• Caroline A Brand, Catherine T Jones, Adrian J Lowe, David A Nielsen, Carol A Roberts, Bellinda L King, and Donald A Campbell.
• Clinical Epidemiology & Health Service Evaluation Unit, Melbourne Health, Parkville, VIC. Caroline.brand@mh.org.au
• Aust Health Rev. 2004 Dec 13;28(3):275-84.

BackgroundMultiple hospital admissions, especially those related to chronic disease, represent a particular challenge to the acute health care sector in Australia.ObjectiveTo determine whether a nurse-led chronic disease management model of transitional care reduced readmissions to acute care.DesignA quasi-experimental controlled trial.SettingA large tertiary metropolitan teaching hospital.Participants166 general medical patients aged > or = 65 years with either a history of readmissions to acute care or multiple medical comorbidities.InterventionImplementation of a chronic disease management model of transitional care aimed at improving patient management and reducing readmissions to acute care.Main Outcome MeasuresReadmission rates and emergency department presentation rates at 3-and 6-month follow up. Secondary outcome measures include quality of life, discharge destination, and primary health care service utilisation.ResultsThere was no difference in readmission rates, emergency department presentation rates, quality of life, discharge destination or primary health care service utilisation. The difficulties inherent in evaluating this type of multifactorial intervention are discussed and consideration is given to patient factors, the difficulty of influencing readmission rates, and local system issues.ConclusionThe outcomes of this study reflect the tension that exists between implementing multifaceted integrated health service programs and attempting to evaluate them within complex and changing environments using robust research methodologies.

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