Efficacy of Transitional Care Services for Patients With Stroke: Systematic Review and Meta-Analysis

Approximately 60% of patients who have a stroke are discharged to their homes, after which they require ongoing community-based rehabilitation to support long-term recovery. Transitional care services (TCS) serve as an intervention aimed at reducing hospital readmissions by maintaining treatment continuity, either when patients transition between different levels of care within the same setting or when they move to a new care environment.

The purpose of this review was to evaluate the efficacy of TCS in reducing readmission rates, enhancing functional outcomes, improving self-efficacy, and boosting the quality of life for patients who had a stroke while also alleviating caregiver burden.

To review randomized clinical trials performed between January 2014 and December 2023, we adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for reporting systematic reviews. We established a search strategy combining "transitional care," "stroke," "cerebrovascular disorders," "patient discharge," and "continuity of patient care" and used the PubMed, Embase, Cochrane Library, and CINAHL databases. We selected readmission rate and functional status as the primary outcomes and quality of life, self-efficacy, and care burden as secondary outcomes. We conducted a meta-analysis for each outcome indicator where quantitative synthesis was possible. For the meta-analysis, we used RevMan 5.4 and performed subgroup analyses according to intervention intensity, postdischarge intervention method, and intervention duration.

In the meta-analysis for each outcome indicator, we observed that TCS was effective in reducing the readmission rate of individuals living with stroke and improving their functional status. Additionally, patients with stroke who received TCS showed better quality of life, improved self-efficacy, and reduced caregiver burden compared to those who received usual care. Subgroup analyses revealed that patients with stroke who received moderate or higher intensity of TCS for 2 months demonstrated improvements in functional status compared to those who received lower intensity or 3-month interventions.

This is the first known systematic review to synthesize studies on the efficacy of TCS for patients with stroke over the past 10 years, examining outcome indicators such as readmission rates and functional status. Based on subgroup analysis, we derived an effective TCS strategy (e.g., intensity and duration) to improve functional status.