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A Systematic Review of Curricular Interventions Teaching Transitional Care to Physicians-in-Training and Physicians

Buchanan, Ian M.; Besdine, Richard W., MD

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doi: 10.1097/ACM.0b013e318212e36c
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Abstract

In 2000, the Institute of Medicine (IOM) published a landmark report highlighting the relationship between medical errors and patient harm in health care. The IOM went on to clarify that, beyond human error, the problem (and subsequent solutions) must be considered from a systems perspective.1 One year later, the IOM published another report specifically addressing improved continuity of care as a priority in responsible and effective health care delivery systems, and in 2008 yet another report emphasized the importance of improved care coordination in light of an aging U.S. demographic.2,3

As articulated in an American Geriatrics Society (AGS) position statement in 2003, “transitional care” is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between locations or different levels of care within the same location.4 Two previously defined bodies of literature deal individually with discharge planning5,6 and physician–physician handoffs7,8; alone, however, neither has sufficient scope to provide comprehensive conclusions applicable to the broader concept of transitional care. Only recently has the notion that transitional care encompasses all transfers, both senders and receivers, crediting patients as active participants, received more substantial treatment in the literature.9,10 Care fragmentation is more than just an issue of medical “customer service” gone awry; rather, inadequate transitions manifest in very serious ways—medical errors, increased recidivism, and poor patient/staff/caregiver preparation for discharge.11,12 The AGS has recognized that every patient transition within or outside an institution has the possibility to significantly compromise health outcomes secondary to care fragmentation.

The AGS position statement specifically defined operational, research, and educational goals set to further the understanding of transitional care. In 2009, the ideas put forth in this statement were reinforced by a more comprehensive consensus policy statement issued by a group of six wide-ranging professional societies: the American College of Physicians (ACP), Society of General Internal Medicine (SGIM), Society of Hospital Medicine, AGS, American College of Emergency Physicians, and Society for Academic Emergency Medicine.13 In recent years, studies have attempted to produce predictive measures for fragmented care,14 to quantify and recognize patterns of poor transitions,15–17 and to develop preventative interventions.5,18,19 Until recently, the formal development and integration of curricular elements that specifically address transitional care had been largely ignored, but this tide is beginning to turn. Our review will therefore present and outline the trends we have identified in the strategies currently employed to educate physicians-in-training and physicians about transitional care.

Method

Literature search

We reviewed relevant interventions published in English in selected databases from January 1, 1973, to June 30, 2010. We accepted publications indexed in PubMed, ISI Web of Science (WOS), Educational Resources Information Center (ERIC), Association of American Medical Colleges MedEdPORTAL, and Portal of Geriatric Online Education (POGOe). We also searched the following professional organization Web sites: the Association of Program Directors in Internal Medicine (APDIM), ACP, SGIM, AGS, and the Association for Medical Education in Europe (AMEE). Search terms were topic-specific descriptors (care transition*, transitional care, transitions in care, hand-off*, discharge planning, continuity of care) combined with educational descriptors (curricul*, educat*, teach*, train*, learn*). When applicable, MeSH terms and exploded subheadings were also combined with the above terms (Patient discharge, Continuity of patient care, Education). We further hand-selected candidate interventions from journals identified from the references cited in captured articles. We consulted experts in the field of transitional care regarding the search strategy and the list of candidate interventions to help ensure completeness. References were stored and organized using EndNote X2 software (Thompson Reuters, Carlsbad, California).

Eligibility criteria

We included interventions if they demonstrated a directed and purposeful development of a curricular element (or elements) designed to teach objectives consistent with the contemporary definition of transitional care. For example, we considered the explicit statement of learning objectives, accompanying educational materials (e.g., instructions for facilitation of didactic sessions/exercises, printed/multimedia supporting materials, mechanism for learner assessment), or preexisting publication of a freestanding curricular element as evidence of such development.4 Interventions consisting of “tools” alone (e.g., checklist, mnemonic) without any supporting curricular component were considered if, as above, they were designed with contemporary transitional care principles in mind and were intended to educate and change learner behaviors experientially, as reported in their associated publication. We analyzed tool-only interventions for date and publication type alone, as the remainder of the abstraction and analysis process was designed for traditional curricular interventions. Our exclusion criteria were (1) interventions designed for a primary audience other than medical students/medical residents/physicians, (2) “tools” without a broader consideration of transitional care themes, (3) elements (e.g., checklists, quantitative measures) of noneducational interventions designed to improve transitional care in practice, or (4) interventions without a complete article/abstract/text available for review.

Data abstraction

We scanned titles for article suitability based on the above criteria; citations of interest received a further in-depth abstract review. One of us (I.M.B.) performed full-text data abstraction for articles meeting eligibility criteria using a standardized form. The following information was collected: (1) year of initial publication, (2) location(s) published (e.g., scholarly journal, conference proceedings, peer-reviewed database), (3) intended primary audience of intervention and group size, (4) total time involved for each intervention, and number of separate interactions each intervention required, (5) type and number of learning objectives, (6) type and number of educational resources used, (7) learner assessment method, and (8) presence of follow-up evaluation of intervention. We defined headings for learning objectives and resources, which were developed to be inclusive of underlying trends present in the eligible studies. One of us (R.W.B.) validated all collected data through an additional in-depth review; however, data were not reabstracted.

Data analysis

After abstracted data were tabulated, they were analyzed as nominal/categorical variables with expression of raw numbers or percentage of the entire group. Ratio variables (learning objectives and resources by number, only) are represented with mean and 95% confidence interval reported as the measure of central tendency. We organized, analyzed, and displayed data using Excel 2003 and Prism 5.0 software (Microsoft Corporation, Redmond, Washington; GraphPad, La Jolla, California).

Results

Literature search

Of the 4,430 references we collected from literature databases (PubMed, ISI WOS, ERIC), 12 matched our inclusion criteria. Of the 14 references we collected from curricular databases (MedEdPORTAL, POGOe), all 14 matched inclusion criteria. Of the 26 references collected from professional society Web sites (APDIM, ACP, SGIM, AGS, AMEE), 1 matched our inclusion criteria. Hand-search and expert consultation yielded no additional interventions. We thus ultimately found 25 unique, eligible interventions, excluding duplicates.

The majority of excluded studies had no relevance to the focus or scope of this manuscript; in particular, results were not relevant to the topic of transitional care, targeted a different learner population than our focus, or did not exhibit purposeful/deliberate development of intervention to teach elements of transitional care, or the publication describing the intervention contained information of insufficient quality and quantity to meaningfully assess by abstraction.

Eligible interventions

Of the 25 unique results mentioned above, 19 of those were mixed-method educational interventions20–38 (Appendix 1), whereas six consisted of tools alone39–44 (Appendix 2). The number of published interventions increased dramatically over the last 10 years: There were 14 publications in 2009 alone, whereas we found only 11 interventions published previously. Also, between 2008 and 2009, a slight increase in peer-reviewed interventions can be seen (5 versus 7, respectively; Figure 1).

Figure 1
Figure 1:
Educational interventions included in the present review, total and peer-reviewed, by year. All eligible interventions represented as raw number by year. An intervention was considered peer-reviewed if published as a journal article, conference abstract, or entry in a peer-reviewed database. No eligible interventions prior to 2001 were found.

When considering the “highest level” (i.e., manuscript > abstract > database) of peer-review attained by any intervention, the majority were mixed-method curricular interventions published as manuscripts (43%; Figure 2).24,25,29,30,32,34,45 The next most common were individual tools also appearing as published manuscripts (38%).39–44 Of note, whereas 13% of interventions achieved peer review in educational databases at best,26,37 overall 56% of interventions were contained therein (data not shown).20–23,26–28,31,33,35–38,44

Figure 2
Figure 2:
Proportions of educational interventions included in the present review, by publication type. This figure demonstrates the classification of all peer-reviewed interventions presented in Figure 1, represented by “highest level” of publication (i.e., manuscript > abstract > database).

Learner characteristics

When considered from the perspective of intended audience (Figure 3), the majority of interventions were designed for clinical learners—namely, third- and fourth-year clerks and residents, accounting for 63% and 53%, respectively, of all interventions.21,22,24,26,27,30–38 A number of interventions have been designed with allied health professionals in mind, mainly pharmacy and nursing trainees, accounting for 16% of the total.23,30,32 With regard to the size of learner groups (i.e., number of participants) that interventions targeted, large-group (group, ≥15) learning dominated, accounting for 53% of interventions overall.23,25,27,29,31–34,36,37 Of note, limiting self-directed learning to clinical trainees and faculty-level learners accounted for 26% of the total.20,21,26,35,38 Small-group (group, <15) learning followed, with 21% of the total.22,24,28,30

Figure 3
Figure 3:
Characteristics of learners for whom each intervention in the present review was designed. This figure illustrates the interventions reviewed according to group size and intended primary audience. *“Other” indicates allied health professionals (e.g., pharmacy and nursing trainees).

Temporal characteristics

The vast majority of curricular elements favored brief, self-limited encounters, with interventions requiring one hour to complete accounting for 63% of the total, and single-session interventions making up 53% (data not shown).20,21,25,26,28–31,33,35–38

Content characteristics

A diverse group of pedagogic resources were drawn on in the educational interventions we reviewed (Figure 4). Classroom-based strategies dominated 74% of all interventions,20,22,23,25–28,30–32,34–37 reinforcing the data presented in Figure 3, consistent with the frequent use of small- and large-group-based learning. With respect to specific content elements, didactic sessions were the most common strategy employed, at 63% of all interventions20,22,23,25–28,30,31,34,36,37; handout-based reference documents20,21,23–27,29,32,37,38 and Web-based curricular elements20,23,26–29,32,35,36,38 were the next most common at 53% of all interventions. Of all interventions, 42% provided evidence-based support for their content, making references to published works available to learners.20,21,23,26–28,35 The average number of resources used by each curricular intervention was 3.74 (95% CI, 2.87–4.60) (data not shown).

Figure 4
Figure 4:
Content characteristics of educational interventions included in the present review, by resources used. Resources are grouped by type used by percentage of total interventions.

Our review revealed a wide range of learning objectives (Figure 5). The most common objectives were increasing learner communication skills (53%)20,21,23,24,27–30,32,35 and a general topical introduction to transitional care (47%).21,23,25,27,28,30,31,34,36 Of note, the next three most frequent learning objectives could be linked thematically: Appropriate patient placement, introduction to care settings, and effective discharge planning represent 37%, 32%, and 32% of all interventions, respectively, and 47% when considered together.20,23,25–28,35,37,38 “Other” learning objectives included blood pressure control, adequate oral intake, and durable medical equipment.25,30,32,33,38 The average number of learning objectives articulated by each curricular intervention was 3.53 (95% CI, 2.53–4.52) (data not shown).

Figure 5
Figure 5:
Content characteristics of educational interventions included in the present review, by learning objectives. Learning objectives are articulated in percentage of total interventions. *For example, blood pressure control, adequate oral intake, durable medical equipment, etc.

Most interventions incorporated learner assessment as an integrated part of the curriculum (Figure 6). Pre-/posttesting was the most common method of assessment (42%)20–25,30,35; posttest assessment was next most common (32%),26,29,31,34,37,38 followed by practical examinations (10%).20,29 Assessment strategies included board-style multiple-choice questions and short-answer written responses.

Figure 6
Figure 6:
Content characteristics of educational interventions included in the present review, by learner assessment method. This illustrates the proportions and types of assessment strategies employed by all interventions.

Postintervention evaluation of the learner-perceived benefit and curricular strengths/weaknesses was only employed by 37% of all interventions (data not shown).20,23,25,29,30,34,37 The most frequently employed evaluation strategy was follow-up surveys using Likert-based metrics.

Discussion

At most institutions, faculty relegate the subject of transitional care to the depths of the hidden curriculum in medicine. Although it is rarely explicitly taught, there exists an expectation that trainees should not only “pick it up” but also acquire a degree of expertise as they move through training. With respect to care transitions, educators seem to hope that learners will gain “an eye” for the patients who are more likely to suffer fragmented care or will intuit the type and depth of information a receiving institution or individual will require or prefer for a given patient. This ad hoc method of learning transitional care skills is flawed in two respects: First, the pedagogical approach lacks standardization of content, explicit learning outcomes, and mechanism for learner evaluation; second, the focus is limited to recognizing and preventing only the most flagrantly failed transitions rather than focusing on the provision of high-quality transitional care to all patients. A clear discrepancy exists between the level of competency physicians need for contemporary practice and the tools they are being provided to achieve this goal.

The search strategy we employed in this systematic review yielded 25 interventions overall. Given the recently consolidated definition of transitional care and, further, the specific calls for the development of curricula,4,11,46 the clustering of these publications within the last 10 years is not surprising. This increase can be partially attributed to the maturation of transitional care as a focus of scholarship, at the time of our review mainly undertaken by geriatrics/gerontology-oriented research groups. Eleven of 25 interventions were developed with support from organizations committed to furthering aging-specific research and education, including the Donald W. Reynolds Foundation, John A. Hartford Foundation, National Institute on Aging, and U.S. Health Resources and Services Administration via the Geriatric Academic Career Award.21–23,25,26,28,31,33,35,36,38 Furthermore, in many cases, curricular interventions were developed in-line with the recommendations and core competencies articulated by numerous accrediting bodies, including the Accreditation Council for Graduate Medical Education, The Joint Commission, and the AGS. Although such an increase is heartening, the translation of policy directives into practical curricular elements is modest considering that the importance of care transitions has been recognized for nearly a decade. As mentioned, the support of the geriatrics/gerontology community has been invaluable; however, the dissemination of care transitions scholarship and subsequent support by a broader academic and professional audience has only occurred recently. Moreover, the treatment of care transitions curricula in the medical education literature in particular has been limited. Broad dissemination of this topic is essential for two reasons: first, for the development of increasingly comprehensive and interdisciplinary curricular elements; second, to provide groups responsible for populating medical education curricula (e.g., medical schools, residency programs, graduate medical education offices) with supporting literature highlighting the importance of formally teaching transitional care, and practical resources allowing its integration into preexisting courses of study.

As seen in the appendices, the interventions included in this review were heterogeneous in all categories of data abstracted. The overall heterogeneity of content and reporting necessitated that we develop standardized categories to classify individual characteristics for abstraction purposes. We made every effort to design inclusive and accurate descriptors of the data at hand. The greatest differences existed between those interventions relying on more traditional curricular elements20–38 (Appendix 1) and those that were designed as stand-alone tools39–44 (Appendix 2). Although equally valuable, and important to be represented as published interventions (see Figure 1), further characterization of tool-based interventions for comparison with traditional curricular elements was difficult; thus, we excluded these studies from further analysis (Figures 3–6).

The array of learners participating in the reviewed interventions ranged from preclinical medical students to attending physicians. For preclinical learners, although the interventions lacked a clinical context for the information presented, they served as an early introduction to the topic of transitional care, allowing learners to hone their skills, even in the earliest clinical interactions faced. As noted previously, learning in large groups with brief, focused, self-limited interactions seemed to be the most common structural characteristic of the interventions we analyzed. This structure seems to cater to the clinical learners' (medical students and residents') busy schedule, often with morning or noon conference as the only protected teaching time in the day. With respect to faculty-level learners, increasing competence and comfort as educators, including the ability to teach transitional care, appeared as a frequent theme.

The inclusion of allied health care professionals in some of the interventions reviewed points to the interdisciplinary nature of transitional care and surely represents a valuable strategy for the development of future curricula. Efforts at curricular development should be undertaken with the input of professionals routinely involved in facilitating effective care transitions; this includes but is not limited to nurses, pharmacists, home health providers, case managers, social workers, nursing home staff, and physical/occupational therapists. Although ambitious, crafting curricular content that is relevant and understandable to such a diverse group of professionals speaks to the crux of facilitating effective care transitions in practice—namely, effective communication between groups, each with a distinct lexicon and priorities. Also of benefit would be curricular interventions designed for mixed audiences including physician–trainees/physicians and the allied professionals named above. It is not unreasonable to project that practical dividends would result if diverse trainees are educated together using curricula that promote communication and collaboration.

A wide variety of learning objectives using a diverse array of educational strategies was seen in the interventions we reviewed. No clear relationship was observed between the amount of time required by interventions and the number of learning objectives articulated. The scope and specific topic areas represented by these objectives mirror the broader treatment of transitional care in the literature as well as the priorities advanced by individual professional organizations. However, as noted above, less than half the interventions referenced published literature in support of curricular elements. Citation of supporting literature should be a priority for all new interventions developed, if the overarching goal is to encourage evidence-based transitional care practices.

Learner assessment following educational interventions provides an opportunity to evaluate the effectiveness of given pedagogic strategies and, additionally, allows for learner reflection with respect to specific areas of competency or deficiency. Coupling pre- and posttest assessment is recognized as the gold standard when attempting to ascribe acquired competency to particular interventions and is the most common method of assessment seen in the interventions we reviewed. Not demonstrated was a slight variation in this approach that can ideally be used when attempting to attribute increases in learner confidence to a particular intervention. Specifically, retrospective pretests coupled with posttest self-assessment allow learners to attribute perceived improvements to the intervention completed. This method has been proven superior to prospective pretests in cases where individuals with limited knowledge of given topics perceive their skills as adequate, thereby inflating pretest ratings.47,48 Notably, the interventions that included a practical assessment included an objective structured teaching exam with “standardized students” to assess faculty-level learners,20 as well as a high-fidelity nursing station simulation, including planned distractions and laboratory clerical errors.29

Overall, the interventions we reviewed were not themselves evaluated in a satisfactory manner. In most cases, no mechanism for postintervention information gathering from learners or facilitators was available. Without such information, quality improvement and further development or refinement of interventions will prove difficult.

Limitations specific to our review include the purely descriptive nature of the analysis performed and, although representing a dramatic relative increase, the limited absolute number of interventions available for review. Also, despite rigorous study design, the risk of incomplete information retrieval may have remained. Similarly, an unavoidable risk of bias owing to our own particular training, expertise, and insights may have served to affect the data collection, analysis, and discussion.

Conclusions

Transitional care represents a diverse set of actions and competencies that have demonstrated an important influence on the quality of patient care. Traditionally, this subject has been un- or underrepresented in curricula for medical trainees or medical professionals. Recently, the number of educational interventions developed to teach this complex topic has increased dramatically. Overall, through a variety of strategies, these interventions can, and should, serve to educate learners across the entire breadth of transitional care topics, providing practical skills to help ensure effective patient transitions in all locations.

Initial efforts at the development of curricular elements teaching transitional care have yielded a body of work of both modest size and scope. Furthermore, it seems that the distribution of these interventions and their subsequent integration into undergraduate, graduate, and professional education programs have also been limited. Three important factors thus emerge when considering the development of future curricula. First, efforts to span the breadth of transitional care in individual interventions should be made. This will involve developing interventions that are heavily evidence based and will most likely require the expansion of elements beyond short, single-sitting educational sessions. Second, increasingly rigorous, purposeful development and validation of novel curricular interventions will allow their publication in a wider range of high-quality, peer-reviewed publications, most significantly including the traditional medical education literature. Third, integration of developed interventions into existing curricula must be incorporated as a priority by those responsible for establishing the curricula of medical educational programs. Although available content will always exceed available time, it is clear that the provision of effective transitional care is an important skill for all medical professionals and, with the trend toward the increasing fragmentation of care, will only become more important in the future.

Our goal has been to detail the strategies used by educational interventions published to date that teach transitional care to a select audience. It remains to be said that beyond specific methods, resources, time investments, or articulated learning objectives, at its very root, effective transitional care is based on high-quality and high-fidelity interdisciplinary communication among individuals charged with a wide array of specific tasks, all related to patient care. Although enhancing the level of education and overall awareness of this topic certainly helps endow medical professionals with the skills necessary to facilitate effective care transitions, ultimately, the provision of consistent, high-quality transitional care requires an investment by these individuals in their daily practice, outside of the classroom. As such, designing novel curricular elements is necessary but not sufficient to achieve this goal—rather, a change in professional culture across all disciplines, incorporating transitional care as a fundamental priority, is required.

Funding/Support:

This work was supported in part by an educational grant provided by the Donald W. Reynolds Foundation.

Other disclosures:

None.

Ethical approval:

Not applicable.

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Appendix 1
Appendix 1:
Educational Interventions (Mixed-Method) Used to Teach Transitional Care to Physicians and Trainees, Identified in a 2010 Systematic Review
Appendix 1
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Appendix 1
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Appendix 1
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Appendix 2
Appendix 2:
Educational Interventions (Tools Only) Used to Teach Transitional Care to Physicians and Trainees, Identified in a 2010 Systematic Review
© 2011 Association of American Medical Colleges