Quality of Transition of Care from Hospital to Home for Patients Hospitalized for COVID-19

Round 1

Reviewer 1 Report

he authors present a study that adfirm produce a "quantitative analysis", I have some doubts: could you please methodologically expicitate how the quantification is produced?  It is a self percived satisfaction? Please specify the validation and effectiveness of "The instrument". 

The authors presented a cross-sectional prospective study to assess continuity of care in a large sample of patients hospitalized for COVID-19. A number of important elements, such as care planning, technology integration, and nurse interventions, affect how well patients with COVID-19 move from hospital to home. In order to guarantee that patients receive the right resources and support during their recuperation at home, several factors are essential. The authors present a study that adfirm produce a "quantitative analysis", I have some doubts: could you please methodologically expicitate how the quantification is produced?  It is a self percived satisfaction? Please specify the validation and effectiveness of "The instrument". Do the authors provide any consideration about rehabilitation? Improving recovery outcomes for COVID-19 survivors requires incorporating rehabilitation services into post-discharge care plans. Rehabilitation programs emphasizing symptom management and at-home fitness training can be crucial in helping patients recover, demonstrating the necessity for healthcare systems to give these treatments first priority when arranging discharges.

 

Author Response

We sincerely appreciate your thoughtful and constructive feedback, as well as the opportunity to further elucidate our methodology. Below, we provide detailed responses to each of your inquiries:

R: Quantification Methodology: Our study employs the Care Transitions Measure (CTM-15), a validated quantitative instrument designed to assess patients' perceptions of care continuity during the transition from hospital to home. Quantification is conducted using a Likert-type scale, in which patients assess their experiences regarding communication, care coordination, and self-care support. The sum of item scores generates an overall transition quality score, enabling statistical comparisons and subgroup analyses.
R: Self-Perceived Satisfaction vs. Care Continuity Measure: Although the CTM-15 captures patient-reported experiences, it extends beyond a mere measure of self-perceived satisfaction. Instead, it evaluates specific dimensions of care transition quality, such as discharge preparation, clarity of post-discharge instructions, and access to necessary follow-up care. Therefore, this instrument offers a structured and standardized evaluation of care continuity, rather than merely reflecting subjective patient satisfaction.

R: Instrument Validation and Effectiveness: The CTM-15 has been extensively utilized in research and quality improvement initiatives to evaluate and refine transitional care practices. It has been widely validated across different healthcare settings and populations, demonstrating strong psychometric properties, including high internal consistency (Cronbach's alpha > 0.90) and construct validity. Its predictive validity has also been established, showing correlations with reduced hospital readmissions and improved clinical outcomes for patients.

R: Considerations on Rehabilitation in Our Study: We acknowledge the importance of rehabilitation in optimizing recovery outcomes for COVID-19 survivors. Although our study primarily focuses on care transition continuity, our findings highlight gaps in transitional care that may impact access to rehabilitation services. Future research should explore the integration of rehabilitation services into post-discharge care plans, emphasizing structured symptom management programs and home-based interventions to support functional recovery.

Reviewer 2 Report

The authors present an interesting study on the quality of transition of care from hospital to home care in patients hospitalized during the COVID-19 pandemic due to SARS-CoV-2 infection. In my opinion, the work is suitable for publication.

 

With data from such a large hospital (over 8 thousand patients), before publication it should be described why the assessed group had only about 650 patients, and after applying the inclusion criteria, only a few over 200 entered the study. Were these all patients in the period?

The second aspect is the use of a tool that is a translation and has not been standardized or pre-tested. I still think that the work is worth publishing, but its results should be carefully compared with other, similar works.

Author Response

We sincerely appreciate the reviewer's insightful comments and the opportunity to clarify some methodological aspects of our study. Below are our responses to the issues raised:

 

R: Sample Size Selection: Regarding the discrepancy between the total number of hospital visits recorded at Hospital Florianópolis (8,234 annual visits) and the number of patients included in the study (approximately 657), we would like to clarify that the 8,234 visits refer to the total hospital services provided across different departments in 2019, representing the hospital's operational reality outside the pandemic period. However, our study was conducted specifically during the critical phase of the COVID-19 pandemic, between 11/01/2020 and 05/31/2021, and the study population was limited to patients hospitalized due to COVID-19 who were subsequently discharged home.

The final sample comprised 201 patients, selected according to the inclusion and exclusion criteria established for this study, as detailed in the Materials and Methods section. Several factors contributed to patient exclusion, including non-responsiveness to contact attempts, absence of COVID-19 diagnosis, death, and transfers to other hospitals. This reduced the initial sample to 657 patients, of whom 201 met the eligibility criteria for participation. Therefore, the number of patients included reflects the reality of COVID-19-affected individuals who were eligible and available for data collection within the pandemic context and its associated constraints.

Below, we detail several factors that influenced the final sample size:

• Non-participation: 37 patients explicitly declined participation.
• Unreachable participants: Despite repeated contact attempts on different days and at varying times, 213 patients remained unreachable.
• Deaths: 169 patients died and were therefore excluded from the study.
• Exclusion due to misdiagnosis: 37 individuals were excluded as they were not diagnosed with COVID-19.

After applying inclusion and exclusion criteria, 201 patients constituted our final sample. This represents the total number of eligible and consenting participants within the study period. We recognize the importance of providing further details on this aspect in the manuscript and will revise the text to ensure greater transparency.

 

R: Use of the Care Transitions Measure (CTM-15) in Brazil: The Care Transitions Measure (CTM-15) employed in our study is a validated version that has undergone translation and cultural adaptation for Brazil, in accordance with established literature guidelines [(reference 17)]. Although this instrument was not specifically pre-tested for the COVID-19 context, its application followed rigorous scientific data collection methods, including a pilot test to identify potential inconsistencies.

Although there is no officially standardized cutoff point, previous studies using the Brazilian version have followed the original methodology. According to the original authors' recommendations, a score above 70 is conventionally considered satisfactory, although this threshold is not based on empirical standardization. To strengthen our findings' interpretation, we compared our results with other studies that utilized the CTM-15.

Additionally, internal consistency was assessed through Cronbach's alpha for the four subdomains and the overall CTM-15 score, ensuring the instrument's reliability in our sample.

REFERENCE: Acosta et al. Brazilian version of the Care Transitions Measure: translation and validation. Int Nurs Rev. 2017;64(3):379-87. Available at: doi: https://doi.org/10.1111/inr.12326.

 

R: Comparison with Studies on CTM and COVID-19: We recognize the limitation in directly comparing our findings with previous research, given the paucity of studies specifically employing CTM-15 in this patient population. We believe that using this tool in our study significantly contributes to bridging this gap in the literature by providing relevant data on transitional care in post-COVID-19 patients. Future research should further investigate the Brazilian version of CTM-15 in specific contexts, such as post-COVID care, to enhance the understanding and validity of its findings.

Thus, we understand that comparing our results with previous studies and interpreting them within the COVID-19 pandemic context are essential to ensuring the relevance and reliability of our findings.

 

REFERENCES ON NATIONAL AND INTERNATIONAL CTM APPLICATIONS TO SUPPORT ITS USAGE

NATIONAL STUDIES

1. Acosta AM, Lima MDAS, Pinto IC, Weber LAF. Care transition of chronic disease patients from emergency discharge to home. Rev Gaúcha Enferm, Porto Alegre, v. 41, n. spe, e20190155, 2020. Available at: https://doi.org/10.1590/1983-1447.2020.20190155
2. Dantas MNP et al. Transition of care in post-hospitalization patients due to COVID-19 in a hospital in northeastern Brazil. Rev Bras Enferm, v. 76, p. e20230030, 2023. Available at: https://doi.org/10.1590/0034-7167-2023-0030.
3. Cechinel-Peiter et al. Quality of transitional care of children with chronic diseases: a cross-sectional study. Rev Esc Enferm USP, 56, e20210535. 2022. Available at: https://doi.org/10.1590/1980-220X-REEUSP-2021-0535.

INTERNATIONAL STUDIES

1. Flink et al. Measuring care transitions in Sweden: validation of the care transitions measure. Int J Qual Health Care. 2018;30(4):291-297. doi:10.1093/intqhc/mzy001.
2. Cao et al. Validity and reliability of the Chinese version of the care transition measure. PLoS One. 2015;10(5):e0127403. doi: https://doi.org/10.1371/journal.pone.0127403.
3. Hwang JI, Chung JH, Kim HK. Psychometric properties of transitional care instruments and their relationships with health literacy: Brief PREPARED and Care Transitions Measure. Journal of the International Society for Quality Health Care, 31(10), 774–780. 2019. Disponível em: https://doi.org/10.1093/intqhc/mzz033.
4. Bakshi et al. Validation of the care transition measure in multi-ethnic South-East Asia in Singapore. BMC health services research, 12, 256. 2012. Disponível em: https://doi.org/10.1186/1472-6963-12-256.

Round 2

Reviewer 1 Report

None

Thank You