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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Multidimensional preventive home visit programs for community-dwelling older adults: a systematic review and meta-analysis of randomized controlled trials

A Huss, AE Stuck, LZ Rubenstein, M Egger, and KM Clough-Gorr.

Review published: 2008.

CRD summary

This review concluded that multi-dimensional preventive home visit programs with a clinical examination as part of the initial assessment had potential to reduce disability burden among older adults. The effects on nursing home admission were variable and likely to depend on a range of factors. This was a well-conducted review. The authors' conclusions were likely to be reliable.

Authors' objectives

To examine the effects of multidimensional preventive home visit programmes in older adults living in the community.

Searching

MEDLINE, EMBASE, Cochrane Database for Systematic Reviews and Cochrane Central Register of Controlled Trials were searched for the period January 2001 to October 2007 without language restrictions (search terms were reported). The references of the four most recently published meta-analyses on the topic were also searched.

Study selection

Randomised controlled trials (RCT) of multidimensional preventive home visit programmes for older adults (mean age in study >70 years) living in the community were eligible for inclusion. Programmes were required to have regular follow-up contact with participants such as multiple home visits. Post-hospital discharge programmes, home-based care management programmes and those that had a specific (such as cardiac rehabilitation) rather than a broad focus were not included. Only trials reporting nursing home admission, functional status decline or mortality as an outcome were included.

The mean age of participants in the included studies ranged from 73 to 83 years. Intervention duration ranged from four months to four years. The median number of home visits was 4.3.The interventions were delivered by a range of different people including community nurse, health visitor, geriatric nurse, geriatrician and volunteer. Most of the studies had a usual care comparator.

Three reviewers independently assessed studies for inclusion. Disagreements were resolved by consensus with a fourth reviewer.

Assessment of study quality

Two reviewers independently assessed the method of randomisation, concealment of allocation and blinding of staff assessing outcomes.

Data extraction

Two reviewers independently extracted data. Odds ratio and 95% confidence interval (CI) were calculated for the outcomes of interest. Where multiple functional outcomes measures were reported the measure based on activities of daily living was used. Trial investigators were contacted if data were missing.

Methods of synthesis

Studies were pooled using DerSimonian and Laird random-effects meta-analyses. The I2 statistic was used to assess statistical heterogeneity. Meta-regression was used to investigate heterogeneity. The variables of interest were mean age, control group mortality rate, intervention dose, use of clinical examination and whether a geriatrician was involved in the intervention. The effects of methodological quality were also assessed. Funnel plots and Egger's test were used to assess publication bias.

Results of the review

Twenty-one RCTs were included (14,597 participants). There was a modest and not statistically significant reduction in the risk of nursing home admission with multidimensional preventive home visit programs (OR 0.86; 95% CI, 0.68, 1.10). The 16 trials were heterogeneous. None of the study characteristics showed an association with nursing home admissions.

The intervention had little effect on functional status (OR 0.89; 95% CI: 0.76, 1.03, 16 trials; corrected data OR 0.87, 95% CI 0.76 to 1.01) or mortality (OR 0.92; 95% CI: 0.80, 1.05, 21 trials). The trials were heterogeneous in both analyses. Studies that included a clinical examination showed a beneficial effect on functional status (OR 0.64; 95% CI: 0.48, 0.87) but the other studies did not; there was significant heterogeneity in the former subgroup analysis. Trials with the youngest mean age group showed a beneficial effect of the intervention on mortality (OR 0.74; 95% CI: 0.58, 0.94) compared to the trials of the oldest participants. Study quality did not appear to influence the results. The authors stated that the funnel plot was symmetrical and the associated statistical tests were non significant.

Authors' conclusions

Multidimensional preventive home visit programs with a clinical examination as part of the initial assessment had potential to reduce functional decline among older adults. The effects on nursing home admission were heterogeneous and likely to depend on population, characteristics of the programme, health care setting and other factors.

CRD commentary

This systematic review had clearly stated inclusion criteria. Relevant databases were searched for relevant studies and appropriate methods were used to reduce error and bias in the review processes. The synthesis was appropriate. Heterogeneity was assessed and its sources investigated; some heterogeneity remained unexplained. Study quality was assessed and considered in the synthesis. The authors' conclusions were appropriate and likely to be reliable.

Implications of the review for practice and research

Implications for practice: the authors stated that multidimensional preventive home visits had the potential to reduce disability burden among older adults. Future programmes should be tailored to the specific regional setting.

Implications for research: high-quality trials were required to further clarify which populations benefit from multidimensional preventive home visit programmes and determine which programme characteristics were important. Individual person data (IPD) analyses of existing trials would also help establish the population, programme, intervention dose and setting characteristics that were associated with a beneficial outcome.

Funding

University of Bern

Bibliographic details

Huss A, Stuck A E, Rubenstein L Z, Egger M, Clough-Gorr K M. Multidimensional preventive home visit programs for community-dwelling older adults: a systematic review and meta-analysis of randomized controlled trials. Journals of Gerontology Series A - Biological Sciences and Medical Sciences 2008; 63(3): 298-307. [PubMed: 18375879]

Other publications of related interest

Erratum in: Journal of Gerontology: Medical Sciences 2009; 64A(2): 318.

Indexing Status

Subject indexing assigned by NLM

MeSH

Aged; Geriatric Assessment /statistics & numerical data; Home Care Services /standards; Homes for the Aged /standards; House Calls /statistics & numerical data; Humans; Interdisciplinary Communication; Patient Care Team; Randomized Controlled Trials as Topic

AccessionNumber

12008103944

Database entry date

31/03/2009

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 18375879

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