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Effects of Postacute Multidisciplinary Rehabilitation Including Exercise in Out-of-Hospital Settings in the Aged: Systematic Review and Meta-analysis

  • Lotte Verweij
    Correspondence
    Corresponding author Lotte Verweij, RN, MSc, Academic Medical Center, Department of Cardiology and Geriatric Medicine, University of Amsterdam, Tafelbergweg 51, 1105 BD, Amsterdam, the Netherlands.
    Affiliations
    ACHIEVE, Center of Applied Research, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands

    Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands

    Department of Cardiology and Geriatric Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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  • Eva van de Korput
    Affiliations
    Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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  • Joost G. Daams
    Affiliations
    Research Support, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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  • Gerben ter Riet
    Affiliations
    Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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  • Ron J.G. Peters
    Affiliations
    Department of Cardiology and Geriatric Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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  • Raoul H.H. Engelbert
    Affiliations
    ACHIEVE, Center of Applied Research, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands

    Department of Rehabilitation, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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  • Wilma J.M. Scholte op Reimer
    Affiliations
    ACHIEVE, Center of Applied Research, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands

    Department of Cardiology and Geriatric Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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  • Bianca M. Buurman
    Affiliations
    ACHIEVE, Center of Applied Research, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands

    Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Open AccessPublished:June 11, 2018DOI:https://doi.org/10.1016/j.apmr.2018.05.010

      Abstract

      Objective

      Many older individuals receive rehabilitation in an out-of-hospital setting (OOHS) after acute hospitalization; however, its effect on mobility and unplanned hospital readmission is unclear. Therefore, a systematic review and meta-analysis were conducted on this topic.

      Data Sources

      Medline OVID, Embase OVID, and CINAHL were searched from their inception until February 22, 2018.

      Study Selection

      OOHS (ie, skilled nursing facilities, outpatient clinics, or community-based at home) randomized trials studying the effect of multidisciplinary rehabilitation were selected, including those assessing exercise in older patients (mean age ≥65y) after discharge from hospital after an acute illness.

      Data Extraction

      Two reviewers independently selected the studies, performed independent data extraction, and assessed the risk of bias. Outcomes were pooled using fixed- or random-effect models as appropriate. The main outcomes were mobility at and unplanned hospital readmission within 3 months of discharge.

      Data Synthesis

      A total of 15 studies (1255 patients) were included in the systematic review and 12 were included in the meta-analysis (7 assessing mobility using the 6-minute walk distance [6MWD] test and 7 assessing unplanned hospital readmission). Based on the 6MWD, patients receiving rehabilitation walked an average of 23 m more than controls (95% confidence interval [CI]=: −1.34 to 48.32; I2: 51%). Rehabilitation did not lower the 3-month risk of unplanned hospital readmission (risk ratio: 0.93; 95% CI: 0.73-1.19; I2: 34%). The risk of bias was present, mainly due to the nonblinded outcome assessment in 3 studies, and 7 studies scored this unclearly.

      Conclusion

      OOHS-based multidisciplinary rehabilitation leads to improved mobility in older patients 3 months after they are discharged from hospital following an acute illness and is not associated with a lower risk of unplanned hospital readmission within 3 months of discharge. However, the wide 95% CIs indicate that the evidence is not robust.

      Keyword

      List of abbreviations:

      CI (confidence interval), MD (mean difference), 6MWD (6-minute walk distance), OOHS (out-of-hospital setting), RR (risk ratio), TIDieR (template for intervention description and replication)
      Every year, approximately 10% of the population aged ≥65 years is acutely admitted to hospital because of a variety of diseases, such as cardiovascular, pulmonary, and infectious diseases.
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      Geriatric conditions in acutely hospitalized older patients: prevalence and one-year survival and functional decline.
      Many of these patients suffer from disabilities and limitations in activities of daily living that are associated with adverse health outcomes after hospitalization.
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      Geriatric conditions in acutely hospitalized older patients: prevalence and one-year survival and functional decline.
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      • Mehta K.M.
      • Boscardin W.J.
      • et al.
      Prediction of recovery, dependence or death in elders who become disabled during hospitalization.
      More than 20% of older patients die within 3 months,
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      • et al.
      Geriatric conditions in acutely hospitalized older patients: prevalence and one-year survival and functional decline.
      and more than 30% die 1 year after hospital discharge.
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      • Mehta K.M.
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      • et al.
      Prediction of recovery, dependence or death in elders who become disabled during hospitalization.
      Of those alive at 3 months, many develop new limitations in activities of daily living when compared to their abilities 2 weeks before hospitalization.
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      • Hoogerduijn J.G.
      • de Haan R.J.
      • et al.
      Geriatric conditions in acutely hospitalized older patients: prevalence and one-year survival and functional decline.
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      • de Rooij S.E.
      Variability in measuring (instrumental) activities of daily living functioning and functional decline in hospitalized older medical patients: a systematic review.
      These patients are at risk of ending up in a vicious circle because these increased disabilities are in turn associated with increased all-cause 30-day hospital readmission.
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      Assessment of function and disability in longitudinal studies.
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      Hospitalization, restricted activity, and the development of disability among older persons.
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      Recovery from disability among community-dwelling older persons.
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      • et al.
      Patient-centred physical therapy is (cost-) effective in increasing physical activity and reducing frailty in older adults with mobility problems: a randomized controlled trial with 6 months follow-up.
      A recent systematic review and meta-analysis of hospital-based inpatient geriatric rehabilitation, including exercise training, demonstrated that rehabilitation strategies cannot only restore functioning but also prevent disabilities.
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      • Huss A.
      • Egger M.
      • Stuck A.E.
      • Clough-Gorr K.M.
      Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials.
      Many studies focus on a diagnosis-based population despite other factors (ie, level of frailty) playing an important role in determining rehabilitation needs.
      • de Vries N.M.
      • Staal J.B.
      • van der Wees P.J.
      • et al.
      Patient-centred physical therapy is (cost-) effective in increasing physical activity and reducing frailty in older adults with mobility problems: a randomized controlled trial with 6 months follow-up.
      The medical diagnosis often insufficiently correlates with disease-related functional consequences. To restore or prevent disabilities in older individuals, rehabilitation programs need to apply a broader multifactorial approach rather than focusing only on body function.
      • Marshall S.
      • Bauer J.
      • Isenring E.
      The consequences of malnutrition following discharge from rehabilitation to the community: a systematic review of current evidence in older adults.
      • Munk T.
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      • et al.
      Individualised dietary counselling for nutritionally at-risk older patients following discharge from acute hospital to home: a systematic review and meta-analysis.
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      • Allore H.
      • Byers A.
      A program to prevent functional decline in physically frail, elderly persons who live at home.
      This is often implemented using a comprehensive geriatric assessment to assess a patient’s health status, geriatric condition, body function, and personal goals and results in a multidisciplinary care and rehabilitation plan.
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      • Farfel J.M.
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      • Campora F.
      • Jacob-Filho W.
      Comprehensive geriatric assessment predicts mortality and adverse outcomes in hospitalized older adults.
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      • Rees K.
      • Dieppe P.
      • et al.
      Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis.
      There is currently no aggregated evidence available regarding multidisciplinary rehabilitation treatment in an out-of-hospital setting (OOHS) (ie, skilled nursing facilities, outpatient clinics, or community-based at home) for older adults after hospital discharge following an acute illness. Current evidence on this type of rehabilitation has mainly focused on patients’ poststroke
      • Duncan P.W.
      • Zorowitz R.
      • Bates B.
      • et al.
      Management of adult stroke rehabilitation care: a clinical practice guideline.
      • Pollock A.
      • Baer G.
      • Campbell P.
      • et al.
      Physical rehabilitation approaches for the recovery of function and mobility following stroke.
      or hip fracture
      • Crotty M.
      • Unroe K.
      • Cameron I.D.
      • Miller M.
      • Ramirez G.
      • Couzner L.
      Rehabilitation interventions for improving physical and psychosocial functioning after hip fracture in older people.
      • Handoll H.H.
      • Sherrington C.
      • Mak J.C.
      Interventions for improving mobility after hip fracture surgery in adults.
      and on older patients who reside in a nursing home and require long-term care.
      • Crocker T.
      • Forster A.
      • Young J.
      • et al.
      Physical rehabilitation for older people in long-term care.
      Therefore, this systematic review and meta-analysis analyzed the effectiveness of multidisciplinary rehabilitation (including exercise compared to usual care or other forms of rehabilitation) on mobility (as a measure of body function) and unplanned hospital readmission in older patients (mean age ≥65y) 3 months after hospital discharge following an acute illness.

      Methods

      This systematic review is registered in the PROSPERO register of systematic reviews (registration number: CRD42017058592). It has been reported according to the PRISMA guidelines.
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      PRISMA Group
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      Inclusion criteria for studies were as follows: design: randomized controlled trials published in peer-reviewed journals. Population: mean age ≥65 years; discharged from hospital following an acute illness (ie, myocardial infarction, exacerbation of chronic obstructive pulmonary disease, or dysregulated diabetes mellitus). Intervention: rehabilitation in an OOHS (ie, a skilled nursing facility, outpatient clinic, or community-based at home); rehabilitation programs starting in hospital and continuing in an OOHS; rehabilitation containing at least exercise therapy, because this is an important contributing intervention to recover from or prevent a decline in body function,
      • Martinez-Velilla N.
      • Cadore L.
      • Casas-Herrero A.
      • Idoate-Saralegui F.
      • Izquierdo M.
      Physical activity and early rehabilitation in hospitalized elderly medical patients: systematic review of randomized clinical trials.
      • Kosse N.M.
      • Dutmer A.L.
      • Dasenbrock L.
      • Bauer J.M.
      • Lamoth C.J.
      Effectiveness and feasibility of early physical rehabilitation programs for geriatric hospitalized patients: a systematic review.
      and including treatment from at least 2 disciplines; intervention compared to care as usual or other forms of rehabilitation. Outcome: primary: mobility (as a measure of body function) and unplanned hospital readmission within 3 months of the initial hospitalization; secondary: mobility (as a measure of body function) and unplanned hospital readmission within 6 and 12 months of the initial hospitalization.
      The focus of the primary and secondary outcome measures at 3 and 6 months after discharge was based on the rationale that older patients are at increased risk of adverse events and declining body function in the first 6 months after hospital discharge.
      • Buurman B.M.
      • Hoogerduijn J.G.
      • de Haan R.J.
      • et al.
      Geriatric conditions in acutely hospitalized older patients: prevalence and one-year survival and functional decline.
      • Barnes D.E.
      • Mehta K.M.
      • Boscardin W.J.
      • et al.
      Prediction of recovery, dependence or death in elders who become disabled during hospitalization.
      • Dharmarajan K.
      • Hsieh A.F.
      • Lin Z.
      • et al.
      Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia.
      The effect of rehabilitation at 12 months was included to present the long-term effects of the interventions.
      Studies were excluded if the intervention was offered after planned hospitalization, was situated within an emergency department, or focused on institutionalized long-term care. Studies on patients with neurologic and traumatic injuries (eg, hip fractures) were excluded because there is sufficient evidence that rehabilitation programs are effective in these populations.
      • Duncan P.W.
      • Zorowitz R.
      • Bates B.
      • et al.
      Management of adult stroke rehabilitation care: a clinical practice guideline.
      • Pollock A.
      • Baer G.
      • Campbell P.
      • et al.
      Physical rehabilitation approaches for the recovery of function and mobility following stroke.
      • Crotty M.
      • Unroe K.
      • Cameron I.D.
      • Miller M.
      • Ramirez G.
      • Couzner L.
      Rehabilitation interventions for improving physical and psychosocial functioning after hip fracture in older people.
      • Handoll H.H.
      • Sherrington C.
      • Mak J.C.
      Interventions for improving mobility after hip fracture surgery in adults.
      Studies were also excluded if the focus was on patients with a severe psychological or psychiatric comorbidity or cognitive impairments.

       Definition of the mobility outcome as a measure of body function

      Although daily functioning is widely used as an important patient-reported outcome measure, many variations exist on the use of the term functioning.
      • Ustun B.
      • Kennedy C.
      What is “functional impairment”? Disentangling disability from clinical significance.
      According to the International Classification of Functioning, functioning consists of 3 main functions: body functions, activities, and involvement in life situations.
      • Ustun B.
      • Kennedy C.
      What is “functional impairment”? Disentangling disability from clinical significance.
      This systematic review focuses on mobility (eg, a 6-minute walk distance [6MWD] test) as a measure of body function.
      The 6MWD test reflects the functional capacity level and is an indicator of activities of daily living as part of body function according to the International Classification of Functioning.
      ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories
      ATS statement: guidelines for the six-minute walk test.
      The 6MWD test is a predictor of morbidity and mortality in older patients.
      ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories
      ATS statement: guidelines for the six-minute walk test.

       Information sources

      A clinical librarian (J.G.D.) conducted a systematic literature search in Medline OVID, Embase OVID, and CINAHL selecting articles that were published between their inception and February 22, 2018. A scoping search was initially performed to identify relevant references in Medline OVID. Reference lists of eligible studies were searched by hand to identify studies potentially missed in the database searches. Appendix 1 shows the full search strategy.

       Study selection

      The studies identified in the scoping search were managed in EndNotea and subsequently exported to Covidence
      • Babineau J.
      Product review: Covidence (systematic review software).
      ,b and Review Manager (version 5.3) software,c which were used for the screening process, data collection, and analysis. Two authors (L.V. and E.V.D.K.) independently screened the titles, abstracts of the identified studies, and full texts after the first screening. After selection, they subsequently extracted data from these studies. In case of a discrepancy, a consensus was reached through discussion with a third reviewer (B.M.B.).

       Data collection

      Based on the Cochrane data collection form
      • Higgins J.P.
      • Green S.
      Cochrane handbook for systematic reviews of interventions.
      and the Template for Intervention Description and Replication (TIDieR) guidelines,
      • Hoffmann T.C.
      • Glasziou P.P.
      • Boutron I.
      • et al.
      Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide.
      data were extracted on the following basis: (1) study characteristics (eg, authors, publication year, journal, country, study setting, study population, sample size, follow-up); (2) patient characteristics (eg, mean age and gender distribution); (3) description of the intervention based on TIDieR guidelines (eg, what [intervention components either exercise, diet, or education], who [multidisciplinary], how, where, and how much)
      • Hoffmann T.C.
      • Glasziou P.P.
      • Boutron I.
      • et al.
      Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide.
      ; (4) intensity (eg, aerobic or anaerobic training, muscle strengthening, balance and stretching exercises, functional exercise, frequency); (5) statistics (eg, absolute numbers, effect size, 95% confidence intervals [CIs]).
      In the case of missing data, the authors were contacted by e-mail and asked for the additional information. One reminder e-mail was sent after 4 weeks.

       Assessment of risk of bias

      The Cochrane Collaboration’s risk of bias tool was used to evaluate the quality of the included studies.
      • Higgins J.P.
      • Altman D.G.
      • Gotzsche P.C.
      • et al.
      The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.
      Two reviewers (L.V. and E.V.D.K.) independently assessed each study based on the sequence generation, allocation concealment, blinding of participants, personnel and outcome assessors, incomplete outcome data, selective outcome reporting, and other sources of bias.
      In the evaluation, a distinction was made between the mobility and unplanned hospital readmission outcomes considering the effect of blinding the outcome assessors. Not blinding the outcome assessors to the rehabilitation intervention was unlikely to have influenced the unplanned hospital readmission rates but could have influenced the measurement of mobility.

       Publication bias

      A plan was made to assess small study bias using the Egger regression asymmetry test if at least 10 studies were included in the meta-analysis.
      • Higgins J.P.
      • Green S.
      Cochrane handbook for systematic reviews of interventions.

       Data synthesis

      Review Manager software was used to pool study data regarding mobility and unplanned hospital readmissions. The mean difference (MD) and 95% CI were calculated for the continuous mobility outcome from the 6MWD data, which were reported in most studies included on the topic. The pooled risk ratio (RR) and its 95% CI were calculated for the unplanned hospital readmission outcome. Heterogeneity across studies was evaluated using the I2 statistic.
      • Higgins J.P.
      • Green S.
      Cochrane handbook for systematic reviews of interventions.
      A fixed-effects model was used for I2 values ≤40%, and a random-effects model (according to the DerSimonian and Laird method to account for substantial statistical heterogeneity) was used for I2 values >40%.
      • Higgins J.P.
      • Green S.
      Cochrane handbook for systematic reviews of interventions.
      A sensitivity analysis of the meta-analysis was also performed to assess the influence of sequentially omitting individual studies on pooled estimates.

      Results

      Online database searches in Medline OVID, Embase OVID, and CINAHL identified 6187 references. The review process is summarized in fig 1. After removing duplicates, the titles and abstracts of 4355 studies were screened. A total of 143 studies were considered for a full-text review, whereas 128 studies were excluded due to inadmissible patient populations (n=68); nonrandomization of the trial (n=19); no rehabilitation intervention, lack of exercise components, or no multidisciplinary approach (n=14); no acute hospitalization (n=12); the study protocol description (n=8); other outcomes (n=5); or excluded settings (n=2) (appendix 2). Ultimately, 15 studies were eligible for inclusion in the systematic review, 7 were eligible for inclusion in the 6MWD meta-analysis, and 7 were eligible for the meta-analysis on unplanned hospital readmission.

       Study characteristics

      The number of participants in the included studies collectively totaled 1255 (624 in the intervention group and 631 in the control group). The mean participant age was 74 years (range: 65-85). Four studies reported on a general patient population,
      • Buhl S.F.
      • Andersen A.L.
      • Andersen J.R.
      • et al.
      The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients—a randomized controlled trial.
      • Courtney M.
      • Edwards H.
      • Chang A.
      • Parker A.
      • Finlayson K.
      • Hamilton K.
      Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
      • Courtney M.D.
      • Edwards H.E.
      • Chang A.M.
      • et al.
      Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial.
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      5 reported on pulmonary patients,
      • Behnke M.
      • Taube C.
      • Kirsten D.
      • Lehnigk B.
      • Jorres R.A.
      • Magnussen H.
      Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease.
      • Eaton T.
      • Young P.
      • Fergusson W.
      • et al.
      Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study.
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      • Song H.-Y.
      • Yong S.J.
      • Hur H.K.
      Effectiveness of a brief self-care support intervention for pulmonary rehabilitation among the elderly patients with chronic obstructive pulmonary disease in Korea.
      and 6 reported on cardiac patients (table 1).
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      • Dolansky M.A.
      • Zullo M.D.
      • Boxer R.S.
      • Moore S.M.
      Initial efficacy of a cardiac rehabilitation transition program: Cardiac TRUST.
      • Li X.
      • Xu S.
      • Zhou L.
      • Li R.
      • Wang J.
      Home-based exercise in older adults recently discharged from the hospital for cardiovascular disease in China: randomized clinical trial.
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Prescott E.
      Home-based cardiac rehabilitation is an attractive alternative to no cardiac rehabilitation for elderly patients with coronary heart disease: results from a randomised clinical trial.
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Simonsen L.
      • Skovgaard L.T.
      • Prescott E.
      Home-based cardiac rehabilitation is as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial.
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      • Stahle A.
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      Table 1Characteristics of included studies
      First Author, Year of PublicationCountryN (I/C)Mean Age ± SD (I/C)Setting
      Setting: SNF.
      Outcome (Instrument)
      Instruments: WIQ/Morton Mobility Index/6MWD in meters/ISWT.
      O A (mo)Outcome (I)
      Data on mobility are presented as mean ± SD, unplanned hospital readmission in absolute numbers.
      Outcome (C)
      Data on mobility are presented as mean ± SD, unplanned hospital readmission in absolute numbers.
      General illness
       Courtney, 2009
      • Courtney M.
      • Edwards H.
      • Chang A.
      • Parker A.
      • Finlayson K.
      • Hamilton K.
      Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
      Australia64/6478±6.3/79.4±7.3Inpatient, hospitalReadmission311/5816/64
      Community, home613/4927/58
       Courtney, 2012
      • Courtney M.D.
      • Edwards H.E.
      • Chang A.M.
      • et al.
      Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial.
      Australia64/6478±6.3/79.4±7.3Inpatient, hospitalMobility (WIQ-distance)354.83±27.7921.59±26.17
      Community, home662.89±28.1719.93±24.93
       Buhl, 2016
      • Buhl S.F.
      • Andersen A.L.
      • Andersen J.R.
      • et al.
      The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients—a randomized controlled trial.
      Denmark14/1273.3±6.29/72.4±7.43Inpatient, hospitalMobility (de Morton Mobility Index)3NRNR
      Community, homeReadmission32/141/12
       Sahota, 2017
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      United Kingdom125/12583.6±6.6/84.5±5.9Inpatient, hospitalReadmission345/12539/125
      Community, home
      Pulmonary illness
       Behnke, 2000
      • Behnke M.
      • Taube C.
      • Kirsten D.
      • Lehnigk B.
      • Jorres R.A.
      • Magnussen H.
      Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease.
      Germany15/1565±1.9/68±2.2Inpatient, hospitalMobility (6MWD)3NRNR
      Community, home6NRNR
       Eaton, 2009
      • Eaton T.
      • Young P.
      • Fergusson W.
      • et al.
      Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study.
      New Zealand47/5070.1±10.3/69.7±9.4Inpatient, hospitalMobility (6MWD)3362±119313±126
      Outpatient, rehab clinicReadmission311/4716/50
       Ko, 2011
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      China30/3073.5±7.7/73.8±6.4Outpatient, rehab clinicMobility (6MWD)3328.77±85.22313.23±76.79
      Community, home6333.30±84.86316.73±72.72
      12330.62±86.11294.66±113.31
      Readmission36/308/30
      611/3011/30
      1216/3013/30
       Seymour, 2010
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      United Kingdom30/3067±10/65±0Outpatient, rehabilitation clinicMobility (ISWT)3216±126183±98
      Readmission32/3010/30
       Song, 2014
      • Song H.-Y.
      • Yong S.J.
      • Hur H.K.
      Effectiveness of a brief self-care support intervention for pulmonary rehabilitation among the elderly patients with chronic obstructive pulmonary disease in Korea.
      South Korea20/2066.6±7./68.1±6.5Inpatient, hospitalMobility (6MWD)3333.5±79.2312.7±72.1
      Community, home
      Cardiac illness
       Davidson, 2010
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      Australia53/5271.6/73.9Outpatient, clinicMobility (6MWD)3361.2±132.34274.98±106.6
      Community, home12386.6±129.97247.27±122.96
      Readmission1222/4927/39
       Dolansky, 2011
      • Dolansky M.A.
      • Zullo M.D.
      • Boxer R.S.
      • Moore S.M.
      Initial efficacy of a cardiac rehabilitation transition program: Cardiac TRUST.
      United States17/2177.6±6.9/76.5±6.9Inpatient, hospitalMobility (no. of steps walked)31307±652782±544
      Inpatient, SNF
      Community, home
       Li, 2015
      • Li X.
      • Xu S.
      • Zhou L.
      • Li R.
      • Wang J.
      Home-based exercise in older adults recently discharged from the hospital for cardiovascular disease in China: randomized clinical trial.
      China37/4080.3±3.8/81.1±4.5Inpatient, hospitalMobility (6MWD)3347.6±63.71338.3±76.25
      Community, home
       Oerkild, 2011
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Simonsen L.
      • Skovgaard L.T.
      • Prescott E.
      Home-based cardiac rehabilitation is as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial.
      Denmark39/3674.7±5.9/74.4±5.8Community, homeMobility (6MWD)3Δ17.4±82.04Δ36.1±83.95
       Oerkild, 2012
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Prescott E.
      Home-based cardiac rehabilitation is an attractive alternative to no cardiac rehabilitation for elderly patients with coronary heart disease: results from a randomised clinical trial.
      Denmark19/2177.3±6.0/76.5±7.7Community, homeMobility (6MWD)3Δ36.3±82.84Δ10.1±78.91
       Sandström, 2005
      • Sandström L.
      • Stahle A.
      Rehabilitation of elderly with coronary heart disease - improvement in quality of life at a low cost.
      Sweden50/5171±64-84/71±65-83Outpatient, rehabilitation clinicReadmission310/506/51
      1211/5011/51
      NOTE. Δ delta: difference between baseline measures and follow-up measures.
      Abbreviations: C, control; I, intervention; ISWT, Incremental Shuttle Walk Test; NR, not reported; OA, outcome assessment; SNF, Skilled Nursing Facility; WIQ, Walking Impairment Questionnaire.
      Setting: SNF.
      Instruments: WIQ/Morton Mobility Index/6MWD in meters/ISWT.
      Data on mobility are presented as mean ± SD, unplanned hospital readmission in absolute numbers.
      Of the 15 included studies, 11 involved transitional rehabilitation interventions that started rehabilitation during hospitalization
      • Buhl S.F.
      • Andersen A.L.
      • Andersen J.R.
      • et al.
      The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients—a randomized controlled trial.
      • Courtney M.
      • Edwards H.
      • Chang A.
      • Parker A.
      • Finlayson K.
      • Hamilton K.
      Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
      • Courtney M.D.
      • Edwards H.E.
      • Chang A.M.
      • et al.
      Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial.
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      • Behnke M.
      • Taube C.
      • Kirsten D.
      • Lehnigk B.
      • Jorres R.A.
      • Magnussen H.
      Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease.
      • Eaton T.
      • Young P.
      • Fergusson W.
      • et al.
      Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study.
      • Song H.-Y.
      • Yong S.J.
      • Hur H.K.
      Effectiveness of a brief self-care support intervention for pulmonary rehabilitation among the elderly patients with chronic obstructive pulmonary disease in Korea.
      • Dolansky M.A.
      • Zullo M.D.
      • Boxer R.S.
      • Moore S.M.
      Initial efficacy of a cardiac rehabilitation transition program: Cardiac TRUST.
      • Li X.
      • Xu S.
      • Zhou L.
      • Li R.
      • Wang J.
      Home-based exercise in older adults recently discharged from the hospital for cardiovascular disease in China: randomized clinical trial.
      or in an outpatient rehabilitation center.
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      The interventions continued with rehabilitation that was home based,
      • Buhl S.F.
      • Andersen A.L.
      • Andersen J.R.
      • et al.
      The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients—a randomized controlled trial.
      • Courtney M.
      • Edwards H.
      • Chang A.
      • Parker A.
      • Finlayson K.
      • Hamilton K.
      Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
      • Courtney M.D.
      • Edwards H.E.
      • Chang A.M.
      • et al.
      Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial.
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      • Behnke M.
      • Taube C.
      • Kirsten D.
      • Lehnigk B.
      • Jorres R.A.
      • Magnussen H.
      Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease.
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      • Song H.-Y.
      • Yong S.J.
      • Hur H.K.
      Effectiveness of a brief self-care support intervention for pulmonary rehabilitation among the elderly patients with chronic obstructive pulmonary disease in Korea.
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      • Li X.
      • Xu S.
      • Zhou L.
      • Li R.
      • Wang J.
      Home-based exercise in older adults recently discharged from the hospital for cardiovascular disease in China: randomized clinical trial.
      in an outpatient setting,
      • Eaton T.
      • Young P.
      • Fergusson W.
      • et al.
      Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study.
      or in a skilled nursing facility.
      • Dolansky M.A.
      • Zullo M.D.
      • Boxer R.S.
      • Moore S.M.
      Initial efficacy of a cardiac rehabilitation transition program: Cardiac TRUST.
      Of the remaining 4 studies, 2 only provided rehabilitation at home
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Prescott E.
      Home-based cardiac rehabilitation is an attractive alternative to no cardiac rehabilitation for elderly patients with coronary heart disease: results from a randomised clinical trial.
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Simonsen L.
      • Skovgaard L.T.
      • Prescott E.
      Home-based cardiac rehabilitation is as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial.
      and 2 provided rehabilitation in an outpatient setting.
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      • Sandström L.
      • Stahle A.
      Rehabilitation of elderly with coronary heart disease - improvement in quality of life at a low cost.
      The exercise component of the included studies consisted of intensity training (ie, walking and endurance exercises), strengthening exercises, and balance and stretching exercises and was mainly performed by physical therapists, occupational therapists, or a multidisciplinary team that was not further specified (table 2). In general, each study included an educational component in the intervention (ie, written or verbal exercise instructions) and counseling and teaching strategies for coping with dyspnea and stress, which were provided by those with expertise on the topic (see table 2). Dieticians were mainly involved in studies on cardiac patients in the context of dietary counseling,
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Prescott E.
      Home-based cardiac rehabilitation is an attractive alternative to no cardiac rehabilitation for elderly patients with coronary heart disease: results from a randomised clinical trial.
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Simonsen L.
      • Skovgaard L.T.
      • Prescott E.
      Home-based cardiac rehabilitation is as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial.
      and in 1 study they were used to prescribe a high-protein diet to a general patient population.
      • Buhl S.F.
      • Andersen A.L.
      • Andersen J.R.
      • et al.
      The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients—a randomized controlled trial.
      Each study included a multidisciplinary team made up of, for example, registered nurses, physical therapists, occupational therapists, and dieticians (see table 2). Three studies performed a comprehensive baseline geriatric assessment
      • Courtney M.
      • Edwards H.
      • Chang A.
      • Parker A.
      • Finlayson K.
      • Hamilton K.
      Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
      • Courtney M.D.
      • Edwards H.E.
      • Chang A.M.
      • et al.
      Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial.
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      ; however, the duration and intensity of rehabilitation sessions differed substantially in these studies (see table 2), ranging from 15
      • Behnke M.
      • Taube C.
      • Kirsten D.
      • Lehnigk B.
      • Jorres R.A.
      • Magnussen H.
      Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease.
      to 120 minutes
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      per session. The frequency of sessions in the rehabilitation programs ranged from 1 in-hospital session and 1 outpatient session in total
      • Song H.-Y.
      • Yong S.J.
      • Hur H.K.
      Effectiveness of a brief self-care support intervention for pulmonary rehabilitation among the elderly patients with chronic obstructive pulmonary disease in Korea.
      to 6 sessions per week over 12 months.
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Simonsen L.
      • Skovgaard L.T.
      • Prescott E.
      Home-based cardiac rehabilitation is as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial.
      Table 2Description of interventions
      First Author, Year of PublicationIntensity and DoseWhat is Delivered?

      Exercise
      What is Delivered?

      Education—Instruction About
      What is Delivered?

      Dietary
      Who Delivered?

      Disciplines
      IntensityStrengthBalance/StretchingExerciseLifestyleCopingMedicationNot Specified/Other
      General illness
       Courtney, 2009
      • Courtney M.
      • Edwards H.
      • Chang A.
      • Parker A.
      • Finlayson K.
      • Hamilton K.
      Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
      24 wk×××××NTNTNANTRN, PT
       Courtney, 2012
      • Courtney M.D.
      • Edwards H.E.
      • Chang A.M.
      • et al.
      Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial.
      24 wk×××××NTNTNANTRN, PT
       Buhl, 2016
      • Buhl S.F.
      • Andersen A.L.
      • Andersen J.R.
      • et al.
      The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients—a randomized controlled trial.
      13 wkNT×NT×NTNTNTNA×Dt, PT
       Sahota, 2017
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      In hospital 7/wk, transition, home visits based on needsPersonalized rehabilitation planNTNANTOT, PT, SSP
      Pulmonary illness
       Behnke, 2000
      • Behnke M.
      • Taube C.
      • Kirsten D.
      • Lehnigk B.
      • Jorres R.A.
      • Magnussen H.
      Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease.
      6 mo, 15 min 3/d×NTNT×NTNTNTNANTPT, MS, RPh
       Eaton, 2009
      • Eaton T.
      • Young P.
      • Fergusson W.
      • et al.
      Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study.
      8 wk, 1 h 2/wk××NTNTNT××NANTMT, APN, MDT
       Ko, 2011
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      8 wk, 120 min 3/wk××NT×NT×NTNANTPT, APN
       Seymour, 2010
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      8 wk, 120 min 2/wk××NTNTNTNTNT×NTPT, MT
       Song, 2014
      • Song H.-Y.
      • Yong S.J.
      • Hur H.K.
      Effectiveness of a brief self-care support intervention for pulmonary rehabilitation among the elderly patients with chronic obstructive pulmonary disease in Korea.
      8 wk×NT××NT××NANTMT, APN
      Cardiac illness
       Davidson, 2010
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      12 wk××NTNTNTNTNT××RN, PT, RPh, OT, Dt
       Dolansky, 2011
      • Dolansky M.A.
      • Zullo M.D.
      • Boxer R.S.
      • Moore S.M.
      Initial efficacy of a cardiac rehabilitation transition program: Cardiac TRUST.
      2 wk×NTNT×NTNTNT×NTRN, PT, OT
       Li, 2015
      • Li X.
      • Xu S.
      • Zhou L.
      • Li R.
      • Wang J.
      Home-based exercise in older adults recently discharged from the hospital for cardiovascular disease in China: randomized clinical trial.
      12 wk, 5/wk×NTNT×NTNTNTNANTMT, PT, APN
       Oerkild, 2011
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Simonsen L.
      • Skovgaard L.T.
      • Prescott E.
      Home-based cardiac rehabilitation is as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial.
      12 mo, 30 min 6/wk×NTNTNT×NTNTNA×PT, Dt
       Oerkild, 2012
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Prescott E.
      Home-based cardiac rehabilitation is an attractive alternative to no cardiac rehabilitation for elderly patients with coronary heart disease: results from a randomised clinical trial.
      12 mo, 30 min 6/wk×NTNT××NTNTNA×PT, MS, Dt
       Sandström, 2005
      • Sandström L.
      • Stahle A.
      Rehabilitation of elderly with coronary heart disease - improvement in quality of life at a low cost.
      3 mo, 50 min 3/wk×NTNT×NTNTNT×NTMDT
      Abbreviations: APN, advanced practice nurse; Dt, dietician; MDT, multidisciplinary team; MS, medical specialist; MT, medical team; NA, not applicable; NT, not tested; OT, occupational therapist; RN, registered nurse, RPh, pharmacist; PT, physical therapist, SSP, social service practitioner.
      All studies defined usual care as providing information and advice on lifestyle and exercise and providing follow-up visits or telephone calls by a physician or nurse (specialist). In addition to this usual care, 2 studies described rehabilitation advice as usual care but did not elaborate on the details of this advice.
      • Courtney M.
      • Edwards H.
      • Chang A.
      • Parker A.
      • Finlayson K.
      • Hamilton K.
      Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
      • Courtney M.D.
      • Edwards H.E.
      • Chang A.M.
      • et al.
      Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial.
      One study described standard rehabilitation as usual care that involved group-based exercise training twice a week, education, and dietary counseling.
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Simonsen L.
      • Skovgaard L.T.
      • Prescott E.
      Home-based cardiac rehabilitation is as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial.
      Another study described standard rehabilitation as an in-hospital multidisciplinary approach by physical therapists and occupational therapists during weekdays with a training schedule based on an individual assessment.
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.

       Risk of bias

      Figure 2 summarizes the risk of bias assessment in the included studies. Sequence generation was clearly described in all studies with the exception of the studies by Oerkild et al
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Prescott E.
      Home-based cardiac rehabilitation is an attractive alternative to no cardiac rehabilitation for elderly patients with coronary heart disease: results from a randomised clinical trial.
      and Sahota et al.
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      Oerkild introduced selection bias by inviting patients to participate in another program, and those who declined were invited to participate in the study program. Sahota did not describe the process of sequence generation. Five studies did not report the allocation concealment process,
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      • Behnke M.
      • Taube C.
      • Kirsten D.
      • Lehnigk B.
      • Jorres R.A.
      • Magnussen H.
      Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease.
      • Song H.-Y.
      • Yong S.J.
      • Hur H.K.
      Effectiveness of a brief self-care support intervention for pulmonary rehabilitation among the elderly patients with chronic obstructive pulmonary disease in Korea.
      • Dolansky M.A.
      • Zullo M.D.
      • Boxer R.S.
      • Moore S.M.
      Initial efficacy of a cardiac rehabilitation transition program: Cardiac TRUST.
      • Sandström L.
      • Stahle A.
      Rehabilitation of elderly with coronary heart disease - improvement in quality of life at a low cost.
      and 1 study reported a partially influenced allocation process.
      • Buhl S.F.
      • Andersen A.L.
      • Andersen J.R.
      • et al.
      The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients—a randomized controlled trial.
      Buhl et al
      • Buhl S.F.
      • Andersen A.L.
      • Andersen J.R.
      • et al.
      The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients—a randomized controlled trial.
      reported that patients living too far from the municipality were included in the control group. Blinding of the outcome assessors to the mobility outcome was poorly described or, in the case of 3 studies, poorly performed.
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      • Li X.
      • Xu S.
      • Zhou L.
      • Li R.
      • Wang J.
      Home-based exercise in older adults recently discharged from the hospital for cardiovascular disease in China: randomized clinical trial.
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Prescott E.
      Home-based cardiac rehabilitation is an attractive alternative to no cardiac rehabilitation for elderly patients with coronary heart disease: results from a randomised clinical trial.
      To assess the risk of bias due to incomplete outcome data, studies were evaluated on the registration or publication of the study protocol and attrition rates with a cutoff point of 20%. Three studies reported a high attrition rate.
      • Behnke M.
      • Taube C.
      • Kirsten D.
      • Lehnigk B.
      • Jorres R.A.
      • Magnussen H.
      Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease.
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      • Li X.
      • Xu S.
      • Zhou L.
      • Li R.
      • Wang J.
      Home-based exercise in older adults recently discharged from the hospital for cardiovascular disease in China: randomized clinical trial.
      All studies reported on predefined outcomes; therefore, reporting bias was scored as a low risk. Other possible introduced biases were caused by financial incentives to participants,
      • Dolansky M.A.
      • Zullo M.D.
      • Boxer R.S.
      • Moore S.M.
      Initial efficacy of a cardiac rehabilitation transition program: Cardiac TRUST.
      underpowering due to low consensus rates,
      • Eaton T.
      • Young P.
      • Fergusson W.
      • et al.
      Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study.
      a high rate of noncompliance to the intervention,
      • Courtney M.
      • Edwards H.
      • Chang A.
      • Parker A.
      • Finlayson K.
      • Hamilton K.
      Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
      and early termination of the study due to health policy changes.
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.

       Publication bias

      The limited number of studies in the meta-analyses (seven 6MWD studies and 7 unplanned hospital readmission studies) meant that the minimal requirement of 10 studies for testing publication bias was not met.

       Mobility

      Twelve studies assessed the mobility outcome: 2 included a general population,
      • Buhl S.F.
      • Andersen A.L.
      • Andersen J.R.
      • et al.
      The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients—a randomized controlled trial.
      • Courtney M.D.
      • Edwards H.E.
      • Chang A.M.
      • et al.
      Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial.
      5 included patients with pulmonary disease,
      • Behnke M.
      • Taube C.
      • Kirsten D.
      • Lehnigk B.
      • Jorres R.A.
      • Magnussen H.
      Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease.
      • Eaton T.
      • Young P.
      • Fergusson W.
      • et al.
      Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study.
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      • Song H.-Y.
      • Yong S.J.
      • Hur H.K.
      Effectiveness of a brief self-care support intervention for pulmonary rehabilitation among the elderly patients with chronic obstructive pulmonary disease in Korea.
      and 5 included patients with cardiac disease.
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      • Dolansky M.A.
      • Zullo M.D.
      • Boxer R.S.
      • Moore S.M.
      Initial efficacy of a cardiac rehabilitation transition program: Cardiac TRUST.
      • Li X.
      • Xu S.
      • Zhou L.
      • Li R.
      • Wang J.
      Home-based exercise in older adults recently discharged from the hospital for cardiovascular disease in China: randomized clinical trial.
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Prescott E.
      Home-based cardiac rehabilitation is an attractive alternative to no cardiac rehabilitation for elderly patients with coronary heart disease: results from a randomised clinical trial.
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Simonsen L.
      • Skovgaard L.T.
      • Prescott E.
      Home-based cardiac rehabilitation is as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial.
      The effect of rehabilitation on the 6MWD test was assessed in 8 of the studies.
      • Behnke M.
      • Taube C.
      • Kirsten D.
      • Lehnigk B.
      • Jorres R.A.
      • Magnussen H.
      Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease.
      • Eaton T.
      • Young P.
      • Fergusson W.
      • et al.
      Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study.
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      • Song H.-Y.
      • Yong S.J.
      • Hur H.K.
      Effectiveness of a brief self-care support intervention for pulmonary rehabilitation among the elderly patients with chronic obstructive pulmonary disease in Korea.
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      • Li X.
      • Xu S.
      • Zhou L.
      • Li R.
      • Wang J.
      Home-based exercise in older adults recently discharged from the hospital for cardiovascular disease in China: randomized clinical trial.
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Prescott E.
      Home-based cardiac rehabilitation is an attractive alternative to no cardiac rehabilitation for elderly patients with coronary heart disease: results from a randomised clinical trial.
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Simonsen L.
      • Skovgaard L.T.
      • Prescott E.
      Home-based cardiac rehabilitation is as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial.
      Other measurement scales used to assess mobility included the Incremental Shuttle Walk Test (ISWT),
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      the de Morton Mobility Index,
      • Buhl S.F.
      • Andersen A.L.
      • Andersen J.R.
      • et al.
      The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients—a randomized controlled trial.
      and the Walking Impairment Questionnaire (self-reported).
      • Courtney M.D.
      • Edwards H.E.
      • Chang A.M.
      • et al.
      Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial.
      Data from the Walking Impairment Questionnaire suggested that the intervention group showed greater mobility at 3 and 6 months after discharge.
      • Courtney M.D.
      • Edwards H.E.
      • Chang A.M.
      • et al.
      Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial.
      Data from the Incremental Shuttle Walk Test also reported that the intervention group showed greater mobility at 3 months after discharge.
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      Dolansky et al
      • Dolansky M.A.
      • Zullo M.D.
      • Boxer R.S.
      • Moore S.M.
      Initial efficacy of a cardiac rehabilitation transition program: Cardiac TRUST.
      counted the number of steps walked using a pedometer and reported a positive trend (see table 1) in the intervention group compared to the control group.
      Seven studies provided sufficient data for a meta-analysis of the 6MWD (fig 3A). The overall MD was 23 m at 3 months (95% CI: −1.34 to 48.32; I2: 51%); however, the I2 test result suggests substantial heterogeneity between studies. The study by Oerkild
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Simonsen L.
      • Skovgaard L.T.
      • Prescott E.
      Home-based cardiac rehabilitation is as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial.
      appeared to be an influential trial because its omission led to a larger pooled effect in favor of OOHS rehabilitation (MD: 31.3; 95% CI: 8.06-54.68), whereas omission of the Davidson et al
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      study led to a smaller pooled effect (MD: 10.76; 95% CI: −7.29 to 28.81) (table 3).
      Figure thumbnail gr3
      Fig 3(A) Meta-analysis mobility (6MWD in meters) at 3 months after hospital discharge. (B) Meta-analysis unplanned hospital readmission within 3 months after hospital discharge.
      Table 3Sensitivity analysis mobility (6MWD) in meters at 3 months after discharge
      Sensitivity AnalysisTotal Included StudiesSample Size of Included Studies CombinedRandom Effects Model Mean Difference (95% CI)
      Complete meta-analysisn=7n=42123.49 (−1.34 to 48.32)
      Without Oerkild 2011
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Simonsen L.
      • Skovgaard L.T.
      • Prescott E.
      Home-based cardiac rehabilitation is as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial.
      n=6n=34631.37 (8.06-54.68)
      Without Oerkild 2012
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Prescott E.
      Home-based cardiac rehabilitation is an attractive alternative to no cardiac rehabilitation for elderly patients with coronary heart disease: results from a randomised clinical trial.
      n=6n=38323.65 (−5.12 to 52.41)
      Without Davidson 2010
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      n=6n=32910.76 (−7.29 to 28.81)
      Without Eaton 2009
      • Eaton T.
      • Young P.
      • Fergusson W.
      • et al.
      Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study.
      n=6n=35720.93 (−6.07 to 47.93)
      Without Ko 2011
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      n=6n=37025.55 (−3.98 to 55.07)
      Without Li 2015
      • Li X.
      • Xu S.
      • Zhou L.
      • Li R.
      • Wang J.
      Home-based exercise in older adults recently discharged from the hospital for cardiovascular disease in China: randomized clinical trial.
      n=6n=36027.22 (−3.07 to 57.51)
      Without Song 2014
      • Song H.-Y.
      • Yong S.J.
      • Hur H.K.
      Effectiveness of a brief self-care support intervention for pulmonary rehabilitation among the elderly patients with chronic obstructive pulmonary disease in Korea.
      n=6n=38124.49 (−4.82 to 53.80)
      Data on mobility measured by the 6MWD at 6 months after hospital discharge were reported in 2 studies. Ko et al
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      showed a favorable effect of the rehabilitation program on the 6MWD in the intervention group (330m) than in the control group (316m), and Behnke et al
      • Behnke M.
      • Taube C.
      • Kirsten D.
      • Lehnigk B.
      • Jorres R.A.
      • Magnussen H.
      Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease.
      also reported a favorable effect at 6 months (P<.001) in the intervention group but did not provide any detailed information. Two studies reported the effect of rehabilitation on mobility at 12 months after hospital discharge measured by the 6MWD.
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      Ko reported a favorable effect in the intervention group (331m) than in the control group (295m).
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.

       Unplanned hospital readmission

      Eight studies assessed the effect of rehabilitation on unplanned hospital readmissions: 7 reported on readmissions within 3 months,
      • Buhl S.F.
      • Andersen A.L.
      • Andersen J.R.
      • et al.
      The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients—a randomized controlled trial.
      • Courtney M.
      • Edwards H.
      • Chang A.
      • Parker A.
      • Finlayson K.
      • Hamilton K.
      Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      • Eaton T.
      • Young P.
      • Fergusson W.
      • et al.
      Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study.
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      • Sandström L.
      • Stahle A.
      Rehabilitation of elderly with coronary heart disease - improvement in quality of life at a low cost.
      2 reported on readmissions within 6 months,
      • Courtney M.
      • Edwards H.
      • Chang A.
      • Parker A.
      • Finlayson K.
      • Hamilton K.
      Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      and 2 reported on readmissions within 12 months.
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      • Sandström L.
      • Stahle A.
      Rehabilitation of elderly with coronary heart disease - improvement in quality of life at a low cost.
      Seven studies provided sufficient data for a meta-analysis of unplanned hospital readmissions within 3 months, which was the primary endpoint.
      • Buhl S.F.
      • Andersen A.L.
      • Andersen J.R.
      • et al.
      The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients—a randomized controlled trial.
      • Courtney M.
      • Edwards H.
      • Chang A.
      • Parker A.
      • Finlayson K.
      • Hamilton K.
      Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      • Eaton T.
      • Young P.
      • Fergusson W.
      • et al.
      Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study.
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      • Sandström L.
      • Stahle A.
      Rehabilitation of elderly with coronary heart disease - improvement in quality of life at a low cost.
      The pooled RR based on a fixed-effects model was 0.93 (95% CI: 0.73-1.19) (fig 3B). Within 6 months of hospitalization, only 1 study reported significantly fewer hospital readmissions in the intervention group than the control group,
      • Courtney M.
      • Edwards H.
      • Chang A.
      • Parker A.
      • Finlayson K.
      • Hamilton K.
      Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
      and data requested from Ko showed comparable unplanned hospital readmission rates (intervention group and control group: 37%).
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      Within 12 months of hospital discharge, Davidson reported lower hospital readmission rates in the intervention group (odds ratio: 0.20; 95% CI: 0.07-0.58; relative risk: 0.63).
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      In the sensitivity analysis of the unplanned hospital readmissions within 3 months of meta-analysis, the studies of Sahota et al
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      and Seymour et al
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      substantially influenced the pooled effect size. When the study of Sahota was excluded from the meta-analysis, the pooled RR changed to 0.77 (95% CI: 0.54-1.10), and omission of the study of Seymour changed the pooled RR to 1.02 (95% CI: 0.79-1.31) (table 4).
      Table 4Sensitivity analysis unplanned hospital readmission within 3 months after discharge
      Sensitivity AnalysisTotal Included StudiesSample Size of Included Studies CombinedFixed-Effects Model Risk Ratio (95% CI)
      Complete meta-analysisn=7n=7190.93 (0.73-1.19)
      Without Seymour 2010
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      n=6n=6591.02 (0.79-1.31)
      Without Eaton 2009
      • Eaton T.
      • Young P.
      • Fergusson W.
      • et al.
      Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study.
      n=6n=6220.97 (0.74-1.27)
      Without Ko 2011
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      n=6n=6590.95 (0.73-1.23)
      Without Courtney 2009
      • Courtney M.
      • Edwards H.
      • Chang A.
      • Parker A.
      • Finlayson K.
      • Hamilton K.
      Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
      n=6n=5970.96 (0.74-1.26)
      Without Sahota 2017
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      n=6n=4690.77 (0.54-1.10)
      Without Sandström 2005
      • Sandström L.
      • Stahle A.
      Rehabilitation of elderly with coronary heart disease - improvement in quality of life at a low cost.
      n=6n=6180.88 (0.68-1.14)
      Without Buhl 2016
      • Buhl S.F.
      • Andersen A.L.
      • Andersen J.R.
      • et al.
      The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients—a randomized controlled trial.
      n=6n=6900.92 (0.71-1.18)

      Discussion

      The randomized trials used in this systematic review support the idea that rehabilitation of older patients in an OOHS improves mobility, which was reflected in an average increase of 23 m on the 6MWD test at 3 months after discharge from hospital following an acute illness. The review also indicates that rehabilitation of older patients in an OOHS after discharge from hospital following an acute illness does not lower the risk of unplanned hospital readmission after 3 months. However, the wide 95% CI and the instability of the pooled effect on mobility indicate that this evidence is not robust.
      In the United States, rehabilitation programs after hospitalization have gained importance due to the recent introduction of payment penalties for hospitals with higher than average 30-day readmission rates.
      • Jennifer M.
      • Michael D.
      • Molly S.
      Does it pay to penalize hospitals for excess readmissions? Intended and unintended consequences of Medicare’s Hospital Readmissions Reductions Program.
      The posthospital syndrome described by Krumholz et al
      • Krumholz H.M.
      Post-hospital syndrome—an acquired, transient condition of generalized risk.
      is a multifactorial phenomenon that occurs after acute hospitalization and increases the risk of rehospitalization. The association of functional impairment and readmission rates after hospitalization has increased awareness of the importance of rehabilitation.
      • Greysen S.R.
      • Stijacic Cenzer I.
      • Auerbach A.D.
      • Covinsky K.E.
      Functional impairment and hospital readmission in Medicare seniors.
      However, in this systematic review and meta-analysis, a positive trend was observed for mobility when treated by a multidisciplinary rehabilitation program but not for unplanned hospital readmission. Although most of the studies continued rehabilitation programs from 1 care setting to another, it was often not as coordinated as in a transitional care system. Transitional care is effective at reducing hospital readmission rates when the care continues between health care settings and contains elements of care coordination, communication between primary care and hospitals, and includes intensive follow-up after hospital discharge.
      • Le Berre M.
      • Maimon G.
      • Sourial N.
      • Gueriton M.
      • Vedel I.
      Impact of transitional care services for chronically ill older patients: a systematic evidence review.
      • Verhaegh K.J.
      • MacNeil-Vroomen J.L.
      • Eslami S.
      • Geerlings S.E.
      • de Rooij S.E.
      • Buurman B.M.
      Transitional care interventions prevent hospital readmissions for adults with chronic illnesses.
      Only 4 of the included studies described a transitional care system including the effective elements, of which only 2 reported the hospital readmission outcome.
      • Courtney M.
      • Edwards H.
      • Chang A.
      • Parker A.
      • Finlayson K.
      • Hamilton K.
      Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      This could explain the positive trend for mobility in this meta-analysis but not for unplanned hospital readmission rates.
      A difference of 23 m in the 6MWD test was considered to be clinically relevant according to Bohannon et al,
      • Bohannon R.W.
      • Crouch R.
      Minimal clinically important difference for change in 6-minute walk test distance of adults with pathology: a systematic review.
      who defined clinical relevance as a change of 14-30.5 m against a background of 295-551 m on the 6MWD test. In the sensitivity analysis, omitting the study of Oerkild et al
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Simonsen L.
      • Skovgaard L.T.
      • Prescott E.
      Home-based cardiac rehabilitation is as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial.
      increased the pooled effect on the 6MWD test from 23 to 31 m. Their intervention was compared with usual care, which was outpatient cardiac rehabilitation. This could partly explain the favorable effect in the control group in contrast to the results obtained by other studies in the meta-analysis and thus the improved effect in the meta-analysis upon omission. Omitting the study of Davidson et al
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      resulted in a smaller pooled effect (MD: 10.76), which could be because the study was stopped prematurely and could have led to the wrong conclusions being drawn because of the smaller sample size.
      Omitting the study of Sahota
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      in the meta-analysis on unplanned hospital readmission caused the RR to change from 0.93 to 0.77, whereas omitting the study by Seymour
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      changed the preventive effect from 7% to a 2% increased risk. Sahota included an older and frailer patient population with a higher risk of adverse events, which could have influenced the effect.
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      Another contributing factor could be their large sample size when compared to other included studies, which may have led to this study having a greater influence in the meta-analysis. The small sample size of the Seymour study (intervention group: 30; control group: 30) could have led to an overestimation of the effect.
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      Most of the included studies focused on specific patient populations, such as patients with cardiac and pulmonary diseases
      • Behnke M.
      • Taube C.
      • Kirsten D.
      • Lehnigk B.
      • Jorres R.A.
      • Magnussen H.
      Home-based exercise is capable of preserving hospital-based improvements in severe chronic obstructive pulmonary disease.
      • Eaton T.
      • Young P.
      • Fergusson W.
      • et al.
      Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study.
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      • Song H.-Y.
      • Yong S.J.
      • Hur H.K.
      Effectiveness of a brief self-care support intervention for pulmonary rehabilitation among the elderly patients with chronic obstructive pulmonary disease in Korea.
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      • Dolansky M.A.
      • Zullo M.D.
      • Boxer R.S.
      • Moore S.M.
      Initial efficacy of a cardiac rehabilitation transition program: Cardiac TRUST.
      • Li X.
      • Xu S.
      • Zhou L.
      • Li R.
      • Wang J.
      Home-based exercise in older adults recently discharged from the hospital for cardiovascular disease in China: randomized clinical trial.
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Prescott E.
      Home-based cardiac rehabilitation is an attractive alternative to no cardiac rehabilitation for elderly patients with coronary heart disease: results from a randomised clinical trial.
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Simonsen L.
      • Skovgaard L.T.
      • Prescott E.
      Home-based cardiac rehabilitation is as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial.
      • Sandström L.
      • Stahle A.
      Rehabilitation of elderly with coronary heart disease - improvement in quality of life at a low cost.
      ; however, 4 studies were performed in general patient populations.
      • Buhl S.F.
      • Andersen A.L.
      • Andersen J.R.
      • et al.
      The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients—a randomized controlled trial.
      • Courtney M.
      • Edwards H.
      • Chang A.
      • Parker A.
      • Finlayson K.
      • Hamilton K.
      Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
      • Courtney M.D.
      • Edwards H.E.
      • Chang A.M.
      • et al.
      Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial.
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      The content of the rehabilitation programs provided in the studies did not differ much between these populations. All interventions consisted of multiple rehabilitation components, such as exercise and education. Nevertheless, the execution of the rehabilitation components varied between the studies or a thorough description of the content was missing in the manuscript; for example, 1 study failed to use the frequency, intensity, time, and therapy criteria to report items in the description of an exercise intervention.
      • Garber C.E.
      • Blissmer B.
      • Deschenes M.R.
      • et al.
      American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise.
      Another study did not report the provided intervention according to the TIDieR guidelines for the reporting of interventions.
      • Hoffmann T.C.
      • Glasziou P.P.
      • Boutron I.
      • et al.
      Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide.
      Using the TIDieR guidelines would make the aggregation and comparison of interventions possible on a level of what was provided by whom, how, where, and when. Therefore, it was not feasible to analyze the effectiveness of the different components of the intervention, neither was it possible to perform subanalysis on the dose of the intervention.
      Nutritional status is an important factor for optimal physical training results and physical recovery (eg, intake of proteins). It is also relevant in acutely hospitalized patients where 52% experience malnutrition
      • Buurman B.M.
      • Hoogerduijn J.G.
      • de Haan R.J.
      • et al.
      Geriatric conditions in acutely hospitalized older patients: prevalence and one-year survival and functional decline.
      ; however, dieticians were only involved in 4 of the included studies.
      • Buhl S.F.
      • Andersen A.L.
      • Andersen J.R.
      • et al.
      The effect of protein intake and resistance training on muscle mass in acutely ill old medical patients—a randomized controlled trial.
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Prescott E.
      Home-based cardiac rehabilitation is an attractive alternative to no cardiac rehabilitation for elderly patients with coronary heart disease: results from a randomised clinical trial.
      • Oerkild B.
      • Frederiksen M.
      • Hansen J.F.
      • Simonsen L.
      • Skovgaard L.T.
      • Prescott E.
      Home-based cardiac rehabilitation is as effective as centre-based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial.
      Gill et al
      • Gill T.M.
      • Baker D.I.
      • Gottschalk M.
      • Peduzzi P.N.
      • Allore H.
      • Byers A.
      A program to prevent functional decline in physically frail, elderly persons who live at home.
      stated that exercise programs should comprise balance exercises, muscle strengthening, transfer exercises, and functional exercises to be beneficial in frail older patients. The studies used in this manuscript mainly focused on intensity training and 4 of these were combined with strengthening exercises.
      • Eaton T.
      • Young P.
      • Fergusson W.
      • et al.
      Does early pulmonary rehabilitation reduce acute health-care utilization in COPD patients admitted with an exacerbation? A randomized controlled study.
      • Ko F.W.S.
      • Dai D.L.K.
      • Ngai J.
      • et al.
      Effect of early pulmonary rehabilitation on health care utilization and health status in patients hospitalized with acute exacerbations of COPD.
      • Seymour J.M.
      • Moore L.
      • Jolley C.J.
      • et al.
      Outpatient pulmonary rehabilitation following acute exacerbations of COPD.
      • Davidson P.M.
      • Cockburn J.
      • Newton P.J.
      • et al.
      Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients?.
      Only 2 studies
      • Courtney M.D.
      • Edwards H.E.
      • Chang A.M.
      • et al.
      Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial.
      • Covinsky K.E.
      • Palmer R.M.
      • Counsell S.R.
      • Pine Z.M.
      • Walter L.C.
      • Chren M.M.
      Functional status before hospitalization in acutely ill older adults: validity and clinical importance of retrospective reports.
      combined all the components of exercise training stated by Gill, and 1 study
      • Sahota O.
      • Pulikottil-Jacob R.
      • Marshall F.
      • et al.
      The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency.
      described an individual approach. This could have influenced the effect in the meta-analysis.
      The location of the intervention in the included studies varied between an outpatient setting, a community-based at-home setting, and a temporary inpatient setting (eg, a skilled nursing facility). The influence of the rehabilitation location and environment on the outcome was studied previously and showed no significant effects in traditional center-based inpatient approaches and alternative models such as telehealth and home-based rehabilitation.
      • Clark R.A.
      • Conway A.
      • Poulsen V.
      • Keech W.
      • Tirimacco R.
      • Tideman P.
      Alternative models of cardiac rehabilitation: a systematic review.
      • Nici L.
      • ZuWallack R.
      Chronic obstructive pulmonary disease-evolving concepts in treatment: advances in pulmonary rehabilitation.
      • Taylor R.S.
      • Dalal H.
      • Jolly K.
      • et al.
      Home-based versus centre-based cardiac rehabilitation.

       Strengths and limitations

      To the author’s knowledge, this is the first systematic review to examine the effectiveness of multidisciplinary rehabilitation in an OOHS in older patients after they are discharged from hospital following an acute illness. Three large international databases (Medline OVID, Embase OVID, CINAHL) were screened. No publication was excluded based on language due to the availability of English abstracts in these databases. Although most of the international publications were covered in these databases, some specific language publications may possibly have been omitted due to their only being available in databases such as Bireme (a Latin American database). The included studies were all randomized trials. The blinding issues in patients and personnel in the included studies were caused by the nature of the intervention; however, the quality of the included studies was limited due to a lack of blinding of the outcome assessors. This could have introduced bias and could have led to an overestimation of the effects. Different studies used different types of outcome measures to report mobility; therefore, it was not possible to include all studies in the meta-analysis. The sensitivity analysis in both meta-analyses provided an insight into the contribution of each study, in the estimate of the true value of unplanned hospital readmissions (fixed effect) or the mean of all possible values for the 6MWD (random effect).

       Implications for further research

      Many studies focus on a diagnosis-based population despite other factors (ie, level of frailty) playing an important role in determining rehabilitation needs.
      • de Vries N.M.
      • Staal J.B.
      • van der Wees P.J.
      • et al.
      Patient-centred physical therapy is (cost-) effective in increasing physical activity and reducing frailty in older adults with mobility problems: a randomized controlled trial with 6 months follow-up.
      The medical diagnosis often correlates badly with the disease-related functional consequences. These needs may be better determined through a comprehensive geriatric assessment that focuses on a patient’s disease, geriatric condition, functional status, and the patient’s own preferences rather than being determined solely from a disease perspective. This would create a more homogeneous patient population and enable tailored rehabilitation interventions to be tested. In addition, patients also transfer back and forth between health care settings; therefore, transitional care rehabilitation interventions should be considered to ensure continuity of care and reduce adverse outcomes such as hospital readmissions.
      • Le Berre M.
      • Maimon G.
      • Sourial N.
      • Gueriton M.
      • Vedel I.
      Impact of transitional care services for chronically ill older patients: a systematic evidence review.
      • Verhaegh K.J.
      • MacNeil-Vroomen J.L.
      • Eslami S.
      • Geerlings S.E.
      • de Rooij S.E.
      • Buurman B.M.
      Transitional care interventions prevent hospital readmissions for adults with chronic illnesses.
      Furthermore, a clear definition of functional capacity is often lacking in rehabilitation intervention manuscripts and should be integrated according to the definition of the International Classification of Functioning. Functional capacity is often described when only physical performance is reported instead of the 3 main domains of functioning: body function, activities, and involvement in life situations.
      • Ustun B.
      • Kennedy C.
      What is “functional impairment”? Disentangling disability from clinical significance.
      A clear definition and a detailed description of the intervention according to the frequency, intensity, time, and therapy criteria and TIDieR guidelines would help to improve comparability and determine the effectiveness of each component of the intervention.

      Conclusions

      This review shows that OOHS-based multidisciplinary rehabilitation leads to improved mobility in older patients (aged ≥65y) 3 months after discharge from hospital following an acute illness; however, this type of rehabilitation is not associated with a lower risk of unplanned hospital readmission within 3 months of hospital discharge. Nevertheless, the wide 95% CI and the instability of the pooled effect on mobility illustrated by the sensitivity analysis indicate that the evidence is not robust.

      Suppliers

      • a.
        EndNote; Clarivate Analytics.
      • b.
        Covidence; Covidence.
      • c.
        Review Manager, version 5.3; The Cochrane Collaboration.

      Supplementary Data

      Appendix 1Search strategy
      No.Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) <1946 to Present> Search date: 22 February 2018
      Searches
      1exp aging/ or exp aged/ or exp nursing homes/ or homes for the aged/ or frail elderly/
      2(older person? or older patient? or seniors or senior citiz* or elder or elders or elderly or geriatric* or frailty or postmenopausal women or community-dwelling or nursing home? or resident* or old* people or old* person? or old* patient? or old* client?).ab,kf,ti.
      3(geriatr* or age or aging or elderl*).jw.
      4or/1-3 [geriatric]
      5rehabilitation/ or "activities of daily living"/ or exp exercise therapy/ or telerehabilitation/ or rehabilitation centers/ or geriatric assessment/
      6(rehabilitation or exercise? oradl or iadl or (daily adj2 (activit* or living or function*)) or barthel index or katz index or alds or amsterdam linear or living indepently or living alone or (function* adj3 (status or capacit* or physical or decline or disabil*)) or geriatric assessment).ab,kf,ti.
      7or/5-6 [rehabilitation]
      84 and 7 [geriatric rehabilitation]
      9home care services/ or outpatients/ or patient compliance/
      10(nursing facilit* or home based or patient home or (home adj2 care) or outpatient or transitional care or home visit or (intervention adj3 home?) or (patient? adj3 complian*)).ab,kf,ti.
      11or/9-10 [outpatient care]
      12hospitalization/ or patient admission/ or patient readmission/
      13(hospital* or admission or readmission or discharge or centre based or center based).ab,kf,ti.
      1412 or 13 [hospitalization]
      15(acute* or rehabilitation).ab,kf,ti.
      16rehabilitation.fs.
      1715 or 16 [acute]
      18pulmonary disease, chronic obstructive/ or exp myocardial infarction/ or exp chest pain/ or heart aneursym/ or exp endocarditis/ or exp heart failure/
      19(copd or chronic obstructive or pulmonary rehabilitation or myocardial infarction or cardiac rehabilitation or (pain adj3 chest) or angina pectoris or heart aneurysm? or cardiac aneurysm? or endocarditis or heart failure or myocardial failure or cardiac failure).ab,kf,ti.
      2018 or 19 [acute specific disorders]
      2114 and 17
      2214 and 20
      23acute hospital*.ab,kf,ti.
      24((acute* adj2 ill*) or (acute adj2 disease?) or (acute adj2 assessment units) or (acute* adj2 admi*) or (acute* adj2 readmi*) or (acute adj2 care) or (stabiliz* adj4 condition) or (stabiliz* adj2 patient?)).ab,kf,ti.
      25or/21-24 [acute hospitalization]
      26and/8,11,25
      27animals/ not humans/
      2826 not 27
      29(trial? or stud* or blind* or random* or experimental or control or placebo?).ab,kf,ti.
      30comparative study/
      31(clinical study or clinical trial or controlled clinical trial or randomized controlled trial).pt.
      32exp clinical trials as topic/
      33or/29-32 [RCT's]
      3428 and 33
      35remove duplicates from 34
      No.Ovid Embase Classic+Embase <1947 to 2018 February 22> Search date: 22 February 2018
      Searches
      1exp aging/ or exp aged/ or nursing home/ or exp elderly care/
      2(older person? or older patient? or seniors or senior citiz* or elder or elders or elderly or geriatric* or frailty or postmenopausal women or community-dwelling or nursing home? or resident* or old* people or old* person? or old* patient? or old* client?).ab,kw,ti.
      3(geriatr* or age or aging or elderl*).jx.
      4or/1-3 [geriatric]
      5rehabilitation/ or exp exercise/ or daily life activity/ or exp kinesiotherapy/ or rehabilitation center/ or geriatric assessment/
      6(rehabilitation or exercise? oradl or iadl or (daily adj2 (activit* or living or function*)) or barthel index or katz index or alds or amsterdam linear or living indepently or living alone or (function* adj3 (status or capacit* or physical or decline or disabil*)) or geriatric assessment).ab,kw,ti.
      7or/5-6 [rehabilitation]
      84 and 7 [geriatric rehabilitation]
      9home care/ or outpatient/ or outpatient care/ or outpatient department/ or patient compliance/
      10(nursing facilit* or home based or patient home or (home adj2 care) or outpatient or transitional care or home visit or (intervention adj3 home?) or (patient? adj3 complian*)).ab,kw,ti.
      11or/9-10 [outpatient care]
      12hospitalization/ or hospital admission/ or hospital discharge/ or hospital readmission/
      13(hospital* or admission or readmission or discharge or centre based or center based).ab,kw,ti.
      1412 or 13 [hospitalization]
      15(acute* or rehabilitation).ab,kw,ti.
      16rh.fs.
      1715 or 16 [acute]
      18chronic obstructive lung disease/ or exp heart infarction/ or thorax pain/ or heart aneursym/ or exp endocarditis/ or exp heart failure/
      19(copd or chronic obstructive or pulmonary rehabilitation or myocardial infarction or cardiac rehabilitation or (pain adj3 chest) or angina pectoris or heart aneurysm? or cardiac aneurysm? or endocarditis or heart failure or myocardial failure or cardiac failure).ab,kw,ti.
      2018 or 19 [acute specific disorders]
      2114 and 17
      2214 and 20
      23acute hospital*.ab,kw,ti.
      24((acute* adj2 ill*) or (acute adj2 disease?) or (acute adj2 assessment units) or (acute* adj2 admi*) or (acute* adj2 readmi*) or (acute adj2 care) or (stabiliz* adj4 condition) or (stabiliz* adj2 patient?)).ab,kw,ti.
      25or/21-24 [acute hospitalization]
      26and/8,11,25
      27(animal/ or animal experiment/ or animal model/ or nonhuman/ or rat/ or mouse/ or (rat or rats or mouse or mice).ti.) not human/
      2826 not 27
      29(trial? or stud* or blind* or random* or experimental or control or placebo?).ab,kw,ti.
      30exp controlled clinical trial/ or clinical study/ or "clinical trial (topic)"/ or comparative study/
      31or/29-30 [RCT's]
      3228 and 31
      33remove duplicates from 32
      No.CINAHL Plus with Full Text Search date: 22 February 2018
      Query
      S23s7 and s10 and s21
      S227 AND S10 AND S21
      S21S15 OR S19 OR S20
      S20AB (acute hospital* OR (acute* NEAR/2 ill*) or (acute NEAR/2 disease?) or (acute NEAR/2 assessment units) or (acute* NEAR/2 admi*) or (acute* NEAR/2 readmi*) or (acute NEAR/2 care) or (stabiliz* adj4 condition) or (stabiliz* NEAR/2 patient?)) OR TI (acute hospital* OR (acute* NEAR/2 ill*) or (acute NEAR/2 disease?) or (acute NEAR/2 assessment units) or (acute* NEAR/2 admi*) or (acute* NEAR/2 readmi*) or (acute NEAR/2 care) or (stabiliz* adj4 condition) or (stabiliz* NEAR/2 patient?)) OR SU (acute hospital* OR (acute* NEAR/2 ill*) or (acute NEAR/2 disease?) or (acute NEAR/2 assessment units) or (acute* NEAR/2 admi*) or (acute* NEAR/2 readmi*) or (acute NEAR/2 care) or (stabiliz* adj4 condition) or (stabiliz* NEAR/2 patient?))
      S19S13 AND S18
      S18S16 OR S17
      S17AB (copd or chronic obstructive or pulmonary rehabilitation or myocardial infarction or cardiac rehabilitation or (pain NEAR/2 chest) or angina pectoris or heart aneurysm? or cardiac aneurysm? or endocarditis or heart failure or myocardial failure or cardiac failure) OR TI (copd or chronic obstructive or pulmonary rehabilitation or myocardial infarction or cardiac rehabilitation or (pain NEAR/2 chest) or angina pectoris or heart aneurysm? or cardiac aneurysm? or endocarditis or heart failure or myocardial failure or cardiac failure) OR SU (copd or chronic obstructive or pulmonary rehabilitation or myocardial infarction or cardiac rehabilitation or (pain NEAR/2 chest) or angina pectoris or heart aneurysm? or cardiac aneurysm? or endocarditis or heart failure or myocardial failure or cardiac failure)
      S16(MH "Pulmonary Disease, Chronic Obstructive+") or (MH "Myocardial Infarction+") or (MH "Chest Pain+") or (MH "Coronary Aneurysm") or (MH "Endocarditis+") or (MH "Heart Failure+")
      S15S13 AND S14
      S14SU (acute* or rehabilitation)
      S13S11 OR S12
      S12AB (hospital* or admission or readmission or discharge or centre based or center based) OR TI (hospital* or admission or readmission or discharge or centre based or center based) OR SU (hospital* or admission or readmission or discharge or centre based or center based)
      S11(MH "Hospitalization+") OR (MH "Patient Admission") OR (MH "Readmission")
      S10S8 OR S9
      S9AB (nursing facilit* or home based or patient home or (home NEAR/1 care) or outpatient or transitional care or home visit or (intervention NEAR/2 home?) or (patient? NEAR/2 complian*)) OR TI (nursing facilit* or home based or patient home or (home NEAR/1 care) or outpatient or transitional care or home visit or (intervention NEAR/2 home?) or (patient? NEAR/2 complian*)) OR SU (nursing facilit* or home based or patient home or (home NEAR/1 care) or outpatient or transitional care or home visit or (intervention NEAR/2 home?) or (patient? NEAR/2 complian*))
      S8(MH "Home Nursing") OR (MH "Home Rehabilitation+") OR (MH "Home Health Care+") OR (MH "Outpatients") OR (MH "Outpatient Service")
      S7S3 AND S6
      S6S4 OR S5
      S5AB (rehabilitation or exercise? oradl or iadl or (daily NEAR/1 (activit* or living or function*)) or barthel index or katz index or alds or amsterdam linear or living indepently or living alone or (function* NEAR/2 (status or capacit* or physical or decline or disabil*)) or geriatric assessment) OR TI (rehabilitation or exercise? oradl or iadl or (daily NEAR/1 (activit* or living or function*)) or barthel index or katz index or alds or amsterdam linear or living indepently or living alone or (function* NEAR/2 (status or capacit* or physical or decline or disabil*)) or geriatric assessment) OR SU (rehabilitation or exercise? oradl or iadl or (daily NEAR/1 (activit* or living or function*)) or barthel index or katz index or alds or amsterdam linear or living indepently or living alone or (function* NEAR/2 (status or capacit* or physical or decline or disabil*)) or geriatric assessment)
      S4(MH "Physical Therapy+") OR (MH "Rehabilitation") OR (MH "Recreational Therapy") OR (MH "Telerehabilitation") OR (MH "Activities of Daily Living+") OR (MH "Therapeutic Exercise+") OR (MH "Rehabilitation Centers+") OR (MH "Geriatric Assessment+")
      S3S1 OR S2
      S2AB (older person? or older patient? or seniors or senior citiz* or elder or elders or elderly or geriatric* or frailty or postmenopausal women or community-dwelling or nursing home? or resident* or old* people or old* person? or old* patient? or old* client?) OR TI(older person? or older patient? or seniors or senior citiz* or elder or elders or elderly or geriatric* or frailty or postmenopausal women or community-dwelling or nursing home? or resident* or old* people or old* person? or old* patient? or old* client?) OR SU (older person? or older patient? or seniors or senior citiz* or elder or elders or elderly or geriatric* or frailty or postmenopausal women or community-dwelling or nursing home? or resident* or old* people or old* person? or old* patient? or old* client?)
      S1(MH "Aged+")
      Appendix 2Reasons for full-text exclusion
      Reason for ExclusionReference
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      Ali MS, Talwar D, Jain SK. The effect of a short-term pulmonary rehabilitation on exercise capacity and quality of life in patients hospitalised with acute exacerbation of chronic obstructive pulmonary disease. Indian J Chest Dis Allied Sci 2014;56:13-9.
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      Study protocol only (n=8)Boxer RS, Dolansky MA, Bodnar CA, Singer ME, Albert JM, Gravenstein S. A randomized trial of heart failure disease management in skilled nursing facilities: design and rationale. J Am Med Dir Assoc 2013;14,710.e5.
      Deer RR, Dickinson JM, Fisher SR, Ju H, Volpi E. Identifying effective and feasible interventions to accelerate functional recovery from hospitalization in older adults: a randomized controlled pilot trial. Contemp Clin Trials 2016;49:6-14.
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      Koopman FS, Beelen A, Gerrits KH, et al. Exercise therapy and cognitive behavioural therapy to improve fatigue, daily activity performance and quality of life in postpoliomyelitis syndrome: the protocol of the FACTS-2-PPS trial. BMC Neurol 2010;10:1.
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      Patient population (n=68)Anderson C, Deepak BV, Amoateng-Adjepong Y, Zarich S. Benefits of comprehensive inpatient education and discharge planning combined with outpatient support in elderly patients with congestive heart failure. Congest Heart Fail 2005;11:315-21.
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      Avlund K, Jepsen E, Vass M, Lundemark H. Effects of comprehensive follow-up home visits after hospitalization on functional ability and readmissions among old patients. A randomized controlled study. Scand J Occup Ther 2002;9:17-22.
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      Brenner LA, Braden CA, Bates M, et al. A health and wellness intervention for those with moderate to severe traumatic brain injury: a randomized controlled trial. J Head Trauma Rehabil 2012;27:E57-68.
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      Carrieri-Kohlman V, Gormley JM, Douglas MK, Paul SM, Stulbarg MS. Exercise training decreases dyspnea and the distress and anxiety associated with it: monitoring alone may be as effective as coaching. Chest 1996;110:1526-35.
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      Corvera-Tindel T, Doering LV, Woo MA, Khan S, Dracup K. Effects of a home walking exercise program on functional status and symptoms in heart failure. Am Heart J 2004;147:339-46.
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      Cowie A, Thow MK, Granat MH, Mitchell SL. Effects of home versus hospital-based exercise training in chronic heart failure. Int J Cardiol 2012;158:296-8.
      Crotty M, Giles LC, Halbert J, Harding J, Miller M. Home versus day rehabilitation: a randomised controlled trial. Age Ageing 2008;37:628-33.
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      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;119:202-11.
      de Godoy DV, de Godoy RF. A randomized controlled trial of the effect of psychotherapy on anxiety and depression in chronic obstructive pulmonary disease. Arch Phys Med Rehabil 2003;84:1154-7.
      Denehy L, Skinner EH, Edbrooke L, et al. Exercise rehabilitation for patients with critical illness: a randomized controlled trial with 12 months of follow-up. Crit Care 2013;17:1.
      de Sousa Pinto JM, Martín-Nogueras AM, Calvo-Arenillas JI, Ramos-González J. Clinical benefits of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil Prev 2014;34:355-9.
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