NIHR DISSEMINATION CENTRE
This review looks at the concept of 'frailty' in older people and what can be done to raise awareness amongst hospital staff, so that they can better identify and manage the needs of this ‘frail’ older people. It features 53 completed and ongoing studies funded by the National Institute of Health Research. The review covers four key aspects of caring for older people living with frailty in hospital: assessment; identifying and managing symptoms associated with frailty in hospital; discharge planning; and caring environments which consider the context in which inpatient diagnosis and treatment is delivered. The review highlights promising evaluations of workplace training and interventions. It also identifies a number of tools, such as the Frailty Index, that can help hospital staff to identify the severity of needs and help to provide targeted support. It also finds good evidence that the Comprehensive Geriatric Assessment (CGA) is a reliable way of diagnosing and meeting the needs of older people with input from multi-disciplinary teams. It also identifies areas where more research is needed, which include: maintaining activities of daily living for people admitted to hospital; and the effectiveness and cost-effectiveness of different models of delivering care. The review also includes a series of questions that hospital boards, staff and families can ask about the care of older people with frailty in hospitals. Summaries of the 53 studies are also included.
DAMERY Sarah, FLANAGAN Sarah, COMBES Gill
Objective: To summarise the evidence regarding the effectiveness of integrated care interventions in reducing hospital activity.
Design: Umbrella review of systematic reviews and meta-analyses.
Setting: Interventions must have delivered care crossing the boundary between at least two health and/or social care settings.
Participants: Adult patients with one or more chronic diseases.
Data sources: MEDLINE, Embase, ASSIA, PsycINFO, HMIC, CINAHL, Cochrane Library (HTA database,DARE, Cochrane Database of Systematic Reviews), EPPI-Centre, TRIP, HEED, manual screening of references.
Outcome measures: Any measure of hospital admission or readmission, length of stay (LoS), accident and emergency use, healthcare costs.
Results: 50 reviews were included. Interventions focused on case management (n=8), chronic care model (CCM) (n=9), discharge management (n=15), complex interventions (n=3), multidisciplinary teams (MDT) (n=10) and self-management (n=5). 29 reviews
reported statistically significant improvements in at least one outcome. 11/21 reviews reported significantly reduced emergency admissions (15–50%); 11/24 showed significant reductions in all-cause (10–30%) or condition-specific (15–50%) readmissions; 9/16 reported LoS reductions of 1–7 days and 4/9 showed significantly lower A&E use (30–40%). 10/25 reviews reported significant cost reductions but provided little robust evidence. Effective interventions included discharge management with post-discharge support, MDT care with teams that include condition-specific expertise, specialist nurses and/or pharmacists and self-management as an adjunct to broader interventions. Interventions were most effective when targeting single conditions such as heart failure, and when care was provided in patients’ homes.
Conclusions: Although all outcomes showed some significant reductions, and a number of potentially effective interventions were found, interventions rarely demonstrated unequivocally positive effects. Despite the centrality of integrated care to current policy, questions remain about whether the magnitude of potentially achievable gains is enough to satisfy national targets for reductions in hospital activity.
SAMPSON Christopher, et al
Introduction: Occupational therapy interventions, such as home visits, have been identified as being resource-intensive, but cost-effectiveness analyses are rarely, if ever, carried out. The authors sought to estimate the cost-effectiveness of occupational therapy home visits after stroke, as part of a feasibility study, and to demonstrate the value and methods of economic evaluation.
Method: The authors completed a cost-effectiveness analysis of pre-discharge occupational therapy home visits after stroke compared with a hospital-based interview, carried out alongside a feasibility randomised controlled trial. Their primary outcome was quality-adjusted life years. Full cost and outcome data were available for 65 trial participants.
Findings: The mean total cost of a home visit was found to be £183, compared with £75 for a hospital interview. Home visits are shown to be slightly more effective, resulting in a cost per quality-adjusted life year of just over £20,000.
Conclusion: The author's analysis is the only economic evaluation of this intervention to date. Home visits are shown to be more expensive and more effective than a hospital-based interview, but the results are subject to a high level of uncertainty and should be treated as such. Further economic evaluations in this field are encouraged.