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CRITICALLY APPRAISED TOPIC

The evidence that preventative home visits delay admission to nursing homes for community dwelling older adults is inconclusive, but there is some evidence to support the use of preventative home visits to delay nursing home admission for older adults who are already dependant in activities of daily living.

AUTHORS:

Prepared by Charmain Jones and Elizabeth Wyatt Date 20 May 2012

Email address cjon9976@uni.sydney.edu.au, ewya4745@uni.sydney.edu.au

CLINIAL SCENARIO

The world’s population is aging. The world-wide proportion of aged people is predicted to increase from 6.9% of population in the year 2000, to 19.3% in 2050 (Low, Yap & Brodaty, 2011). In Australia, the remaining life expectancy for a 65 year old has increased from 15.7 years in 1969, to 21.8 years in 2009 (Australian Bureau of Statistics [ABS], 2011). These statistics put into sharp focus questions about the best ways to manage the increasing aged care need (Low et al.,2011).

There has been some shift in emphasis towards community based care, due to both cost and consumer preference (Low et al.,2011). In 2009, the Australian government spent 0.8% GDP on aged care and this is expected to increase to 1.8 of GDP by 2049 (ABS, 2011). The main contributor to this cost was institutional care (ABS, 2011). In addition to the financial cost of nursing home care, there is a price to be paid in terms of quality of life. Nursing home residents report depression relating to lack of freedom and privacy, a sense of social isolation and discontinuity from their previous life which can contribute to declining physical and functional status (Choi et al., 2008). Given that home visit programs are commonly undertaken by occupational therapists as well as by other allied health professionals, we sought to evaluate evidence for the effectiveness of preventative home visits in supporting older adults to continue living at home. Improving the ability of older adults to live at home is thought to improve quality of life and reduce the financial burden on the health care system by delaying admission into nursing homes.

FOCUSSED CLINICAL QUESTION

Do preventative home visits to community dwelling elderly adults delay admission to nursing homes when compared to their peers who do not receive preventative home visits?

SUMMARY OF SEARCH

A systematic review and meta-regression analysis by Huss and colleagues (2008) investigated the effects of preventative home visits by allied health professionals on nursing home admission, functional decline and mortality. This review found varied results between individual trials, but overall no significant effect upon combined analysis. No statistically significant results were established in regards to nursing home admission and mortality. There was minimal improvement on functional decline overall, however studies including clinical examination exhibited statistically significant improvements on functional status.

Since 2008, no further studies answering our PICO question in relation to nursing home admission were identified. A randomised controlled trial, by Kono and colleagues (2012), measuring effects of home visits on activities of daily living (ADL), instrumental activities of daily living (IADL) and social support was identified. We accepted these outcomes measures as being indicative of risk of functional decline which can result in nursing home admission.

Kono et al, (2012) investigated the effects of preventative home visits on elders using the outcome measures of ADL, IADL, depression, social support and services usage. Sub-group comparisons examined outcomes for participants with low ADL support needs and participants with high ADL support needs at baseline. They found no effect on any primary measures for the group overall, or for the sub-group that had low ADL needs at baseline. The sub-group with high ADL dependency at baseline, showed a statistically significant greater deterioration than the control group for ADL, IADL and depression.

CLINICAL BOTTOM LINE

There is evidence to support the use of preventative home visits as an effective intervention to delay nursing home admissions for community dwelling older adults who are already dependant on assistance with ADLs.

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Limitation of this CAT

This critically appraised topic has not been peer-reviewed by one independent lecturer

SEARCH STRATEGY

Terms used to guide the search strategy

• Patient/Client Group: Aged, elderly, frail, older adults, older people, geriatric all community dwelling, living at home, living independently.

• Intervention (or Assessment): Home visits, home modification/s, structural home modification/s, assistive devices, home aids.

• Comparison: Patient group receiving no home interventions.

• Outcome(s): Patient group receiving the intervention experienced delayed admission to nursing homes compared to the control group.

Databases and Sites Searched Search Terms Limits Used

Medline

Cinahl

Web of Science

Cochrane

OT Seeker

OT – CATS

Aged OR elderly OR older adults OR frail OR older people OR older persons OR geriatric AND Community dwelling OR community living OR resides/residing at home OR lives/living at home OR Independent living AND Home modification OR Home structural modification OR Home improvement/s OR Home visit/s OR preventative home visit/s OR aged health service OR self-help device/s OR Home aid/s OR home occupational therapy visit/s OR assistive technology OR home visits AND Nursing home/s OR nursing home admission OR aged care facilities admission OR long term care OR admission OR instutionalisation

For Medline, Cinahl, Web of Science and Cochrane databases the following limits were used

• Publications written in English

• Publication dates 2007-2012

• Subjects aged 65years plus

• Where possible - RCT’s and systematic reviews were selected in limits

OT-seeker

• All Systematic reviews and RCT’s

• Publications in English

• Publication dates 2000 - 2012

OT-CATS

No Limits used as no related papers were found on our topic

INCLUSION and EXCLUSION CRITERIA

Inclusion Criteria

Publications written in English that addressed the effect of preventative home visits on the population group of community dwelling older adults.

Exclusion Criteria

Non English written papers, abstracts only, interventions within nursing homes or hospitals, interventions for hospital discharge, interventions for disabled or non-elderly people.

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RESULTS OF SEARCH

A total of 215 papers were identified from Medline, Web of Science, Cinahl, Cochrane, OT-Seeker and OT-CATS databases using the search terms listed. Fifteen publications were selected for abstract review. From these 15 publications 2 articles met the inclusion criteria. It was found that these articles were both systematic reviews and meta-analyses. The first was published in 2002, the second in 2008. The second systematic review acknowledged and was developed from the 2002 study. Both reviews were similar in their outcome measures however we selected the 2008 systematic review for inclusion in this CAT because it was more rigorously undertaken and provided higher quality results.

A further critical appraisal of the remaining 13 articles and their reference lists was undertaken in order to find more recent evidence on this topic. A randomised controlled trial published in 2012, was selected as it is a recent study and its potential to answer our PICO question by using ADL’s and IADLS as determining factors which impact on functional decline, which we identified as the risk factors associated with nursing home admission.

A total of 3 relevant studies were located and categorised as shown in Table 1 (based on Levels of Evidence, Centre for Evidence Based Medicine, 2012)

Table 1: Summary of Study Designs of Articles Retrieved

Study Design/Methodology of Articles Retrieved

Level Number Located

Author (Year)

Systematic review and meta-analysis I

2 Stuck, Egger, Hammer, Minder, & Beck. (2002).

Huss, Stuck, Rubenstein, Egger, & Clough-Gorr. (2008).

Randomised controlled trial II 1 Kono, Kanaya, Fujita, Tsumura, Kondo, Kushiyama, & Rubenstein. (2012).

BEST EVIDENCE

The following 2 papers were identified as the ‘best’ evidence and selected for critical appraisal.

Huss, A., Stuck, A. E., Rubenstein, L. Z., Egger, M., & Clough-Gorr, K. (2008). Multidimensional preventive home visit programs for community-dwelling older adults: A systematic review and meta-analysis of randomized controlled trials. Journals of Gerontology, 63A(3), 298-307.

Kono, A. Kanaya, Y., Fujita, T., Tsumura, C., Kondo, T., Kushiyama, K., & Rubenstein, L.Z. (2012). Effects of a preventive home visit program in ambulatory frail older people: A randomized controlled trial. Journal of Gerontology, 67A(3), 302 – 309.

Reasons for selecting these studies were:

Ø Both high-quality study designs

Ø SELECTED - Paper by Stuck et al (2008) most recent study that directly addressed our PICO question.

Ø SELECTED - Study by Kono et al (2012) addressed outcome measures that we accepted as indicative of the outcome in our PICO. The study addressed our PICO Person, Interaction and Comparison factors. We did not find a study subsequent to 2008 that directly addressed our PICO outcome.

Ø NOT SELECTED – Paper by Huss et al (2002) although it directly addressed our PICO question, this study was 10 years old and we sought more recent evidence. In addition, it was not as rigorously performed as the 2008 systematic review and therefore could not be deemed as high quality evidence.

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SUMMARY OF BEST EVIDENCE

Table 2: Description and appraisal of the Systematic review and meta-analysis by

Huss, Stuck, Rubenstein, Egger, & Clough-Gorr. (2008).

Objective of the Systematic Review:

To systematically review randomised controlled trials to evaluate the effect of preventative home visits on community dwelling elderly adults with respect to their functional status, nursing home admission and mortality.

Study Design

Search strategy

Randomised controlled trials included in the most recently published meta-analyses (see this studies reference lists, items 2–5) were reviewed for inclusion systematic review and meta-analysis.

The Medline and Embase databases were searched for published studies of randomised controlled trials from January 2001 – October 2007 . The Cochrane central register for controlled trials were searched in addition to the Cochrane database of systematic reviews (issue 4, 2007).

The original authors were contacted when information in the published data was incomplete or missing. Additional unpublished information for nine studies was obtained.

No language restrictions were applied.

Excluded studies included post hospital discharge or home based care management programs, programs that did not offer broad preventative interventions and programs which had specific therapeutic or rehabilitative goals only.

The included studies needed to have regular contact and follow-up visits with the participants.

Selection Criteria

The search was limited to randomised controlled trials outlining the effects of multidimensional preventative home visit programs in community dwelling older adults aged >70 years. The included trials had to report at least one of the following outcomes: nursing home admissions, functional status decline, or mortality.

Methods

Three reviewers independently screened titles, abstracts and full texts. Discrepancies were resolved by consensus with a fourth reviewer.

4770 publications were identified for consideration in this study.

4526 were excluded at title and/or abstract review for not including home visits or pertaining to the correct population group.

244 papers were selected for detailed analysis. Further papers were excluded because they were either duplicate trials, not RCTs, the program investigated was post hospital discharge, or had specific therapeutic or rehabilitative goals, no home care visits, or only baseline data was reported and participants did not meet the inclusion criteria for aged adults.

20 publications (describing 21 RCTs) were included in this meta-analysis.

Setting

All randomised controlled trials included in this meta-analysis were conducted within community settings.

Participants

A total of 14,603 participants were recruited for this meta-analysis. Eligible participants were adults aged 65 years more. The mean age of study participants at baseline ranged from 73 years to 83 years, with a median of 78.

Intervention Investigated

Control

The control groups in 17 of the 21 trials used ‘usual care’ as the control condition. In 4 of the trials, the control groups received other interventions (such as telephone follow up, home safety visit, single counselling session or social worker visit).

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Experimental

Interventions comprised of more than one home visit by various allied health professionals and included multidimensional assessments and clinical examinations. Allied health professionals included nurses, health visitors, physicians, physical therapists, social workers or volunteers.

The number of home visits ranged from 0 to 12, with a median of 4.3 and the duration of the intervention period was from 4 months to 4 years.

Blinding

Adequate blinding was noted in 11 out of 21 RCTs in relation to nursing home admissions, and 10 out of 21 RCTs for functional decline.

Concealment

Concealed allocation was said to be adequate in 6 out of the 21 randomised controlled trials.

The authors concluded that concealed allocation or blinding differences should not influence the results. There was no evidence of funnel plot asymmetry (all p= 0.02).

Randomisation

The authors did not comment on the methods of randomisation.

Outcome Measures

Three outcome measures were included in this meta-analysis. They were nursing home admissions, mortality, and functional status.

Nursing home admission

Of the 21 trials included, 16 measured nursing home admission as an outcome. The number of patients admitted to nursing homes was recorded (excluding short term stays).

Functional status

Functional status was defined in terms of activities of daily living scales or other relevant measures such as Groningen Activity Restriction Scale.

Mortality

The number and cause of all deaths of participants during this study was recorded for both the intervention and the control groups.

Main Findings

Nursing home admission

The results of the nursing home admissions were heterogeneous (I2 42.5%, p=0.04). The reduction in risk of admission was not statistically significant with an odds ratio of 0.86 (95% CI, 0.68 – 1.10).

Figure 1. From: (Huss et al, 2008, p304)

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Functional status or decline

The results on functional status or decline were heterogeneous (I2 52.4%, p= 0.01). There was minimal effect on functional decline. The odds ratio of 0.89 (95% CI, 0.76 – 1.03).

However studies including a clinical examination exhibited a beneficial effect on functional status with an odds ratio of 0.64 (95%CI, 0.48-0.87), whereas studies without a clinical examination did not have a beneficial effect on functional status. In these studies the odds ratio was 1.00, 95%CI, 0.88-1.14). For this factor the results prove statistically significant (p=0.02), and I2 was reduced from 52.4% to 31.0%.

Mortality

The results on mortality were heterogeneous (I2 35.6%, p= 0.055) with an odds ratio of 0.92 (95% CI, 0.80 – 1.05).

Figure 2. From: (Huss et al, 2008, p304)

Figure 3. From: (Huss et al, 2008, p305)

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Trial participants who were in the lowest tertile (<77 years of age) (ie; the younger adults) showed beneficial effect in the intervention group on mortality. The intervention group in the lowest tertile range had an odds ratio of 0.74 (95%CI, 0.58-0.94), whereas participants in the intervention group in the upper tertile range (ie; the older adults) had an odds ratio of 1.14 (95% CI, 0.90-1.43). Age was deemed to be borderline statistically significant (p=0.06), and I2 was reduced from 35.6% to 12.6%.

Refer appendix 1 for glossary of terms.

Original Authors’ Conclusions

Preventative home visits had no statistically significant effect on delaying admission to nursing homes.

Preventative home visit programs are beneficial in preventing or significantly delaying decline in functional status provided a clinical examination was included in the initial assessment. The use of multidimensional geriatric assessments including an initial clinical examination and regular follow-up visits was important in determining the effects of functional status outcomes. Others factors in determining functional status decline such as determining and providing interventions for risk factors needs further research.

Preventative home visits to younger populations produced beneficial effects on mortality and that the overall results are ‘borderline’ statistically significant.

The authors acknowledge bias, confounding and other limitations of this study.

They suggest further high quality randomised controlled trials, with well documented interventions to target populations would further clarify which populations may receive maximum benefit from preventative home visits.

Critical Appraisal

Validity

This systematic review and meta-analysis was assessed against the PRISMA 2009 Checklist for methodological quality in reporting systematic reviews. It met the majority of the 27 items listed on the checklist with a few exceptions.

Title

The study was clearly identified as a systematic review and meta-analysis.

Abstract

The abstract was well structured and included background information for the purpose of this research. The study objectives were outlined and the participants and interventions were clearly identified. The data sources, study selection and eligibility criteria were listed and the study appraisal methods were clearly outlined. Detailed results of 21 trials including relative risk, 95% confidence intervals for each of the three endpoints were present.

The key findings were discussed in the conclusion however the implications of these key findings weren't noted.

No limitations were discussed and there was no systematic review registration number within the abstract.

Introduction

The rationale behind this study is explained in depth and well-articulated.

This study does provide an explicit statement in relation to the PICO question. The participants of this study are community dwelling elderly adults aged 65 years plus, the interventions are multidimensional preventative home visits, the intervention group received home visits whereas the control group either received no or other types of home visits.

Three outcome endpoints were clearly identified. They included nursing home admissions, functional status or decline and mortality.

Methods

The protocol, registration and search strategy for at least one electronic database was not included. This means that the search strategy used is unable to be replicated without contacting the authors.

The databases searched were listed and the years the search strategy covered were clearly identified. It was also clearly indicated that the studies selected were restricted to randomised controlled trials and there was no restriction on language.

The eligibility criteria for this study was clearly outlined in the Figure 1. Initial search numbers of potentially relevant publications were listed then various levels of exclusion criteria were applied, resulting in 21 trials being included in the meta-analysis. Studies were independently screened for inclusion in the meta-analysis by

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three reviewers.

The relevant data were extracted in relation to the three outcome measures being investigated. During this process two of the authors reviewed the methods of randomisation, allocation of concealment and blinding for each study and the results of this was described.

A statistical analysis of trial heterogeneity using I2 was discussed. Results from the 3 outcome measures were analysed in tertiles. Aged tertiles included lower <77years, middle tertile 78-<80years and upper tertile >80 years. The mortality rate per year was also indicated as <0.067, 0.067-0.081, >0.081 as a baseline risk of death. The number of preventative home visits per year was divided into 2 tertiles, <3 or >3 visits. These preventative home visits were further classified Yes/No depending on whether a geriatrician was involved in the intervention.

The authors concluded that this study was limited because the comparisons made between the randomised controlled trials in the met meta-regression analysis were observational only. They are also aware that subgroup analysis can be prone to bias and confounding and results need to be interpreted with caution.

Interpretation of Results

The study selection process was well explained and depicted in Figure 1. The mean age of participants, the median number of home visits performed, the duration of intervention and the persons performing the home visit was reported in detail for both the intervention and control groups in relation to the three outcome measures.

The review found varied results between individual trials, but overall no significant effect upon combined analysis. The results relating to nursing home admission and mortality were not statistically significant. There was minimal effect on functional decline overall however studies including clinical examination during a home visit exhibited a beneficial effect on functional status which proved to be statistically significant.

There was little evidence to suggest that blinding or allocation concealment would affect the results. There was no evidence of funnel plot asymmetry (all p>0.2).

Conclusion

Nursing home admission

This study found that preventative home visits by allied health professionals (including nurses, health visitors, physicians, physical therapists, social workers and volunteers), had no statistically significant effect on admission to nursing homes.

Functional status or decline

Preventative home visits aimed at the younger aged population (<77 years) showed a beneficial effect on functional status which was statistically significant (p=0.02), providing a clinical examination is included in the initial assessment on home visit. The authors do not indicate what effect level they consider to be clinically significant, therefore we are unable to comment on whether this finding was clinically significant or not.

We suggest that further high quality randomised control trials should be undertaken with specific age groups, with clearly identified interventions provided by nominated allied health professionals. Including power calculations in these trials would be beneficial to determine whether a result is clinically significant or not.

Identifying risk factors with the view to providing interventions for these, in order to maintain an individual's functional status also needs further research.

Mortality

Beneficial results were discussed in the intervention group in the lowest tertile range (<77 years of age) with respect to mortality. However p values for this range were not given, so we are unable to evaluate and comment on these results.

The overall result for mortality was that it was ‘borderline’ statistically significant (p=0.06). We would have identified this result as not statically significant as the p value is >0.05.

Study Design

The authors claim that they conducted a ‘more stringent’ study design than the 2002 study. We agree that this research was conducted much more strategically and extensively when compared with the previous 2002 study, in the area of study design, inclusion and exclusion criteria, population selection and program characteristics. A higher level of inclusion and exclusion criteria was applied in order to reduce variations in program characteristics between the trials.

Limitations of the study

The authors acknowledge bias, confounding and other limitations such as attrition bias of this study.

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Opportunities for further research

We are in agreement with the authors that further research using high quality randomised controlled trials, that are well documented, outlining specific interventions to target populations be performed in their true clinical practice settings. This would be further pinpoint the population groups that would receive maximum benefit from provision of preventative home visits and from here it would also allow government policy expenditure to be directed to those who will receive most benefit.

General comments

This study also notes the widespread confusion regarding terminology for ‘multidimensional preventative home visit programs’ which can lead to confusion over program definitions and potentiality of inclusion. We agree future studies need to use clear and concise language and be more specific in respect to what they define as multidimensional preventative home visit.

Funding

This study was funded by institutional funds from the University of Bern.

SUMMARY OF BEST EVIDENCE

STUDY TWO

Table 3: Description and appraisal of the randomized control trial by Kono, A. Kanaya, Y., Fujita, T., Tsumura, C., Kondo, T., Kushiyama, K., & Rubenstein, L.Z. (2012).

Objective of the Randomised Controlled Trial

The objective of this study was to assess the effects of preventative home visits for frail, elderly Japanese people.

Study Design

This was a randomised controlled trial with four primary outcome measures relating to functional and psychosocial performance, being 1) ADLs, 2) IADLs, 3) depression and 4) social support. Additionally, one secondary outcome measure, being usage of the Japanese Long-Term-Care-Insurance (LTCI) System, was examined. Planned sub-group comparisons were also undertaken in relation to the primary outcomes.

Primary outcome measures were taken at baseline and again at 1 and 2 years. Secondary outcome measures were taken monthly.

Setting

This was a community based study, undertaken in three Japanese suburban areas – Izumiostu, Sennan and Misaki.

Participants

Study N = 323 (Control group N = 162, Intervention group N = 161)

The mean age of participants was 79.9 years (SD 6.55). 73.9% of participants were female (73.9% of intervention group and 74.1% of control group). To meet the eligibility criteria, participants were 65 years or older, registered as support need category ‘1’ or ‘2’ under the Japanese public long term care insurance scheme and had not used services under LTCI scheme in the past 3 months.

Participants were identified from local government lists of LTCI certified people and were recruited via mail. Japanese individuals over 65 years of age are required to register under the LTCI scheme. From LTCI lists, 1764 people were identified as support need category 1 or 2. Of this list, 1196 were excluded due to not meeting the criteria of ‘not using care services for past 3 months’ and 245 were excluded due to having been hospitalised, died, increased care level needs or refusing to participate. The remaining 323 were randomly allocated to intervention or control group. Participants were similar at baseline on age, gender, support level category, living alone, ADLs, IADLs, depression and social support. At follow up, 29 had been lost from the intervention group and 35 from the control group, due to hospitalisation, death or moving.

Intervention Investigated

Control

Control group did not receive preventative home visits.

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Experimental

Preventative home visits were conducted every 6 months by nurses, care managers or social workers. Visits consisted of documenting health and psychosocial impairments and making recommendations. Recommendations related to categories of self-care, needs attention from family or neighbours, needs professional consultation, needs care services or needs care.

Outcome Measures

Primary Outcomes:

Primary outcomes related functional and psychosocial performance. Data were collected from mailed questionaires at 1 and 2 year follow ups. The measurement questionnaires were:

ADLs – Barthel Index (bad to good = 0 – 100)

IADLs – Index of Competence (by Tokyo Metropolitan Institute of Gerentology) (bad to good = 0 – 13)

Depression – Geriatric Depression Scale (bad to good = 15 – 0)

Social support – Social Support Scale (by Noguchi) (0 – 32)

Secondary Outcomes:

Secondary outcomes related to the usage of care services under the LTCI scheme. This scheme funds home aid, nurse visits, day care and nursing home services. Records of the amount of funding used by participants were collected monthly, for two years, from local government.

Main Findings

Primary Outcomes:

Two-way repeated analysis of covariance comparing changes between groups was undertaken. As shown in table 1, there were no significant differences between control and intervention groups on measures of functional and psychosocial status throughout the study. Table was adapted from the article. As there were no statistically significant findings, we have not calculated confidence intervals.

Table 1. Change of Functional and Psychosocial Parameters Over 2 years in All Participants

Measures

(bad to good)

1 year 2year Difference Group F effect value

Group x time, F effect value

ADLs – Barthel Index (0-100)

Intervention (n = 161) 89.0 (14.3) 88.1 (14.7) - 0.9 2.32 0.90

Control (n = 162) 89.8 (15.1) 89.0 (18.7) - 0.2 IADLs – Index of Competence (0-13)

Intervention (n = 161) 7.1 (3.8) 7.0 (3.8) - 0.1 1.09 0.32

Control (n = 162) 7.1 (3.9) 7.0 (4.0) - 0.1 Depression - Geriatric Depression Scale (15-0)

Intervention (n = 161) 6.7 (4.1) 7.1 (4.0) 0.4 3.70 2.86

Control (n = 162) 6.9 (4.0) 7.2 (3.8) 0.3 Social Support – Social Support Scale (0-32)

Intervention (n = 161) 7.2 (4.2) 7.1 (4.1) - 0.1 0 0.70

Control (n = 162) 6.9 (4.7) 7.3 (4.5) 0.4

Primary Outcomes Sub-Group Comparisons:

Tests of sub-groups that did, and did not, have ADL dependency at baseline were also undertaken.

The sub-group without ADL dependency at baseline did not exhibit significant differences for changes between control and intervention groups across the study

However, the sub-group which had ADL dependency at baseline did exhibit significant differences for changes between control and intervention groups across the study, as shown in Table 2. Table was adapted from the article.

At two years, the control group rated more poorly for ADLs than the treatment group by a rating margin of 1

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point on the Barthel index for ADL. Possible scores on this index range from 0 (poor) – 100 (good).

At two years, the control group rated more poorly for IADLs than the treatment group by a rating margin 0.6 point on the Tokyo Metropolitan Institute of Gerentology Index of Competence. Possible scores on this index range from 0 (poor) – 13 (good).

At two years, the control group rated more poorly for depression than the treatment group by a rating margin of 0.6 points on the Geriatric Depression Scale. Possible scores on this index range from 15 (poor) – 0 (good).

Table 2. Change of Functional and Psychosocial Parameters Over 2 years in ADL Dependency subgroup

Measures

(bad to good)

Baseline 1 year 2 year Group F effect value

Group x time, F effect value

ADLs – Barthel Index (0-100)

Intervention (n = 105)

85.0 (11.5) 85.1 (15.6) 85.4 (14.8) 4.72* (p = 0.0311)

1.86

Control (n = 100)

86.0 (13.0) 85.7 (16.2) 84.4 (20.3)

IADLs – Index of Competence (0-13)

Intervention (n = 105)

6.3 (3.2) 6.4 (3.6) 6.7 (3.4) 6.52* (p = 0.0114)

2.79

Control (n = 100)

6.1 (3.7) 6.0 (3.7) 6.1 (3.9)

Depression - Geriatric Depression Scale (15-0)

Intervention (n = 105)

7.7 (3.9) 7.0 (4.2) 7.5 (4.0) 15.44*** (p = 0.0001)

5.93***

Control (n = 100)

7.7 (4.0) 7.8 (4.0) 8.1 (4.0)

Differences of means between sub-groups at 2 years:

ADLs = -1 (95% CI, -5.88 to – 3.88)

IADLs = -0.6 (95% CI, -1.61 to 0.41)

Depression = 0.6 (95% CI, -0.5 to 1.7)

All above confidence intervals cross zero, indicating no significant difference of means between groups at 2 years. However, note that the authors have reported statistically significant difference between groups for changes across time.

Secondary Outcomes:

Based on monthly comparisons, participants in the intervention group accessed significantly more LTCI services that the control group.

Refer appendix 1 for glossary of terms.

Original Authors’ Conclusions

The authors concluded that preventative home visits did not impact on functional or psychosocial outcomes for ambulatory frail elders overall. However, they found that these visits may be helpful in the domains of ADLs, IADLs and depression for a sub-group of elders who are already ADL dependant at baseline.

In regards to the question of postponing the need for nursing home care, the authors commented that their results did not sufficiently clarify this issue and that further research is needed.

Critical Appraisal

This study scored 3/8 for validity on the PeDro scale. Participants in the control and intervention groups were similar at baseline:

Intervention (N = 161) Control (N = 162)

Age 80.3 (SD 6.7) 79.6 (SD 6.4) Female (N) 119 120 Support level category 1 76 79 Living alone

43 47

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ADLs – Barthel Index (0-100)

90.2 (SD 11.7) 91.4 (SD 12.2)

IADLs – Index of Competence (0-13)

7.3 (SD 3.5) 7.2 (SD 3.7)

Depression – Geriatric Depression Scale (15-0)

7.1 (SD 4.0) 7.0 (SD 4.0)

Social Support – Social Support Scale (0-32)

6.8 (SD 4.2) 6.6 (SD 4.6)

Computer generated random numbers were used to randomly allocate participants to control/intervention groups.

The study did not explicitly state that concealed allocation to groups occurred and so did not receive a yes rating for that on PeDro. However, we note that allocation to groups occurred after the process of eligibility exclusion was completed, therefore the person assessing exclusion criteria did not know which group each subject would be allocated to.

Study design was described as ‘single blind’, but did not specify whether it was the subject, therapist or assessor who was blinded. It is possible, but not certain, that subjects did not know whether the treatment they received was usual care or was the treatment being investigated. Primary outcomes were assessed using postal questionnaires (standardised scales). Secondary outcomes were measured using government statistics. It is unclear whether blinding occurred, however given that the measures were scores on standardised questionnaires and government statistics of service usage, results were not actually subject to assessor or therapist interpretation.

Outcome measures of only 80% of participants were analysed at follow-up (N = 323 at allocation, N = 259 at analysis). However, analysis was undertaken on an intention to treat basis.

The study scored 2/2 on the PeDro scale for statistical results. Between group ANOVAs were conducted with both f and p scores provided, along with means and standard deviations of means.

The authors did not provide confidence intervals for the difference between groups for change across time. Sufficient information is provided to enable calculation of confidence intervals of the differences between group means, but not to allow calculation of confidence intervals for the difference between groups for change across time (no standard deviations).

The only statistically significant findings were for the sub-group of participants who had ADL dependency at baseline. For this group the controls showed greater deterioration in ADL, IADL and depression scores than the treatment group. Whilst these findings were statistically significant, we would question their clinical significance. The authors appear to regard a difference of 0.5 as clinically significant since they have nominated this as their effect size in the power analysis. The differences found were 1 point on a scale on 100 for ADLs, 0.6 point on a scale of 13 for IADLs and 0.6 point on a scale of 15 for depression. These effect sizes do not seem large relative to their rating scales. For example, Shah et al. (1989) indicated that scores on the barthel index could be interpreted in range groups, being: score of 0-20 = total dependency, 21-60 = severe dependency, 61-90 = moderate dependency, 91-99 = slight dependency. On this basis, a score change of 1 may not mean a great deal clinically.

Table 4: Characteristics of included studies

Study 1

Huss, A., Stuck, A. E., Rubenstein, L. Z., Egger, M., & Clough-Gorr, K.

(2008).

Study 2

Kono, A. Kanaya, Y., Fujita, T., Tsumura, C., Kondo, T.,

Kushiyama, K., & Rubenstein, L.Z. (2012).

Intervention investigated Multidimensional preventative home visit programs

Preventative home visits

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Comparison intervention Either no home visits or single different home visits

No home visit

Outcomes used Admission to nursing home, functional status, mortality

ADL, IADL, depression, social support, use of support services

Findings No statistically significant results were seen in relation to admission to nursing homes or mortality.

Statistically significant results were seen when preventative home visits were provided to the younger aged population providing a clinical examination was included in the initial assessment.

No significant effect overall for any outcome measures.

Significant effect for a sub-group which had ADL dependency at baseline. This effect was for outcomes ADL, IADL and depression

IMPLICATIONS FOR PRACTICE, EDUCATION and FUTURE RESEARCH

The Australian government has recently announced an aged care reform package of $3.7 billion over 5 years (Australian Government Department of Health and Aging, 2012). This program aims to improve the aged care system in Australia and provide older Australians with greater choice and control over their services. One of the program’s priorities is to provide more support for people to stay at home rather than enter care facilities. Given the large investment proposed, it is important to understand which services and interventions are effective in achieving the goal of keeping people in their own homes for longer.

The articles reviewed suggest that preventative home visit programs and interventions may be an effective method to delay nursing home admission for specific sub-populations.

It is important to ensure that home visit programs are targeted to groups that can be expected to derive benefit. Therefore, there is a need for more research to identify which sub-populations of community dwelling older adults derive benefit from home visits to delay or prevent nursing home admission. Additionally, more research is needed to identify whether home visits conducted by specific allied heath disciplines or by multi-disciplinary teams composed of specific groups of disciplines are most effective.

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REFERENCES

Australian Bureau of Statistics. (2011). Life expectancy trends – Australia. (Cat. No. 4012.0). Canberra, Australia: ABS. Retrieved from www.abs.gov/socialtrends

Australian Government Department of Health and Aging. (2012). Current issues. Aged care can't wait budget 2012. Retreived on 16 May 2012 at: http://www.health.gov.au/internet/main/publishing.nsf/Content/currentissue-P11000028

Choi, N. G., Ransom, S., & Wyllie, R. J. (2008). Depression in older nursing home residents: the influence of nursing home environmental stressors, coping, and acceptance of group and individual therapy. Aging & Mental Health, 12(5), 536-547. doi:10.1080/13607860802343001

Gravetter, F.J., & Wallnau, L.B. (2004). Statistics for the behavioural sciences. Thomson Wadsworth:

Southbank, Victoria. Hoffmann, T., Del Mar, C., & Bennett, S. (2010). Evidence-based practice across the health professions.

Chatswood, NSW: Churchill Livingstone. Huss, A., Stuck, A. E., Rubenstein, L. Z., Egger, M., & Clough-Gorr, K. (2008). Multidimensional preventive

home visit programs for community-dwelling older adults: A systematic review and meta-analysis of randomized controlled trials. Journals of Gerontology, 63A(3), 298-307

Kono, A. Kanaya, Y., Fujita, T., Tsumura, C., Kondo, T., Kushiyama, K., & Rubenstein, L.Z. (2012). Effects of a preventive home visit program in ambulatory frail older people: A randomized controlled trial. Journal of Gerontology, 67A(3): 302 – 309

Low, L. F., Yap, M., & Brodaty, H. (2011). A systematic review of different models of home and community care services for older persons. BMC Health Services Research, 11(93), 1-15. doi:10.1186/1472-6963-11-93

Shah, S., Vanclay, F., & Cooper, B. (1989). Improving the sensitivity of the barthel index for stroke rehabilitation. Journal of Clinical Epidemiology, 42(8):703-709.

Stuck, A. E., Minder, C. E., Wuest, I. P., Gillmann, G., Egli, C., Kesselring, A., … Beck, J. C. (2000). A randomized trial of in-home visits for disability prevention in community-dwelling older people at low and high risk for nursing home admission. Archives of Internal Medicine, 160(7), 977-986. Retrieved from www.archintermed.com

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Appendix 1: GLOSSARY

Allocation Bias - refers to the way the participants have been selected and divided into groups which can ultimately affect the results.

Attrition bias - is associated with an number of participants who withdraw, or are a loss to follow up. If all participants are lost from one group this could significantly affect the results.

Baseline - randomisation aims to ensure that groups, both the intervention and control group are similar at the start of the trial in all respects. The only exception is whether they receive the intervention or not.

Bias - bias is a systematic error in the way that participants are selected for a study, the outcomes are measured or data is analysed, which in turn can lead to inaccurate results.

Blinding - blinding is a technique used to prevent participants, health professionals and researchers from knowing which group a participant has been assigned. This ensures that the results will not be influenced by that knowledge.

Clinical significance - refers to whether a statistically significant result can result in enough positive change to make implementation of the intervention worthwhile to the individual.

Concealed allocation - means that the person performing the study is unaware to which group intervention or control the participants have been allocated

Confidence intervals - confidence intervals estimate the range that the true value lies within. Confidence intervals are normally set at 95%.

Confound - An uncontrolled variable which varies systematically with the independent variable.

Mean - The most common measure of centre. Calculated as the sum of values divided by the number of values.

Measurement bias - errors in measuring outcome results can lead to differential accuracy of information between groups which can lead to bias.

Median - Another measure of centre. Is the value which divides the distribution of values in half.

Odds ratio - this term is used instead of relative risk. It is similar except that odds ratio refers to a ratio of odds rather than a ratio of risks.

p value – P stands for ‘probability’. The p value estimates the probability of how likely the differences are because of chance alone.

Power Calculation - The power of the test is the likelihood that it will be abkle to detect an effect when there is actually an effect. That is, that it will not fail to detect an actual effect (type ll error).

Publication bias - relates to research. There is a tendency for researches to only submit positive results for publication and all there is a tendency of journal editors to only accept articles with positive results.

Randomisation- the principle of randomisation is that each participant has an equal chance of being assigned to any group, the intervention group or the control group, and that their allocation is due to chance alone.

Relative risk - is a ratio of the probability that any events occurring in the intervention group when compared to the control group.

Sampling bias - selects participants for studies which are representative of the population the study aims to investigate the effects of the intervention on.

Standard Deviation - A measurement to describe the typical distance of values from the mean of the distribution. A measure of variability within the distribution.

Statistical significance - Traditionally a p value of <0.05 means that the differences are not likely to have been caused by chance alone. Thereby the results of the intervention must be the difference between outcome results.

(Hoffmann, Del Mar, & Bennett, 2010), (Gravetter & Wallnau, 2004)