Update of the previous review (November 2011) of the …...reducing hospital admissions of older people (aged 65 years & over). The evidence was generated by The evidence was generated

Epidemiology & Health Science Team, NHS Highland

Epidemiology & Health Sciences Team (Public Health)

Update of the previous review (November 2011) of the evidence for the

effectiveness of interventions to reduce hospital admissions of older

people: full report

February 2016

Update of the previous review

(November 2011) of the evidence

for the effectiveness of

interventions to reduce hospital

admissions of older people

Full Report

Epidemiology & Health Science Team, NHS Highland

Contents

Background ...................................................................................................................... 1

Method ............................................................................................................................ 1

Results .............................................................................................................................. 2

Category A: The way care is organised ............................................................................ 3

A1: Integrated care ...................................................................................................... 3

A1 and A2: Integrated care with generic case management ....................................... 4

A2: Generic case management .................................................................................... 4

A3: Intermediate care .................................................................................................. 5

A4: Multidisciplinary care ............................................................................................ 6

A5: Integration of hospital emergency service ............................................................ 6

Category B: Specific ways of proving care ....................................................................... 8

B1: Telecare & Telehealth care .................................................................................... 8

B2: Discharge Planning from hospital to home ......................................................... 12

B3: Hospital at home .................................................................................................. 13

B4: Nurse-led interventions ....................................................................................... 15

B5: Home Visits .......................................................................................................... 16

B6: Rehabilitation ....................................................................................................... 16

B7: Interventions by the emergency services including those in the hospital

Emergency Department ............................................................................................. 19

Category C: Specific aims of care ................................................................................... 21

C1: Prevention of falls ................................................................................................ 21

C2: Self-care ............................................................................................................... 25

C3: Medication reviews/promotion of adherence .................................................... 26

C4: Specific disease management .............................................................................. 28

C5: Preventative/promoting well-being and general health ..................................... 28

C6: Reducing hospital admissions from Care Homes................................................. 29

Overall Summary ............................................................................................................ 31

Key findings and recommendations .............................................................................. 34

References ..................................................................................................................... 35

Appendix 1: Trends in emergency admissions ........................................................... 40

Appendix 2: Search methodology .............................................................................. 41

Appendix 3: Previous and up to date grading of evidence of each intervention by

category of intervention ........................................................................ 45

Epidemiology & Health Science Team, NHS Highland 1

Background

Unplanned hospital admissions account for nearly 50% of all admissions to acute hospitals in NHS

Highland and of these, nearly 50% (47%) involve those aged 65 years and over. Although the trend in

recent years appears to be decreasing (Figure 1, appendix 1 shows a 9% decrease in the rates for the

65y & over age group over the last ten years). Identifying interventions for which there is evidence

of effectiveness is a pre-requisite if these admissions are to be reduced further. This is not only

advantageous in terms of resource use, but should allow the care and management of older people

in more appropriate settings. This was the rationale for the previous review undertaken in 2011

(intranet link), and this report updates this in its inclusion of more recent evidence covering the

period 2011 to current date (February 2016).

The previous review (intranet link) considered the evidence for the effectiveness for interventions in

reducing hospital admissions of older people (aged 65 years & over). The evidence was generated by

a literature search of reviews published from 1995 to June 2011. Interventions were categorised into

three groups:

A: The way care is organised

B: Specific ways of providing care

C: Specific aims

The effectiveness and cost-effectiveness of the interventions were separately graded in terms of:

SATISFACTORY: satisfactorily established evidence of effectiveness-usually by systematic review of

randomised control trials (RCTs) or single RCTs

CONFLICTING: evidence conflicts

INSUFFICIENT: insufficient evidence, due to poor quality studies e.g. observational design where

bias is likely, or insufficient number of studies or numbers of participants

INEFFECTIVE: does not reduce hospital service utilisation or may in fact increase it i.e. ineffective

This brief report presents the results of the grading of the effectiveness of interventions, after more

recent evidence has been considered.

Method

An identical literature search (appendix 2) used in the previous review was applied to the same

literature sources for the period 2011 to the present (October 2015). The results were screened and

sorted for:

(i) duplication with previous review (a short period of time overlapped in the two searches (ii)

category of intervention (iii) cross checking with previous findings to generate four groups of

evidence:

http://intranet.nhsh.scot.nhs.uk/Org/CorpServ/PublicHealth/Epidemiology-HealthSciences/Documents/Publications%20+%20Resources/Reducing%20Hospital%20Admissions%20in%20Elderly%20Evidence%20-%20Final%20Report%20Nov%202011.pdfhttp://intranet.nhsh.scot.nhs.uk/Org/CorpServ/PublicHealth/Epidemiology-HealthSciences/Documents/Publications%20+%20Resources/Reducing%20Hospital%20Admissions%20in%20Elderly%20Evidence%20-%20Final%20Report%20Nov%202011.pdf


Supportive: new evidence supports the previous grading of effectiveness or cost-effectiveness

Changed: new evidence changes the previous grading of effectiveness or cost-effectiveness

New: evidence for a relevant intervention not considered in the previous review

Non-additional: more recent evidence not found

Results

Out of 84 new references/articles, 58 were considered appropriate to include in the update of

evidence. In terms of the three categories, the following three sections describe the additional

evidence with a summary sub-section of what the new evidence adds to the previous.


Category A: The way care is organised

A1: Integrated care

In the previous review, the evidence for structural integrated care without generic case

management being specified at organisational, team or service level was insufficient. There were no additional sources of evidence for this in the update search.

There was also no additional evidence for integrated processes in the updated search which was also

previously assessed as insufficient.

Evidence for early preventative integrated care (addressing low level need to avoid progression to

acute need) was assessed as insufficient in the previous review mainly due to the before and after

design of the evaluative method. The updated search revealed the published results of sixteen

integrated care pilot sites across England that were set up and funded by the Department of Health

in 2009 (RAND Europe 2012).

Each site varied in the type and extent of integration, but mostly it was between Primary care,

Community health and social care. Mostly but not all, the pilots involved the care of older people.

The evaluation was published online in 2012 using a mixture of methods, the quantitative element

being a difference-in-difference study (DiD) which is basically a before and after study, but

accounting for any regression to the mean by comparing the outcome without the intervention (no

integration) in a control population. It was expected that a reduction in emergency admissions

would be an outcome as well as improving the quality of care. The results however, included an

increase in emergency admissions (2%) which was outbalanced in terms of resource use by a

decrease in elective admissions (4%) and a decrease in outpatient attendances (20%). The suggested

explanation for the reductions in outpatient activity was a shift from secondary to primary care

which was the aim of several of the sites. Possible reasons for the reduction in elective admissions

but increased emergency admissions were not discussed. There was no overall significant impact on

secondary care costs. The diversity of these sites also makes interpretation uncertain.

GRADING

For early preventative integrated care, the results were variable in terms of the effects on

emergency versus elective care and there was no overall impact on secondary care costs. Therefore,

the latest grading was assigned insufficient for effectiveness and ineffective for cost-effectiveness.

Summary of the evidence for structural integration, integration of processes and early preventative

integration without generic case management

Intervention Attribute Previous grade Latest grade Compared to previous grade

Structural integration Effectiveness Insufficient None Non-additional

Cost-effectiveness Insufficient None Non-additional

Integrated processes Effectiveness Insufficient None Non-additional


Early preventative integration

Effectiveness Insufficient Insufficient Supportive

Cost-effectiveness Insufficient Ineffective Changed


A1 and A2: Integrated care with generic case management

A sub-group of these pilot sites (n=6), that used case management of older patients at risk of

emergency hospital admission was separately evaluated and reported on, also using observational

design. (Roland M et al 2012). Again there was a range in the types of integration but mainly it was

horizontal (primary care with other community services). The case management interventions (using

a variety of risk-profiling tools or screening methods) were in most of them, generic with one site

only, in patients with COPD. The main objective of the case management interventions which

involved a case manager (usually a nurse) was to reduce emergency hospital admissions. Using a

DiD method, the overall results included a 9% increase in emergency admissions but significant

reductions in elective admissions (21%) and outpatient attendance (22%) in the six months following

the intervention.

GRADING

Integrated care with generic case management was graded satisfactory previously. The more up to

date evidence supports the lower use of hospital services in terms of elective but not emergency

care.

Summary of the evidence of integrated care with generic case management


Integration with generic case management

Effectiveness Satisfactory Satisfactory Supportive

Cost-effectiveness Satisfactory None Non-additional

A2: Generic case management

The previous review had uncovered conflicting evidence on generic case management with earlier

studies tending to be positively evaluated. This latter phenomenon was thought to be due to

previous lack of anticipatory care.

The updated search uncovered a systematic review which looked at the impact of case management

on unplanned hospital admissions of older people (Huntly AL et al 2013). It included RCTs (n = 11) of

which six involved hospital-initiated case management and five of community-initiated case

management. Three of the hospital-initiated interventions trials were subject to meta-analysis and

even though in two of the trials, unplanned admissions were reduced, overall there was no

statistically significant effect. None of the community-initiated interventions reported reductions in

unplanned admissions.

GRADING

Taking into account the previously found conflict between earlier and later studies, this update

supports the lack of evidence for this intervention.


Summary of the evidence for generic case management


Generic case management

Effectiveness Conflicting Ineffective Changed


A3: Intermediate care

The evidence for reducing hospital admissions through comprehensive geriatric assessment (CGA) in

the emergency department had previously been assessed as insufficient. This was due to

methodological design although it had suggested an avoidance of over one quarter of hospital

admissions and saved nearly £1000 per patient. A more recent review of the literature (Ellis G et al

2014) suggests that this is an emerging intervention which requires controlled trials using

multidisciplinary and comprehensive geriatric assessment in the Emergency Department to fully

evaluate it. The authors cited an evaluation of a service development involving the implementation

of an elderly frailty unit (EFU) with eight to twelve beds situated in the emergency department of

Leicester Royal Infirmary (Conroy SP et al 2014). The EFU was concerned with older frail patients

who were likely to be discharged within 24 hours. The comprehensive geriatric assessment

comprised medical diagnosis, medication problem list, mental health, basic and instrumental

activities of daily living, social circumstances, environmental issue and spirituality carried out by a

multidisciplinary team of primary care co-ordinators working with nurses, therapists, supported by

emergency physicians but with specialist geriatrician input and integrated clerking proforma. The

difference in assessment of older people before and during the intervention period was the input of

the geriatrician and the integrated clerking proforma with additional education and training and

team- working. The study design was a pre-post cohort study with the primary outcome of

admission avoidance from the Emergency department (ED). Secondary outcomes were

readmissions, length of stay and bed-day use as secondary outcomes. The results included a

statistically significant reduction in conversion rates (i.e. proportion admitted from ED) from70% to

61% and a reduction in readmission rates at three months from 36% to 20% in patients aged 85

years and over. Inpatient bed-day use increased slightly as did the mean length of stays. There was

no cost-effectiveness analysis associated with this study. However, the design of the study (pre and

post difference without a control population and the specific configuration of the emergency

department (it comprised also of an emergency decision unit) renders the evidence of effectiveness

uncertain and less likely to be generalisable to other hospitals.

Evidence from a Cochrane review (Ellis G et al 2011) suggests that patients receiving comprehensive

geriatric assessment undertaken in hospitals have an increased likelihood of being alive and in their

own home at up to one year after an emergency hospital admission. The effect was consistently

seen in studies where outpatients were assessed in a dedicated ward area and not clearly seen

where patients remained in a general ward and received assessment from a visiting team. However,

there was no effect on re-admissions to hospital or on length of stay, the latter showing a wide

variation.


GRADING

Summary of the evidence for intermediate care


Comprehensive geriatric assessment in ED/Hospital



A4: Multidisciplinary care

Only one publication was retrieved which was a narrative systematic review of the literature on

studies of communication pathways amongst multi-professional teams in transitional care of older

people (Allen J et al 2012). The authors used a definition of transitional care of: “care provision

across varying services and care environments occurring when a person is discharged from inpatient

care or an emergency department to home” and a definition of multi-professional communication

as: “communication between professionals with distinct skills, knowledge and culture regarding

older people in transitional care. Older people were defined as 60 years and over. From the ten year

period (2000 to 2009) they analysed fifteen publications, ten regarding communication pathways

and five regarding contextual factors reported to enable or constrain multi-professional

communication. Only three studies measured hospital/emergency department admissions after the

intervention. All reported statistically significant reductions but all of them had used a before and

after study design without control groups.

GRADING

Summary of the evidence of multidisciplinary care


MD teams & Communication pathways

Effectiveness None Insufficient New

Cost-effectiveness None None Non-additional

A5: Integration of hospital emergency service

This is a new sub-category i.e. evidence for this was not retrieved during the earlier literature search.

An article (Boyle AA et al 2012) reported on the impact of re-locating a medical admissions unit to

the emergency department of an acute hospital in England. The evaluation used a quasi-

experimental design of a before and after study. The comparison was with twenty three similar

other hospitals between 2001 and 2009 in which there were separate emergency departments and

medical assessment units (MAU). The outcomes included hospital standardised mortality ratios

(HSMR) and standardised admission ratios (SAR). MAUs receive referrals directly from GPs (50%) and

also from the emergency department (50%). This arrangement is considered to add delays for

definitive treatment or discharge decisions and fragments care. The integrated service, named

emergency assessment unit (EAU) comprised of Emergency Department staff with medical and

surgical doctors. The EAU was opened in 2006 and thereafter both the HSMR and SAR decreased.


The difference with the comparator hospitals was statistically significant. This statistical difference

was maintained after correction for differences in deprivation. As this involved a single unit, it is

impossible to know whether the results can be generalised to other hospitals. Further, it included

the total age range and may not be effective for the full range of older people. The cost-

effectiveness of the new arrangement was not evaluated.

GRADING

Summary of the evidence for integration of hospital emergency service


Integration of hospital Emergency Dept. service




Category B: Specific ways of proving care

B1: Telecare & Telehealth care

(i) Telecare (using technology to assist people to be safe in their own home such as falls sensors)

Previously the evidence for effectiveness and cost-effectiveness was graded as insufficient. Since

then the evaluation of the Whole System Demonstrator project (WSD) has been published

(Steventon A et al 2013). The WSD is a large cluster randomised control trial (purported to be the

largest conducted to date) to evaluate the effectiveness of telecare and telehealth. It involved the

randomisation of GP practices in three areas of southern England covering up to 6,000 patients. Each

practice acted as a control and an intervention arm for Telecare or Telehealth i.e. each could either

be a telecare intervention and telehealth control or a telehealth intervention and telecare control.

The telecare trial involved under three thousand patients (2,600) aged 18 years and over who met

one or more of the following criteria:

- Requirement for minimal level of social care service - Mobility difficulties - History of falls or high risk of falling - Cognitive impairment or confusion with a live-in or nearby carer - A carer facing difficulties

The Telecare intervention consisted of a Tunstall Lifeline or Connect+ base unit together with a

pendant alarm and up to twenty seven peripheral devices covering environmental sensors, security

monitoring, standalone devices such as big button phones, functional monitoring including the

Lifeline base units and pendants such as fall detectors, medication dispensers. The primary outcome

was the proportion of patients having an inpatient hospital admission within twelve months. There

were several secondary outcomes measured such as mortality, admission to permanent residential

or nursing care, inpatient bed days, emergency and elective admissions, inpatient length of stay, GP

contacts and costs of hospital, social and GP care. The results during the twelve months of the trail

included a non-statistically significant smaller percentage hospitalised (47% versus 49%), significantly

higher rate of GP contacts, (2.3 versus 2.0 per head), similar outcomes for the other measurements

such as mortality. The higher rates of GP contacts did not pertain when pre-trial rates of contacts

were adjusted for (the intervention group had higher prior rates that the control group). There were

no differences in hospital and social care costs between the groups although primary care costs were

not compared due to not being able to adjust for prior differences in GP contacts.

This part of the WSD trial was specifically assessed for cost-effectiveness (Henderson C et al 2014).

The cost per additional QALY with Telecare was estimated to be £297,000 which far exceeds the

threshold NICE uses (£20K-£30K per QALY).

The literature search failed to find any additional sources of evidence for the effectiveness of

Telecare. However, there was some grey literature in relation to the evaluation of the National

Telecare Development Programme in Scotland. This commenced in 2006/7 and was initially a two

year programme funded by £8.35 million, but subsequently extended for a further two years with an

extra £8 million. It covered all thirty two local authorities led partnerships in Scotland and estimated

that 43, 000 people were assisted with Telecare during the programme. The final report which can


be accessed from the Joint Improvement Team (Scotland) web site unfortunately did not provide

specific information on the methodology (Telecare Development Programme in Scotland 2006-11;

Newhaven Research, July 2011). It appears that the evaluation was based on quarterly standardised

monitoring forms submitted by each of the Local Authority partnerships. The outcomes considered

included reductions in delayed discharges from hospital, number of unplanned hospital admissions

and number of care home admissions as assessed by each LA partnerships self reported position in

relation to expected reductions in these outcomes. The final assessment over the four years across

Scotland indicated that 2,500 hospital discharges were expedited, 8,700 unplanned hospital

admissions and more than 3,800 care home admissions avoided. This translated to the saving of

546,000 care home beds, 109,000 hospital bed days, 48,000 of sleepover/wakened night care and

444,000 home check visits. However as indicated in the report, these efficiencies would not provide

any cash releasing savings unless ward closures and other service adjustments had been made as a

result of them. There is no way of knowing whether the Telecare itself had directly resulted in these

reductions as they were not compared with control populations and would be subject to

confounders such as regression to the mean or other external influences during the four year period.

It is unfortunate that this programme had not been subjected to more rigour in terms of its

evaluation. However it has demonstrated the range of actual application of Telecare in terms of

patient need. The demographics of those in receipt during the programme show an almost 2:1 ratio

of women to men, 85% aged over 65 years, 9% with dementia, 23% physical need and most (60%)

categorised as “older” need. It was noted that its use for patients with Dementia was most likely an

under-estimate due to the believed under-diagnosis of this condition. The SGHSCD identified a lack

of good quality evidence for the effectiveness of Telecare in this group after commissioning a

literature review (Pleace N, 2011). Renfrewshire amongst the 32 LA partnerships, recorded 30%

(compared to the average of under 10% amongst other LA Partnerships) of the Telecare funded in

the national Telecare Development Programme had been provided to people with Dementia living in

their own home. The JIT and the Scottish Centre for Telehealth & Telecare (SCTT), commissioned

from the York Health Economics Consortium, an additional evaluation based on five years of the

provision of Telecare to people with Dementia in Renfrewshire (n = 325) within the National

Telecare Programme (York Health Economics Consortium, Joint Improvement Team, 2013).

Unfortunately the methodology was also limited to self-reported monitoring reports. It did conclude

that the use of Telecare is cost saving for users with Dementia with net savings of £0.38 million over

five years for the three hundred and twenty five users (i.e. £1,150 per user). Unit costs in the overall

TDP evaluation were then revised to reflect the different patient group. Application of the revised

resources saved and unit costs to the self-reported outcomes of the Renfrewshire Partnership then

provided a higher net saving cost of £8,650 per client with dementia receiving Telecare. There were

significant limitations and assumptions made in association with this evaluation although it is

possible that for people with dementia, Telecare in the persons own home compared to standard

care does have savings in relation to inpatient stays and avoidance of admission to a care home.

Potentially better quality evidence for its effectiveness is expected to be derived from the results of

an on-going randomised control trial comparing Assistive Technology and Telecare (ATTILA) with

standard care of people with Dementia in England (Leroi I et al 2013; ISRCTN86537017). It is set to

run for four years having commenced in January 2013.


(ii) Telehealth/Telemedicine (remote exchange of data between an individual and a healthcare

professional for diagnosis/management of healthcare conditions)

Previously the evidence for effectiveness and cost-effectiveness for telehealth in the management of

long-term conditions had been graded as satisfactory for effectiveness and conflicting for cost-

effectiveness. This was in advance of the results of the evaluation of the Whole System

Demonstrator programme, (WSD). These results have now been published (Steventon A et al 2012)

comparing patients with a long-term condition or a combination of them out of COPD, Heart Failure

and Diabetes who have usual care with those who have telehealth care. The telehealth care patients

were in receipt of, was variable but minimally consisted of a pulse oximeter for those with COPD;

weighing scales for heart failure and glucometer for those with diabetes. There were over three

thousand patients in the trial. During twelve months of the trial, compared to controls, those in

receipt of Telehealth care, had fewer hospital admissions (18% (2-31%, 95% CI)), fewer hospital bed

days, lower mortality (47% (28-61%, 95% CI)) and attended emergency departments less frequently

(15%, (0-27%, 95% CI)). These were all statistically significant differences. Hospital emergency

admissions were also lower in the intervention arm of the trial but this difference was not

statistically significant after adjustment for baseline characteristics. It was noted that the difference

in health service use was most marked at the start of the trial and had the first quarter year of data

been excluded, would not have resulted in lower admission rates. This could have been the result of

the identification of need amongst participants during the recruitment phase with a greater

likelihood of intervention to meet these needs if the patient was in the control group (this was not a

blinded trial). However this is only speculation.

This part of the WSD trial was also specifically assessed for cost-effectiveness (Henderson C et al

2013). The study was a nested economic evaluation involving just under one thousand participants

from a total of three thousand in the trial and one thousand six hundred of participants receiving a

questionnaire. The result was that the QALY gain by Telehealth users in addition to usual care was

similar to users of usual care only. Therefore the higher costs of Telehealth care made this not a

cost-effective addition to usual care.

Other sources of evidence for the effectiveness of Telehealth included a Cochrane review with meta-

analysis (McLean S et al 2011) involving patients with COPD. It included ten randomised control trials

in which the intervention arm involved the interaction with a healthcare professional providing

personalised feedback relating to the management of the illness at a distance. The findings

supported the results of the twelve month evaluation of the WSD programme in that the

intervention was associated with fewer hospital admissions (54%) over 12 months, (OR 0.46 (95% CI

0.33-0.65)) from four of the trials in which this was measured, n = 604. Three of the trials (n= 449)

measured attendance to Emergency Department during twelve months and these were also

statistically significantly lower (73%) in the Telehealth care group (OR 0.27(95%CI 0.11-0.66). No

cost-effectiveness was considered.

An earlier systematic review also evaluating the effectiveness of Telehealth care in the management

of patients with COPD, (Bolton CE et al 2011) concluded that the evidence was insufficient. The

authors’ suggested that the quality of the included studies was too variable, risk of bias high with

heterogeneous interventions and patient populations. There were six included studies, only two of


which were RCTs. This contrasted with the systematic review reported above (McLean S et al 2011)

based on the meta-analysis of ten RCTs.

Two RCTs published too recently to have been included in either of the reviews described above also

measured secondary care uptake between Telehealth care receivers and controls. One based in

Denmark (n = 111) concluded that Telehealth care of COPD patients statistically significantly reduced

hospital admission rates over a ten month period (Dineson B et al 2012). The mean admission rate

was almost 60% lower, with non-statistically significantly lower admission costs. The second RCT

based in Spain, was smaller (n=58) and included older patients with either Heart Failure or Chronic

Lung Disease (mainly COPD & Asthma) who had at least two hospital admissions for their disease in

the previous twelve months (Martín-LesendeI et al 2013). This was a Primary Care-based study in

which patients were managed at home either by usual care or by Telemonitoring provided by

Primary care based health professionals who had received specific training aimed at strengthening

and standardising the management of the clinical conditions before the trial. Over twelve months,

the intervention group had a lower proportion of at least one hospital admission (57% versus

86.4%), lower mean length of stay for all cause admissions (9 days versus 10.7 days) and a lower

cause-specific length of stay (9 days versus 11.8 days). Only the effect on the rate of hospital

admission was statistically significant.

Evidence for the effectiveness of Telehealth care in the wider older population is derived from a

systematic literature review (van den Berg et al. 2012) which involved controlled (not necessarily

randomised) studies of patients aged 60 years and over with a variety of diseases, mainly

cardiovascular and diabetes. For inclusion in the review, the interventions studied had to have (i)

been conducted directly in the patients’ home (ii) required a Telemedical connection between a

medical provider and the patient in their home and (iii) involved patients with a specific diagnosis or

medical indication. Of the 68 studies identified for the review, 21 appeared to have reported on

service utilisation outcomes such as hospital admissions, hospital re-admissions, emergency

department admissions and hospital stays (length and bed days). For these outcomes the results

were predominantly positive although in some studies no differences or even negative differences

were observed in intervention versus control groups. Amongst the studies there was a wide range in

patient medical conditions and in the Telehealth care interventions used and in the types of

healthcare workers involved. Therefore the discussion section was useful in highlighting the

probable importance of pre-training patients, carers and healthcare staff before intervention. They

also noted the assumption of the specific competences of hearing, vision and communication

amongst patients and the co-operation of carers. The need for future research to address the issue

of how to adapt Telemedicine systems and processes to the needs and resources of patients with

cognitive and physical limitations and co-morbidities to make the concepts suitable and available for

a larger group of older patients was also highlighted in the discussion.

GRADING

Telecare:

Although the results of the Whole System Demonstrator project (WSD) did not support evidence of

either its effectiveness or cost-effectiveness in reducing hospital admissions, the results of the

Scottish National Telecare Development Programme suggested otherwise. Taking into account that

the latter evaluation was of poor quality in terms of evidence, the grading of insufficient evidence


rather than conflicting evidence, remains i.e. the new evidence supports the previous grading of

insufficient evidence for effectiveness and cost-effectiveness

However, there may be some new evidence for the effectiveness of Telecare for people with

dementia living at home. This requires better quality study which may be obtained in future years.

Telehealth Care:

The results of the WSD and of a Cochrane review with meta-analysis both measured fewer hospital

admissions and attendances at Emergency departments for the management of long-term

conditions (only COPD in the case of the Cochrane review), using Telehealth compared to standard

care. This supports the previous grading of satisfactory evidence for its effectiveness.

The Telehealth care in the WSD was evaluated for cost-effectiveness and this was found to be more

expensive than usual care when the cost of the technology is taken into account. This is an addition

to previous conflicting cost-effectiveness assessment and therefore the grading remains conflicting

although more now in favour of it not being cost-effective.

Summary of grading for Telecare and Telehealth:

Intervention Attribute Previous grade

Latest grade Compared to previous grade

Telecare: Generic Effectiveness Insufficient Insufficient Supportive

Cost-effectiveness Insufficient Insufficient Supportive

Telecare: Dementia Effectiveness None Insufficient New

Cost-effectiveness None Insufficient New

Telehealth Care in LTCs Effectiveness Satisfactory Satisfactory Supportive

Cost-effectiveness Conflicting Conflicting Supportive

B2: Discharge Planning from hospital to home

The 2010 Cochrane systematic review included in the previous report has been updated (Shepperd

et al. in 2013). In this latest review a further 3 RCTs, making a total of 24 RCTs, were included. The

definition of discharge planning used for the search was “the development of an individualised

discharge plan for a patient prior to them leaving hospital for home”. Trials included in the review

evaluated a broadly similar intervention of discharge planning which included assessment, planning,

implementing and monitoring. Pooling only trials involving older patients with a medical admission

(n = 1,765), there was a small but statistically significant shorter length of stay for those receiving

discharge planning (mean difference of -1.01d, 95% CI of -1.61 to -0.41) compared with usual care. In

addition, the rate of hospital unscheduled re-admissions within 3 months of discharge was 18%

lower for those receiving discharge planning (RR 0.82, 95% CI 0.73-0.92). Some trials reported cost

savings to the health service from implementation of discharge planning, although these had not

specifically recruited older people to the intervention.

A systematic review with meta-analysis, (Fox MT et al. (2013)) compared the effectiveness of early

discharge planning to usual care in older patients (aged 65 years and over). Early discharge planning

was defined as interventions to facilitate the transition of care back to the community which were


initiated during the acute illness or injury phase (i.e. the period during which an illness or injury is

being intensively treated and stabilized). In total, nine studies were included in the review, the

majority (67%) conducted in the US involving 1,736 participants. Compared to usual care, those

receiving early discharge planning ( 7 trials) experienced 22% fewer hospital re-admissions within 1

to 12 months of the index hospital discharge (RR 0.78, 95%CI= 0.69-0.90). The length of stay for any

re-admissions within 3 to 12 months of the index hospital discharge was also found to be statistically

significantly lower (by almost 2½ days ) for those receiving early discharge planning versus usual

care (meta analysis of n=3 studies). There was no difference found between the index hospital

length of stay or in the mortality rate within 2 to 12 months of the index hospital discharge, between

those with or without early discharge planning.

A systematic review of the literature looking at a range of interventions to reduce hospital bed use

by frail older people also suggested that discharge planning was associated with shorter length of

hospital stay and reduced re-admissions (Philp I et al. 2013). The conclusions were based on one

systematic review, one literature review, one systematic meta-review and one quasi-experimental

pre-post study design. The results of these papers were varied but the best results were seen when

discharge planning was tailored to the individual patient; addressed family inclusion and education,

communication between health care workers and family, interdisciplinary communication; provided

on-going support after discharge; and was commenced well before discharge.

GRADING

The findings from the updated Cochrane review and from two other recent systematic reviews are

consistent with the grading in the previous report of satisfactory in hospital discharge planning in

reducing hospitalisation. Whilst the reduced hospitalisation was on the basis of reduced rates of

readmissions and the length of stay of the index admission, there may be some additional evidence

that the length of stay of readmissions themselves may be shorter. Also consistent with previous

report, there was insufficient evidence to assess the cost-effectiveness of this intervention.

Summary of grading for discharge planning


Discharge Planning (hospital to home)



B3: Hospital at home

Since the previous report, a series of systematic reviews (Purdy et al. 2012) included this service

where it was termed ‘early discharge hospital at home’ and defined as a service that provides active

treatment by health care professionals in the patient’s home for a condition that otherwise would

require acute hospital in-patient care, The authors base their findings for hospital at home on one

Cochrane review by Shepperd et al. 2010 which looked at hospital at home following early discharge.

From this they summarise that there is evidence that for older people with a mixture of conditions,

re-admission rates are significantly increased for those allocated to hospital at home services. This is

consistent with the previous grading of ineffective for this intervention.


A more recent meta-analysis (Caplan et al. (2012)), of RCTs assessed the effect of hospital in the

home (HITH) services that significantly substitute for in-hospital time, on mortality, re-admission

rates, patient and carer satisfaction and costs. To be included in the review intervention groups in

the trials had to have had a significant substitution of in-hospital care which equated to the duration

of out-of-hospital care being either ≥ 7 days or ≥ 25% of the average length of stay for control

hospital admissions. Studies were included from the community, emergency departments,

hospitalisation in other departments, hospital-based outreach teams and community-based teams

and involved patients aged > 16 years. A total of 61 RCTs met the criteria for inclusion in the meta-

analysis. Studies included also involved a wide range of patient types (Psychiatric, Surgical, Medical,

Rehabilitation) and types of HIHT).

Results of the meta-analysis found there was a clinically significant reduction in mortality for those

receiving HITH (19% relative reduction and 2% absolute reduction) which was especially seen in the

middle age group (average age 70-73 years). The absolute reduction seen in re-admission rates of

intervention groups was 2.1% and overall cost for HITH care was 73.5% of the average for the

control groups. Although meta-analysis could not be performed for patient and carer satisfaction

outcomes these were generally found to be better in those receiving HITH care versus those

receiving usual in-hospital care. It should be noted that this meta-analysis included three times more

studies than the Cochrane Review of Shepperd et al,2009b, so had greater statistical power. It also

involved specific patient groups not included in the Cochrane review (Psychiatric) and different types

of HITH (substituting non-acute care, such as rehabilitation). The problem in the interpretation of

the results of this review, is in the identification of what elements affected the outcomes.

A Cochrane Review (Jeppesen E at al 2012) evaluated the efficacy of hospital at home care compared

with standard hospital inpatient care in patients presenting to emergency departments with acute

exacerbations of COPD. Home support (i.e. hospital at home) involved patients being under the care

of a specialist respiratory nurse who made regular scheduled visits to the patient in their own home,

and had to commence within 72 hours of the patient presenting to the emergency department.

Control patients received usual in-hospital care. Primary outcomes examined in the review were re-

admission rates and mortality, and secondary outcomes included measures of costs and/or health

economics and total days of care provision.

In total eight RCTs were included in the review (n =870) and on average, 27% (range 11-39%) of

patients who presented to the hospital emergency department with acute exacerbations of COPD

were considered relevant to receive treatment at home. Trials originated from Australia, Denmark,

Italy, Spain and the UK (4 trials). All trials reported hospital re-admission and together showed a

24% reduction in rates in favour of hospital at home (RR 0.76; 95% CI 0.59 to 0.99). There was a

trend towards lower mortality for the hospital at home group but the pooled effect estimate for the

seven studies reporting this outcome did not reach statistical significance. In terms of direct costs

associated with supplying care the three studies which reported data favoured a reduction in costs

for hospital at home. However, the authors considered the quality of evidence presented by these

studies to be too weak to make firm conclusions regarding effects on direct costs.

GRADING

The additional evidence suggests that hospital at home may reduce re-admissions of patients with

exacerbations of COPD. There may also be evidence for hospital at home when its duration is either


≥ 7 days or ≥ 25% of the average length of stay for control hospital admissions. This applied to a wide

range of patient types and various types of care at home. Therefore this more recent evidence is

graded as conflicting when considered together with the results of two previous Cochrane reviews.

Again there was insufficient evidence with which to assess its cost-effectiveness.

Summary of grading for hospital at home


Hospital at Home (early discharge)

Effectiveness Ineffective Ineffective Supportive

Cost-effectiveness Conflicting None Non-additional

Hospital at Home Effectiveness Ineffective Conflicting Changed


B4: Nurse-led interventions

In the previous report, nurse-led units within hospitals were rated as being effective in reducing the

rate of re-admissions (48%) within four weeks of discharge and reducing discharges to institutional

care by 56% of older patients on the basis of a Cochrane systematic review. The updated literature

search failed to reveal any additional evaluations of these units. A systematic review of the literature

looking at a range of interventions to reduce hospital bed use by frail older people (Philp et al, 2013)

cited a before and after evaluation of a USA-based nurse-led programme for homebound older

patients. These patients were all homebound, defined as “able to leave home only with great

difficulty and for absences that are infrequent or of short duration”. Their care at home on discharge

was co-ordinated by two nurses within a home-based primary care programme involving physicians,

social care workers and nurses. The evaluation did not support the intervention in reducing

readmissions or in hospital length of stay. As this was a before and after study, this evidence is of

lower quality and is probably non-generalisable due to its situation within a specific healthcare

system. Therefore, this evidence was discounted.

GRADING

As there was no more recent evidence, the previous ratings for Nurse-led units remain the same as

previously.

Summary of grading for Nurse-led units


Nurse-led units Effectiveness Satisfactory Satisfactory Supportive



B5: Home Visits

In the previous report, home-visiting as initiated from need that was assessed in the community had

been rated as non-effective. Published work since then includes a synthesis of evidence for

community interventions (Purdy S et al 2012), in which three RCTs were cited involving older

patients and three on heart patients. One RCT relating to older people had already been included in

a systematic review of home visiting which itself had been included in our previous report. The other

two were not relevant to home visiting, one of which involved the ambulance service. This latter one

is included in a new (to this update) category of interventions by emergency services (B7) as

reported below. The three trials on heart patients are more relevant to the category of specific

disease management (C4) and some of these have been included later in this update.

Other more recent publications include a systematic review without meta-analysis which assessed

interventions that were either hospital-based or home-based care aimed at reducing unplanned

hospital admissions in the elderly (Linertova R et al 2011). Two categories of RCTs were included:

those that were in-hospital (n = 17) and those that were hospital interventions/assessment with

home follow-up. (n = 15). Seven out of the latter group found statistically significantly lower rates of

re-admission compared to usual care. However, these studies were heterogeneous, some involved

medication review as the hospital-based intervention, some had care plans/discharge planning

processes. The conclusion of the authors was that most of the interventions evaluated did not have

any effect on reducing re-admissions but that compared to hospital-based alone interventions (i.e.

without follow-up), those with follow-up home visits were more likely to reduce re-admissions. As

this was not a meta-analysis and involved a range of different hospital interventions some of which

would be included under discharge planning, the evidence for effectiveness is insufficient.

GRADING

There was no more recent evidence of sufficient quality relating to home visits initiated from

assessment of need in the community to add to the previous finding of ineffectiveness in reducing

hospitalisation. There were no studies assessing the cost-effectiveness of home visiting. More recent

evidence relating to home visiting as initiated in the hospital was too heterogeneous to be

interpreted and remained as insufficient.

Summary of the grading of effectiveness of home-visiting


Home visiting initiated in community

Effectiveness Ineffective Ineffective Supportive


Home visiting initiated in hospital



B6: Rehabilitation

In the previous report, the evidence was rated as insufficient on the basis of only one relevant

source (Cochrane systematic review on exercise-based rehabilitation for Heart Failure), which was

un-representative in terms of (i) case-mix where it only included mild to moderate cases (ii) age-


range which was from age 18 years and over with mean ages ranging from 43 years to 72 years, (iii)

gender proportion which was predominantly male. This also applied to the rating of the cost-

effectiveness evidence carried out in the same review.

The more recent literature search found three new Cochrane reviews involving rehabilitation of a

long-term condition.

The first one was an update of the previously included review (Davies EJ et al 2010) on exercise-

based rehabilitation in heart failure (Taylor RS et al 2014). In total 33 trials (n=4,740) were included,

fourteen of which were new to the previous systematic review. The findings were similar to that of

the previous review in that the intervention was associated with a reduced rate of all cause hospital

admission (n = 1,328, RR= 0.75; 95%CI= 0.62 to 0.92) and Heart Failure-specific admissions (n= 1,036;

RR – 0.61; 95%CI =0.46-0.80).These reductions applied for up to one year of follow-up but not for

any longer-term follow-up. Reduced hospitalisation was independent of age, gender and degree of

heart failure severity. The mortality rate was not different although there was a tendency for it to be

lower with longer term follow-up (>1year). This review has added to the previous evidence in

respect of its effectiveness being independent of participants characteristics of age and gender.

However, the included trials were relatively small and the lack of reporting methods made it difficult

to judge bias. In addition, the included cases were predominantly mild to moderate HFREF (systolic

heart failure).Therefore there is still a need for further primary studies which should include more

cases of those with HFPEF (diastolic heart failure).

More recently, another Cochrane systematic review also on exercise-based cardiac rehabilitation has

been published but in coronary heart disease of various modalities (Anderson L et al 2016). This was

itself an update of a previous review in 2011. Again the case-mix was of lower-risk patients, who

were predominantly middle-aged men following myocardial Infarction (MI) or coronary

revascularisation. The average (median) duration of cardiac rehabilitation was six months. Hospital

admission was an outcome measured in fifteen studies (n = 3,030) but reported at either short term

(6-12 months) or medium term follow-up (13-36 months), none at any longer-term follow-up. Only

the short-term rates were statistically significantly lower with a pooled (all 15 studies) reduction in

risk of 18% (RR=0.82, 95%CI 0.70 to 0.96). There was no significant reduction in all cause mortality

but the cardiovascular mortality rate was 27 % lower in the rehabilitation population (n = 7,469;

RR=0.74, 95%CI 0.64-0.86). Again only studies (n=15) measuring at short-term follow up were

associated with significant reductions. The cost-effectiveness had been measured in some of the

studies (n = 7), and although the authors suggested that this intervention was potentially cost-

effective, the variation in the differential between the arms of each of the studies, with some being

more expensive and others less expensive, suggests that this is very uncertain.

According to the authors, the review compared to the previous one, has more external validity. This

however only applied to the more recent studies where women and older patients were included.

Overall, the review is not representative in terms of age, gender and case-mix as stable angina cases

were under represented compared to its proportion of the general population affected by coronary

heart disease.

Another Cochrane Review was found on the effects of pulmonary rehabilitation after COPD

exacerbations on future hospital admissions and other patient outcomes (Puhan MA et al. in 2011)

which updated a previous review of 2009 but not included in our previous report. It included RCTs


comparing pulmonary rehabilitation (which must include a physical exercise element) of any

duration with conventional community care without rehabilitation. In total nine trials were included

involving patients (n = 432) with mean age ranging from 62 to 70 years. The patients had to have had

recent acute care for exacerbation of COPD and to have received pulmonary rehabilitation (if in the

intervention arm) either immediately after or within three weeks of initiation of treatment for

exacerbation. For the effects on admissions to hospital, five studies (250 patients) contributed data

to the meta-analysis and pooled odds ratios showed a significant reduction in hospital re-admissions,

where follow up periods for these studies ranged from 3 to 18 months. The reduction equated to

treating four patients to avoid hospital readmission of one patient (NNT = 4). In three studies (n=110

patients) mortality data was also pooled and the odds of death between treatment versus control

groups found to be significantly reduced (NNT = 6). Therefore within the limitation of the low

numbers included in the studies, the findings show pulmonary rehabilitation with exercise to be safe

and effective in those with unstable COPD.

Community rehabilitation was also included in a review of literature (Philp I at al 2013). One

observational cohort study reported significant reductions in the hospital length of stay of patients

with knee or hip replacement before discharge to rehabilitation in the community without any

increase in complications (n = 394). However the size and design of the study warrants this evidence

as uncertain. Also included was a Cochrane Review with meta-analysis of RCTs (Handoll HHG et al

2009) looking at the effects on readmission and other outcomes of multidisciplinary rehabilitation of

older patients with hip fracture. The majority of the trials (n=11) provided rehabilitation

interventions in hospitals. Similar to the findings of the observational study detailed above, one trial

involving patients with home-based rehabilitation (n = 66) had shorter hospital length of stays but

longer periods of rehabilitation.

There was little by way of evidence to support a reduction in hospital service use by rehabilitation in

the generally frail older patient (Linertova R et al 2011). This systematic review without meta-

analysis included four primary studies (3 x RCT + 1 x quasi- experimental). Each study looked at a

different rehabilitation intervention and there was only one study in which there was a statistically

significant reduction in hospital readmission rate. This occurred within 18 months where 56% of the

controls had been readmitted compared to 52% of those with rehabilitation. The percentage within

three months (23%) was identical in both controls and the intervention group of patients.

GRADING

The previous report rated the evidence for rehabilitation in reducing hospital admissions as

insufficient based on only one Cochrane systematic review involving exercise-based rehabilitation of

patients diagnosed with heart failure. The update found other evidence from three Cochrane

reviews that exercise-based rehabilitation reduces hospital readmissions in patients with heart

failure, coronary heart disease and exacerbation of COPD. However there were limitations as to how

generalisable each of them were. This applied to the specific case-mix of the study patients in terms

of type of heart disease and its severity and to the small number of patients included in the meta-

analysis of patients with COPD exacerbations. This also applied to patients with joint replacements

(Hip or Knee) and those with hip fractures receiving community rehabilitation. The evidence from

these sources was limited in respect of the quality of the study design (in the joint replacement

study) and the size of the study in the case of hip fracture. There was no reliable source of cost-


effectiveness evaluation for any of these interventions. In terms of generally frail patients, there was

no evidence of the effectiveness of community provided rehabilitation.

Summary of the grading of rehabilitation interventions


Latest grade

Compared to previous grade

Exercise-based rehabilitation for Heart Failure



Exercise-based rehabilitation for Coronary Heart Disease



Exercise-based rehabilitation for Exacerbations of COPD



Community-based rehabilitation for Hip/Knee replacement



Community-based rehabilitation for Hip fracture



Rehabilitation in the general frail older patient



B7: Interventions by the emergency services including those in the hospital

Emergency Department

In a cluster RCT (n = 3,018), older patients (aged 60 years & over) for whom a 999 call had been

made, either received standard 999 ambulance service or were attended by a specifically trained

Paramedic (Mason S et al 2007). For both control and intervention cohorts, patients may or may not

have been transported to hospital after attendance. Outcomes including re-admissions and

emergency department visits either at the time of the incident or within 28 days of it were

compared between the cohorts. The included patients were those that had suffered minor injury or

illness which fell within the scope of practice of the Paramedic practitioner. The participants lived in

the catchment of the South Yorkshire Ambulance Service and were predominantly in an urban

setting. Outcomes were an 18% lower risk of subsequent attendance at an emergency department

((RR 0.72; 95% CI 0.68 to 0.75) and a 13% lower risk of re-admission (RR 0.87, 95%CI 0.81 to 0.94)

within 28 days of a paramedic practitioner intervention.

A systematic review of older people who had fallen and to whom the ambulance service had been

called out, looked at the rates of those who were not transported to hospital and their subsequent

outcomes (Mikolaizak, AS et al, 2013). It included various studies of differing designs in which the

proportion of people called out to but not transported to hospital, ranged from 11% to 56%. One

included study (a retrospective study) based in the UK of older patients (n = 1,005, aged 65 years &

over), reported that while 52% of the patients who had received standard ambulance care had been

transported to hospital, only 27% of those who received the care of an Emergency Care Practitioner

had. The authors estimated that 56% of the ECP treated fallers had avoided subsequent hospital

admission within 72 hours. This study design is subject to bias.

The impact of interventions in the hospital Emergency Department (ED) on admission rates was the

subject of one study and one systematic review. The study, (Arendts G et al 2012), was measuring


the effect of a Care Co-ordination team (comprising physiotherapist, occupational therapist, social

worker with co-opted Geriatrician, nursing, and other allied health staff (e.g. speech therapist)) prior

to/in parallel with assessment by Emergency Department medical team on whether a patient is

admitted or discharged from the ED. Patients (n = 5,265), were identified for inclusion if they

presented to the ED department with one or more out of ten medical conditions/complaints. The

patients were then prospectively assigned either to CCT functional assessment followed by the

initiation of services to address any needs (intervention) or no CCT assessment before a decision was

made to admit or discharge was made. The patients were not randomised to intervention or control

and the study was conducted in two Australian hospitals. Overall the admission rates were found to

be lower in the intervention group but this was of borderline significance. When sub-groups of

conditions were analysed, the rates were statistically significantly lower for patients with a

musculoskeletal diagnosis (OR = 0.67, 95% CI=0.49 to 0.93) and for those with Angina (OR = 0.91 95%

CI = 0.53 to 0.93). The latter is an episodic condition that is likely to have been resolved by the time

the patient has arrived at ED. This study without randomisation is subject to bias.

The systematic review was concerned with nursing interventions in patients aged 60 years and over

undertaken in an emergency department concluded that there was some evidence that they

reduced service use and functional decline (Fealy, G et al 2009). The interventions could be nursing

alone or nurses as part of a multidisciplinary team. It include nine studies (n = 6,715) of various

designs. Hospital usage was measured in seven of the studies in which it was statistically lower in

one RCT and in two before and after studies. Three RCTs and one non-randomised control trial did

not find any significant differences and one quasi study reported mixed results. On this basis, the

evidence is uncertain.

GRADING

The previous report did not include any evidence relating to interventions based in the Emergency

Department other than geriatric assessment carried out by a multidisciplinary/integrated team. New

evidence for this is described in a previous section (A3) in this report but classified under

intermediate care as it involved structural intervention (i.e. a specific unit).

Summary of the grading of intervention by the emergency service and in the emergency department


Latest grade


Ambulance call out to fallers/minor injuries (Em Care/Paramedic Practners)

Effectiveness None Satisfactory New

Cost-effectiveness None Satisfactory New

Care co-ordination team in the Emergency Department



Nursing intervention in the emergency department




Category C: Specific aims of care

C1: Prevention of falls

These interventions can be sub-grouped according to the setting they take place in and type of

individuals involved. In the previous review, there was satisfactory evidence to support the

effectiveness of many different types of interventions based in community settings and in

institutions. Interventions in the cognitively impaired were assessed as ineffective in reducing

hospital admissions.

A Cochrane systematic review which is an updated version of evidence provided in the previous

report, provided the results of meta-analysis of 159 trials (n = 79,193) for various interventions in

community-dwellers (Gillepsie LD et al 2012). These included people aged 65 years & over living at

home or in institutions that do not involve residential health-related care or rehabilitation (e.g.

sheltered housing, hostels, retirement villages would be included). These are summarised in table 1

below:

Table 1: Interventions in Community settings

Intervention Rate of falls1 Risk of falling2

Multi-factorial3 RaR 0.76 (95%CI 0.67-0.86) Non significant reduction

Multi-component group exercise4

RaR 0.71 (95%CI 0.63-0.82) RR 0.85 (95%CI 0.76-0.96)

Tai Chi group exercise RaR 0.72 (95%CI 0.52-1.0) RR 0.71 (95%CI 0.57-0.87)

Individualised multi-component Home-based exercise

5 RaR 0.68 (95%CI 0.58-0.80) RR 0.78 (95%CI 0.64-0.94)

Overall exercise interventions RR 0.34 (95%CI 0.18-0.63)

Overall Vit D6

Non significant reduction Non significant reduction

Overall Home safety

RaR 0.81 (95%CI 0.68-0.97) RR 0.88 (95%CI 0.80-0.96)

Gradual withdrawal of psychotropic medication

RaR 0.34 (95%CI 0.16-0.73) Non significant reduction

Pacemakers in those with carotid sinus hypersensitivity

RaR 0.73 (95%CI 0.57-0.93) Non significant reduction

First eye cataract surgery

RaR0.66 (95%CI 0.45-0.95) Non significant reduction 1The number of falls per person per year;

2The number of people falling per year

3Assesses an individual’s risk of falling & manage appropriately to reduce these risks

4Intevention with more than one

component delivered to all in a group; 5

Intervention with more than one component based on individual assessment of risk (e.g. Otago)

6Intervention provided regardless of baseline level of Vit. D

Data source: Gillespie LD et al 2012

These findings were similar to those reported in the earlier version of this review with the exception

of: (i) overall home safety interventions, where the inclusion of more trials in the recent Cochrane

review resulted in statistically significant reduction in the rate of falling and in the risk of falling and

(ii) Tai Chi where in the earlier version, both the risk and the rate were significantly reduced but in

the latest with more trials, this only applied to the risk of falling.

The authors’ conclusions from the latest version were that overall home safety interventions and

home-based exercise programmes reduce both the rate and the risk of falling. Tai Chi reduces the

risk of falling (but only marginally the rate of falling) whilst multi-factorial (based on individual risks)

programmes reduced the rate but not the risk of falling. Although Vitamin D supplementation had

no effect, subgroup analysis showed a reduction in both the rate of falls and the risk of falling in

those who had lower vitamin D at the start of the supplementation.


The review did not include an economic analysis other than reporting from some of the included

individual trials. Thirteen trials had undertaken a comprehensive economic evaluation out of which

three had indicated cost-savings for (i) home-based exercise (Otago) in the 80 years & over (ii) home

safety assessment and modification in those with a previous fall (iii) a multi-factorial programme in

those with four or more of the eight targeted risk factors.

A second Cochrane systematic review which updates an included review in the previous report,

provided the results of meta-analysis of 60 trials (n = 60,345; 43 in care facilities, n = 30,373 and 17

in hospitals, n = 29,972) for various interventions to prevent falls in older people in these care

settings (Cameron ID et al 2012). The results are summarised in table 2 below:

Table 2: Effectiveness of falls prevention interventions in care facilities and hospital settings

Intervention Rate of falls1 Risk of falling2

Any exercise types in care facility Non-significant & conflicting Non-significant & conflicting

Multi-factorial in care facility Non-significant reduction Non-significant reduction

Medication review by Pharmacist in care facility Conflicting No effect

Additional physiotherapy (supervised exercises) in sub-acute hospital wards

Non-significant reduction RR 0.36 (95%CI 0.14-0.93)

Vit D supplementation in care facility RaR 0.63 (95%CI 0.46-0.86) Non significant reduction

Vit D + calcium in hospital patients with LOS>30d3

Not reported Non significant reduction

Multi-factorial in hospital RaR 0.69 (95%CI 0.49-0.96) Non significant reduction

Multidisciplinary care after hip fracture surgery in geriatric ward compared to orthopaedic

3 RaR 0.38 (95%CI 0.19-0.74) RR 0.41 (95%CI 0.20-0.83)

1The number of falls per person per year;

2The number of people falling per year

3From single trial only

These findings were similar to those reported in the earlier version of this review with the exception

of: (i) Medication review by Pharmacist for care facility patients was rated as effective in the

previous review in reducing the rate of falling although based on a single trial only. The addition of

other trials in the update rendered the rating as either conflicting or with no effect (ii) previously,

additional physiotherapy intervention in sub-acute ward was not covered; in the update there was

only a single trial measuring the rate of falling, and two measuring a statistically significant reduction

in the risk of falling (iii) Multi-factorial intervention in hospital was rated as effective in reducing the

risk and the rate of falling in the previous review, whilst in the update, it was effective only in

reducing the rate of falling.

The authors’ conclusions from the latest version were that vitamin D supplementation in care

facilities reduces the rate of falls; that exercise appears effective in sub-acute hospital wards but

results are conflicting in care facilities possibly reflecting different types of exercise and the range in

the level of dependency amongst the residents. Multi-factorial interventions in hospital appears

effective in reducing the rate of falls and with those delivered in care facilities, suggesting to be

beneficial.

The review did not include an economic analysis other than reporting from some of the included

individual trials. There were examples of single trials (n = 8) where there was a wide range in the

economic outcome measured and in the type of intervention used. These provided different

estimates; some where there was an increase in healthcare use, others where there was no

difference.


Three non-Cochrane systematic reviews were found: two concerned with the prevention of falls in

community-dwellers and one in long-term care facilities.

One of these reviewed with meta-analysis, trials (n = 17) of fall prevention exercise programmes in

community-dwelling older people (n = 3,305), (El-Khoury F et al 2013). The programmes were

exclusively exercise but differed in their components e.g. balance, gait, functional training. The

authors categorised outcomes in terms of the rates and severity of falls and reported that the

programmes significantly reduced the rate of falls resulting in medical care (RR 0.70, 95%CI = 0.54 to

0.92), falls resulting in severe injury, (RR 0.57, 95%CI = 0.36-0.90), and falls resulting in fractures (RR

0.39, 95%CI = 0.22 to 0.66). Overall i.e. for all injurious falls they found 37% lower rates with exercise

programmes (RR 0.63, 95% CI = 0.51 to 0.77). Although the authors provided references for the

categorisation of the falls, the precise definitions were not provided and the methods used to verify

the classification were not included. There was significant heterogeneity of the trials recording

outcomes of injurious falls but more consistency in those recording severe injurious falls.

A second systematic review without meta-analysis also involved falls prevention in community-

dwelling older people but specifically in those with cognitive impairment (Winter H et al 2013).

Eleven studies were reviewed (1,928 participants) and the interventions were diverse including

exercise, health assessment and management of risk, multi-component and cognitive-behavioural

programmes and hip protectors as risk reduction strategies. The outcomes measured were also

diverse and included proxy-measures for falls such as balance, mobility, activities of daily living and

other physical functional outcomes and psychological factors such as fear of falling. The authors

reported that in all of the studies in which all the participants were cognitively impaired or had

dementia, two demonstrated effectiveness of exercise-based interventions in improving falls risk

factors but the other three studies did not show an effect. This review highlights the difficulty in

compiling evidence from this population due to the variations in study design, interventions used

and outcomes measured. The authors concluded that there is conflicting evidence and inconclusive

results for interventions aimed at preventing falls in such a complex population.

The third systematic review also without meta-analysis, included twenty three trials (all RCTs) of

interventions to prevent falls in older people in long-term care facilities (Neyens JC et al 2011).

Participants of the trials were disabled cognitively or physically, and required functional support or

nursing care. The conclusions were that in general the evidence of effectiveness was inconclusive in

relation to single interventions or multi-faceted interventions. There was more evidence to support

multi-factorial or mono-factorial interventions where seven trials had reported significant reductions

in the fall rate and in the percentage of recurrent fallers. The review did not specify the criteria for

defining the different types of intervention.

The National Institute for Health and Care Excellence (NICE) updated its guidance (2004) for falls in

older people (NICE cg161, 2013). It recommends multi-factorial assessment and interventions in

both the community and during a hospital stay. Also recommended are strength and balance

training (particularly in the community), exercise in extended care settings, home hazard and safety

intervention but only in conjunction with follow-up and intervention, encouragement of older

people to take part in falls prevention programmes (address potential barriers such as fear of

falling). Due to insufficient evidence, it does not recommend amongst others, Vitamin D


supplementation and hip protectors. Most of the recommendations appear to be consistent with the

evidence provided by the two Cochrane reviews as described previously.

In contrast, a cost-utility evaluation of falls prevention strategies failed to demonstrate the cost-

effectiveness of most of them (Church J et al 2011). The authors used the effectiveness measures

from the earlier Cochrane review of 2009 for interventions in community dwellers and those from

the Centre for Health Economics & Evaluation, Australia for interventions in residential care

residents. Only those interventions with statistically significant reductions in the risk of falling were

included. Using a cost-effectiveness threshold of AUS $50K - $60K (roughly equivalent to that of NICE

of £20K-£30K), for the general older population, only Tai Chi was considered cost-effective at $44.9K

per QALY. For specific populations, expedited cataract surgery at $2.2K and psychotropic medication

withdrawal at $16.6K were also cost-effective. For older people in residential care, medication

review and vitamin D supplementation were the most cost-effective. It should be noted that the

effectiveness measures the economic evaluation was based on, have been superseded in the two

more recent Cochrane reviews. Home safety was not included in the economic analysis but would

have been if based on the more recent effectiveness data. Conversely, medication review in care

facilities would not have been included as this was more recently found not to be effective.

A single economic evaluation of a multi-factorial falls prevention programme in Canada, failed to

demonstrate its cost-effectiveness. This result is consistent with the Australian study above in which

this intervention was found to cost $130K to $172K per QALY.

GRADING

In the original report, interventions to prevent falls in those not specifically cognitively impaired was

overall considered to be satisfactory whilst the cost-effectiveness was rated as insufficient. The

additional evidence compiled in this report in general agrees with the previous report. In

comparison, the strength of evidence for the effectiveness of multi-factorial intervention was

similar. There was stronger evidence for home safety interventions. Vitamin D provision in the

community dwellers was again not found to be effective but again effective in residential care

settings.

Summary of the grading of interventions to prevent falls

Intervention in Community dwellers

Attribute Previous grade

Latest grade


Tai Chi group exercise Effectiveness Satisfactory Satisfactory Supportive

Cost-effectiveness Insufficient Satisfactory Changed

Multi-factorial Effectiveness Satisfactory Satisfactory Supportive


Individualised multi-component home-based exercise



Home safety Effectiveness Insufficient Satisfactory Changed


Gradual withdrawal of psychotropic medication



Vitamin D Effectiveness Insufficient Insufficient Supportive



Intervention in Community dwellers

Attribute Previous grade

Latest grade


First Eye cataract surgery Effectiveness Satisfactory Satisfactory Supportive


Falls prevention (all types) in cognitively impaired

Effectiveness Ineffective Conflicting Changed


Intervention in care facilities Attribute Previous grade

Latest grade


Multi-factorial Effectiveness Satisfactory Insufficient Supportive


Exercise Effectiveness Conflicting Conflicting Supportive


Medication review Effectiveness Satisfactory Conflicting Changed


Vitamin D supplementation Effectiveness Satisfactory Satisfactory Supportive


Intervention in hospitals Attribute Previous grade

Latest grade


Multi-factorial Effectiveness Satisfactory Satisfactory Supportive


Supervised Exercise Effectiveness Satisfactory Satisfactory Supportive


Medication review Effectiveness Satisfactory Conflicting Changed


Multidisciplinary care after hip fracture surgery

Effectiveness None Satisfactory New


C2: Self-care

Only two more recent sources of evidence were found and both relate to the management of COPD

and none in relation to gener