Table 1 Article Characteristics

Missel et al., 2015, Denmark, Manuscript

To assess the effect of nurse-led systematic rehabilitation counselling performed before discharge to prevent concerns in the hospital-to-home gap in rehabilitation of lung cancer patients.

Quasi-experimental intervention study

Thoracic Surgery; Video-assisted thoracoscopic surgery, Thoracotomy; Elective

n = 120

Control group (59% female, 41% male); intervention group (43% female, 57% male)

Control group mean 69.6 (SD 9.4); intervention group mean 68 (SD 8.9)

Sawatsky et al., 2013; Canada; Manuscript

To describe and compare the outcomes of a Nurse Practitioner Follow-Up (NPFU) intervention with the standard model of post-discharge care for Coronary Artery Bypass Graft (CABG) patients.

Randomized clinical trial, two group, repeated measures design

Cardiac Surgery; Coronary Artery Bypass Graft; Elective

N = 200

81% male, 19% female

Mean 64.5

Young et al., 2013; Australia; Manuscript

To investigate the effectiveness of a centralized, nurse-delivered telephone-based service to improve care coordination and patient-reported outcomes after surgery for colorectal cancer.

Two-arm, parallel-group multi-centre randomized trial

General Surgery; Colorectal resections; Elective

N = 756

Control group (54.2% male); intervention group (56.8% male)

Control group mean 67 (SD 12.1); intervention group mean 68.6 (SD 12.2)

Middleton et al., 2004; Australia; Manuscript

To evaluate the short-term impact of nursing-led, coordinated care for patients after discharge following CEA.

Randomized Controlled Trial

Vascular Surgery; Re-vascularization surgery; Elective

N = 133

61.1% male, 38.9% female

Mean 70.4

Norcott et al., 2020; USA; Conference Poster Abstract

To evaluate whether a primary care visit before, rather than after, an elective surgery can potentially improve post-operative care transitions.

Retrospective observational cohort study

Unspecified; Unspecified; Elective

N = 1951

51% male, 49% female

Mean 77 (SD 5.6)

Czarnecki et al. 2019; Canada; Manuscript

To identify the causes of readmission after TAVR, determine whether transitional care factors were associated with a reduction in readmission and to identify other predictors that could be used to target quality improvement efforts.

Retrospective observational cohort study

Cardiac Surgery; Transcatheter Aortic Valve Replacement; 90.7% Elective, 9.3% Urgent

N = 937

55.7% male, 44.3% female

Median 83 (IQR 78–97)

Smucker et al., 2019; USA; Conference Poster Abstract

To identify predictors for unsuccessful postoperative transitions of care after major abdominal oncological operations.

Retrospective observational cohort study

General Surgery; Cancer resection Procedures (upper and lower GI, pancreatic, hepatobiliary); Elective

N = 240

55.4% men, 44.6% women

Median 67 (range 17 to 98)

McDonald et al., 2018; USA; Manuscript

To assess clinical outcomes for older adults undergoing elective abdominal surgery via a collaborative intervention by surgery, geriatrics, and anesthesia focused on perioperative health optimization.

Prospective observational cohort study

General Surgery; Colorectal, general, and hepato-pancreaticobiliary surgical procedures (specific procedures unspecified); Elective

N = 326

Control group (51.0% male, 49.0% female) intervention group (46.6% male, 54.4% female)

N

Shargall et al., 2016; Canada; Manuscript

To evaluate the Integrated Comprehensive Care (ICC) program, a novel health system integration initiative that coordinates home care and hospital-based clinical services for patients undergoing major thoracic surgery relative to traditional home care delivery.

Pilot retrospective cohort study

Thoracic Surgery; Open and Video-assisted thoracoscopic surgeries. Resections (wedge, multiple wedges, segmentectomy, lobectomy, bilobectomy, pneumonectomy, pleural, mediastinum); Elective

N = 686

Control group (58% male, 42% female); intervention group (48.5% male, 51.5% female)

Control group mean 63.8 (SD 0.78) intervention group mean 65.6 (0.71)

Xourafas et al., 2016; USA; Manuscript

To identify transitional care gaps, which could point out preventive perioperative clinical pathways to decrease post-pancreatectomy readmissions for nutritional causes.

Retrospective observational cohort study

General Surgery; Pancreatic resections; Elective

N = 172

non-readmitted group (51.7% female), readmitted group (67.7% female)

Non-re-admitted group median 66 (range 25 to 90); re-admitted group median 67 (range 32 to 83).

Weinberg et al., 2007; USA; Manuscript

To examine whether effective relational coordination better prepares caregivers to provide and manage care and examine the effects of caregiver preparation on patient clinical outcomes.

Prospective observational cohort study

Orthopaedic Surgery; Knee replacements; Elective

N = 222

38% male, 62% female

Mean 66.34 (SD 10.16)

Weinberg et al., 2007; USA; Manuscript

To investigate patients’ experience with coordination of their postsurgical care across multiple settings and the effects on key outcomes.

Prospective observational cohort study

Orthopaedic Surgery; Knee replacements; Elective

n = 222 patients n = 2 surgeons

38% male, a/62% female

Mean 66.34 (SD 10.16)

Quinlan et al., 2020; Canada; Conference Abstract

To design, implement and evaluate an adaptable smart phone or tablet design technology that would be offered to patients in follow up in addition to Interactive Voice Response technology, email and texting options, based on patient choice.

Quality Improvement Project

Cardiac Surgery; Transcatheter Aortic Valve Implants; 80% Elective, 20% Urgent

N = 265

Not reported

Mean 80

Brooke et al., 2019; USA; Manuscript

To characterize the extent to which information regarding a medically complex older patient’s functional status, cognitive status, social status, and emotional factors are mutually shared among PCPs and surgical providers during transitions of surgical care.

Qualitative interview study

General and Vascular Surgery; Procedures unspecified; Elective

N = 12 patients

N = 35

Health-Care

providers

83% male, 17% female

[patients]

Mean 68.75 (SD 5.49) [patients]

Oksholm et al., 2018; Norway; Manuscript

To explore patients’ experiences of being transferred between hospitals after lung cancer surgery. The study aim was to improve the quality of transitional care.

Qualitative interview study

Thoracic Surgery; specific procedure unspecified; Elective

N = 14

6 men, 8 women

Mean 72 (range 56 to 87 years)

Wong et al., 2018; Canada; Manuscript

To minimize common risks associated with care transitions (such as early signs of heart failure exacerbation, complications with incisional sites, and medication confusion), and to promote optimal recovery through patient education and self-care support.

Pilot initiative using qualitative interviews

Cardiac Surgery; Transcatheter Aortic Valve Implants; 80% Elective, 20% Urgent

N = 77

40% male, 60% female

Median 84 (range 61 to 96)

Chan et al., 2017; USA; Conference Poster Abstract

To understand the geriatric surgical journey by identifying the personal and systemic factors associated with care transitions, readmissions, and care satisfaction, and to inform optimal care transitions for older adults experiencing elective surgery.

Qualitative interview study

Unspecified; Unspecified; Elective

N = 15

66% male, 44% female

mean 71 [range 65 to 88]

Thomsen et al., 2017; Denmark; Manuscript

To identify the perspectives of fast-track colorectal cancer surgery patients on challenges experienced in the transition from being a hospitalized patient with cancer to being a cancer survivor.

Qualitative participatory action research

General Surgery; Colorectal resections; Elective

N = 12

42% male, 58% female

Mean 72.4

Slager et al., 2017; USA; Manuscript

To characterize what, where, when and how surgical and primary care providers communicate clinical goals and expectations during transitions of care.

Qualitative interview study

General and Vascular Surgery; Procedures unspecified; Elective

25 patients, 17 surgical providers, and 16 Primary Care physicians

55% male, 45% female

Mean 68.75 (SD of 5.49) [patients]

Hughes et al., 2000; USA; Manuscript

To describe information needs of elderly postsurgical cancer patients.

Descriptive qualitative study

Oncological Surgery; Prostate, breast, gastrointestinal, lung, and head and neck cancer procedures (specific procedures unspecified); Elective

N = 148

57% male, 43% female

61% were 65 and older