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QUESTION: In elderly people, what are the effects of preventive home visits on nursing home admission, functional status, and mortality?
Data sources
Studies reported in English, French, German, Italian, and Spanish were identified by searching Medline, EMBASE/Excerpta Medica, PsycINFO (1985 to November 2001), the Cochrane Controlled Trials Register, conference proceedings, and specialty journals; reviewing bibliographies of earlier reviews and book chapters; and contacting experts.
Study selection
Studies were selected if they were randomised trials of the effects of preventive home visits in elderly people (mean age >70 y) living in the community.
Data extraction
Data were extracted on the study population, characteristics of the intervention (multidimensional geriatric assessment, average number of home visits, and duration of intervention), and end points. Quality of individual trials was assessed (method of randomisation, blinding, and proportion of patients included in analyses).
Main results
18 trials (n=13 447, mean age at baseline 73–82 y) met the selection criteria. Meta-analysis of 13 trials (n=11 167) showed no difference between home visiting and the control intervention for nursing home admissions (table⇓). Analysis stratified by the number of follow up visits found reduced nursing home admissions in programmes with >9 follow up visits (4 trials, n=2291) (table⇓).
Preventive home visits v control interventions for elderly people†
Meta-analysis of 16 trials {n=8719}* showed no difference between home visiting and the control intervention for functional status (table⇑). When trials were stratified according to whether the programme involved multidimensional assessment, home visiting programmes reduced functional decline more than did the control intervention only in programmes with multidimensional assessment (6 trials, {n=4061}*) (table⇑). When trials were stratified by control group mortality rates, home visiting programmes improved functioning more than did control only in people with the lowest risk of mortality {5 trials, n=2340}* (table⇑).
Meta-analysis of 18 trials (n=13 365) found no difference between home visiting and the control intervention for mortality (table⇑); analysis stratified by age found that mortality was reduced only in the lowest age tertile (mean age 72.7–77.5 y) (6 trials, n=3044) (table⇑).
Conclusion
Preventive home visitation programmes that involve multidimensional geriatric assessment and >9 follow up visits reduce nursing home admissions, improve functional status in elderly people at lower risk of death, and reduce mortality in young–old people.
COMMENTARY
Although evidence regarding the effectiveness of preventive home visitation programmes has been contradictory,1,2 programmes that offer these services are being reduced or cut in Canada because of increased pressure for postacute care services.3 The systematic review by Stuck et al adds important scientific evidence to the debate. The authors used rigorous methods in the assessment of the methodological quality of individual studies and statistical analyses. However, one limitation of the review is the lack of description and examination of the interventions incorporated in the home visitation programmes. The providers of the interventions ranged from lay community workers to nurse practitioners and geriatricians, and the types of interventions implemented during visits (ie, counselling, behavioural modifications, and referral) may also have been diverse. An assessment of how these factors contributed to the heterogeneity of the studies included in the review would have been helpful. Although a formal cost effectiveness analysis was not done, the authors provide an estimate of the costs of preventive home visits.
Subgroup analyses yielded significant results: different factors predicted the 3 main end points. Nurses, programme planners, and policy makers must have a clear understanding of the determinants of the outcomes they are attempting to achieve. Further research is needed to show which types of providers and interventions are most effective in preventing functional decline and nursing home admission in the elderly.
Footnotes
Sources of funding: Swiss National Science Foundation; Swiss Federal Office for Education and Research; Swiss Foundation for Health Promotion.
For correspondence: Dr A E Stuck, Spital Bern Ziegler, Bern, Switzerland. andreas.stuck{at}spitalbern.ch
A modified version of this abstract appears in ACP Journal Club.
↵* Information provided by author.