong Kong Med J 2009;15(3 Suppl 4):42-6. Exclude - not 

system-level transitional intervention 

Huijbregts MP, Myers AM, Streiner D, et al. Implementation, process, and preliminary outcome 

evaluation of two community programs for persons with stroke and their care partners. Top 

Stroke Rehabil 2008;15(5):503-20. Exclude - not system-level transitional intervention

Ilarraza H, Myers J, Kottman W, et al. An evaluation of training responses using self-regulation 

in a residential rehabilitation program. J Cardiopulm Rehabil 2004;24(1):27-33. Exclude - not 

system-level transitional intervention 
E-22

Ilett PA, Brock KA, Graven CJ, et al. Selecting patients for rehabilitation after acute stroke: are 

there variations in practice? Arch Phys Med Rehabil 2010;91(5):788-93. Exclude - not systemlevel transitional intervention 

Ilse IB, Feys H, de Wit L, et al. Stroke caregivers' strain: prevalence and determinants in the first 

six months after stroke. Disabil Rehabil 2008;30(7):523-30. Exclude - not system-level 

transitional intervention 

Indredavik B, Rohweder G, Naalsund E, et al. Medical complications in a comprehensive stroke 

unit and an early supported discharge service. Stroke 2008;39(2):414-20. Exclude - not systemlevel transitional intervention 

Ivanhoe CB, Francisco GE, McGuire JR, et al. Intrathecal baclofen management of poststroke 

spastic hypertonia: implications for function and quality of life. Arch Phys Med Rehabil 

2006;87(11):1509-15. Exclude - not system-level transitional intervention 

Izawa K, Hirano Y, Yamada S, et al. Improvement in physiological outcomes and health-related 

quality of life following cardiac rehabilitation in patients with acute myocardial infarction. Circ J 

2004;68(4):315-20. Exclude - not system-level transitional intervention 

Jackevicius CA, Li P, Tu JV. Prevalence, predictors, and outcomes of primary nonadherence 

after acute myocardial infarction. Circulation 2008;117(8):1028-36. Exclude - not system-level 

transitional intervention

Jacob L, Poletick EB. Systematic review: predictors of successful transition to community-based 

care for adults with chronic care needs. Care Management Journals 2008;9(4):154-165. Exclude -

SR/MA for background

Jarrell LA, Hains SJ, Kisilevsky BS, et al. Gender differences in functional capacity following 

myocardial infarction: an exploratory study. Can J Cardiovasc Nurs 2005;15(1):28-33. Exclude -

not system-level transitional intervention 

Jennings S, Carey D. Capacity and equity in cardiac rehabilitation in the eastern region: good 

and bad news. Ir J Med Sci 2004;173(3):151-4. Exclude - not system-level transitional 

intervention 

Jia H, Zheng Y, Reker DM, et al. Multiple system utilization and mortality for veterans with 

stroke. Stroke 2007;38(2):355-60. Exclude - not system-level transitional intervention

Jiang Q, Zhang ZG, Zhang L, et al. MRI evaluation of treatment of embolic stroke in rat with 

intra-arterial and intravenous rt-PA. J Neurol Sci 2004;224(1-2):57-67. Exclude - not 

humans/under 18

Jirmar R, Widimsky P, Capek J, et al. Next day discharge after successful primary angioplasty 

for acute ST elevation myocardial infarction. An open randomized study "Prague-5". Int Heart J 

2008;49(6):653-9. Exclude - not system-level transitional intervention

Jobin J. Long-term effects of cardiac rehabilitation and the paradigms of cardiac rehabilitation. J 

Cardiopulm Rehabil 2005;25(2):103-6. Exclude - no acceptable comparator

Joekes K, Maes S, Warrens M. Predicting quality of life and self-management from dyadic 

support and overprotection after myocardial infarction. Br J Health Psychol 2007;12(Pt 4):473-

89. Exclude - not system-level transitional intervention
E-23

Johnson EA, Bakas T, Lyon BL. Cognitive Appraisal of Health Scale: early instrument 

development in stroke. Clin Nurse Spec 2008;22(1):12-8. Exclude - not system-level transitional 

intervention 

Johnston SC, Sidney S, Hills NK, et al. Standardized discharge orders after stroke: results of the 

quality improvement in stroke prevention (QUISP) cluster randomized trial. Ann Neurol 

2010;67(5):579-89. Exclude - not stroke/MI

Jolliffe JA, Rees K, Taylor RS, et al. Exercise-based rehabilitation for coronary heart disease. 

Cochrane Database Syst Rev 2001(1):CD001800. Exclude - not original peer-reviewed data

Jolly K, Taylor R, Lip GY, et al. The Birmingham Rehabilitation Uptake Maximisation Study 

(BRUM). Home-based compared with hospital-based cardiac rehabilitation in a multi-ethnic 

population: cost-effectiveness and patient adherence. Health Technol Assess 2007;11(35):1-118. 

Exclude - not system-level transitional intervention

Jones F, Mandy A, Partridge C. Changing self-efficacy in individuals following a first time 

stroke: preliminary study of a novel self-management intervention. Clin Rehabil 2009;23(6):522-

33. Exclude - insufficient detail/sample size

Kalra L, Langhorne P. Facilitating recovery: evidence for organized stroke care. J Rehabil Med 

2007;39(2):97-102. Exclude - Meta-Analysis for background

Kandzari DE, Tcheng JE, Cohen DJ, et al. Feasibility and implications of an early discharge 

strategy after percutaneous intervention with abciximab in acute myocardial infarction (the 

CADILLAC Trial). Am J Cardiol 2003;92(7):779-84. Exclude - not system-level transitional 

intervention

Kapral MK, Wang H, Mamdani M, et al. Effect of socioeconomic status on treatment and 

mortality after stroke. Stroke 2002;33(1):268-73. Exclude - not system-level transitional 

intervention

Katalinic A, Waldmann A, Schwaab B, et al. The TeleGuard trial of additional telemedicine care 

in CAD patients. 1 Utilization of the system. J Telemed Telecare 2008;14(1):17-21. Exclude -

insufficient detail/sample size

Katrak PH, Black D, Peeva V. Do stroke patients with intracerebral hemorrhage have a better 

functional outcome than patients with cerebral infarction? PM R 2009;1(5):427-33. Exclude - not 

system-level transitional intervention 

Kaul P, Newby LK, Fu Y, et al. International differences in evolution of early discharge after 

acute myocardial infarction. Lancet 2004;363(9408):511-7. Exclude - not system-level 

transitional intervention 

Kawamura A, Lombardi DA, Tilem ME, et al. Stroke complicating percutaneous coronary 

intervention in patients with acute myocardial infarction. Circ J 2007;71(9):1370-5. Exclude - not 

system-level transitional intervention 

Kelly H, Brady MC, Enderby P. Speech and language therapy for aphasia following stroke. 

Cochrane Database Syst Rev 2010;5:CD000425. Exclude - not original peer-reviewed data

Kendall E, Catalano T, Kuipers P, et al. Recovery following stroke: the role of self-management 

education. Soc Sci Med 2007;64(3):735-46. Exclude - not system-level transitional intervention 
E-24

Keren O, Motin M, Heinemann AW, et al. Relationship between rehabilitation therapies and 

outcome of stroke patients in Israel: a preliminary study. Isr Med Assoc J 2004;6(12):736-41. 

Exclude - not system-level transitional intervention

Khan TI, Kamali F, Kesteven P, et al. The value of education and self-monitoring in the 

management of warfarin therapy in older patients with unstable control of anticoagulation. Br J 

Haematol 2004;126(4):557-64. Exclude - not stroke/MI

Kim JH, Jang SH, Kim CS, et al. Use of virtual reality to enhance balance and ambulation in 

chronic stroke: a double-blind, randomized controlled study. Am J Phys Med Rehabil 

2009;88(9):693-701. Exclude - not system-level transitional intervention

Kim YJ, Soeken KL. A meta-analysis of the effect of hospital-based case management on 

hospital length-of-stay and readmission. Nurs Res 2005;54(4):255-64. Exclude - not original 

peer-reviewed data

Kind AJ, Smith MA, Frytak JR, et al. Bouncing back: patterns and predictors of complicated 

transitions 30 days after hospitalization for acute ischemic stroke. J Am Geriatr Soc 

2007;55(3):365-73. Exclude - no acceptable comparator 

Kind AJ, Smith MA, Liou JI, et al. The price of bouncing back: one-year mortality and payments 

for acute stroke patients with 30-day bounce-backs. J Am Geriatr Soc 2008;56(6):999-1005. 

Exclude - no acceptable comparator 

King KM, Humen DP, Smith HL, et al. Psychosocial components of cardiac recovery and 

rehabilitation attendance. Heart 2001;85(3):290-4. Exclude - no acceptable comparator

King RB, Carlson CE, Shade-Zeldow Y, et al. Transition to home care after stroke: depression, 

physical health, and adaptive processes in support persons. Res Nurs Health 2001;24(4):307-23. 

Exclude - no acceptable comparator

King RB, Semik PE. Stroke caregiving: difficult times, resource use, and needs during the first 2 

years. J Gerontol Nurs 2006;32(4):37-44. Exclude - no acceptable comparator

Kinjo K, Sato H, Sakata Y, et al. Identification of uncomplicated patients with acute myocardial 

infarction undergoing percutaneous coronary intervention: are these patients suitable for early 

discharge? Circ J 2005;69(10):1163-9. Exclude - not system-level transitional intervention 

Kinsman LD, Buykx P, Humphreys JS, et al. A cluster randomised trial to assess the impact of 

clinical pathways on AMI management in rural Australian emergency departments. BMC Health 

Serv Res 2009;9:83. Exclude - not system-level transitional intervention

Koizumi T, Miyazaki A, Komiyama N, et al. Improvement of left ventricular dysfunction during 

exercise by walking in patients with successful percutaneous coronary intervention for acute 

myocardial infarction. Circ J 2003;67(3):233-7. Exclude - not system-level transitional 

intervention

Kollen BJ, Lennon S, Lyons B, et al. The effectiveness of the Bobath concept in stroke 

rehabilitation: what is the evidence? Stroke 2009;40(4):e89-97. Exclude - not original peerreviewed data

Kountouris E, Pappa E, Korantzopoulos P, et al. Usefulness of predischarge exercise 

electrocardiographic testing in detecting the late patency status of the infarct-related artery. Heart 

Vessels 2004;19(3):111-5. Exclude - not system-level transitional intervention 
E-25

Kramer JM, Hammill B, Anstrom KJ, et al. National evaluation of adherence to beta-blocker 

therapy for 1 year after acute myocardial infarction in patients with commercial health insurance. 

Am Heart J 2006;152(3):454 e1-8. Exclude - not system-level transitional intervention

Kristensen SD, Andersen HR, Thuesen L, et al. Should patients with acute ST elevation MI be 

transferred for primary PCI? Heart 2004;90(11):1358-63. Exclude - not system-level transitional 

intervention 

Kristofferzon ML, Lofmark R, Carlsson M. Striving for balance in daily life: experiences of 

Swedish women and men shortly after a myocardial infarction. J Clin Nurs 2007;16(2):391-401. 

Exclude - not system-level transitional intervention

Krupicka J, Widimsky P, Nechvatal L, et al. Inter-hospital transport for primary angioplasty does 

not compromise left ventricular function: six-month echocardiographic follow-up of the 

PRAGUE 1 Study. Jpn Heart J 2003;44(3):313-22. Exclude - not system-level transitional 

intervention 

Kulzer AM, Scolari CC, Gus M. Relationship between usual physical, cognitive and social 

activities and functional recovery at hospital discharge after acute stroke. J Rehabil Med 

2008;40(3):195-9. Exclude - not system-level transitional intervention 

Kuo YF, Ostir GV, Granger CV, et al. Examination of follow-up therapy in patients with stroke. 

Am J Phys Med Rehabil 2006;85(3):192-200. Exclude - not system-level transitional 

intervention

Kurdyak PA, Gnam WH, Goering P, et al. The relationship between depressive symptoms, 

health service consumption, and prognosis after acute myocardial infarction: a prospective cohort 

study. BMC Health Serv Res 2008;8:200. Exclude - not system-level transitional intervention 

Kwan J. Care pathways for acute stroke care and stroke rehabilitation: from theory to evidence. J 

Clin Neurosci 2007;14(3):189-200. Exclude - not system-level transitional intervention 

Kwan J, Hand P, Dennis M, et al. Effects of introducing an integrated care pathway in an acute 

stroke unit. Age Ageing 2004;33(4):362-7. Exclude - not system-level transitional intervention 

Kwan J, Sandercock P. In-hospital care pathways for stroke. Cochrane Database Syst Rev 

2002(2):CD002924. Exclude - not system-level transitional intervention 

Kwan J, Sandercock P. In-hospital care pathways for stroke: a Cochrane systematic review. 

Stroke 2003;34(2):587-8. Exclude - not system-level transitional intervention 

Kyei G, Oakeshott P, Kerry S, et al. Supporting self-care in general practice. Br J Gen Pract 

2007;57(545):995-6. Exclude - not original peer-reviewed data

Ladeia AM, Guimaraes AC. Assessment of risk factors in coronary patients being followed by 

cardiologists: control of risk factors in coronary patients. Prev Cardiol 2003;6(3):122-7. Exclude 

- not system-level transitional intervention 

Lamb SE, Ferrucci L, Volapto S, et al. Risk factors for falling in home-dwelling older women 

with stroke: the Women's Health and Aging Study. Stroke 2003;34(2):494-501. Exclude - not 

system-level transitional intervention 
E-26

Landi F, Cesari M, Onder G, et al. Effects of an occupational therapy program on functional 

outcomes in older stroke patients. Gerontology 2006;52(2):85-91. Exclude - not system-level 

transitional intervention 

Lane D, Carroll D, Ring C, et al. Predictors of attendance at cardiac rehabilitation after 

myocardial infarction. J Psychosom Res 2001;51(3):497-501. Exclude - not system-level 

transitional intervention 

Langhammer B, Stanghelle JK. Bobath or motor relearning programme? A follow-up one and 

four years post stroke. Clin Rehabil 2003;17(7):731-4. Exclude - not system-level transitional 

intervention 

Langhammer B, Stanghelle JK, Lindmark B. Exercise and health-related quality of life during 

the first year following acute stroke. A randomized controlled trial. Brain Inj 2008;22(2):135-45. 

Exclude - not system-level transitional intervention 

Langhorne P, Duncan P. Does the organization of postacute stroke care really matter? Stroke 

2001;32(1):268-74. Exclude - not system-level transitional intervention 

Langhorne P, Holmqvist LW. Early supported discharge after stroke. J Rehabil Med 

2007;39(2):103-8. Exclude - Systematic Review for background

Langhorne P, Taylor G, Murray G, et al. Early supported discharge services for stroke patients: a 

meta-analysis of individual patients' data. Lancet 2005;365(9458):501-6. Exclude - MetaAnalysis for background

Lapointe F, Lepage S, Larrivee L, et al. Surveillance and treatment of dyslipidemia in the postinfarct patient: can a nurse-led management approach make a difference? Can J Cardiol 

2006;22(9):761-7. Exclude - no outcomes of interest

Larsen T, Olsen TS, Sorensen J. Early home-supported discharge of stroke patients: a health 

technology assessment. Int J Technol Assess Health Care 2006;22(3):313-20. Exclude -

Systematic Review for background

Lau AL, McKenna K, Chan CC, et al. Defining quality of life for Chinese elderly stroke 

survivors. Disabil Rehabil 2003;25(13):699-711. Exclude - not system-level transitional 

intervention 

Lee PG, Cigolle C, Blaum C. The co-occurrence of chronic diseases and geriatric syndromes: the 

health and retirement study. J Am Geriatr Soc 2009;57(3):511-6. Exclude - not system-level 

transitional intervention 

Legg L, Langhorne P. Rehabilitation therapy services for stroke patients living at home: 

systematic review of randomised trials. Lancet 2004;363(9406):352-6. Exclude - Systematic 

Review for background

Lieberman D. Rehabilitation following stroke in patients aged 85 and above. J Rehabil Res Dev 

2005;42(1):47-53. Exclude - not system-level transitional intervention 

Liem SS, van der Hoeven BL, Oemrawsingh PV, et al. MISSION!: optimization of acute and 

chronic care for patients with acute myocardial infarction. Am Heart J 2007;153(1):14 e1-11. 

Exclude - no outcomes of interest
E-27

Loeppke R, Edington DW, Beg S. Impact of the prevention plan on employee health risk 

reduction. Population Health Management 2010;13(5):275-284. Exclude - does not study stroke 

or MI

Low JT, Roderick P, Payne S. An exploration looking at the impact of domiciliary and day 

hospital delivery of stroke rehabilitation on informal carers. Clin Rehabil 2004;18(7):776-84. 

Exclude - no acceptable comparator

Luft HS. Variations in patterns of care and outcomes after acute myocardial infarction for 

Medicare beneficiaries in fee-for-service and HMO settings. Health Serv Res 2003;38(4):1065-

79. Exclude - not system-level transitional intervention 

Lummis HL, Sketris IS, Gubitz GJ, et al. Medication persistence rates and factors associated 

with persistence in patients following stroke: a cohort study. BMC Neurol 2008;8:25. Exclude -

not system-level transitional intervention 

Ma R, Wang C, Zhao X, et al. A survey on compliance with secondary stroke prevention 

guidelines and follow up for the inpatients with atherosclerotic cerebral infarction/transient 

ischemic attack. Neurol Res 2008;30(4):383-8. Exclude - not system-level transitional 

intervention 

Machecourt J, Bonnefoy E, Vanzetto G, et al. Primary angioplasty is cost-minimizing compared 

with pre-hospital thrombolysis for patients within 60 min of a percutaneous coronary 

intervention center: the Comparison of Angioplasty and Pre-hospital Thrombolysis in Acute 

Myocardial Infarction (CAPTIM) cost-efficacy sub-study. J Am Coll Cardiol 2005;45(4):515-24. 

Exclude - not system-level transitional intervention 

MacIsaac L, Harrison MB, Godfrey C. Supportive care needs of caregivers of individuals 

following stroke: a synopsis of research. Can J Neurosci Nurs 2010;32(1):39-46. Exclude - not 

original peer-reviewed data

Mackintosh SF, Hill K, Dodd KJ, et al. Falls and injury prevention should be part of every stroke 

rehabilitation plan. Clin Rehabil 2005;19(4):441-51. Exclude - not system-level transitional 

intervention 

Majumdar SR, Inui TS, Gurwitz JH, et al. Influence of physician specialty on adoption and 

relinquishment of calcium channel blockers and other treatments for myocardial infarction. J 

Gen Intern Med 2001;16(6):351-9. Exclude - not system-level transitional intervention 

Malfatto G, Blengino S, Annoni L, et al. Original articles primary coronary angioplasty and 

subsequent cardiovascular rehabilitation are linked to a favorable sympathovagal balance after a 

first anterior myocardial infarction. Ital Heart J 2005;6(1):21-7. Exclude - not system-level 

transitional intervention 

Mark L, Dani G, Nagy E, et al. The evaluation of short and long-term administration of drugs 

improving life expectancy in patients with myocardial infarction in a Hungarian county hospital. 

Cent Eur J Public Health 2006;14(1):6-9. Exclude - not system-level transitional intervention 

Massucci M, Perdon L, Agosti M, et al. Prognostic factors of activity limitation and discharge 

destination after stroke rehabilitation. Am J Phys Med Rehabil 2006;85(12):963-70. Exclude -

not system-level transitional intervention 
E-28

Maulden SA, Gassaway J, Horn SD, et al. Timing of initiation of rehabilitation after stroke. Arch 

Phys Med Rehabil 2005;86(12 Suppl 2):S34-S40. Exclude - no acceptable comparator

Mayo NE, Scott SC, Ahmed S. Case management poststroke did not induce response shift: the 

value of residuals. J Clin Epidemiol 2009;62(11):1148-56. Exclude - not original peer-reviewed 

data

Mayo NE, Wood-Dauphinee S, Cote R, et al. Activity, participation, and quality of life 6 months 

poststroke. Arch Phys Med Rehabil 2002;83(8):1035-42. Exclude - not system-level transitional 

intervention 

Mazzini MJ, Stevens GR, Whalen D, et al. Effect of an American Heart Association Get With 

the Guidelines program-based clinical pathway on referral and enrollment into cardiac 

rehabilitation after acute myocardial infarction. Am J Cardiol 2008;101(8):1084-7. Exclude - no 

acceptable comparator 

McLaughlin TJ, Aupont O, Bambauer KZ, et al. Improving psychologic adjustment to chronic 

illness in cardiac patients. The role of depression and anxiety. J Gen Intern Med 

2005;20(12):1084-90. Exclude - not system-level transitional intervention

Mead GE, Greig CA, Cunningham I, et al. Stroke: a randomized trial of exercise or relaxation. J 

Am Geriatr Soc 2007;55(6):892-9. Exclude - not system-level transitional intervention 

Mehta RH, Montoye CK, Faul J, et al. Enhancing quality of care for acute myocardial infarction: 

shifting the focus of improvement from key indicators to process of care and tool use: the 

American College of Cardiology Acute Myocardial Infarction Guidelines Applied in Practice 

Project in Michigan: Flint and Saginaw Expansion. J Am Coll Cardiol 2004;43(12):2166-73. 

Exclude - not system-level transitional intervention

Mehta RH, Montoye CK, Gallogly M, et al. Improving quality of care for acute myocardial 

infarction: The Guidelines Applied in Practice (GAP) Initiative. JAMA 2002;287(10):1269-76. 

Exclude - not system-level transitional intervention

Meijer R, van Limbeek J, de Haan R. Development of the Stroke-unit Discharge Guideline: 

choice of assessment instruments for prediction in the subacute phase post-stroke. Int J Rehabil 

Res 2006;29(1):1-8. Exclude - not system-level transitional intervention

Meijer R, van Limbeek J, Peusens G, et al. The Stroke Unit Discharge Guideline, a prognostic 

framework for the discharge outcome from the hospital stroke unit. A prospective cohort study. 

Clin Rehabil 2005;19(7):770-8. Exclude - no acceptable comparator 

Meisel ZF, Armstrong K, Mechem CC, et al. Influence of sex on the out-of-hospital management 

of chest pain. Acad Emerg Med 2010;17(1):80-7. Exclude - not stroke/MI

Miller D, Ellis T, Fetters L. Does the literature indicate that patients who have had a stroke have 

better outcomes after receiving rehabilitation from an acute rehabilitation facility than from a 

skilled nursing facility? Phys Ther 2005;85(1):67-76. Exclude - not original peer-reveiwed data

Miyoshi Y, Teraoka JK, Date ES, et al. Changes in stroke rehabilitation outcomes after the 

implementation of Japan's long-term care insurance system: a hospital-based study. Am J Phys 

Med Rehabil 2005;84(8):613-9. Exclude - not system-level transitional intervention 
E-29

Montalescot G, Dallongeville J, Van Belle E, et al. STEMI and NSTEMI: are they so different? 1 

year outcomes in acute myocardial infarction as defined by the ESC/ACC definition (the 

OPERA registry). Eur Heart J 2007;28(12):1409-17. Exclude - not system-level transitional 

intervention 

Mudge AM, Brockett R, Foxcroft KF, et al. Lipid-lowering therapy following major cardiac 

events: progress and deficits. Med J Aust 2001;175(3):138-40. Exclude - not system-level 

transitional intervention

Mullard AJ, Reeves MJ, Jacobs BS, et al. Lipid testing and lipid-lowering therapy in hospitalized 

ischemic stroke and transient ischemic attack patients: results from a statewide stroke registry. 

Stroke 2006;37(1):44-9. Exclude - not system-level transitional intervention 

Murray J, Ashworth R, Forster A, et al. Developing a primary care-based stroke service: a 

review of the qualitative literature. Br J Gen Pract 2003;53(487):137-42. Exclude - no acceptable 

comparator

Murray J, Forster A, Young J. Survey to investigate the role of the community stroke care 

coordinator. Br J Community Nurs 2008;13(1):31-6. Exclude - no acceptable comparator

Musicco M, Emberti L, Nappi G, et al. Early and long-term outcome of rehabilitation in stroke 

patients: the role of patient characteristics, time of initiation, and duration of interventions. Arch 

Phys Med Rehabil 2003;84(4):551-8. Exclude - no acceptable comparator

Myint PK, Vowler SL, Redmayne O, et al. Cognition, continence and transfer status at the time 

of discharge from an acute hospital setting and their associations with an unfavourable discharge 

outcome after stroke. Gerontology 2008;54(4):202-9. Exclude - not system-level transition 

Naylor MD, McCauley KM. The effects of a discharge planning and home follow-up 

intervention on elders hospitalized with common medical and surgical cardiac conditions. J 

Cardiovasc Nurs 1999;14(1):44-54. Exclude - not original peer-reviewed data

Newby LK, Hasselblad V, Armstrong PW, et al. Time-based risk assessment after myocardial 

infarction. Implications for timing of discharge and applications to medical decision-making. Eur 

Heart J 2003;24(2):182-9. Exclude - not system-level transition 

Nguyen TA, Page A, Aggarwal A, et al. Social determinants of discharge destination for patients 

after stroke with low admission FIM instrument scores. Arch Phys Med Rehabil 2007;88(6):740-

4. Exclude - not system-level transition 

Nicolau JC, Baracioli LM, Serrano CV, Jr., et al. The influence of health insurance plans on the 

long term outcome of patients with acute myocardial infarction. Arq Bras Cardiol 

2008;91(6):347-51. Exclude - not system-level transition 

Nir Z, Zolotogorsky Z, Sugarman H. Structured nursing intervention versus routine rehabilitation 

after stroke. Am J Phys Med Rehabil 2004;83(7):522-9. Exclude - not system-level transition 

Nori D, Johnson J, Kapke A, et al. Use of discharge-worksheet enhances compliance with 

evidence-based myocardial infarction care. J Thromb Thrombolysis 2002;14(1):43-9. Exclude -

not system-level transition

Olney SJ, Nymark J, Brouwer B, et al. A randomized controlled trial of supervised versus 

unsupervised exercise programs for ambulatory stroke survivors. Stroke 2006;37(2):476-81. 

Exclude - not system-level transition 
E-30

Onukwugha E, Mullins CD. Racial differences in hospital discharge disposition among stroke 

patients in Maryland. Med Decis Making 2007;27(3):233-42. Exclude - not system-level 

transition 

Ostir GV, Smith PM, Smith D, et al. Functional status and satisfaction with community 

participation in persons with stroke following medical rehabilitation. Aging Clin Exp Res 

2005;17(1):35-41. Exclude - not system-level transition 

Ostwald SK, Davis S, Hersch G, et al. Evidence-based educational guidelines for stroke 

survivors after discharge home. J Neurosci Nurs 2008;40(3):173-9, 191. Exclude - insufficient 

detail/sample size

Ostwald SK, Godwin KM, Cheong H, et al. Predictors of resuming therapy within four weeks 

after discharge from inpatient rehabilitation. Top Stroke Rehabil 2009;16(1):80-91. Exclude - not 

system-level transition 

Ostwald SK, Godwin KM, Cron SG. Predictors of life satisfaction in stroke survivors and 

spousal caregivers after inpatient rehabilitation. Rehabil Nurs 2009;34(4):160-7, 174; discussion 

174. Exclude - not system-level transition 

Oterhals K, Hanestad BR, Eide GE, et al. The relationship between in-hospital information and 

patient satisfaction after acute myocardial infarction. Eur J Cardiovasc Nurs 2006;5(4):303-10. 

Exclude - no acceptable comparator

Ottenbacher KJ, Campbell J, Kuo YF, et al. Racial and ethnic differences in postacute 

rehabilitation outcomes after stroke in the United States. Stroke 2008;39(5):1514-9. Exclude -

not system-level transition 

Ovbiagele B. Pessin award lecture 2008: lessons from the Stroke PROTECT program. J Neurol 

Sci 2008;275(1-2):1-6. Exclude - not original peer-reviewed data

Ovbiagele B. Pathways and tools of Stroke PROTECT: a hospital-based recurrent stroke 

prevention program. Crit Pathw Cardiol 2009;8(4):151-5. Exclude - not original peer-reviewed 

data

Ovbiagele B, Hills NK, Saver JL, et al. Antihypertensive medications prescribed at discharge 

after an acute ischemic cerebrovascular event. Stroke 2005;36(9):1944-7. Exclude - not systemlevel transition 

Ovbiagele B, Sachdeva S. Preventing another event: role of the hospitalist in discharge stroke 

prevention. J Hosp Med 2007;2(1):31-8. Exclude - no acceptable comparator

Ovbiagele B, Sanossian N, Liebeskind DS, et al. Indices of kidney dysfunction and discharge 

outcomes in hospitalized stroke patients without known renal disease. Cerebrovasc Dis 

2009;28(6):582-8. Exclude - not system-level transition

Ovbiagele B, Saver JL, Fredieu A, et al. PROTECT: a coordinated stroke treatment program to 

prevent recurrent thromboembolic events. Neurology 2004;63(7):1217-22. Exclude - not systemlevel transition 

Ovbiagele B, Schwamm LH, Smith EE, et al. Recent nationwide trends in discharge statin 

treatment of hospitalized patients with stroke. Stroke 2010;41(7):1508-13. Exclude - not systemlevel transition 
E-31

Owen A, Khan W, Griffiths KD. Troponin T: role in altering patient management and enabling 

earlier discharge from a district general hospital. Ann Clin Biochem 2001;38(Pt 2):135-9. 

Exclude - not system-level transitional intervention

Ozdemir F, Birtane M, Tabatabaei R, et al. Comparing stroke rehabilitation outcomes between 

acute inpatient and nonintense home settings. Arch Phys Med Rehabil 2001;82(10):1375-9. 

Exclude - not system-level transitional intervention

Palazzolo JJ, Ferraro M, Krebs HI, et al. Stochastic estimation of arm mechanical impedance 

during robotic stroke rehabilitation. IEEE Trans Neural Syst Rehabil Eng 2007;15(1):94-103. 

Exclude - not system-level transitional intervention

Panella M, Marchisio S, Barbieri A, et al. A cluster randomized trial to assess the impact of 

clinical pathways for patients with stroke: rationale and design of the Clinical Pathways for 

Effective and Appropriate Care Study [NCT00673491]. BMC Health Serv Res 2008;8:223. 

Exclude - not original peer-reviewed data

Panella M, Marchisio S, Di Stanislao F. Reducing clinical variations with clinical pathways: do 

pathways work? Int J Qual Health Care 2003;15(6):509-21. Exclude - not original peer-reviewed 

data

Paolucci S, Antonucci G, Grasso MG, et al. Functional outcome of ischemic and hemorrhagic 

stroke patients after inpatient rehabilitation: a matched comparison. Stroke 2003;34(12):2861-5. 

Exclude - not system-level transitional intervention 

Paolucci S, Antonucci G, Grasso MG, et al. Post-stroke depression, antidepressant treatment and 

rehabilitation results. A case-control study. Cerebrovasc Dis 2001;12(3):264-71. Exclude - not 

system-level transitional intervention 

Park YH. Day healthcare services for family caregivers of older people with stroke: needs and 

satisfaction. J Adv Nurs 2008;61(6):619-30. Exclude - no acceptable comparator

Parker SG, Oliver P, Pennington M, et al. Rehabilitation of older patients: Day hospital 

compared with rehabilitation at home. A randomised controlled trial. Health Technol Assess 

2009;13(39):ix-168. Exclude - does not study stroke or MI

Parry RH. Communication during goal-setting in physiotherapy treatment sessions. Clin Rehabil 

2004;18(6):668-82. Exclude - insufficient detail/sample size

Patel MR, Chen AY, Roe MT, et al. A comparison of acute coronary syndrome care at academic 

and nonacademic hospitals. Am J Med 2007;120(1):40-6. Exclude - not system-level transitional 

intervention

Patel MR, Meine TJ, Radeva J, et al. State-mandated continuing medical education and the use 

of proven therapies in patients with an acute myocardial infarction. J Am Coll Cardiol 

2004;44(1):192-8. Exclude - not system-level transitional intervention 

Pearson S, Inglis SC, McLennan SN, et al. Prolonged effects of a home-based intervention in 

patients with chronic illness. Arch Intern Med 2006;166(6):645-50. Exclude - not stroke/MI

Pedone C, Di Pasquale G, Greco C, et al. Prescription at discharge of recommended treatments 

for secondary prevention in patients with ST-segment elevation myocardial infarction according 

to reperfusion strategies. Results from the IN-ACS outcome study. Acute Card Care 

2009;11(4):222-8. Exclude - not system-level transitional intervention 
E-32

Penning-van Beest FJ, Termorshuizen F, Goettsch WG, et al. Adherence to evidence-based statin 

guidelines reduces the risk of hospitalizations for acute myocardial infarction by 40%: a cohort 

study. Eur Heart J 2007;28(2):154-9. Exclude - not system-level transitional intervention 

Pepine CJ. Optimizing lipid management in patients with acute coronary syndromes. Am J 

Cardiol 2003;91(4A):30B-35B. Exclude - not system-level transitional intervention

Perers E, From Attebring M, Caidahl K, et al. Low risk is associated with poorer quality of life 

than high risk following acute coronary syndrome. Coron Artery Dis 2006;17(6):501-10. 

Exclude - not system-level transitional intervention 

Perez CE. Ontario hospitals--mergers, shorter stays and readmissions. Health Rep 

2002;14(1):25-36. Exclude - not system-level transitional intervention 

Perrin PB, Heesacker M, Hinojosa MS, et al. Identifying at-risk, ethnically diverse stroke 

caregivers for counseling: a longitudinal study of mental health. Rehabil Psychol 

2009;54(2):138-49. Exclude - not system-level transitional intervention

Perry L, McLaren S. An exploration of nutrition and eating disabilities in relation to quality of 

life at 6 months post-stroke. Health Soc Care Community 2004;12(4):288-97. Exclude - not 

system-level transitional intervention 

Pessah-Rasmussen H, Wendel K. Early supported discharge after stroke and continued 

rehabilitation at home coordinated and delivered by a stroke unit in an urban area. J Rehabil Med 

2009;41(6):482-8. Exclude - no acceptable comparator

Petersen LA, Normand SL, Druss BG, et al. Process of care and outcome after acute myocardial 

infarction for patients with mental illness in the VA health care system: are there disparities? 

Health Serv Res 2003;38(1 Pt 1):41-63. Exclude - not system-level transitional intervention 

Petersen LA, Normand SL, Leape LL, et al. Comparison of use of medications after acute 

myocardial infarction in the Veterans Health Administration and Medicare. Circulation 

2001;104(24):2898-904. Exclude - not system-level transitional intervention 

Petersen LA, Wright SM, Peterson ED, et al. Impact of race on cardiac care and outcomes in 

veterans with acute myocardial infarction. Med Care 2002;40(1 Suppl):I86-96. Exclude - not 

system-level transitional intervention 

Petrea RE, Beiser AS, Seshadri S, et al. Gender differences in stroke incidence and poststroke 

disability in the Framingham heart study. Stroke 2009;40(4):1032-7. Exclude - not system-level 

transitional intervention

Pettersen R, Dahl T, Wyller TB. Prediction of long-term functional outcome after stroke 

rehabilitation. Clin Rehabil 2002;16(2):149-59. Exclude - not system-level transitional 

intervention

Peurala SH, Airaksinen O, Huuskonen P, et al. Effects of intensive therapy using gait trainer or 

floor walking exercises early after stroke. J Rehabil Med 2009;41(3):166-73. Exclude - not 

system-level transitional intervention

Peurala SH, Airaksinen O, Jakala P, et al. Effects of intensive gait-oriented physiotherapy during 

early acute phase of stroke. J Rehabil Res Dev 2007;44(5):637-48. Exclude - not system-level 

transitional intervention
E-33

Peurala SH, Tarkka IM, Pitkanen K, et al. The effectiveness of body weight-supported gait 

training and floor walking in patients with chronic stroke. Arch Phys Med Rehabil 

2005;86(8):1557-64. Exclude - not system-level transitional intervention

Pierce LL, Gordon M, Steiner V. Families dealing with stroke desire information about self-care 

needs. Rehabil Nurs 2004;29(1):14-7. Exclude - not system-level transitional intervention

Pierce LL, Steiner VL, Khuder SA, et al. The effect of a Web-based stroke intervention on 

carers' well-being and survivors' use of healthcare services. Disabil Rehabil 2009;31(20):1676-

1684. Exclude - not stroke/MI

Pilote L, Beck C, Richard H, et al. The effects of cost-sharing on essential drug prescriptions, 

utilization of medical care and outcomes after acute myocardial infarction in elderly patients. 

CMAJ 2002;167(3):246-52. Exclude - not system-level transitional intervention 

Pilote L, Beck CA, Karp I, et al. Secondary prevention after acute myocardial infarction in four 

Canadian provinces, 1997-2000. Can J Cardiol 2004;20(1):61-7. Exclude - not system-level 

transitional intervention 

Piron L, Tonin P, Trivello E, et al. Motor tele-rehabilitation in post-stroke patients. Med Inform 

Internet Med 2004;29(2):119-25. Exclude - not system-level transitional intervention

Piron L, Turolla A, Agostini M, et al. Exercises for paretic upper limb after stroke: a combined 

virtual-reality and telemedicine approach. J Rehabil Med 2009;41(12):1016-102. Exclude - not 

system-level transitional intervention

Pohjasvaara T, Vataja R, Leppavuori A, et al. Cognitive functions and depression as predictors 

of poor outcome 15 months after stroke. Cerebrovasc Dis 2002;14(3-4):228-33. Exclude - not 

system-level transitional intervention

Pollock A, Baer G, Langhorne P, et al. Physiotherapy treatment approaches for the recovery of 

postural control and lower limb function following stroke: a systematic review. Clin Rehabil 

2007;21(5):395-410. Exclude - not system-level transitional intervention 

Pollock A, Baer G, Pomeroy V, et al. Physiotherapy treatment approaches for the recovery of 

postural control and lower limb function following stroke. Cochrane Database Syst Rev 

2003(2):CD001920. Exclude - not system-level transitional intervention 

Pollock A, Baer G, Pomeroy V, et al. Physiotherapy treatment approaches for the recovery of 

postural control and lower limb function following stroke. Cochrane Database Syst Rev 

2007(1):CD001920. Exclude - not system-level transitional intervention 

Polsky D, Jha AK, Lave J, et al. Short- and long-term mortality after an acute illness for elderly 

whites and blacks. Health Serv Res 2008;43(4):1388-402. Exclude - not system-level transitional 

intervention

Popa MA, Branch LG, Andel R. The white-black disability gap revisited: does an incident heart 

attack change this gap? J Gerontol A Biol Sci Med Sci 2008;63(4):420-5. Exclude - not systemlevel transitional intervention 

Popescu I, Werner RM, Vaughan-Sarrazin MS, et al. Characteristics and outcomes of America's 

lowest-performing hospitals: an analysis of acute myocardial infarction hospital care in the 

United States. Circ Cardiovasc Qual Outcomes 2009;2(3):221-7. Exclude - not system-level 

transitional intervention 
E-34

Portelli R, Lowe D, Irwin P, et al. Institutionalization after stroke. Clin Rehabil 2005;19(1):97-

108. Exclude - not system-level transitional intervention 

Prange GB, Jannink MJ, Groothuis-Oudshoorn CG, et al. Systematic review of the effect of 

robot-aided therapy on recovery of the hemiparetic arm after stroke. J Rehabil Res Dev 

2006;43(2):171-84. Exclude - not system-level transitional intervention 

Price CI, Pandyan AD. Electrical stimulation for preventing and treating post-stroke shoulder 

pain: a systematic Cochrane review. Clin Rehabil 2001;15(1):5-19. Exclude - not system-level 

transitional intervention 

Pringle J, Hendry C, McLafferty E. A review of the early discharge experiences of stroke 

survivors and their carers. J Clin Nurs 2008;17(18):2384-97. Exclude - not original peerreviewed data

Prvu Bettger JA, Stineman MG. Effectiveness of multidisciplinary rehabilitation services in 

postacute care: state-of-the-science. A review. Arch Phys Med Rehabil 2007;88(11):1526-34. 

Exclude - systematic review for background

Pullenayegum S, Fielding B, Du Plessis E, et al. The value of the role of the rehabilitation 

assistant. Br J Nurs 2005;14(14):778-84. Exclude - not system-level transitional intervention

Putman K, De Wit L, Schoonacker M, et al. Effect of socioeconomic status on functional and 

motor recovery after stroke: a European multicentre study. J Neurol Neurosurg Psychiatry 

2007;78(6):593-9. Exclude - not system-level transitional intervention

Putman K, De Wit L, Schupp W, et al. Variations in follow-up services after inpatient stroke 

rehabilitation: a multicentre study. J Rehabil Med 2009;41(8):646-53. Exclude - no acceptable 

comparator

Pyoria O, Talvitie U, Nyrkko H, et al. The effect of two physiotherapy approaches on physical 

and cognitive functions and independent coping at home in stroke rehabilitation. A preliminary 

follow-up study. Disabil Rehabil 2007;29(6):503-11. Exclude - not system-level transitional 

intervention

Qiu Y, Li S. Stroke: coping strategies and depression among Chinese caregivers of survivors 

during hospitalisation. J Clin Nurs 2008;17(12):1563-73. Exclude - not system-level transitional 

intervention

Quan H, Cujec B, Jin Y, et al. Home care before and after hospitalization for acute myocardial 

infarction in Alberta, Canada. Home Health Care Serv Q 2004;23(1):43-61. Exclude - not 

system-level transitional intervention

Quinn TJ, Paolucci S, Sivenius J, et al. Evidence-based stroke r-ehabilitation: an expanded 

guidance document from the european stroke organisation (ESO) guidelines for management of 

ischaemic stroke and transient ischaemic attack 2008. J Rehabil Med 2009;41(2):99-111. 

Exclude - not system-level transitional intervention

Rabadi M, Galgano M, Lynch D, et al. A pilot study of activity-based therapy in the arm motor 

recovery post stroke: a randomized controlled trial. Clin Rehabil 2008;22(12):1071-82. Exclude -

not system-level transitional intervention

Rabadi MH. Randomized clinical stroke rehabilitation trials in 2005. Neurochem Res 2007;32(4-

5):807-21. Exclude - not system-level transitional intervention 
E-35

Rahiman A, Saver JL, Porter V, et al. In-hospital initiation of secondary prevention is associated 

with improved vascular outcomes at 3 months. J Stroke Cerebrovasc Dis 2008;17(1):5-8. 

Exclude - not system-level transitional intervention

Rameezan BA, Zaliha O. Functional status of acute stroke patients in University Malaya Medical 

Centre (UMMC), Kuala Lumpur, Malaysia. Med J Malaysia 2005;60(5):548-59. Exclude -

insufficient detail/sample size

Rankin SH. Women recovering from acute myocardial infarction: psychosocial and physical 

functioning outcomes for 12 months after acute myocardial infarction. Heart Lung 

2002;31(6):399-410. Exclude - not system-level transitional intervention 

Rankin SH, Fukuoka Y. Predictors of quality of life in women 1 year after myocardial infarction. 

Prog Cardiovasc Nurs 2003;18(1):6-12. Exclude - insufficient detail/sample size

Rathore SS, Masoudi FA, Havranek EP, et al. Regional variations in racial differences in the 

treatment of elderly patients hospitalized with acute myocardial infarction. Am J Med 

2004;117(11):811-22. Exclude - not system-level transitional intervention 

Rathore SS, Mehta RH, Wang Y, et al. Effects of age on the quality of care provided to older 

patients with acute myocardial infarction. Am J Med 2003;114(4):307-15. Exclude - not systemlevel transitional intervention

Razinia T, Saver JL, Liebeskind DS, et al. Body mass index and hospital discharge outcomes 

after ischemic stroke. Arch Neurol 2007;64(3):388-91. Exclude - not system-level transitional 

intervention 

Read SJ, Levy J. Differences in stroke care practices between regional and metropolitan 

hospitals. Intern Med J 2005;35(8):447-50. Exclude - not system-level transitional intervention

Read SJ, Levy J. Effects of care pathways on stroke care practices at regional hospitals. Intern 

Med J 2006;36(10):638-42. Exclude - not system-level transitional intervention

Redfern J, Ellis E, Briffa T, et al. Modular prevention of heart disease following acute coronary 

syndrome (ACS) [ISRCTN42984084]. BMC Cardiovasc Disord 2006;6:26. Exclude - not 

original peer-reviewed data

Redfern J, McKevitt C, Rudd AG, et al. Health care follow-up after stroke: opportunities for 

secondary prevention. Fam Pract 2002;19(4):378-82. Exclude - not system-level transitional 

intervention

Reeves MJ, Broderick JP, Frankel M, et al. The Paul Coverdell National Acute Stroke Registry: 

initial results from four prototypes. Am J Prev Med 2006;31(6 Suppl 2):S202-9. Exclude - not 

system-level transitional intervention

Reeves MJ, Vaidya RS, Fonarow GC, et al. Quality of care and outcomes in patients with 

diabetes hospitalized with ischemic stroke: findings from Get With the Guidelines-Stroke. Stroke 

2010;41(5):e409-17. Exclude - not system-level transitional intervention 

Reikvam A, Kvan E, Aursnes I. Use of cardiovascular drugs after acute myocardial infarction: a 

marked shift towards evidence-based drug therapy. Cardiovasc Drugs Ther 2002;16(5):451-6. 

Exclude - not system-level transitional intervention 
E-36

Reistetter TA, Graham JE, Deutsch A, et al. Utility of functional status for classifying 

community versus institutional discharges after inpatient rehabilitation for stroke. Arch Phys 

Med Rehabil 2010;91(3):345-50. Exclude - not system-level transitional intervention 

Reker DM, Duncan PW, Horner RD, et al. Postacute stroke guideline compliance is associated 

with greater patient satisfaction. Arch Phys Med Rehabil 2002;83(6):750-6. Exclude - not 

system-level transitional intervention 

Rensink M, Schuurmans M, Lindeman E, et al. Task-oriented training in rehabilitation after 

stroke: systematic review. J Adv Nurs 2009;65(4):737-54. Exclude - not original peer-reviewed 

data

Richards CL, Malouin F, Bravo G, et al. The role of technology in task-oriented training in 

persons with subacute stroke: a randomized controlled trial. Neurorehabil Neural Repair 

2004;18(4):199-211. Exclude - not system-level transitional intervention 

Richards L, Gonzalez Rothi LJ, Davis S, et al. Limited dose response to constraint-induced 

movement therapy in patients with chronic stroke. Clin Rehabil 2006;20(12):1066-74. Exclude -

not system-level transitional intervention 

Richards LG, Latham NK, Jette DU, et al. Characterizing occupational therapy practice in stroke 

rehabilitation. Arch Phys Med Rehabil 2005;86(12 Suppl 2):S51-S60. Exclude - not system-level 

transitional intervention 

Rimmer JH, Rauworth AE, Wang EC, et al. A preliminary study to examine the effects of 

aerobic and therapeutic (nonaerobic) exercise on cardiorespiratory fitness and coronary risk 

reduction in stroke survivors. Arch Phys Med Rehabil 2009;90(3):407-12. Exclude - not systemlevel transitional intervention 

Rimmer JH, Wang E. Aerobic exercise training in stroke survivors. Top Stroke Rehabil 

2005;12(1):17-30. Exclude - not system-level transitional intervention 

Rinere O'Brien S. Trends in inpatient rehabilitation stroke outcomes before and after advent of 

the prospective payment system: a systematic review. J Neurol Phys Ther 2010;34(1):17-23. 

Exclude - not system-level transitional intervention 

Ring H, Rosenthal N. Controlled study of neuroprosthetic functional electrical stimulation in 

sub-acute post-stroke rehabilitation. J Rehabil Med 2005;37(1):32-6. Exclude - not system-level 

transitional intervention 

Ring H, Treger I, Gruendlinger L, et al. Neuroprosthesis for footdrop compared with an anklefoot orthosis: effects on postural control during walking. J Stroke Cerebrovasc Dis 

2009;18(1):41-7. Exclude - not system-level transitional intervention 

Ripley DL, Seel RT, Macciocchi SN, et al. The impact of diabetes mellitus on stroke acute 

rehabilitation outcomes. Am J Phys Med Rehabil 2007;86(9):754-61. Exclude - not system-level 

transitional intervention 

Robbins SM, Houghton PE, Woodbury MG, et al. The therapeutic effect of functional and 

transcutaneous electric stimulation on improving gait speed in stroke patients: a meta-analysis. 

Arch Phys Med Rehabil 2006;87(6):853-9. Exclude - not original peer-reviewed data

Rocco A, Pasquini M, Cecconi E, et al. Monitoring after the acute stage of stroke: a prospective 

study. Stroke 2007;38(4):1225-8. Exclude - not system-level transitional intervention
E-37

Rochette A, Desrosiers J. Coping with the consequences of a stroke. Int J Rehabil Res 

2002;25(1):17-24. Exclude - not system-level transitional intervention 

Rochette A, Korner-Bitensky N, Bishop D, et al. Study protocol of the YOU CALL--WE CALL 

TRIAL: impact of a multimodal support intervention after a "mild" stroke. BMC Neurol 

2010;10:3. Exclude - insufficient detail/sample size

Rochette A, Korner-Bitensky N, Desrosiers J. Actual vs best practice for families post-stroke 

according to three rehabilitation disciplines. J Rehabil Med 2007;39(7):513-9. Exclude - not 

system-level transitional intervention 

Rockson SG, deGoma EM, Fonarow GC. Reinforcing a continuum of care: in-hospital initiation 

of long-term secondary prevention following acute coronary syndromes. Cardiovasc Drugs Ther 

2007;21(5):375-88. Exclude - insufficient detail/sample size

Roderick P, Low J, Day R, et al. Stroke rehabilitation after hospital discharge: a randomized trial 

comparing domiciliary and day-hospital care. Age Ageing 2001;30(4):303-10. Exclude - no 

outcomes of interest

Rodgers H, Mackintosh J, Price C, et al. Does an early increased-intensity interdisciplinary upper 

limb therapy programme following acute stroke improve outcome? Clin Rehabil 2003;17(6):579-

89. Exclude - not system-level transitional intervention 

Rodgers H, Soutter J, Kaiser W, et al. Early supported hospital discharge following acute stroke: 

pilot study results. Clin Rehabil 1997;11(4):280-287. Exclude - outside scope of acceptable 

publication dates (pre-2000)

Roebuck A, Furze G, Thompson DR. Health-related quality of life after myocardial infarction: 

an interview study. J Adv Nurs 2001;34(6):787-94. Exclude - not system-level transitional 

intervention 

Rossnagel K, Jungehulsing GJ, Nolte CH, et al. Out-of-hospital delays in patients with acute 

stroke. Ann Emerg Med 2004;44(5):476-83. Exclude - not system-level transitional intervention 

Roth EJ, Lovell L, Harvey RL, et al. Delay in transfer to inpatient stroke rehabilitation: the role 

of acute hospital medical complications and stroke characteristics. Top Stroke Rehabil 

2007;14(1):57-64. Exclude - not system-level transitional intervention 

Rousseaux M, Daveluy W, Kozlowski R. Value and efficacy of early supported discharge from 

stroke units. Ann Phys Rehabil Med 2009;52(3):224-33. Exclude - not original peer-reviewed 

data

Rubenach S, Shadbolt B, McCallum J, et al. Assessing health-related quality of life following 

myocardial infarction: is the SF-12 useful? J Clin Epidemiol 2002;55(3):306-9. Exclude - not 

system-level transitional intervention 

Rudd AG, Lowe D, Irwin P, et al. National stroke audit: a tool for change? Qual Health Care 

2001;10(3):141-51. Exclude - not system-level transitional intervention 

Rundek T, Nielsen K, Phillips S, et al. Health care resource use after acute stroke in the Glycine 

Antagonist in Neuroprotection (GAIN) Americas trial. Stroke 2004;35(6):1368-74. Exclude - not 

system-level transitional intervention 
E-38

Rushford N, Murphy BM, Worcester MU, et al. Recall of information received in hospital by 

female cardiac patients. Eur J Cardiovasc Prev Rehabil 2007;14(3):463-9. Exclude - not systemlevel transitional intervention 

Ryan T, Enderby P, Rigby AS. A randomized controlled trial to evaluate intensity of 

community-based rehabilitation provision following stroke or hip fracture in old age. Clin 

Rehabil 2006;20(2):123-31. Exclude - not system-level transitional intervention

Saban KL, Sherwood PR, DeVon HA, et al. Measures of psychological stress and physical health 

in family caregivers of stroke survivors: a literature review. J Neurosci Nurs 2010;42(3):128-38. 

Exclude - not stroke/MI

Sackley C, Pound K. Setting priorities for a discharge plan for stroke patients entering nursing 

home care. Clin Rehabil 2002;16(8):859-66. Exclude - insufficient detail/sample size

Sackley CM, Pound K. Stroke patients entering nursing home care: a content analysis of 

discharge letters. Clin Rehabil 2002;16(7):736-40. Exclude - not system-level transitional 

intervention

Salbach NM, Mayo NE, Wood-Dauphinee S, et al. A task-orientated intervention enhances 

walking distance and speed in the first year post stroke: a randomized controlled trial. Clin 

Rehabil 2004;18(5):509-19. Exclude - not system-level transitional intervention 

Saleh SS, Hannan EL, Ting L. A multistate comparison of patient characteristics, outcomes, and 

treatment practices in acute myocardial infarction. Am J Cardiol 2005;96(9):1190-6. Exclude -

not system-level transitional intervention 

Salter K, Foley N, Teasell R. Social support interventions and mood status post stroke: a review. 

Int J Nurs Stud 2010;47(5):616-25. Exclude - not original peer-reviewed data

Salter K, Hellings C, Foley N, et al. The experience of living with stroke: a qualitative metasynthesis. J Rehabil Med 2008;40(8):595-602. Exclude - not original peer-reviewed data

Salter K, Jutai J, Hartley M, et al. Impact of early vs delayed admission to rehabilitation on 

functional outcomes in persons with stroke. J Rehabil Med 2006;38(2):113-7. Exclude - not 

system-level transitional intervention

Salter KL, Teasell RW, Foley NC, et al. Outcome assessment in randomized controlled trials of 

stroke rehabilitation. Am J Phys Med Rehabil 2007;86(12):1007-12. Exclude - not original peerreviewed data

Sampaio F, Mateus P, Bettencourt N, et al. Determinants of left ventricular systolic function 

recovery after an acute coronary syndrome. Rev Port Cardiol 2006;25(3):321-7. Exclude - not 

system-level transitional intervention 

Samuelsson SM, Mahonen M, Hassaf D, et al. Short-term functional outcome of hospitalised 

first-ever strokes in Finnmark, Norway in 1998-1999. Results from the Finnmark Stroke 

Register. Int J Circumpolar Health 2001;60(2):235-44. Exclude - not system-level transitional 

intervention 

San Segundo RM, Aguilar JJ, Santos F, et al. A model for predicting delay in discharge of stroke 

patients. Ann Readapt Med Phys 2007;50(1):14-9. Exclude - not system-level transitional 

intervention
E-39

Sanchez M, Cox RA, Rodriguez JM, et al. Review of clinical characteristics and management of 

patients with ST segment elevation myocardial infarction at atertiary care center. P R Health Sci 

J 2006;25(3):219-24. Exclude - not system-level transitional intervention

Sandel ME, Wang H, Terdiman J, et al. Disparities in stroke rehabilitation: results of a study in 

an integrated health system in northern California. PM R 2009;1(1):29-40. Exclude - not systemlevel transitional intervention 

Sanossian N, Saver JL, Liebeskind DS, et al. Achieving target cholesterol goals after stroke: is 

in-hospital statin initiation the key? Arch Neurol 2006;63(8):1081-3. Exclude - no aceptable 

comparator

Saposnik G, Black S. Stroke in the very elderly: hospital care, case fatality and disposition. 

Cerebrovasc Dis 2009;27(6):537-43. Exclude - not system-level transitional intervention 

Saposnik G, Cote R, Phillips S, et al. Stroke outcome in those over 80: a multicenter cohort study 

across Canada. Stroke 2008;39(8):2310-7. Exclude - not system-level transitional intervention 

Saposnik G, Mamdani M, Bayley M, et al. Effectiveness of Virtual Reality Exercises in STroke 

Rehabilitation (EVREST): rationale, design, and protocol of a pilot randomized clinical trial 

assessing the Wii gaming system. Int J Stroke 2010;5(1):47-51. Exclude - not system-level 

transitional intervention 

Saposnik G, Teasell R, Mamdani M, et al. Effectiveness of virtual reality using Wii gaming 

technology in stroke rehabilitation: a pilot randomized clinical trial and proof of principle. Stroke 

2010;41(7):1477-84. Exclude - not system-level transitional intervention 

Saposnik G, Webster F, O'Callaghan C, et al. Optimizing discharge planning: clinical predictors 

of longer stay after recombinant tissue plasminogen activator for acute stroke. Stroke 

2005;36(1):147-50. Exclude - not system-level transitional intervention 

Saunders DH, Greig CA, Mead GE, et al. Physical fitness training for stroke patients. Cochrane 

Database Syst Rev 2009(4):CD003316. Exclude - not system-level transitional intervention 

Saunders DH, Greig CA, Young A, et al. Physical fitness training for stroke patients. Cochrane 

Database Syst Rev 2004(1):CD003316. Exclude - not system-level transitional intervention 

Saxena SK, Ng TP, Yong D, et al. Total direct cost, length of hospital stay, institutional 

discharges and their determinants from rehabilitation settings in stroke patients. Acta Neurol 

Scand 2006;114(5):307-14. Exclude - not system-level transitional intervention 

Schaer BA, Jenni D, Rickenbacher P, et al. Long-term performance of a simple algorithm for 

early discharge after ruling out acute coronary syndrome: a prospective multicenter trial. Chest 

2005;127(4):1364-70. Exclude - not stroke/MI

Schlegel D, Kolb SJ, Luciano JM, et al. Utility of the NIH Stroke Scale as a predictor of hospital 

disposition. Stroke 2003;34(1):134-7. Exclude - not system-level transitional intervention 

Schlegel DJ, Tanne D, Demchuk AM, et al. Prediction of hospital disposition after thrombolysis 

for acute ischemic stroke using the National Institutes of Health Stroke Scale. Arch Neurol 

2004;61(7):1061-4. Exclude - not system-level transitional intervention 
E-40

Schlote A, Richter M, Frank B, et al. A longitudinal study of health-related quality of life of first 

stroke survivors' close relatives. Cerebrovasc Dis 2006;22(2-3):137-42. Exclude - not systemlevel transitional intervention 

Schmaltz HN, Southern D, Ghali WA, et al. Living alone, patient sex and mortality after acute 

myocardial infarction. J Gen Intern Med 2007;22(5):572-8. Exclude - not system-level 

transitional intervention 

Schmidt SM, Guo L, Scheer SJ. Changes in the status of hospitalized stroke patients since 

inception of the prospective payment system in 1983. Arch Phys Med Rehabil 2002;83(7):894-8. 

Exclude - not system-level transitional intervention 

Schmidt WP, Taeger D, Buecker-Nott HJ, et al. The impact of the day of the week and month of 

admission on the length of hospital stay in stroke patients. Cerebrovasc Dis 2003;16(3):247-52. 

Exclude - not system-level transitional intervention 

Schouten LM, Hulscher ME, Akkermans R, et al. Factors that influence the stroke care team's 

effectiveness in reducing the length of hospital stay. Stroke 2008;39(9):2515-21. Exclude - no 

outcomes of interest

Schwamm LH, Fonarow GC, Reeves MJ, et al. Get With the Guidelines-Stroke is associated 

with sustained improvement in care for patients hospitalized with acute stroke or transient 

ischemic attack. Circulation 2009;119(1):107-15. Exclude - not system-level transitional 

intervention

Schwamm LH, Reeves MJ, Pan W, et al. Race/ethnicity, quality of care, and outcomes in 

ischemic stroke. Circulation 2010;121(13):1492-501. Exclude - not system-level transitional 

intervention

Scott IA, Lindsay KA, Harden HE. Utilisation of outpatient cardiac rehabilitation in Queensland. 

Med J Aust 2003;179(7):341-5. Exclude - not system-level transitional intervention 

Sergeant P, Meyns B, Wouters P, et al. Long-term outcome after coronary artery bypass grafting 

in cardiogenic shock or cardiopulmonary resuscitation. J Thorac Cardiovasc Surg 

2003;126(5):1279-86. Exclude - not stroke/MI

Setoguchi S, Glynn RJ, Avorn J, et al. Improvements in long-term mortality after myocardial 

infarction and increased use of cardiovascular drugs after discharge: a 10-year trend analysis. J 

Am Coll Cardiol 2008;51(13):1247-54. Exclude - not system-level transitional intervention 

Shah ND, Dunlay SM, Ting HH, et al. Long-term medication adherence after myocardial 

infarction: experience of a community. Am J Med 2009;122(10):961 e7-13. Exclude - not 

system-level transitional intervention

Sheikh K, Bullock C. Urban-rural differences in the quality of care for medicare patients with 

acute myocardial infarction. Arch Intern Med 2001;161(5):737-43. Exclude - not system-level 

transitional intervention 

Shen Q, Cordato D, Chan DK, et al. Identifying the determinants of 1-year post-stroke outcomes 

in elderly patients. Acta Neurol Scand 2006;113(2):114-20. Exclude - not system-level 

transitional intervention 
E-41

Shen Y, Findley PA, Maney M, et al. Department of Veterans Affairs-Medicare dual 

beneficiaries with stroke: where do they get care? J Rehabil Res Dev 2008;45(1):43-51. Exclude 

- not system-level transitional intervention 

Shepperd S, Doll H, Broad J, et al. Early discharge hospital at home. Cochrane Database of 

Systematic Reviews 2009(1). Exclude - SR/MA for background

Shiflett SC. Does acupuncture work for stroke rehabilitation: what do recent clinical trials really 

show? Top Stroke Rehabil 2007;14(4):40-58. Exclude - not system-level transitional intervention

Shiflett SC, Nayak S, Bid C, et al. Effect of Reiki treatments on functional recovery in patients in 

poststroke rehabilitation: a pilot study. J Altern Complement Med 2002;8(6):755-63. Exclude -

not system-level transitional intervention 

Shyu YI, Chen MC, Chen ST, et al. A family caregiver-oriented discharge planning program for 

older stroke patients and their family caregivers. J Clin Nurs 2008;17(18):2497-508. Exclude -

not stroke/MI

Simon C, Kendrick T. Community provision for informal live-in carers of stroke patients. Br J 

Community Nurs 2002;7(6):292-8. Exclude - not system-level transitional intervention

Simon C, Kumar S, Kendrick T. Formal support of stroke survivors and their informal carers in 

the community: a cohort study. Health Soc Care Community 2008;16(6):582-92. Exclude - not 

system-level transitional intervention

Sims J, Galea M, Taylor N, et al. Regenerate: assessing the feasibility of a strength-training 

program to enhance the physical and mental health of chronic post stroke patients with 

depression. Int J Geriatr Psychiatry 2009;24(1):76-83. Exclude - not system-level transitional 

intervention 

Sit JW, Wong TK, Clinton M, et al. Stroke care in the home: the impact of social support on the 

general health of family caregivers. J Clin Nurs 2004;13(7):816-24. Exclude - no acceptable 

comparator

Sit JW, Yip VY, Ko SK, et al. A quasi-experimental study on a community-based stroke 

prevention programme for clients with minor stroke. J Clin Nurs 2007;16(2):272-81. Exclude -

not outcomes of interest

Ski C, O'Connell B. Stroke: the increasing complexity of carer needs. J Neurosci Nurs 

2007;39(3):172-9. Exclude - not system-level transitional intervention 

Skibicka I, Niewada M, Skowronska M, et al. Poststroke service in Poland: results of a 2-year 

prospective, observational study. Int J Stroke 2009;4(5):318-9. Exclude - not system-level 

transitional intervention 

Smith DH, Kramer JM, Perrin N, et al. A randomized trial of direct-to-patient communication to 

enhance adherence to beta-blocker therapy following myocardial infarction. Arch Intern Med 

2008;168(5):477-83; discussion 483; quiz 447. Exclude - not system-level transitional 

intervention 

Smith J, Liles C. Information needs before hospital discharge of myocardial infarction patients: a 

comparative, descriptive study. J Clin Nurs 2007;16(4):662-71. Exclude - not system-level 

transitional intervention 
E-42

Smith MA, Frytak JR, Liou JI, et al. Rehospitalization and survival for stroke patients in 

managed care and traditional Medicare plans. Med Care 2005;43(9):902-10. Exclude - not 

system-level transitional intervention 

Smith PM, Ottenbacher KJ, Cranley M, et al. Predicting follow-up living setting in patients with 

stroke. Arch Phys Med Rehabil 2002;83(6):764-70. Exclude - not system-level transitional 

intervention

Somerford PJ, Lee AH, Yau KK. Ischemic stroke hospital stay and discharge destination. Ann 

Epidemiol 2004;14(10):773-7. Exclude - not system-level transitional intervention 

Sonde L, Viitanen M. Length of hospital stay, functional independence and life satisfaction after 

stroke. Int J Rehabil Res 2001;24(1):73-8. Exclude - not system-level transitional intervention 

Song R, Lee H. Managing health habits for myocardial infarction (MI) patients. Int J Nurs Stud 

2001;38(4):375-80. Exclude - not system-level transitional intervention

Song YM, Ferrer RL, Cho SI, et al. Socioeconomic status and cardiovascular disease among 

men: the Korean national health service prospective cohort study. Am J Public Health 

2006;96(1):152-9. Exclude - not system-level transitional intervention 

Sonoda S, Saitoh E, Nagai S, et al. Full-time integrated treatment program, a new system for 

stroke rehabilitation in Japan: comparison with conventional rehabilitation. Am J Phys Med 

Rehabil 2004;83(2):88-93. Exclude - not system-level transitional intervention 

Sorensen HV, Lendal S, Schultz-Larsen K, et al. Stroke rehabilitation: assistive technology 

devices and environmental modifications following primary rehabilitation in hospital--a 

therapeutic perspective. Assist Technol 2003;15(1):39-48. Exclude - not system-level transitional 

intervention 

Southern WN, Berger MA, Bellin EY, et al. Hospitalist care and length of stay in patients 

requiring complex discharge planning and close clinical monitoring. Arch Intern Med 

2007;167(17):1869-74. Exclude - not system-level transitional intervention 

Spencer FA, Lessard D, Yarzebski J, et al. Decade-long changes in the use of combination 

evidence-based medical therapy at discharge for patients surviving acute myocardial infarction. 

Am Heart J 2005;150(4):838-44. Exclude - not system-level transitional intervention 

Spencer FA, Salami B, Yarzebski J, et al. Temporal trends and associated factors of inpatient 

cardiac rehabilitation in patients with acute myocardial infarction: a community-wide 

perspective. J Cardiopulm Rehabil 2001;21(6):377-84. Exclude - not system-level transitional 

intervention

Spertus JA, Peterson E, Rumsfeld JS, et al. The Prospective Registry Evaluating Myocardial 

Infarction: Events and Recovery (PREMIER)--evaluating the impact of myocardial infarction on 

patient outcomes. Am Heart J 2006;151(3):589-97. Exclude - not system-level transitional 

intervention

Spieler JF, Lanoe JL, Amarenco P. Socioeconomic aspects of postacute care for patients with 

brain infarction in France. Cerebrovasc Dis 2002;13(2):132-41. Exclude - not system-level 

transitional intervention 
E-43

Spieler JF, Lanoe JL, Amarenco P. Costs of stroke care according to handicap levels and stroke 

subtypes. Cerebrovasc Dis 2004;17(2-3):134-42. Exclude - not system-level transitional 

intervention 

Stahle A, Lindquist I, Mattsson E. Important factors for physical activity among elderly patients 

one year after an acute myocardial infarction. Scand J Rehabil Med 2000;32(3):111-6. Exclude -

not system-level transitional intervention 

Stein J, Krebs HI, Frontera WR, et al. Comparison of two techniques of robot-aided upper limb 

exercise training after stroke. Am J Phys Med Rehabil 2004;83(9):720-8. Exclude - not systemlevel transitional intervention 

Stephens S, Kenny RA, Rowan E, et al. Association between mild vascular cognitive impairment 

and impaired activities of daily living in older stroke survivors without dementia. J Am Geriatr 

Soc 2005;53(1):103-7. Exclude - not system-level transitional intervention 

Steultjens EM, Dekker J, Bouter LM, et al. Evidence of the efficacy of occupational therapy in 

different conditions: an overview of systematic reviews. Clin Rehabil 2005;19(3):247-54. 

Exclude - not originial peer-reviewed data

Steultjens EM, Dekker J, Bouter LM, et al. Occupational therapy for stroke patients: a systematic 

review. Stroke 2003;34(3):676-87. Exclude - not original peer-reviewed data

Stewart DE, Abbey SE, Shnek ZM, et al. Gender differences in health information needs and 

decisional preferences in patients recovering from an acute ischemic coronary event. Psychosom 

Med 2004;66(1):42-8. Exclude - not system-level transitional intervention

Stewart KC, Cauraugh JH, Summers JJ. Bilateral movement training and stroke rehabilitation: a 

systematic review and meta-analysis. J Neurol Sci 2006;244(1-2):89-95. Exclude - not systemlevel transitional intervention 

Stibrant Sunnerhagen K. Circuit training in community-living "younger" men after stroke. J 

Stroke Cerebrovasc Dis 2007;16(3):122-9. Exclude - not system-level transitional intervention

Stineman MG, Asch DA. Comparing VA and non-VA health care: the case of post-stroke 

rehabilitation. LDI Issue Brief 2001;6(5):1-4. Exclude - not original peer-reviewed data

Stineman MG, Ross RN, Hamilton BB, et al. Inpatient rehabilitation after stroke: a comparison 

of lengths of stay and outcomes in the Veterans Affairs and non-Veterans Affairs health care 

system. Med Care 2001;39(2):123-37. Exclude - not system-level transitional intervention

Stone J. Cardiac rehabilitation: Cost and care effective. Can J Cardiol 2004;20(12):1256-7. 

Exclude - not system-level transitional intervention 

Strasser DC, Falconer JA, Herrin JS, et al. Team functioning and patient outcomes in stroke 

rehabilitation. Arch Phys Med Rehabil 2005;86(3):403-9. Exclude - not system-level transitional 

intervention 

Strasser DC, Falconer JA, Stevens AB, et al. Team training and stroke rehabilitation outcomes: a 

cluster randomized trial. Arch Phys Med Rehabil 2008;89(1):10-5. Exclude - not system-level 

transitional intervention
E-44

Stuart M, Benvenuti F, Macko R, et al. Community-based adaptive physical activity program for 

chronic stroke: feasibility, safety, and efficacy of the Empoli model. Neurorehabil Neural Repair 

2009;23(7):726-34. Exclude - not system-level transitional intervention 

Stuart M, Ryser C, Levitt A, et al. Stroke rehabilitation in Switzerland versus the United States: a 

preliminary comparison. Neurorehabil Neural Repair 2005;19(2):139-47. Exclude - not systemlevel transitional intervention 

Studenski S, Duncan PW, Perera S, et al. Daily functioning and quality of life in a randomized 

controlled trial of therapeutic exercise for subacute stroke survivors. Stroke 2005;36(8):1764-70. 

Exclude - not system-level transitional intervention 

Stukel TA, Alter DA, Schull MJ, et al. Association between hospital cardiac management and 

outcomes for acute myocardial infarction patients. Med Care 2010;48(2):157-65. Exclude - not 

system-level transitional intervention 

Suaya JA, Shepard DS, Normand SL, et al. Use of cardiac rehabilitation by Medicare 

beneficiaries after myocardial infarction or coronary bypass surgery. Circulation 

2007;116(15):1653-62. Exclude - not system-level transitional intervention 

Subramanian U, Weinberger M, Eckert GJ, et al. Geographic variation in health care utilization 

and outcomes in veterans with acute myocardial infarction. J Gen Intern Med 2002;17(8):604-11. 

Exclude - not system-level transitional intervention

Suh M, Kim K, Kim I, et al. Caregiver's burden, depression and support as predictors of poststroke depression: a cross-sectional survey. Int J Nurs Stud 2005;42(6):611-8. Exclude - not 

system-level transitional intervention 

Sullivan KA, Katajamaki A. Stroke education: retention effects in those at low- and high-risk of 

stroke. Patient Educ Couns 2009;74(2):205-12. Exclude - not system-level transitional 

intervention 

Suwanwela NC, Eusattasak N, Phanthumchinda K, et al. Combination of acute stroke unit and 

short-term stroke ward with early supported discharge decreases mortality and complications 

after acute ischemic stroke. J Med Assoc Thai 2007;90(6):1089-96. Exclude - not system-level 

transitional intervention

Suzuki M, Omori M, Hatakeyama M, et al. Predicting recovery of upper-body dressing ability 

after stroke. Arch Phys Med Rehabil 2006;87(11):1496-502. Exclude - not system-level 

transitional intervention

Sweileh WM, Sawalha AF, Zyoud SH, et al. Discharge medications among ischemic stroke 

survivors. J Stroke Cerebrovasc Dis 2009;18(2):97-102. Exclude - not system-level transitional 

intervention 

Sze FK, Wong E, Yi X, et al. Does acupuncture have additional value to standard poststroke 

motor rehabilitation? Stroke 2002;33(1):186-94. Exclude - not system-level transitional 

intervention 

Tabereaux PB, Brass LM, Concato J, et al. Hospital admissions for stroke among the very old in 

the USA. Neuroepidemiology 2008;31(2):93-9. Exclude - not system-level transitional 

intervention 
E-45

Tan WS, Heng BH, Chua KS, et al. Factors predicting inpatient rehabilitation length of stay of 

acute stroke patients in Singapore. Arch Phys Med Rehabil 2009;90(7):1202-7. Exclude - not 

system-level transitional intervention 

Tang A, Closson V, Marzolini S, et al. Cardiac rehabilitation after stroke-need and opportunity. J

Cardiopulm Rehabil Prev 2009;29(2):97-104. Exclude - not system-level transitional intervention 

Tang EW, Wong CK, Herbison P. Community hospital versus tertiary hospital comparison in the 

treatment and outcome of patients with acute coronary syndrome: a New Zealand experience. N 

Z Med J 2006;119(1238):U2078. Exclude - not system-level transitional intervention 

Tang EW, Wong CK, Herbison P. Global Registry of Acute Coronary Events (GRACE) hospital 

discharge risk score accurately predicts long-term mortality post acute coronary syndrome. Am 

Heart J 2007;153(1):29-35. Exclude - not system-level transitional intervention 

Taub E, Lum PS, Hardin P, et al. AutoCITE: automated delivery of CI therapy with reduced 

effort by therapists. Stroke 2005;36(6):1301-4. Exclude - not system-level transitional 

intervention 

Taub E, Uswatte G, King DK, et al. A placebo-controlled trial of constraint-induced movement 

therapy for upper extremity after stroke. Stroke 2006;37(4):1045-9. Exclude - not system-level 

transitional intervention 

Taylor RS, Watt A, Dalal HM, et al. Home-based cardiac rehabilitation versus hospital-based 

rehabilitation: a cost effectiveness analysis. Int J Cardiol 2007;119(2):196-201. Exclude - no 

outcomes of interest

Teasdale TW, Engberg AW. Disability pensions in relation to stroke: a population study. Brain 

Inj 2002;16(11):997-1009. Exclude - not system-level transitional intervention 

Teasdale TW, Engberg AW. Psychosocial consequences of stroke: a long-term population-based 

follow-up. Brain Inj 2005;19(12):1049-58. Exclude - not system-level transitional intervention 

Teasell R, Bitensky J, Salter K, et al. The role of timing and intensity of rehabilitation therapies. 

Top Stroke Rehabil 2005;12(3):46-57. Exclude - not system-level transitional intervention 

Teasell R, Foley N, Salter K, et al. Evidence-Based Review of Stroke Rehabilitation: executive 

summary, 12th edition. Top Stroke Rehabil 2009;16(6):463-88. Exclude - not system-level 

transitional intervention

Teasell RW, Bhogal SK, Foley NC, et al. Gait retraining post stroke. Top Stroke Rehabil 

2003;10(2):34-65. not system-level transitional intervention

Teasell RW, Foley NC, Bhogal SK, et al. Early supported discharge in stroke rehabilitation. Top 

Stroke Rehabil 2003;10(2):19-33. Exclude - systematic review

Teasell RW, Foley NC, Salter KL, et al. A blueprint for transforming stroke rehabilitation care in 

Canada: the case for change. Arch Phys Med Rehabil 2008;89(3):575-8. Exclude - not original 

peer-reviewed data

Tellier M, Rochette A. Falling through the cracks: a literature review to understand the reality of 

mild stroke survivors. Top Stroke Rehabil 2009;16(6):454-62. Exclude - systematic review
E-46

Thorsen AM, Holmqvist LW, de Pedro-Cuesta J, et al. A randomized controlled trial of early 

supported discharge and continued rehabilitation at home after stroke: five-year follow-up of 

patient outcome. Stroke 2005;36(2):297-303. Exclude - no acceptable comparator

Timlin MT, Shores KV, Reicks M. Behavior change outcomes in an outpatient cardiac 

rehabilitation program. J Am Diet Assoc 2002;102(5):664-71. Exclude - not system-level 

transitional intervention 

Timmins F, Kaliszer M. Information needs of myocardial infarction patients. Eur J Cardiovasc 

Nurs 2003;2(1):57-65. Exclude - not system-level transitional intervention

Tonne C, Schwartz J, Mittleman M, et al. Long-term survival after acute myocardial infarction is 

lower in more deprived neighborhoods. Circulation 2005;111(23):3063-70. Exclude - not systemlevel transitional intervention 

Tooth L, McKenna K, Barnett A, et al. Caregiver burden, time spent caring and health status in 

the first 12 months following stroke. Brain Inj 2005;19(12):963-74. Exclude - not system-level 

transitional intervention 

Tooth L, McKenna K, Goh K, et al. Length of stay, discharge destination, and functional 

improvement: utility of the Australian National Subacute and Nonacute Patient Casemix 

Classification. Stroke 2005;36(7):1519-25. Exclude - not system-level transitional intervention 

Toschke AM, Tilling K, Cox AM, et al. Patient-specific recovery patterns over time measured by 

dependence in activities of daily living after stroke and post-stroke care: The South London 

Stroke Register (SLSR). Eur J Neurol 2010;17(2):219-225. Exclude - not system-level 

transitional intervention

Tosun N, Akbayrak N. Global case management: using the case management model for the care 

of patients with acute myocardial infarction in a military hospital in Turkey. Lippincotts Case 

Manag 2006;11(4):207-15. Exclude - is a case report, letter, etc.

Trombly CA, Ma HI. A synthesis of the effects of occupational therapy for persons with stroke, 

Part I: Restoration of roles, tasks, and activities. Am J Occup Ther 2002;56(3):250-9. Exclude -

not system-level transitional intervention 

Tseng MC, Lin HJ. Readmission after hospitalization for stroke in Taiwan: results from a 

national sample. J Neurol Sci 2009;284(1-2):52-5. Exclude - not system-level transitional 

intervention 

Turner-Stokes L. Cost-efficiency of longer-stay rehabilitation programmes: can they provide 

value for money? Brain Inj 2007;21(10):1015-21. Exclude - not system-level transitional 

intervention

Turner-Stokes L, Hassan N. Depression after stroke: a review of the evidence base to inform the 

development of an integrated care pathway. Part 1: Diagnosis, frequency and impact. Clin 

Rehabil 2002;16(3):231-47. Exclude - not system-level transitional intervention 

Turner-Stokes L, Hassan N. Depression after stroke: a review of the evidence base to inform the 

development of an integrated care pathway. Part 2: Treatment alternatives. Clin Rehabil 

2002;16(3):248-60. Exclude - not system-level transitional intervention
E-47

Turner-Stokes L, Hassan N, Pierce K, et al. Managing depression in brain injury rehabilitation: 

the use of an integrated care pathway and preliminary report of response to sertraline. Clin 

Rehabil 2002;16(3):261-8. Exclude - not system-level transitional intervention 

Tyden P, Hansen O, Engstrom G, et al. Myocardial infarction in an urban population: worse long 

term prognosis for patients from less affluent residential areas. J Epidemiol Community Health 

2002;56(10):785-90. Exclude - not system-level transitional intervention 

Tyedin K, Cumming TB, Bernhardt J. Quality of life: an important outcome measure in a trial of 

very early mobilisation after stroke. Disabil Rehabil 2010;32(11):875-84. Exclude - not systemlevel transitional intervention 

Underwood P, Beck P. Secondary prevention following myocardial infarction: evidence from an 

audit in South Wales that the National Service Framework for coronary heart disease does not 

address all the issues. Qual Saf Health Care 2002;11(3):230-2. Exclude - not system-level 

transitional intervention 

Urton ML, Kohia M, Davis J, et al. Systematic literature review of treatment interventions for 

upper extremity hemiparesis following stroke. Occup Ther Int 2007;14(1):11-27. Exclude - not 

system-level transitional intervention 

van de Port IG, Wood-Dauphinee S, Lindeman E, et al. Effects of exercise training programs on 

walking competency after stroke: a systematic review. Am J Phys Med Rehabil 

2007;86(11):935-51. Exclude - not system-level transitional intervention 

van den Bos GA, Smits JP, Westert GP, et al. Socioeconomic variations in the course of stroke: 

unequal health outcomes, equal care? J Epidemiol Community Health 2002;56(12):943-8. 

Exclude - not system-level transitional intervention 

van der Gaag A, Brooks R. Economic aspects of a therapy and support service for people with 

long-term stroke and aphasia. Int J Lang Commun Disord 2008;43(3):233-44. Exclude - not 

system-level transitional intervention 

van der Meijden MJ, Solen I, Hasman A, et al. Two patient care information systems in the same 

hospital: beyond technical aspects. Methods Inf Med 2003;42(4):423-7. Exclude - not systemlevel transitional intervention 

van Peppen RP, Hendriks HJ, van Meeteren NL, et al. The development of a clinical practice 

stroke guideline for physiotherapists in The Netherlands: a systematic review of available 

evidence. Disabil Rehabil 2007;29(10):767-83. Exclude - not system-level transitional 

intervention 

Van Peppen RP, Kwakkel G, Wood-Dauphinee S, et al. The impact of physical therapy on 

functional outcomes after stroke: what's the evidence? Clin Rehabil 2004;18(8):833-62. Exclude 

- not system-level transitional intervention 

van Zandvoort MJ, Kessels RP, Nys GM, et al. Early neuropsychological evaluation in patients 

with ischaemic stroke provides valid information. Clin Neurol Neurosurg 2005;107(5):385-92. 

Exclude - not system-level transitional intervention 

Varnava AM, Sedgwick JE, Deaner A, et al. Restricted weekend service inappropriately delays 

discharge after acute myocardial infarction. Heart 2002;87(3):216-9. Exclude - not system-level 

transitional intervention 
E-48

Venketasubramanian N. Stroke pathways. Ann Acad Med Singapore 2001;30(4 Suppl):27-35. 

Exclude - insufficient detail/sample size

Venketasubramanian N, Ang YH, Chan BP, et al. Bridging the gap between primary and 

specialist care--an integrative model for stroke. Ann Acad Med Singapore 2008;37(2):118-27. 

Exclude - insufficient detail/sample size

Verdouw-van Tol HC, Peltenburg HG, Koster T. Improved cardiovascular risk profile in patients 

referred to a specialised vascular outpatient clinic: a cohort study. Eur J Cardiovasc Nurs 

2010;9(2):101-7. Exclude - not system-level transitional intervention

Vincent C, Deaudelin I, Robichaud L, et al. Rehabilitation needs for older adults with stroke 

living at home: perceptions of four populations. BMC Geriatr 2007;7:20. Exclude - not systemlevel transitional intervention 

Vincent C, Desrosiers J, Landreville P, et al. Burden of caregivers of people with stroke: 

evolution and predictors. Cerebrovasc Dis 2009;27(5):456-64. Exclude - not system-level 

transitional intervention 

Visser-Keizer AC, Meyboom-de Jong B, Deelman BG, et al. Subjective changes in emotion, 

cognition and behaviour after stroke: factors affecting the perception of patients and partners. J 

Clin Exp Neuropsychol 2002;24(8):1032-45. Exclude - not system-level transitional intervention 

Visser-Meily A, Post M, Meijer AM, et al. When a parent has a stroke: clinical course and 

prediction of mood, behavior problems, and health status of their young children. Stroke 

2005;36(11):2436-40. Exclude - not system-level transitional intervention 

Volpp KG, Williams SV, Waldfogel J, et al. Market reform in New Jersey and the effect on 

mortality from acute myocardial infarction. Health Serv Res 2003;38(2):515-33. Exclude - not 

system-level transitional intervention 

von Koch L, Holmqvist L, Kostulas V, et al. A Randomized Controlled Trial of Rehabilitation at 

Home After Stroke in Southwest Stockholm: Outcome at Six Months. Scandanavian Journal of 

Rehabiliation Medicine 1998;32:80-86. Exclude - pre-2000

Votruba ME, Cebul RD. Redirecting patients to improve stroke outcomes: implications of a 

volume-based approach in one urban market. Med Care 2006;44(12):1129-36. Exclude - not 

system-level transitional intervention 

Wachters-Kaufmann C, Schuling J, The H, et al. Actual and desired information provision after a 

stroke. Patient Educ Couns 2005;56(2):211-7. Exclude - not system-level transitional 

intervention

Walker C, Brouwer BJ, Culham EG. Use of visual feedback in retraining balance following 

acute stroke. Phys Ther 2000;80(9):886-95. Exclude - not system-level transitional intervention 

Walker MF, Hawkins K, Gladman JR, et al. Randomised controlled trial of occupational therapy 

at home: results at 1 year. J Neurol Neurosurg Psychiatry 2001;70(2):267. Exclude - not systemlevel transitional intervention

Walker MF, Leonardi-Bee J, Bath P, et al. Individual patient data meta-analysis of randomized 

controlled trials of community occupational therapy for stroke patients. Stroke 2004;35(9):2226-

32. Exclude meta-analysis
E-49

Walsh T, Cotter S, Boland M, et al. Stroke unit care is superior to general rehabilitation unit care. 

Ir Med J 2006;99(10):300-2. Exclude - not system-level transitional intervention

Wang Y, Lim LL, Levi C, et al. A prognostic index for 30-day mortality after stroke. J Clin 

Epidemiol 2001;54(8):766-73. Exclude - not system-level transitional intervention

Wang Y, Wu D, Ma R, et al. A survey on adherence to secondary ischemic stroke prevention. 

Neurol Res 2006;28(1):16-20. Exclude - not system-level transitional intervention

Watkins CL, Auton MF, Deans CF, et al. Motivational interviewing early after acute stroke: a 

randomized, controlled trial. Stroke 2007;38(3):1004-9. Exclude - not system-level transitional 

intervention

Wee JY, Hopman WM. Stroke impairment predictors of discharge function, length of stay, and 

discharge destination in stroke rehabilitation. Am J Phys Med Rehabil 2005;84(8):604-12. 

Exclude - not system-level transitional intervention 

Weimar C, Weber C, Wagner M, et al. Management patterns and health care use after 

intracerebral hemorrhage. a cost-of-illness study from a societal perspective in Germany. 

Cerebrovasc Dis 2003;15(1-2):29-36. Exclude - not system-level transitional intervention 

Weimar C, Ziegler A, Konig IR, et al. Predicting functional outcome and survival after acute 

ischemic stroke. J Neurol 2002;249(7):888-95. Exclude - not system-level transitional 

intervention 

Wen M, Christakis NA. Neighborhood effects on posthospitalization mortality: a populationbased cohort study of the elderly in Chicago. Health Serv Res 2005;40(4):1108-27. Exclude - not 

system-level transitional intervention 

White JH, Alston MK, Marquez JL, et al. Community-dwelling stroke survivors: function is not 

the whole story with quality of life. Arch Phys Med Rehabil 2007;88(9):1140-6. Exclude - not 

system-level transitional intervention 

Widjaja LS, Chan BP, Chen H, et al. Variance analysis applied to a stroke pathway: how this can 

improve efficiency of healthcare delivery. Ann Acad Med Singapore 2002;31(4):425-30. 

Exclude - not system-level transitional intervention

Wiles R, Ashburn A, Payne S, et al. Discharge from physiotherapy following stroke: the 

management of disappointment. Soc Sci Med 2004;59(6):1263-73. Exclude - not system-level 

transitional intervention

Wilkins S, Jung B, Wishart L, et al. The effectiveness of community-based occupational therapy 

education and functional training programs for older adults: a critical literature review. Can J 

Occup Ther 2003;70(4):214-25. Exclude - systematic review

Wilz G, Kalytta T. Anxiety symptoms in spouses of stroke patients. Cerebrovasc Dis 

2008;25(4):311-5. Exclude - not system-level transitional intervention

Wita K, Filipecki A, Szydlo K, et al. Prediction of long-term outcome after primary percutaneous 

coronary intervention for acute anterior myocardial infarction. Kardiol Pol 2010;68(4):393-400. 

Exclude - not system-level transitional intervention 
E-50

Wodchis WP, Teare GF, Naglie G, et al. Skilled nursing facility rehabilitation and discharge to 

home after stroke. Arch Phys Med Rehabil 2005;86(3):442-8. Exclude - not system-level 

transitional intervention

Wolf SL, Winstein CJ, Miller JP, et al. Retention of upper limb function in stroke survivors who 

have received constraint-induced movement therapy: the EXCITE randomised trial. Lancet 

Neurol 2008;7(1):33-40. Exclude - not system-level transitional intervention 

Wolfe CD, Tilling K, Rudd AG. The effectiveness of community-based rehabilitation for stroke 

patients who remain at home: a pilot randomized trial. Clin Rehabil 2000;14(6):563-9. Exclude -

insufficient deatil/sample size

Wolinsky FD, Bentler SE, Cook EA, et al. A 12-year prospective study of stroke risk in older 

Medicare beneficiaries. BMC Geriatr 2009;9:17. Exclude - not system-level transitional 

intervention 

Woo J, Chan SY, Sum MW, et al. In patient stroke rehabilitation efficiency: influence of 

organization of service delivery and staff numbers. BMC Health Serv Res 2008;8:86. Exclude -

not system-level transitional intervention 

Woods SE, Chandran P, Levin L. Does the patient's sex influence cardiovascular outcome after 

acute myocardial infarction? J Fam Pract 2002;51(3):237-40. Exclude - not system-level 

transitional intervention 

Wozniak MA, Kittner SJ. Return to work after ischemic stroke: a methodological review. 

Neuroepidemiology 2002;21(4):159-66. Exclude - not system-level transitional intervention 

Wright DJ, Khan KM, Gossage EM, et al. Assessment of a low-intensity cardiac rehabilitation 

programme using the six-minute walk test. Clin Rehabil 2001;15(2):119-24. Exclude - not 

system-level transitional intervention

Wu CY, Chen CL, Tsai WC, et al. A randomized controlled trial of modified constraint-induced 

movement therapy for elderly stroke survivors: changes in motor impairment, daily functioning, 

and quality of life. Arch Phys Med Rehabil 2007;88(3):273-8. Exclude - not system-level 

transitional intervention 

Wu HM, Tang JL, Lin XP, et al. Acupuncture for stroke rehabilitation. Cochrane Database Syst 

Rev 2006;3:CD004131. Exclude - not system-level transitional intervention 

Yagura H, Miyai I, Seike Y, et al. Benefit of inpatient multidisciplinary rehabilitation up to 1 

year after stroke. Arch Phys Med Rehabil 2003;84(11):1687-91. Exclude - not system-level 

transitional intervention 

Yan AT, Tan M, Fitchett D, et al. One-year outcome of patients after acute coronary syndromes 

(from the Canadian Acute Coronary Syndromes Registry). Am J Cardiol 2004;94(1):25-9. 

Exclude - not system-level transitional intervention 

Yan RT, Yan AT, Tan M, et al. Age-related differences in the management and outcome of 

patients with acute coronary syndromes. Am Heart J 2006;151(2):352-9. Exclude - not systemlevel transitional intervention 

Yan T, Hui-Chan CW. Transcutaneous electrical stimulation on acupuncture points improves 

muscle function in subjects after acute stroke: a randomized controlled trial. J Rehabil Med 

2009;41(5):312-6. Exclude - not system-level transitional intervention
E-51

Yan T, Hui-Chan CW, Li LS. Functional electrical stimulation improves motor recovery of the 

lower extremity and walking ability of subjects with first acute stroke: a randomized placebocontrolled trial. Stroke 2005;36(1):80-5. Exclude - not system-level transitional intervention 

Yang YR, Wang RY, Chen YC, et al. Dual-task exercise improves walking ability in chronic 

stroke: a randomized controlled trial. Arch Phys Med Rehabil 2007;88(10):1236-40. Exclude -

not system-level transitional intervention 

Yang YR, Wang RY, Lin KH, et al. Task-oriented progressive resistance strength training 

improves muscle strength and functional performance in individuals with stroke. Clin Rehabil 

2006;20(10):860-70. Exclude - not system-level transitional intervention 

Yavuzer G, Kucukdeveci A, Arasil T, et al. Rehabilitation of stroke patients: clinical profile and 

functional outcome. Am J Phys Med Rehabil 2001;80(4):250-5. Exclude - not system-level 

transitional intervention 

Yavuzer G, Senel A, Atay MB, et al. ''Playstation eyetoy games'' improve upper extremityrelated motor functioning in subacute stroke: a randomized controlled clinical trial. Eur J Phys 

Rehabil Med 2008;44(3):237-44. Exclude - not system-level transitional intervention 

Yeh PS, Lin HJ, Bai CH, et al. Effect of in-hospital initiation of lipid-lowering therapy on sixmonth outcomes in patients with acute ischemic stroke or transient ischemic attack. Am J 

Cardiol 2010;105(10):1490-4. Exclude - not system-level transitional intervention 

Yen CL, Wang RY, Liao KK, et al. Gait training induced change in corticomotor excitability in 

patients with chronic stroke. Neurorehabil Neural Repair 2008;22(1):22-30. Exclude - not 

system-level transitional intervention 

Yen JG, Wang RY, Chen HH, et al. Effectiveness of modified constraint-induced movement 

therapy on upper limb function in stroke subjects. Acta Neurol Taiwan 2005;14(1):16-20. 

Exclude - not system-level transitional intervention 

Yeung S, Lui MH, Ross F, et al. Family carers in stroke care: examining the relationship 

between problem-solving, depression and general health. J Clin Nurs 2007;16(2):344-52. 

Exclude - not system-level transitional intervention 

Yip BC, Man DW. Virtual reality (VR)-based community living skills training for people with 

acquired brain injury: A pilot study. Brain Inj 2009;23(13-14):1017-26. Exclude - insufficient 

detail/sample size

Yonezawa R, Masuda T, Matsunaga A, et al. Effects of phase II cardiac rehabilitation on job 

stress and health-related quality of life after return to work in middle-aged patients with acute 

myocardial infarction. Int Heart J 2009;50(3):279-90. Exclude - not system-level transitional 

intervention 

Yong Joo L, Soon Yin T, Xu D, et al. A feasibility study using interactive commercial off-theshelf computer gaming in upper limb rehabilitation in patients after stroke. J Rehabil Med 

2010;42(5):437-41. Exclude - not system-level transitional intervention 

Young W, McShane J, O'Connor T, et al. Registered nurses' experiences with an evidence-based 

home care pathway for myocardial infarction clients. Can J Cardiovasc Nurs 2004;14(3):24-31. 

Exclude - no outcomes of interest
E-52

Yu BR. Influences of health insurance status on clinical treatments and outcomes for 4,714 

patients after acute myocardial infarction in 14 Chinese general hospitals. J Med Dent Sci 

2005;52(2):143-51. Exclude - not system-level transitional intervention 

Yu CM, Lau CP, Chau J, et al. A short course of cardiac rehabilitation program is highly cost 

effective in improving long-term quality of life in patients with recent myocardial infarction or 

percutaneous coronary intervention. Arch Phys Med Rehabil 2004;85(12):1915-22. Exclude - not 

system-level transitional intervention

Yuval R, Halon DA, Lewis BS. Perceived disability and lifestyle modification following 

hospitalization for non-ST elevation versus ST elevation acute coronary syndromes: the patients' 

point of view. Eur J Cardiovasc Nurs 2007;6(4):287-92. Exclude - not system-level transitional 

intervention 

Zahger D, Hod H, Gottlieb S, et al. Influence of the new definition of acute myocardial infarction 

on coronary care unit admission, discharge diagnosis, management and outcome in patients with 

non-ST elevation acute coronary syndromes: a national survey. Int J Cardiol 2006;106(2):164-9. 

Exclude - not system-level transitional intervention 

Zdrenghea D, Predescu D, Ducasz E, et al. Results of a long-term training program after acute 

myocardial infarction. Rom J Intern Med 2004;42(3):513-9. Exclude - not system-level 

transitional intervention

Zorowitz RD, Chen E, Tong KB, et al. Costs and rehabilitation use of stroke survivors: a 

retrospective study of Medicare beneficiaries. Top Stroke Rehabil 2009;16(5):309-20. Exclude -

not system-level transitional intervention 

Zuckerman IH, Weiss SR, McNally D, et al. Impact of an educational intervention for secondary 

prevention of myocardial infarction on Medicaid drug use and cost. Am J Manag Care 2004;10(7 

Pt 2):493-500. Exclude - not system-level transitional intervention