Transitional Care After Hospitalization for Acute Stroke or Myocardial Infarction: A Systematic Review

Study Questions:

What are the features of and outcomes associated with transitional care service models for patients hospitalized for first or recurrent stroke or myocardial infarction (MI)?


This was a systematic review of peer-reviewed literature. The following reported outcomes were reviewed: death, re-hospitalization, return to premorbid functional ability, quality of life, patient or caregiver burden, and resource use (e.g., hospital-free days).


Forty-four studies were included in the systematic review (27 involved patients hospitalized for stroke and 17 involved patients hospitalized for MI). Only six of the studies were conducted in the United States. Four intervention types were characterized: hospital-initiated, patient and family education, community-based, and disease management. Hospital-initiated transitional care reduced the total number of hospitalized days for patients who had stroke (moderate-strength evidence) and reduced mortality for patients who had an MI (low-strength evidence). There was insufficient evidence to determine benefits and harms associated with other transitional care interventions.


This systematic review reported low- to moderate-strength evidence for the effectiveness of hospital-initiated transitional care and insufficient evidence for other models of transitional care.


Well-coordinated transitional care is a priority to counter potentially discontinuous care following hospitalization. The authors offer a conceptual framework for the characterization of transitional care services, and create momentum toward the need for a more standardized classification of the heterogeneous range of transitional care options available. Only six studies were conducted in the United States, and most were of only fair quality. This systematic review should serve as a call for high-quality, well-structured research to examine national transitional care models.

Keywords: Myocardial Infarction, Stroke, Hospitalization, United States

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