Implementation and Evaluation of Discharge Planning for Patients Undergoing Umbilical Cord Blood Transplantation

Introduction

Umbilical cord blood transplantation (UCBT) is an important curative treatment for many malignant or nonmalignant hematologic disorders, especially for patients who lack a matched family donor [1]. With the continuous progress of transplantation technology and supportive care, the number of UCBTs performed and survival rates are significantly increasing, and more than 40 000 UCBTs have been performed worldwide [2]. However, patients treated with UCBT have higher rates of readmission than with other kinds of hematopoietic stem cell transplantation (HSCT) [3]. In addition, HSCT recipients face severe challenges after discharge, such as continued immunosuppression and management of transplant-related complications, which seriously affects their quality of life (QoL) [4,5].

Previous studies have demonstrated that discharge planning can reduce hospital readmissions within 30 days after discharge, and promote self-efficacy and QoL of patients with other diseases [6–8]. Kucharczuk et al [6] reported that the 30-day unplanned readmission rate was decreased by 29.0% after an evidence-based discharge planning intervention. Hu et al [7] conducted an innovative transitional care program for kidney transplant recipients, which reduced the patients’ readmission rates within 30 days after discharge. Lin et al [8] reported that a hospital-to-home transitional care program improved the self-efficacy and QoL of the stroke survivors, and reduced unplanned hospital readmissions during the 24-week follow-up. To date, only 1 study has explored the feasibility of a discharge intervention named “Rooming in” for caregivers of pediatric HSCT recipients, and they demonstrated that “Rooming in” could lower the coping difficulty scores of caregivers [9]. However, no study has focused on the effects of discharge planning on UCBT recipients; in addition, the impact of discharge planning on patients’ readmission rates, self-efficacy, QoL, and clinical outcomes are still uncertain.

Our study aimed to determine whether discharge planning was more beneficial for UCBT recipients than usual care. The hypotheses of this study were as follows: (1) UCBT recipients in the discharge planning group will have a lower rate of unplanned readmissions than those in the controls, and (2) UCBT recipients in the discharge planning group will have higher self-efficacy and QoL, and better clinical outcomes than those in the control group.

Material and Methods

PATIENTS:

The study was conducted from April 2022 to March 2023 in the First Affiliated Hospital of University of Science and Technology of China (USTC). A total of 80 patients who received their first UCBT were enrolled in the study. Eligibility criteria: (1) age ≥18 years; (2) Karnofsky performance score ≥70; (3) ability to read and speak Chinese; and (4) agreement to and signing of the informed consent form. The exclusion criteria were as follows: (1) evidence of cardiovascular, orthopedic, or neurological deficits; (2) cognitive dysfunction; and (3) a life expectancy less than 3 months. Seventy-two patients met the inclusion criteria and participated in the study. At admission, patients were assigned to a control group (CG: from April 2022 to August 2022) or an intervention group (IG: from September 2022 to April 2023) by comparing usual care with discharge planning. The study protocol was approved by the ethics commission of the First Affiliated Hospital of USTC (NO. 2022KY-039).

INTERVENTION GROUP: A nurse-led multidisciplinary team was organized to implement discharge planning for UCBT recipients in September 2022, which comprised 1 chief physician, 1 physical therapist, and 5 nurses. The discharge planning program was based on the theory of “Timing It Right” [10], which was conducted 5–7 days before admission to 100 days after UCBT. The program included 5 different phases: event/UCBT, stabilization, preparation, implementation, and adaptation (Table 1). Patients were assessed face-to-face before admission and were provided individualized professional educative programs during hospitalization. Patients were discharged from the hospital once their neutrophil count had recovered and they were free of any severe complications. Following hospital discharge, all patients were asked to remain close to the hospital with their caregivers until 100 days after UCBT, and they were reviewed by HSCT physicians once a week. In addition, patients received weekly telephone follow-ups and monthly home visits from the research team, and patients could consult the WeChat group or the HSCT network consulting clinic at any time when needed.

CONTROL GROUP:

During the hospital stay, all patients were reviewed by physicians individually and received professional care from the nursing team daily. The day before discharge, instructions on diet, medication, exercise, emotional support, and symptom self-observation were provided by HSCT nurses. Following discharge, the patients received the same observation at clinics.

MEASURES:

The primary outcome measures were unplanned hospital readmissions within 30 days after discharge and at 100 days after UCBT, a key time point in transplant medicine. Readmissions were identified as events due to transplant-related reasons following an index admission for UCBT.

Secondary outcomes included self-efficacy, QoL, and clinical outcomes. Self-efficacy and QoL were evaluated at admission and at 100 days after UCBT. Clinical outcomes were derived from medical records.

Self-efficacy was documented using the 10-item General Self-Efficacy Scale (GSES), which was developed by Schwarzer et al [11], to evaluate the participants’ confidence to cope with stressful or challenging demands. The scale was rated on a 4-point Likert scale, with each item ranging from 1 (not at all confident) to 4 (total confidence); a higher total score corresponded to higher self-efficacy. The internal consistency of the Chinese version was 0.91 [12].

QoL was assessed via the validated Chinese version of the Functional Assessment of Cancer Therapy-Bone Marrow Transplantation (FACT-BMT) version 4 [13]. The scale is a validated tool developed by McQuellon et al [14] and consists of 5 dimensions: physical well-being (PWB, 7 items), social well-being (SWB, 7 items), emotional well-being (EWB, 6 items), functional well-being (FWB, 7 items), and bone marrow transplant subscale (BMTS, 10 items). The questionnaire was scored using a 5-point Likert scale, with each item ranging from 0 (not at all) to 4 (very much). For the negative statements, the score must be converted from 4 to 0, and a higher score demonstrates better QoL. The Cronbach’s alpha coefficient of the Chinese version ranged from 0.71 to 0.92 [13].

Clinical outcomes included engraftment kinetics (days to neutrophil engraftment and to platelet engraftment), transplant-related complications (number of infections, grade of acute graft-versus-host-disease [aGVHD], and hemorrhagic cystitis), weight loss, and hospital length of stay (LOS).

STATISTICAL ANALYSIS:

Data were analyzed using SPSS for Windows Version 22.0 (SPSS, Inc., Chicago, IL, USA). For demographic and medical variables, the normal data were presented as the means and standard deviations (mean±SD) and analyzed with an independent t test. Nonnormal data were presented as the median with ranges (median [range]) and compared by the Mann-Whitney U test, while categorical data were presented as numbers (n) and examined by the chi-square test or a Fisher exact test.

Patients who died during their transplant admission and those who died before 30 days from discharge or 100 days after UCBT were excluded. The cumulative unplanned hospital readmission incidences 30 days after discharge and 100 days after UCBT were analyzed using the log-rank test. Between-group intervention effects on self-efficacy and QoL at 100 days after UCBT were assessed using analysis of covariance. When P<0.05, the results were considered statistically significant.

Results

RECRUITMENT:

The recruitment flow diagram is presented in Figure 1. A total of 80 patients who received their first UCBT were recruited, of which 72 met the inclusion criteria and participated in the study, and 6 patients were withdrawn because of death.

PATIENT AND MEDICAL CHARACTERISTICS:

Of the 66 patients – CG: n=32; mean age (37.19±11.52) years; IG: n=34; mean age (36.21±10.41) years) – no significant differences in demographic and medical characteristics were noted (Table 2).

DISCHARGE PLANNING ON UNPLANNED HOSPITAL READMISSION:

The readmission rates of 30 days after discharge in the CG and IG were 31.25% and 20.59%, respectively (Figure 2; P=0.376). The cumulative incidences of unplanned readmission at 100 days after UCBT were 34.38% in the CG and 29.41% in the IG (Figure 3; P=0.629). The main reasons for readmissions were blood product transfusions and aGVHD in the IG, and infection in the CG at 30 days after discharge and 100 days after UCBT (Supplementary Figure 1).

EFFECT OF DISCHARGE PLANNING ON SELF-EFFICACY:

The total GSES scores were decreased in the CG (28.31±3.77 vs 28.94±5.68), but the scores were increased in the IG (30.35±3.66 vs 27.65±5.99) at 100 days after UCBT (Figure 4; P<0.001).

EFFECT OF DISCHARGE PLANNING ON QOL:

The total scores of QoL were 97.47±8.37 and 107.50±9.41 in the CG and IG at 100 days after UCBT (Table 3; P<0.001). In addition, the scores of PWB, FWB, BMTS, FACT-general, and FACT-trial outcome index at 100 days after UCBT were also higher in the IG than in the controls (Table 3; P<0.05).

EFFECT OF DISCHARGE PLANNING ON CLINICAL OUTCOMES:

No significant differences were found for engraftment kinetics, transplant-related complications, weight loss, or hospital LOS (Table 4).

Discussion

This is the first study to implement and evaluate discharge planning for patients undergoing UCBT. The findings indicated that discharge planning did not reduce unplanned readmissions. However, it improved UCBT recipients’ self-efficacy and QoL.

Discharge planning was not effective at reducing unplanned readmission rates for UCBT recipients. The finding is in line with those of previous studies reporting that discharge planning for older patients did not reduce hospital readmissions [15,16]. However, the result is not consistent with reports that the discharge planning program was associated with lower readmission rates in patients with chronic disease [17,18]. Regarding the incidence of unplanned readmissions, Dhakal et al [3] reported that the overall incidence of 30-day readmission was 24.4% for allo-HSCT. However, cord blood had significantly higher readmission rates than peripheral blood (aOR=2.4; 95% CI=1.83–3.16). Crombie et al [19] showed that 33.3% of patients were readmitted within 30 days after discharge, and 46.3% were readmitted by 100 days after UCBT. In the present study, the readmission rates at 30 days after discharge and 100 days after UCBT in the IG were lower than that in other studies, which may be related to long-term LOS. Additionally, patients fully recovered during hospitalization.

It is well known that UCBT is associated with delayed immune reconstitution and a high incidence of aGVHD [20,21]. Delayed immune reconstitution increases infection risks and the need for blood product transfusions, requiring more healthcare resource utilization [22]. Acute GVHD is a common complication of HSCT; approximately 30% of patients who receive UCBT develop aGVHD [21]. Previous studies have confirmed that patients with aGVHD had significantly more medical visits than those with no GVHD within 100 days after HSCT [23,24]. The main reasons for readmissions in the IG were blood product transfusions and aGVHD. However, infection was the most common cause of readmissions in the CG in this study, which is supported by previous reports [19,22,25].

By improving self-efficacy, the positive effect of a discharge plan intervention was demonstrated. This finding is consistent with those of previous studies involving other populations, such as spinal cord injury patients and stroke survivors [8,26]. Liu et al [26] reported that transitional care improved patients’ self-efficacy at 12-week and 24-week follow-ups. The improvement in our study might be associated with the nurse-led intervention, which involved both knowledge and skills for self-care during hospitalization. In addition, the WeChat group, HSCT network consulting clinic, and home visits supported solving problems immediately after discharge, all of which contributed to helping patients build their self-confidence.

Patients’ QoL was enhanced by the implementation of discharge planning program in UCBT recipients. The results are in line with previous studies, which demonstrated that QoL was improved after transition care [8,27]. Improvements in PWB and FWB were closely related to the benefits of the tailored exercise intervention in our program, which helped UCBT recipients maintain a better personal status. A study demonstrated that exercise can increase patients’ muscle strength and promote their functional capacity [28]. For BMTS, discharge planning may be effective for improving QoL by the patient-centered novel components, which ensured continuity of care and reduced symptom burden of patients. No changes were found between groups in SWB and EWB, which may be associated with our emotional intervention measures, lack of involvement from psychiatrists, and failure to identify key psychosocial problems and reduce their psychosocial burden. Further research is necessary to guide psychosocial interventions under professional psychiatrists.

Our study had some limitations. First, it was not a randomized trial, and the nature of the study design limited our ability to determine the effectiveness of the discharge plan intervention, but the baseline data of the 2 groups were comparable. Second, the subjects were selected from among UCBT patients, which limits generalizability to other types of transplant patients. Finally, this was a single-center trial, which may have biased our results. The present findings need to be confirmed by larger multicenter randomized studies.

Conclusions

This study demonstrated that discharge planning was useful for improving self-efficacy and QoL in UCBT recipients. Overall, our findings suggest that for successful hospital-to-home transitions, the implementation of discharge planning is important, but further studies are needed to confirm these benefits.