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Older people

Interventions to decrease hospital admissions among older people - All settings

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People aged 65 and older comprise about 16% of the general population in the UK, but they use 46% of NHS expenditure and occupy about 70% of acute hospital beds. After attending an emergency department they are three times more likely to be admitted to hospital than younger adults, will have a longer average length of stay in hospital, and are more likely to have serious complications associated with being in hospital, such as confusion, falls and life threatening infections, including MRSA and C difficile.

Interventions that decrease hospital admissions have the potential to reduce the incidence of these complications, improve clinical outcomes, reduce pressure on acute hospital beds, and generate cost savings.

We looked at RCTs and systematic reviews that were concerned with decreasing the number of hospital admissions among older people. During our research we found many studies of conditions that predominantly affect older people, so we also included these. The subgroups with the most information relating to them involved patients with COPD and heart failure.

We found 61 relevant studies. Of these 56 were RCTs and five were systematic reviews, meta-analyses, or both. The overall standard of the evidence was good, with a large number of patients involved in the studies.



In this section:

Key Messages

  • There is strong evidence that disease management programmes are effective in decreasing hospital admissions amongst older people with heart failure. There is also evidence that telephone management and self management for patients with heart failure are effective.
  • A smaller number of disease management trials in people with other conditions also showed evidence of effectiveness.
  • Supported discharge interventions which are integrated into rehabilitation or disease management programmes are effective in reducing readmission rates.
  • Geriatric assessment and case management with long term follow up were effective for older people with complex needs in most studies.
  • Preventive home visits improve patients’ experience but do not reduce rates of admission to hospital.
  • Many types of interventions were used in the large number of studies we looked at and these were separated into nine groups: disease management; comprehensive geriatric assessment; self management programmes; telephone management; early supported discharge; pharmacist led medication reviews; preventative home visits; nurse led case management for older people with complex needs; and other interventions with evidence from single RCTs.

Population Interventions

Interventions that do work

Disease management

There is strong evidence from a large number of studies (including many RCTs) that disease management programmes for older people with heart failure help reduce rates of admission to hospital as well as producing other benefits. 1 2 3 4 5 6 7 8 9 10 11 These programmes involve care coordination, with access to multidisciplinary specialist teams combined with patient and family education. Many of the programmes were started after a first hospitalisation with heart failure. The effect was mainly in reducing rates of readmission.

Other studies show that this approach is effective in other conditions including following myocardial infarction, 12 COPD, 13 and cancer. 14

The SPAN-CHF trial was an RCT of disease management for heart failure in 200 patients with a high use of medications for heart failure. 3 Patients randomised to the intervention arm received a home visit from a nurse manager. A caregiver also provided patients with education about dietary and medical compliance, daily weights, self monitoring, and early reporting of changes in medical status. The patient and caregiver were given a handbook outlining the SPAN-CHF programme, and the nurse identified any impediments to compliance during the home visit. The nurse manager phoned patients weekly or biweekly. Patients were instructed to report changes in weight greater than 2 lb.

The intervention lasted 90 days, during which patients in the intervention arm had fewer hospital admissions (0.55 ± 0.15 per patient year alive in the intervention arm, versus 1.14 ± 0.22 per patient year alive in the control arm. Relative risk 0.48; P = 0.027). Patients in the intervention arm also spent fewer days in hospital. A cost utility ratio analysis showed that the management strategy was cost effective. 4

Interventions that may work

Comprehensive geriatric assessment

A large number of studies, including at least four RCTs, has examined the effectiveness of comprehensive geriatric assessment and case management of older people with complex needs. 15 16 17 18 19 20 21 22 23 24 Although the effect of the intervention on hospital admission rates in the studies was mixed, the intervention does appear to be effective where there are strong systems for long term follow up and management. 23 There are also other benefits on mortality, functional status, and need for residential care.

The studies were conducted in various countries including Sweden, Australia, Italy, and the US. The DEED 11 study 19 looked at 739 patients aged 75 and older who had been discharged from the emergency department of a large public hospital in Southern Australia. Patients were randomised into a usual care group or an initial comprehensive geriatric assessment group with follow up at home for 28 days by a hospital based multidisciplinary team.

Patients in the intervention group had lower rates of admissions to hospital during the first 30 days after the initial emergency room visit (16.5% versus 22.2%; P =. 048). They also had a lower rate of emergency admissions during the 18 month follow up period. There was no difference in mortality.

See Factfile: Comprehensive geriatric assessment

Self management programmes

Studies (mostly RCTs) of self management programmes for older people include trials of patients with specific conditions such as COPD, 25 26 heart failure, 27 and complex needs. 28

The programmes appear to be effective, although evidence was conflicting in one study. 26 In this study 92 patients with COPD were randomised to usual care or to a care plan. The care plan was developed by specialist nurses, GPs, specialists, healthcare professionals in after hours clinics, and hospital providers. There was no significant difference in hospital admissions or quality of life over the 12 month follow up period.

One RCT looked at self management for heart failure in patients with all levels of literacy. 27 Some 123 patients were randomised to an intervention group, which involved education on self care (such as on weight gain, managing doses of diuretic, and recognising and responding to symptoms). 27 Picture based educational materials, a digital scale, and telephone follow up were used. Patients in the control group were given a generic heart failure brochure and usual care.

Patients in the intervention group had lower rates of hospitalisation or death (crude incidence rate ratio (IRR) = 0.69, CI = 0.4–1.2; adjusted IRR = 0.53, CI = 0.32–0.89). Further studies are needed, particularly in older people with complex needs.

Telephone management

Telephone management as a means of patient education, counselling, and follow up has been evaluated in a number of RCTs involving older people. Most showed benefits in reducing hospital admissions, 29 30 31 32 particularly among people with heart failure. 29 30 31 But there were negative results in a study of telephone support in older people of Mexican origin with heart failure, 33 and in a group of predominantly male older people with complex health and care needs. 34

The DIAL trial involved 51 centres in Argentina and followed up 1518 outpatients with chronic heart failure who were stratified by the attending cardiologist to usual care or to telephone intervention. 29 Patients in the intervention group were given an education booklet. Telephone calls from nurses were used to educate and monitor patients. The intervention was based on five objectives: adherence to diet, adherence to drug treatment, monitoring of symptoms, control of hydrosaline retention (daily weight and oedema), and daily physical exercise.

The 758 patients in the usual care group were more likely to be admitted for worsening heart failure or to die (235 events, 31%) than the 760 patients in the intervention group (200 events, 26.3%) (relative risk reduction = 20%, 95% CI 3–334; P = 0.005). This benefit was largely due to a significant reduction in admissions for heart failure. Mortality was similar in both groups.

Telephone management appears to be a valuable adjunct to disease management programmes for older people with heart failure, but there is insufficient evidence for its effectiveness in other groups.

Early supported discharge

Most but not all of the seven studies of early supported discharge showed positive benefits for rates of readmission in addition to benefits in reducing length of stay. 35 36 37 38 39 40 41

One cluster RCT looked at 680 residents aged 65 and older in 22 nursing homes in Canada. 41 Patients with pneumonia were randomised to usual care or to treatment in the home according to a clinical pathway, including oral microbials, portable chest x-rays, oxygen saturation monitoring, rehydration, and close monitoring by a nurse.

Thirty four (17%) of the clinical pathway group were hospitalised, compared with 78 (22%) of the usual care group. Adjusting for clustering, the weighted mean reduction in hospitalisations was 12% (95% CI 5–18%; P = 0.001). Length of stay in hospital was also reduced to 0.79 days in the clinical pathway group, compared with 1.74 days in the usual care group, with a weighted mean difference of 0.95 days per resident (95% CI 0.34–1.55 days; P = .0004). The clinical pathway was estimated to reduce costs by US$1016 per resident.

In another RCT 363 patients were randomised after hospital admission to usual care or to a comprehensive discharge planning and home follow up protocol designed specifically for older people at high risk of poorer outcomes after discharge. 36 Patients were followed up for four weeks. In the intervention group advance practice nurses carried out the discharge planning, and this was taken over by the visiting nurse on discharge. Patients received regular visits from the nurse, and telephone contact was also used. The nurses assessed individual needs and focused on diet, activity, medications, and symptom management with written instructions and medication schedules. The mean age of participants was 75. By week 24 after hospital discharge patients in the control group were more likely than patients in the intervention group to be readmitted at least once (37.1% versus 20.3%; P < 0.001).

See Factfile: Early supported discharge

Pharmacist led medication reviews

Three RCTs of medicines reviews by pharmacists during discharge planning or during post hospital care have shown mixed results. 42 43 44 One RCT looked at 872 patients older than 80 recruited during an emergency admission who were on two or more drugs on admission and were returning to their own home or warden controlled flat. 43 They were randomised to usual care or to an intervention group, which received two visits by a pharmacist within two and eight weeks of discharge. The pharmacist educated patients and carers about their drugs, removed out of date drugs, and informed their GP of drug reactions or interactions.

By six months 178 readmissions had occurred in the control group and 234 readmissions had occurred in the intervention group (rate ratio = 1.30, 95% CI 1.07–1.58; P = 0.0009). There was no significant difference in mortality rates between the groups. The authors speculated that getting older people to adhere to drugs may increase iatrogenic conditions. However, adherence was not measured in this study. Further research is needed to identify where medicines reviews by pharmacists will have greatest benefit for patients and on impact on hospital bed use.

Specific interventions with evidence from single RCTs

There is evidence from single RCTs about impact on hospital admission rates from a range of interventions. Positive effects are reported for telemonitoring for patients with heart failure, 45 rapid access to specialist care for older people with cancer, 14 group visits in primary care, 46 and physical activity counselling for older people. 47

Studies of GP guidelines for managing patients with COPD and organised stroke care in hospital showed no impact on admission. 48 49

Interventions that do not work

Preventative home visits

Although there are benefits (including improved wellbeing, functional status, and reduced need for care home placement) from providing preventive home visits to the general population of older people, two systematic reviews of 15 trials showed no impact on rates of admissions to hospital. 50 51 52 53

Nurse led case management for older people with complex needs

Three RCTs examined the role of specialist nurses in assessing and coordinating care for older people with complex needs. 34 54 55 These did not show evidence of reducing the need for hospital admission, although other benefits – particularly in relation to patient satisfaction – were observed. 54 55

What we don’t know

Introducing community matrons into primary care systems to undertake chronic disease management for older people with complex needs has not been shown to be effective in reducing the need for hospital based care.

However, our review suggests that as the community matron model is developed and evaluated it should build on the successful models of disease management for people with single conditions (where there is a multidisciplinary approach and rapid access to secondary care specialists) or of comprehensive geriatric assessment for people with complex problems (where there is not only a multidisciplinary approach and rapid access to secondary care specialists, but also integration with the social care response).

References

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Contributors

Professor Ian Philp

Older People

Professor Ian Philp was appointed Professor and Honorary Consultant Physician in Sheffield in 1994 and his clinical team won the older people’s category of the UK Hospital Doctor of the Year Award in 1998. He established the Sheffield Institute for Studies on Ageing, which went on to win the Queen’s Award for Higher Education in 2002 for its research into the health and social care of older people. He has been an adviser to the World Health Organisation’s European Regional Office on quality evaluation in the care of older people and was co-chair of the External Reference Group of the National Service Framework for Elderly People Services for the NHS. He is currently National Director for Older People's Services with the Department of Health, with responsibility for implementing both the National Service Framework for Older People and Long Term Conditions. His current research centres on assessing the needs of older people and their family carers and he has published widely on this topic.

Kelly MacKenzie

Older People

Kelly MacKenzie is currently studying medicine at Leeds University where she has worked with Professor Ian Philp in the area of public health and older people. She has produced reports on conditions that particularly affect elderly populations, such as arthritis and heart disease, and has researched the social and psychological impact of such diseases. She has also produced work on Comprehensive Geriatric Assessments and their effectiveness. She will shortly be completing an Academic Foundation Programme at St James University Hospital in Leeds.