Impact of post-discharge nutritional interventions on hospital readmissions: A systematic review

Table 1 Database search strategy

Database search strategy
PubMed
("Patient discharge"[MeSH] OR post-discharge OR after hospitalization) AND ("nutritional support"[MeSH] OR nutrition intervention OR oral supplements OR dietary counselling OR malnutrition) AND (readmission OR rehospitalization OR 30-day readmission)
EMBASE
('Patient discharge'/exp OR 'post discharge':ab,ti OR 'after hospitalization':ab,ti) AND ('nutritional support'/exp OR 'nutrition intervention':ab,ti OR 'oral supplements':ab,ti OR 'dietary counselling':ab,ti OR malnutrition:ab,ti) AND (readmission:ab,ti OR rehospitalization:ab,ti OR '30 day readmission':ab,ti)

Table 2 Inclusion criteria and exclusion criteria

Inclusion criteria
Population	Patients discharged home after a period of hospitalisation for acute illnesses
Intervention/comparison	Any nutritional intervention (dietary counselling, oral nutritional supplementation, feeding support, etc.)
Control	Usual nutrition
Outcome	Unplanned hospital readmission (any definition, e.g., 30-day readmission, unplanned readmission)
Study design	Randomised controlled trials, cohort studies, case-control studies
Setting	Any healthcare setting, worldwide
Exclusion criteria
Population	Paediatric populations: Patients admitted for elective procedures or rehabilitation
Setting	Nutritional intervention only during inpatient admission period

Table 3 Summary of key study characteristics

Ref.	Type of study, patient demographics and number	Nutritional intervention	Comparator/control group	Conclusions
Follow-up counselling by clinical nutritionists or dietitians
Beck et al[14]	RCT. Geriatric patients (> 75), n = 71	A discharge Liaison-Team in cooperation with a dietician, who performed a total of three home visits with the aim of developing and implementing an individual nutritional care plan	For the comparator group, the team did not include the dietician	Adding a dietician to the discharge Liaison-Team after discharge of geriatric patients may reduce the number of times hospitalized within 6 months
Blondal et al[19]	Secondary analysis of RCT. Geriatric patients (> 65), n = 106	The clinical nutritionist provided the intervention group with nutrition therapy during five home visits (conducted the day after hospital discharge and at one, 3, 6, and 12 weeks from discharge)	The control group did not receive any further nutritional care or service by the hospital, primary care sector and community	Six-month nutrition therapy in older Icelandic adults discharged from hospital reduced hospital readmissions and shortens length of stay at the hospital up to 18-months post-discharge. However, it did not affect mortality, emergency room visits, nor need of long-term care residence in this group
Cramon et al[24]	Pilot RCT. Geriatric patients, n = 40	The nutritionists conducted two visits to the patients’ homes in the course of the 4 weeks subsequent to discharge. Patients received follow-up phone calls between visits, if necessary	The patients in the control group received standard treatment and were offered nutritional guidance after the last follow-up	Individual nutritional intervention did not prevent readmission among geriatric patients in this trial
Sharma et al[23]	RCT. Geriatric patients, n = 148	Individualized nutrition care plan and monthly post-discharge telehealth follow-up	Control patients were allowed to follow the same intervention until hospital discharge, but did not receive any additional post-discharge telephone follow-up	There is no significant difference in complication rate during hospitalization, quality of life and mortality at 3 months or readmission rate at 1 month, 3 months, or 6 months following hospital discharge
Wyers et al[21]	RCT. Geriatric patients (> 55), n = 152	Weekly dietetic consultation, energy-protein-enriched diet, and oral nutritional supplements (400 mL per day) for 3 months	Control patients received usual nutritional care as provided in the hospital, rehabilitation clinic, or at home	Intensive nutritional intervention after hip fracture did not improve clinical outcomes (did not affect readmissions)
Lindegaard Pedersen et al[20]	RCT. Geriatric patients (> 75), n = 208	Individualized nutritional counselling of the patient and the patient's daily home carer by a clinical dietician 1, 2, and 4 weeks after discharge from hospital	Control patients received standard care in hospital and on discharge	Individualized nutritional follow-up performed as home visits seems to reduce readmission to hospital 30 days and 90 days after discharge. Intervention by telephone consultations may also prevent readmission, but only among participants who receive the full intervention
Munk et al[22]	RCT. Geriatric patients, n = 191	Dietetic counselling including a recommendation of daily training, an individual nutrition plan and a package containing foods and drinks covering dietary requirements for the next 24 hours. Further, a goodie-bag containing samples of protein-rich milk-based drinks were provided. The dietician performed telephone follow-ups on day 4 and 30 and a home visit at 16 weeks	The control group received standard care at discharge following the standard procedure for ward discharge of patients	The present study, using a multimodal nutritional approach, revealed no significant effect on readmissions however a significant positive effect on nutritional status, quality of life and physical function was found
Individualised meals thrice a day (as evaluated and enhanced by dietitian)
Buys et al[25]	Pilot RCT. Geriatric patients (> 65), n = 21	The intervention group received three meals per day for 10 days. Meals were based upon National Institute on Aging’s recommendations from What’s on Your Plate: Smart Choices for Healthy Aging 2021 and the Academy of Nutrition and Dietetics 2012 Position Statement on Food and Nutrition for Older Adults living in the community	Control participants received the care or treatment as prescribed by their attending physician or nurse practitioner (usual care)	Conducting a randomized controlled trial to assess outcomes of providing home-delivered meals to older adults after hospital discharge in partnership with a small nonprofit organization is feasible and warrants future research. This study did not show any statistical differences in hospital readmission
Individualised nutrition care plans
Beck et al[28]	RCT. Geriatric patients (> 65), n = 152	The registered dietitians performed a comprehensive nutritional assessment at the first home visit as a basis for developing a nutrition care plan consistent with estimated nutritional requirements and nutritional rehabilitation goals	Discharge follow-up by general practitioners was planned to consist of three contacts, conducted approximately 1, 3, and 8 weeks after discharge in both control and intervention participants	Follow-up home visits with registered dietitians have a positive effect on the functional and nutritional status of geriatric medical patients after discharge. A larger study with a longer intervention period is needed to see if there is a positive effect on risk of re-admission and mortality
Yang et al[26]	RCT. Geriatric patients, n = 82	Individualized nutritional intervention program, according to energy and protein intake requirements in addition to dietary advice based on face-to-face interviews with their family caregivers during hospitalization, with phone calls post-discharge for prescribing individualized nutritional iNIP	The standard care group was only provided standard nutritional supplements according to the Kaohsiung Chang Gung Memorial Hospital Nutrition Department, and patients’ family caregivers were not provided dietary advice	A 6-month iNIP under dietitian and patient family nutritional support for malnourished older adults with pneumonia can significantly improve their nutritional status and reduce the readmission rate
Terp et al[27]	RCT. Geriatric patients, n = 144	Individual dietary plan for home, including pre-discharge advice on nutritional intake, combined with three follow-up visits after discharge (1, 4, and 8 weeks)	Patients in the control group received usual care, which meant screening for nutritional risk within 24 hours of hospital admission using Nutritional Risk Screening-2002 and weekly monitoring of their nutritional status	There is no effect on readmissions noted
Oral nutritional supplementation (with whey protein)
Deer et al[29]	RCT. Geriatric patients, n = 100	One of five post-hospital interventions: Whey protein supplementation, in-home rehabilitation with placebo supplementation, in-home rehabilitation with protein supplementation, single testosterone injection, or isocaloric placebo supplementation, the control group	The control group received an isocaloric placebo supplementation together with usual care	Post-hospital protein supplementation, in-home exercise, and testosterone interventions are safe, can accelerate recovery, and may reduce readmission rates in geriatric patients
Diet supplementation with watermelon
Tan et al[30]	RCT. Pregnant patients, n = 128	Participants randomized to watermelon and dietary advice leaflet were supplied with two fresh red-fleshed watermelon (approximately 4 kg weight) to take home in addition to the dietary advice leaflet which they were advised to read and heed	Participants randomized to advice leaflet were provided with an identical advice leaflet to read and heed	Adding watermelon to the diet after hospital discharge for HG improves body weight, HG symptoms, appetite, wellbeing and satisfaction (no effect on hospitalisation)

HG: Hyperemesis gravidarum; iNIP: Intervention program; RCT: Randomised controlled trial.

Table 4 Summary of key findings, n (%)

Intervention	Number of participant (studies)	Readmission windows	Risk of bias	Inconsistency	Indirectness	Imprecision	Publication bias	Effect	Certainty
Follow-up counselling by clinical nutritionists or dieticians	916 (7)	1 month, 6 months, 12 months, 18 months	Some concerns in 2/7	Very serious	Not serious	Serious	Low suspicion	Mixed results (3/7 studies show reduction in readmission rates)	Very low
Individualised meals thrice a day (as evaluated and enhanced by a dietician)	21 (1)	1 month	Some concerns	NA (only 1 study)	Not serious	Very serious	Low suspicion	No significant difference (single-study evidence)	Very low
Individualised nutrition care plans	378 (3)	3 months, 6 months	Some concerns in 2/3	Serious	Not serious	Serious	Low suspicion	Mixed results (1/3 studies show reduction in readmission rates)	Low
Oral nutritional supplementation (with whey protein)	100 (1)	1 month	High	NA (only 1 study)	Not serious	Very serious	Low suspicion	Trend towards benefit (single-study evidence)	Very low
Diet supplementation with watermelon	128 (1)	2 weeks	Some concerns	NA (only 1 study)	Very serious	Very serious	Low suspicion	No significant difference (single-study evidence)	Very low

NA: Not available.