Contextualizing evidence-based nurse-led peri-discharge interventions for reducing 30-day hospital readmissions using GRADE Evidence to Decision Framework: A Delphi study
2Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong; School of Chinese Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, Hong Kong SAR
Background: Effectiveness of nurse-led peri-discharge interventions on 30-day hospital readmissions has been synthesized in previous network meta-analysis. However, generalizability of such results is expected to vary in health system contexts given their complexity.
Objectives: To translate evidence-based nurse-led interventions into local-adaptable intervention options for reducing 30-day hospital readmissions with the engagement of local stakeholders, using Hong Kong as an example.
Methods: Eighteen local healthcare stakeholders were recruited to carry out a two-step process. In step 1, stakeholders were invited to prioritize nurse-led interventions which are supported by existing evidence and suggest important combinations of different interventions. For all interventions prioritized in step 1, step 2 involved stakeholders to perform a two-round Delphi questionnaire aiming to generate consensus-based interventions appropriate to the local context. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) Evidence to Decision (EtD) framework was applied to guide the decision-making process, taking into account certainty of evidence, benefits and harms, resource use, equity, acceptability, and feasibility.
Results: Four out of eight nurse-led interventions reached a positive consensus with percentage agreement ranging from 70.6% to 82.4%. GRADE EtD criteria ratings showed that over 70% of stakeholders agreed these four interventions were probably acceptable and feasible, although the certainty of evidence was low or moderate. Half of stakeholders believed their desirable effects compared to undesirable effects were large. However, the resources required and how these nurse-led interventions might affect health inequities when implemented were uncertain. Preliminary implementation issues included high complexity of delivering multiple nurse-led intervention components and challenges of coordinating different involved parties in delivering the interventions. Appropriate resource allocation and training should be provided to address these potential problems, as suggested by stakeholders.
Conclusions: Using the GRADE EtD framework, four nurse-led interventions were recommended by healthcare stakeholders as possible strategies for reducing 30-day hospital readmissions among general medical patients in Hong Kong. To address preliminary implementation issues, nurses’ role as care coordinators should also be strengthened to ensure smooth delivery of nurse-led intervention components and to facilitate multidisciplinary collaboration during service delivery. Patient, public, healthcare consumer involvement: NA.