Home Visits to Prevent Nursing Home
Admission and Functional Decline in Elderly People
Systematic Review and Meta-regression
Analysis
JAMA. 2002;287:1022-1028
Andreas E. Stuck, MD; Matthias Egger, MD; Andreas Hammer; Christoph E.
Minder, PhD; John C. Beck, MD
Context The effects of home visitation programs to prevent functional
decline in elderly persons have been inconsistent, and the value of these
programs is controversial.
Objective To evaluate the effect of preventive home visits on functional
status, nursing home admission, and mortality.
Data Sources Studies published in English, French, German, Italian, or Spanish
reporting randomized trials of the effects of preventive in-home visits in
older people (mean age >70 years) living in the community were identified
through searches of MEDLINE, PSYCHINFO, and EMBASE (January 1985–November
2001). We also searched the Cochrane Controlled Trials Register, checked
reference lists of earlier reviews and book chapters, searched conference
proceedings and specialty journals, and contacted experts.
Study Selection We screened 1349 abstracts and excluded those that did not test
in-home interventions or in which the mean age of the study population was
younger than 70 years. After further exclusions, 17 articles describing 18
trials were analyzed.
Data Extraction Two reviewers independently screened abstracts. Discrepancies were
resolved by consensus with a third reviewer. For each included trial, we
extracted data on the study population and the characteristics of the
intervention. Two of us extracted information on 3 end points: nursing home
admissions, mortality, and functional status. One of us assessed trial quality,
including an examination of the method of randomization, blinding of caregivers
and research staff ascertaining outcomes, and proportion of patients included
in analyses of the 3 end points.
Data Synthesis The 18 trials included 13 447 individuals aged 65 years and
older. The effect on nursing home admissions depended on the number of visits
performed during follow-up. The pooled relative risk (RR) was 0.66 (95%
confidence interval [CI], 0.48-0.92) for trials in the upper tertile (>9
visits) but was 1.05 (95% CI, 0.85-1.30) in the lower tertile (0-4 visits).
Functional decline was reduced in trials that used multidimensional assessment
with follow-up (RR, 0.76; 95% CI, 0.64-0.91) but not in other trials (RR, 1.01;
95% CI, 0.92-1.11). Functional decline was reduced (RR, 0.78; 95% CI,
0.64-0.95) in trials with a control group mortality rate in the lower tertile
(3.4%-5.8%) but not (RR, 0.98; 95% CI, 0.84-1.13) in those with a control-group
mortality rate in the upper tertile (8.3%-10.7%). A beneficial effect on
mortality was evident in younger study populations (RR, 0.76; 95% CI, 0.65-0.88
for ages 72.7-77.5 years) but not in older study populations (RR, 1.09; 95% CI,
0.92-1.28 for ages 80.2-81.6 years).
Conclusion Preventive home visitation programs appear to be effective,
provided the interventions are based on multidimensional geriatric assessment
and include multiple follow-up home visits and target persons at lower risk for
death. Benefits on survival were seen in young-old rather than old-old
populations.
JAMA. 2002;287:1022-1028
Preventive home visitation programs in elderly
people are part of national policy in several countries, including the United
Kingdom, Denmark, and Australia.1 The rationale is to
delay or prevent functional impairment and subsequent nursing home admissions
by primary prevention (eg, immunization and exercise), secondary prevention
(eg, detection of untreated problems), and tertiary prevention (eg, improvement
of medication use).2 However, the value of
home visitation programs is controversial. Although individual trials and
meta-analyses3, 4 suggest that some
programs are effective, there is uncertainty regarding whether they can prevent
functional status decline, which program components are effective, and which
populations are most likely to benefit.5, 6
In an earlier analysis of hospital-based
comprehensive geriatric assessment programs, we found that programs including
extended ambulatory follow-up were more effective than other schemes.3 A subgroup analysis of
a trial of a home visitation program suggested that older people with
relatively good functional status at baseline were more likely to benefit.7, 8 We confirmed this
hypothesis in a planned analysis of a subsequent trial, which showed favorable
effects among individuals at low risk but not among those at high risk for
nursing home admission.9 Finally, evaluation in
the home setting results in a high yield of undetected problems.10 Therefore, it seems
likely that successful programs should include multidimensional geriatric
assessment as a basis for in-home prevention.
We performed an updated meta-analysis to
evaluate the effect of preventive home visits on functional status, nursing
home admission, and mortality and to test the hypotheses that they are
beneficial if they are based on multidimensional geriatric assessment and
frequent follow-up visits and conducted in individuals at low risk of
functional decline at baseline.
METHODS
Literature Search and
Eligibility Criteria
We aimed to identify all randomized trials of the effects of preventive in-home
visits in older people (mean age >70 years) living in the community.
Published studies were identified through searches of MEDLINE, PSYCHINFO, and
EMBASE (January 1985 to November 2001; key words: aged, home or in-home, prevention,
and geriatric assessment). We
also searched the Cochrane Controlled Trials Register, checked reference lists
of earlier reviews and book chapters, searched conference proceedings and
specialty journals, and contacted experts. Articles published in English,
French, German, Italian, or Spanish were considered. Two reviewers screened
abstracts. Discrepancies were resolved by consensus with a third reviewer.
Data Extraction and Outcome
Definition
For each trial, we extracted data on the study population and the
characteristics of the intervention. Programs were classified as being based on
multidimensional geriatric assessment for identification of risk factors with
follow-up if they included a systematic evaluation in medical, functional,
psychosocial, and environmental domains and a follow-up for the implementation
of the intervention plan.11 The average number of
preventive home visits performed and the total duration of the intervention
were also recorded.
For each study, 2 of us extracted information on
3 end points: nursing home admissions, mortality, and functional status. We
recorded the number of participants admitted to nursing homes (excluding
short-term and residential or board and care-unit admissions) and the number of
persons for whom information about nursing home admissions was available. For
mortality, the number of deaths from all causes and participants with known
vital status were recorded for intervention and control groups. We abstracted
the number of persons with functional status decline. The definition of
functional status was based on activities of daily living or lower or upper
extremity function. If several outcome measures were reported, we used the
measure for which the prevalence of impairment at follow-up was closest to 20%,
corresponding to the disability rate of 19.7% in the elderly US population.12 Four trials used
continuous rather than discrete outcomes and provided their means and SDs.13-16 These results were
converted to an estimate of the risk ratio.17
Original investigators were contacted if
published data on study populations and interventions were incomplete or if
reporting of at least 1 of the 3 types of outcome data (functional status,
nursing home admissions, and mortality) was missing or incomplete. Additional
unpublished information was obtained from 9 studies.13-15, 18-23
Assessment of Methodological
Quality and Statistical Analysis
One of us assessed trial quality by examining the method of randomization,
blinding of caregivers and research staff ascertaining outcomes, and the proportion
of patients included in the analyses of the 3 end points.24
We combined results on the risk ratio scale by
using fixed and random effects models.25 The degree of
intertrial heterogeneity (
2) was
estimated with an iterative restricted maximum likelihood method.26 A statistical test of
funnel plot asymmetry, which may indicate the presence of publication bias, was
performed.27 Standard tests
of homogeneity of risk ratios were also calculated.26 The extent to which 1
or more study-level variables explained heterogeneity in the treatment effects
was then explored by fitting meta-regression models.26 The following
variables were considered: mean age of the study population and mortality rate
(per year) in control groups (indicators of baseline risk), duration of the
intervention, number of home visits, and whether the intervention was based on
multidimensional geriatric assessment with follow-up. Variables relating to the
quality of trials, the geographic location of the study, and groups of authors
were also considered. Fixed effects meta-analysis stratified by the factors
that explained part of the intertrial heterogeneity was then performed. A
random effects model was used to calculate a typical risk difference, which was
converted to the number needed to visit to prevent 1 adverse outcome. In a
sensitivity analysis we excluded 1 trial9 whose results had been
influential when we formulated study hypotheses.
RESULTS
Identification of Eligible
Trials
We screened 1349 abstracts and excluded 1266 studies because they either did
not test in-home interventions or the mean age of the study population was
younger than 70 years. We excluded 29 studies that were based on patients at
hospital discharge, 22 studies that analyzed home visits for therapeutic or
rehabilitative purposes (treatment of depression, support for dementia, cardiac
rehabilitation, stroke rehabilitation, terminal care, exercise programs,
vaccination programs, or pharmacy programs), 12 studies that tested home care
services for disabled persons, and 1 study that did not include home visits.
Nineteen articles with eligible trials were
identified.7, 9, 13-15, 18-23, 28-34 Two articles were
excluded because no information on relevant outcomes was reported and attempts
to obtain unpublished data from the authors were unsuccessful.33, 34 A total of 17 trial
reports with data on 18 trials (1 report included the results of 2 trials) were
available for analysis (Figure 1).
Characteristics of Trials,
Patients, and Interventions
These trials included a total of 13 447 individuals aged 65 years and
older. Study participants were selected from general practice lists and
population or insurance registers (Table 1).
Ten trials included all individuals older than a certain threshold (between 65
and 75 years). Eight studies had additional selection criteria (eg, individuals
living alone) or excluded some individuals (eg, those receiving home care).
Mean age of study participants at baseline ranged from 72.7 years to 81.6
years. The yearly mortality rates in control groups ranged from 3.4% to 10.7%.
Twelve of the 18 trials were classified as not based on multidimensional
geriatric assessment and follow-up because they did not include a medical,
functional, and psychosocial assessment16, 18, 20, 22, 28-31 or because these
assessments were not combined with a follow-up intervention.15, 19, 21 Reported outcome data
of the individual trials are provided in online Table 1.
Methodological Quality of
Trials
Measures of allocation concealment were described for 5 trials.7, 9, 13-15 Randomization was
stratified in several trials, but block sizes were reported only in 2 reports.9, 32 For 7 trials,7, 9, 15, 16, 18, 23, 30 some measures of
blinding were described. The proportion of trials analyzed using intent to
treat without missing outcome data was 72.2% (13/18) for mortality, 69.2%
(9/13) for nursing home admission, and 0% (0/16) for functional status. Results
of a detailed quality assessment are available in online Table 2.
In meta-regression analyses, there was little evidence (P>.10) that these aspects of
methodological quality influenced results. There was also little evidence of
funnel plot asymmetry (P>.10).
Finally, results did not differ significantly according to geographical region
or groups of investigators (P>.10).
Effects on Nursing Home
Admission
The analysis was based on 13 trials. Four studies did not report on nursing
home admissions, and in 1 study, no admissions occurred. Overall, the reduction
in the risk of admission was modest and nonsignificant (Table 2).
In meta-regression analysis, there was evidence of an association of treatment
effect with the number of follow-up visits (P
= .05), which explained a large proportion of intertrial heterogeneity (2 was
reduced from 0.034 to 0.012). Meta-analysis of trials stratified by tertiles of
the number of follow-up visits is shown in Figure 2:
the reduction in admissions is evident only for programs with at least 5
follow-up visits. The estimated reduction in the risk of admission for trials
in the upper tertile (>9 follow-up visits) was 34% (RR, 0.66; 95% CI,
0.48-0.92) and the typical risk difference was 2.3%, for a number needed to
visit of 43.
Effects on Functional Status
Data were available for 16 trials. Overall, preventive home visits appeared to
have little effect on functional status, but results were heterogeneous (Table 2).
In meta-regression analysis, beneficial effects were associated with multidimensional
geriatric assessment with follow-up (P
= .01) and inversely correlated with control-group mortality (P = .04). In multivariable analysis, the
type of intervention was the more important factor and explained about half of
intertrial heterogeneity (2 was
reduced from 0.021 to 0.010). Combining trials according to multidimensional
assessment and follow-up resulted in a 24% reduction in the risk of functional
decline (RR, 0.76; 95% CI, 0.64-0.91) (Figure 3).
The typical absolute reduction in risk was 6.7%, for a number needed to visit
of 15. When trials were analyzed by tertiles of control group mortality, a
beneficial effect on function was evident for the first tertile (5 trials with
annual mortality from 3.4%-5.8%), with an RR of 0.78 (95% CI, 0.64-0.95). The
combined RR for the middle tertile (6 trials with mortality rates from
6.1%-8.2%) was 1.00 (95% CI, 0.89-1.13); for the third tertile, 0.98 (95% CI,
0.84-1.13; 5 trials with mortality from 8.3%-10.7%).
Effects on Mortality
This analysis was based on 18 trials. Preventive home visits appeared to reduce
mortality, but results were again heterogeneous (Table 2).
In meta-regression analysis, there was strong evidence (P = .004) that the mean age of study
participants was negatively associated with effects on mortality. Intertrial
variance was reduced from 0.021 to 0.003 when age was included in the model.
Meta-analysis of trials stratified by tertiles of age is shown in Figure 4:
the reduction of mortality diminishes as mean age approaches 80 years. The
estimated reduction in mortality in the lowest tertile (mean age, 72.7-77.5
years) was 24% (RR, 0.76; 95% CI, 0.65-0.88) and the typical risk difference
4.1%, for a number needed to visit of 24.
Sensitivity Analysis
Results were not materially changed after the trial9 whose results had
influenced the formulation of study hypotheses was excluded. There was still
evidence supporting the importance of the number of follow-up visits for the
prevention of nursing home admissions (P
= .02), of multidimensional geriatric assessment with follow-up for the prevention
of functional decline (P = .01),
and of age as an effect modifier for all-cause mortality (P = .03). The RRs of nursing home
admission (95% CIs) from meta-analysis of trials stratified by tertiles of the
number of follow-up visits were 1.05 (0.85-1.30, lower tertile), 0.81
(0.66-0.99, middle tertile) and 0.66 (0.48-0.92, upper tertile). The RRs for
functional status decline was 0.77 (0.62-0.95) if programs included
multidimensional geriatric assessment with follow-up and 1.01 (0.92-1.11) if
they did not. Finally, RRs for mortality from meta-analysis of trials
stratified by tertiles of mean age were 0.76 (0.65-0.88, lower tertile), 0.97
(0.89-1.05, middle tertile), and 1.00 (0.83-1.21, upper tertile).
COMMENT
We hypothesized that preventive home visitation
programs are effective if based on multidimensional geriatric assessment with
extended follow-up and if offered to older persons with relatively good
function at baseline. Based on a large number of trials, the findings from our
meta-analysis support these hypotheses and indicate that preventive home
visitation programs are effective only if interventions are based on
multidimensional geriatric assessment, include multiple follow-up home visits,
and target persons at lower risk for death and those who are relatively young.
Our results contrast with those of the recent
review by Elkan et al.4 Those authors reported
favorable effects on mortality and nursing home admissions when combining all
types of home-based programs but found no improvement in functional status,
which is inconsistent with the rationale for home visits. The discrepant
results may be explained by differences in the number and type of studies
included. Elkan and colleagues' analysis combined trials of in-home preventive
programs with trials of home-based care coordination programs for patients
discharged from the hospital, whereas our analysis was restricted to trials of
preventive home visitation programs. Furthermore, the authors did not include 4
recently published randomized trials9, 14, 15, 32 and included
quasi-randomized studies. Finally, Elkan et al did not obtain additional
information from the investigators,4 which meant, for
example, that their pooled analysis of functional status was based on 4 studies
only, rather than the 16 trials included in our analysis, and that the power of
detecting program effects and explaining heterogeneity was limited.
In our study, the use of multidimensional
geriatric assessment and follow-up was the most important determinant of
program effects on functional status outcomes. This finding is compatible with
the concept that functional status decline can be delayed or prevented by
periodic multidimensional evaluation for detection of modifiable risk factors
and subsequent long-term intervention to modify these risk factors as well as
to identify new risks. The result that a higher number of follow-up home visits
was associated with a greater reduction of nursing home admissions is
consistent with this concept.
Favorable intervention effects on functional
status were also related to a low underlying mortality rate of the study
population, which is compatible with the hypothesis of better reversibility in
the earlier stages of decline. Preventive programs reduced mortality in the
younger study populations (mean age <80 years) but not in older populations,
indicating that mortality risk was modifiable in the former group but not the
latter. Further studies are required to determine whether, in very old populations,
in-home prevention might affect disability-free survival without prolonging
overall survival. It is noteworthy that the factors associated with effects on
mortality differed from those predicting effects on functional status and
nursing home admissions, which supports the notion that different processes of
care are important in mortality and functional status outcomes.35
These results can be used to approximate the
cost implications of preventive home visits. The lifetime costs for a person
admitted to long-term care in a UK nursing home has been estimated as
$65 000 (£42 250).36 We found that the
number needed to visit to prevent 1 admission in programs with frequent
follow-up visits is about 40. Therefore, programs with expenditures of less
than $1500 (£1000) per participant should reduce costs. Furthermore, costs are
approximate and probably not linear over time. We found that preventive home
visits required an initial investment of $433 per person the first year to
produce net savings of $1403 per person annually in the third year.9
Our study has limitations because it was based
on randomized controlled trials; the comparisons made in meta-regression
analyses are observational. Meta-analytic subgroup analyses, like subgroup
analyses within trials, are prone to bias and confounding and therefore need to
be interpreted with caution.37-39 Particular caution
is required when the data inspire hypotheses. However, this problem is unlikely
to have introduced bias in this study. Both hypotheses were defined a priori.
The hypothesis regarding program characteristics was generated in a previous
meta-analysis of a different set of trials of hospital-based interventions.3 The other hypothesis
was based on a planned subgroup analysis of a trial that was also included in
the present study9; however,
results were robust after the exclusion of this trial. Nevertheless,
prospective validation of these results is warranted.
Our results have important policy implications.
In countries with existing national programs of preventive home visits, the
process and organization of these visits should be reconsidered according to
the criteria identified in this meta-analysis. In the United States, a system
for functional impairment risk identification and appropriate intervention to
prevent or delay functional impairment should be considered. A variety of health
maintenance organization programs specifically address the care needs of
elderly patients.40 In addition, an
increasing number of chronic-disease management programs have been introduced.41-43 Grafting the key
concepts of home-based preventive care programs into these programs should be
feasible as they continue to evolve and should be cost-effective. Identifying risks
and dealing with them as an essential component of the care of older persons is
central to reducing the emerging burden of disability and improving the quality
of life in elderly people.
Author/Article Information
Author Affiliations: Department of
Geriatrics and Rehabilitation, Spital Bern Ziegler, Bern, Switzerland (Dr Stuck
and Mr Hammer); MRC Health Services Research Collaboration, Department of Social
Medicine, University of Bristol, Bristol, England (Dr Egger); Department of
Social and Preventive Medicine, University of Bern, Switzerland (Dr Minder);
and University of California, Los Angeles School of Medicine (Dr Beck).
Corresponding Author: Andreas E.
Stuck, MD, Zentrum Geriatrie-Rehabilitation, Spital Bern Ziegler,
Morillonstrasse 75, CH-3001, Bern, Switzerland (e-mail: [log in to unmask]).
Reprints not available from the
authors.
Author Contributions: Study concept and design:
Stuck, Egger, Minder, Beck.
Acquisition of data: Stuck, Hammer.
Analysis and interpretation of
data: Stuck, Egger, Hammer,
Minder, Beck.
Drafting of the manuscript: Stuck, Egger, Beck.
Critical revision of the
manuscript for important intellectual content: Stuck, Egger, Hammer, Minder, Beck.
Statistical expertise: Egger, Minder.
Obtained funding: Stuck.
Administrative, technical, or
material support: Hammer, Beck.
Study supervision: Stuck.
Funding/Support: This project was supported by grants from the Swiss National
Science Foundation (32-52804.97), the Swiss Federal Office for Education and
Research (BBW990311.1 and QLK6-CT-1999-02205), and the Swiss Foundation for
Health Promotion (398).
Acknowledgment: We would like to thank the authors who provided additional data
and Gerhard Gillman, Eva Gerber, MD, Daniel Weyermann, MD, and Jutta Walthert,
MD, for help with the literature search.
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Edward E.
Rylander, M.D.
Diplomat American
Board of Family Practice.
Diplomat American
Board of Palliative Medicine.