Effects of preventive home visits to elderly people living in the community: systematic review
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7237.754 (Published 18 March 2000) Cite this as: BMJ 2000;320:754
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EDITOR - In their response to our review of preventive home visits to
community-living elderly persons [1], Stuck [2] and Fletcher [3]
criticised several aspects of our study. Stuck discussed our method of
analysis, which he considers to be inadequate. As we reported in our
paper, we seriously considered statistical pooling of the data of the
included trials. However, owing to the large clinical heterogeneity of our
set of trials, statistically pooling the data of these fifteen trials is
extremely hazardous and in our opinion inappropriate. Only when clinically
homogeneous subsets could be generated from this set of trials, data
pooling could be justified and potentially useful. Yet, in our opinion, it
is not possible to distinguish such homogeneous subsets, mainly owing to
the large clinical heterogeneity of the interventions. In addition,
considerable differences exist between subjects, outcome measures, timing
of outcome measurement and the health care settings in which the
interventions were performed. We therefore chose for a more generic
approach by performing a detailed qualitative systematic review of the
effects of this diverse set of preventive home visit programmes.
Fletcher stated that lack of power is one of the major limitations of
most of the trials included in our review. It can be observed however that
ten of the fifteen studies we reviewed, included between 200 and 700
subjects per group which makes it highly unlikely that a lack of power
could have seriously influenced the results of these studies. Moreover,
when we seperately analyse the results of these ten large studies, we
still come to the same conclusion: no clear evidence exist in favour of
the effectiveness of preventive home visits to elderly people living in
the community.
With regard to our methodological quality assessment, Stuck stated
that rather than calculating a summary score, the methodological aspects
that are important should have been identified and assessed individually.
That is what we did in our study: identify methodologically relevant
aspects and assess them individually.
- One could argue about the relevance of items included in quality scales.
Stuck for example argues that co-interventions are an integral part of
preventive home visits, and are therefor not relevant. However, the
relevance of this item completely depends on the way one defines co-
interventions. We defined it as 'every additional intervention that is not
included in the intervention protocol and does not result from it'.
- We agree with Stuck that concealment of treatment allocation is a
relevant measure of methodological quality. It is however very unlikely
that including this item in our quality scale would have differentiated
between trials of different quality, because for the majority of trials it
could not be assessed whether treatment allocation was successfully
concealed or not.
- In our paper we only presented the summary scores of our methodological
quality scale and its four subscales, because the main purpose of our
quality assessment was to give an indication of the overall methodological
quality of each trial. A copy of the scores on the individual items is
available on request.
Currently, we think it is not possible to properly distinguish the
active components from the total set of components of preventive home
visit programmes, because of the 'black box' character of the intervention
programmes. However, with regard to future research we certainly agree
with Stuck that researchers should aim at clarifying what components of
preventive home visits work in which population groups. This could
possibly improve consensus in this field of study and hopefully may result
in the development of more effective interventions.
[1] van Haastregt JCM, Diederiks JPM, van Rossum E, de Witte LP,
Crebolder HFJM. Effects of preventive home visits to elderly people living
in the community: systematic review. BMJ 2000;320:754-8.
[2] Stuck AE. Review of preventive home visits to elderly people: Is
vote counting the answer? Response published on BMJ website: 11 april
2000.
[3] Fletcher A. Effects of preventive home visits to elderly people
living in the community: systematic review. Response published on BMJ
website: 11 april 2000.
Competing interests: No competing interests
Dear Sir - We were interested to see your systematic review on
preventive home visits from a care attendant to elderly people (1). One
specific area in which such visits have been found to be of significant
value is to those over 75 years at hospital discharge.
We evaluated a scheme in which elderly patients were visited at home by a
care attendant immediately after hospital discharge irrespective of
apparent need; and followed up 903 patients for 18 months in a randomised
controlled trial, half receiving only standard discharge care (2). The
scheme aimed to provide a safety net to include patients assessed as not
needing care and to check gaps in provision or failure to implement
services. This age group has a high readmission rate with half being
readmitted at least once within the year. Those receiving visits had
significantly fewer multiple readmissions (7% v 14% twice or more in 18
months) and emergency readmissions (3). Hospital days were reduced
particularly for those living alone (17 days v 31 days over 18 months).
The scheme cost £26 000 per 100 000 population with short-term savings of
£115 000 and much higher long-term savings (1985/6 values).
The NHS
successfully implemented and evaluated schemes in four centres in North
Thames (Waltham Forest, Basildon, Enfield and Tower Hamlets) based on this
research. Similar results to the original research were reported together
with clear evidence that they were highly valued by the patients, health
and social services staff (4).
It seems that at least one home visit immediately after discharge of an
elderly individual from hospital, in addition to usual assessment, is
highly beneficial and cost effective.
Joy Townsend
Andrew Frank
Mary Piper
References
1. van Haastregt, JCM, Diederiks JPM, van Rossum E, de Witte LP,
Crebolder HFJM. Effects of preventive home visits to elderly people living
in the community: systematic review. BMJ 2000; 320: 754-8
2. Townsend J, Piper M, Frank AO, Dyer S, North WRS, Meade TW.
Reduction in hospital readmission stay of elderly patients by a community-
based hospital discharge scheme: a randomised controlled trial. BMJ 1988;
297: 544-7
3. Townsend J, Dyer S, Cooper J, Piper M, Frank AO. Emergency
hospital admissions and readmissions of patients aged over 75 years and
the effects of a community-based discharge scheme. Health Trends 1992;
24(4): 136-9
4. Townsend J. Hospital Aftercare Service for older people (care
attended scheme) implementation study. Report to NHSE North Thames,
November 1997.
Competing interests: No competing interests
Dear Sir - The authors (1) rightly point out that a formal pooling of the results of
the RCTs on preventive home visits was not appropriate given the
"considerable heterogeneity of the
interventions". However the information they provide is uninformative:
they present only the results for selected outcomes in terms of being
"significant" or "non significant" with no information on the estimates of
effect or the confidence intervals. This information is
essential to understand the magnitude of possible benefits, and the
precision of estimates of benefit. Lack of power is one of the major
limitations of most of the studies reviewed
especially for mortality outcomes.
Their review also misses some other important methodological problems (2).
The studies in general practice used within practice individual
randomisation and this may have resulted in 'contamination' of the control
group. Most European trials suffered from "black box" interventions while
the US trials had low participation rates and over-represented high-income
fit elderly. In none of the trials was there adequate information
regarding the cost-effectiveness of multidimensional assessment.
We agree with the authors' conclusions that there is currently limited
evidence for the benefit of multidimensional assessment of older people.
These concerns are more than "academic" since regular health checks for
the over 75s were introduced by the DOH in 1990 as a contractual
obligation of GPs. Not surprisingly, most general practitioners view the
policy unfavourably while nurses and elderly people are enthusiastic about
the health checks and consider them to be of value (3-5).
The current situation is unsatisfactory but abandoning the health checks
is not a sensible option at the present time. Within the UK there are some
models of good practice and ongoing research. A large trial is in
progress, which will provide important data on the cost effectiveness of
different methods of assessment and management of elderly people within
the context of the 1990 contract of service. The trial, funded by the MRC
and Department of Health
has been designed to have adequate power to detect benefits in mortality,
hospital admissions and quality of life. 106 General Practices and 33,000
elderly people from the MRC GP Research Framework are participating with
results expected in 2001.
There are strong arguments for regular assessment of elderly people on the
basis of their special needs. The UK policy was introduced prematurely in
the absence of evidence of benefit.
It would be equally premature to withdraw the policy based on the results
of the small, low powered studies, with a mixed and uncertain bag of
interventions, described in this review.
Astrid Fletcher,
Professor of Epidemiology & Ageing,
London School of Hygiene &
Tropical Medicine
Christopher Bulpitt,
Professor of Geriatric Medicine,
Imperial College School of Medicine
London, Hammersmith Campus
on behalf of the MRC Trial of Assessment and Management of elderly
people in the community
1. van Haastregt JCM, Diederiks JPM, van Rossum E, de Witte LP,
Crebolder HFJM. Effects of
preventive home visits to elderly people living in the community:
systematic review. BMJ
2000;320:754-8
2. Fletcher AE. Multidimensional assessment of elderly people.
British Medical Bulletin 1998; 1998;54:945-960.
3. Tremellen J Assessment of patients aged over 75 in general
practice. BMJ 1992;305:621-624
4. Chew CA, Wilkin D, Glendenning C. Annual assessment of patients
aged 75 years and over; general practitioners and practice nurses views
and experiences. Br J Gen Pract 1994;44:263-7
5. McIntosh IB, Power KG. Elderly people's views of an annual
screening assessment. Br J Gen Prac1993;43:189-192
Competing interests: No competing interests
EDITOR - Haastregt et al conclude that there is little evidence
supporting the effectiveness of preventive home visits to elderly people
living in the community (1). Their review is timely but methodological
shortcomings limit its usefulness. The principal method of analysis
consisted of "vote counting": adding up the number of studies showing
statistically significant effects. This procedure is a sad relic from the
times of unsystematic, narrative reviews, ignoring sample size, effect
size, type of intervention and methodological quality (2). For example, it
is important to distinguish between preventive home visits that included
multidimensional geriatric assessment with follow-up and interventions
that did not (3).
Assessment of the quality of trials was also problematic. Empirical
research has shown that the scale used by Haastregt et al, and scales in
general, may produce misleading results (4). Rather than calculating a
summary score the methodological aspects that are important in a given
context should be identified and assessed individually. Some of the items
included by Haastregt et al are not relevant in this context ("co-
interventions" are an integral part of preventive home visits), others do
not measure the quality of a trial (adverse effects are an important
outcome but not a measure of methodological quality), while important
dimensions of quality (for example, concealment of allocation) were
lacking from the list of items.
Three of us (AS, JCB, CM) were involved in a randomised trial of
preventive home visits which was conducted in Berne, Switzerland (5). The
findings from this trial, which was published after the review by
Haastregt et al appeared showed that preventive home visits can reduce
disability, which in a 3-year period may save up to 1400 US $ per person
per year (5). In a planned subgroup analysis we found that the effect of
the intervention depended on the base-line risk status of trial
participants (disability was reduced among persons at low-risk at base-
line, but not among high-risk participants). In addition, the professional
experience of the person visiting was an important factor determining
programme efficacy. These findings indicate that the composition of the
study population and the type and quality of the intervention are
important factors which may explain the discrepant results obtained from
randomised trials of preventive home visits.
Although there are conflicting results between individual trials of
preventive home visits, some trials clearly demonstrate that home visits
can substantially reduce or delay the onset of disability. Thus, research
is needed to explicitly define the conditions for cost-effective
programmes for reducing disability among older people. We agree with
Haastregt et al that it is often inappropriate to combine a heterogeneous
set of trials. However, vote counting cannot identify the factors
introducing heterogeneity. Further meta-analytic and trial research is
required to clarify what components of this complex intervention work in
which population groups.
Andreas Stuck, medical director
Department of Geriatrics and Rehabilitation, 3001 Bern, Switzerland
andreas.stuck@zieglerspital.bern
Matthias Egger, senior lecturer in epidemiology and public health
medicine
MRC Health Services Research Collaboration,
Department of Social Medicine, University of Bristol
Christoph E. Minder, senior biostatistician
Department of Social and Preventive Medicine, University of Bern
Steve Iliffe, reader in general practice
Department of Primary Care & Population Sciences, Royal Free &
University College
London Medical School
John C. Beck, MD, professor of medicine (geriatrics),
UCLA School of Medicine, Los Angeles, USA
References
(1) Van Haastregt JCM, Diederiks JPM, van Rossum et al. Effects of
preventive home visits to elderly people living in the community:
systematic review. BMJ 2000;320:754-8.
(2) Egger M, Davey Smith G. Rationale, potentials and promise. In:
Egger M, Davey Smith G, Altman DG. Systematic Reviews in Health Care: Meta
-Analysis in Context. London: BMJ Books (in press).
(3) Stuck AE, Walthert J, Nikolaus T, Büla CJ, Hohmann C, Beck JC.
Risk factors for functional status decline in community-dwelling elderly
people: a systematic literature review. Soc Sci Med 1999; 48:445-469.
(4) Jüni P, Witschi A, Bloch R, Egger M. The hazards of scoring the
quality of clinical trials for meta-analysis. JAMA 1999; 282:1054-1060
(5) Stuck AE, Minder CE, Peter-Wüest I, Gillmann G, Egli C,
Kesselring A, Leu RE, Beck JC. A randomized trial of in-home visits for
disability prevention in community-dwelling older people at low and at
high risk for nursing home admission. Arch Intern Med 2000 . Arch Intern
Med 2000; 160:977-986
Competing interests: No competing interests
“75+ Health Assessment in Australia.”
The systematic review by Van Haastregt et al of trials of preventive
home visit for the elderly (65+) reported that “no clear evidence was
found in favour” of such visits (1) . Some of the trials reviewed found
favourable effects in some of the five main outcome measures (physical
functioning, psychosocial functioning, falls, admissions to institutions
and mortality) but most found no effect. However, van Haarstregt’s review
demonstrates, but does not comment on, the observation that favourable
outcomes were more prevalent in studies conducted in older subjects (75+).
Table 1 is constructed from the analysis they report.
Table 1
_______________________________________________________
Number of Number (%)
favourable of these
studies favourable
studies in 75+
people
_______________________________________________________
Physical functioning 5 1 (20)
Psychosocial functioning 1 1 (100)
Falls 2 1 (50)
Admission to institution 2 2 (100)
Mortality 3 2 (67)
_______________________________________________________
Physical functioning outcomes are the exception with only 1 of the 5
favourable studies being in 75+ people. This is not unexpected. The
ability to improve physical functioning may be easier in the 65+ group
generally than in the 75+ group specifically.
General practitioners in Australia have recently been funded for “75+
Health Assessments”.
We have just concluded a randomised controlled trial of “75+ Health
Assessments”. The protocol for the trial was briefly described in a
previous letter (2) . A nurse visited 100 community living elderly people
twice, one year apart (50 control, 50 intervention). No interval
assessment nor reminder was included in the protocol.
Initial analysis includes:
Fewer people reported falls in intervention group in the study year (12 vs
22, p= 0.055)
Mortality less in intervention group (1 vs 5, p = 0.2)
No change in physical functioning (Barthel Index of Activities of Daily
Living)
Psychosocial functioning improvement. (Geriatric Depression Scale 15,
Wilcoxon scores (rank sums) p =0.09 )
Our study is consistent with the other published trials, demonstrating
modest improvement in the measured outcomes in the 75+ age group.
Van Haarstregt et al call for either improved effectiveness of
preventive home visits or their discontinuation. Their data support, as do
our initial results, that annual preventive home visits are most useful in
the 75+ age group. A BMJ editorial 12 years ago also made the point that
65 is too young to start preventive home visits . Evaluation of the
Australian “75+ Health Assessments” will establish if they have a
beneficial effect on outcome.
Dr. Jonathan Newbury
Professor John Marley
Department of General Practice,
University of Adelaide,
Adelaide 5005, Australia
jnewbury@medicine.adelaide.edu.au
(1) Van Haarstregt JCM, Diederiks JPM, van Rossum E, de Witte LP, Crebolder HFJM. Effects of preventive home visits to elderly people living in the community: systematic review. BMJ 2000; 320: 754-758.
(2) Newbury J, Marley J. eLetter BMJ www.bmj.com/cgi/content/abstract/319/7211/683#responses
(3) Buckley EG, Williamson J. What sort of "health checks" for older people? BMJ 1988; 296:1145.
Competing interests: Table 1_______________________________________________________ Number of Number (%) favourable of these studies favourable studies in 75+ people_______________________________________________________Physical functioning 5 1 (20)Psychosocial functioning 1 1 (100)Falls 2 1 (50)Admission to institution 2 2 (100)Mortality 3 2 (67)_______________________________________________________
I read with interest the article by van Haastregt et al on preventive
home visits to elderly people1. As a general practitioner in an area with
a large elderly population, I have experienced personally the advantages
of thorough assessment of individuals during home visits. This leads to
the detection of significant amounts of previously undiagnosed pathology,
much of which might be potentially serious if left untreated.
Many of these individuals have few social contacts and their quality
of life is improved by the personal interaction provided by health
professionals. Other advantages gained by these visits include the support
provided to family and carers.
Under the red book regulations, general practitioners should offer
each patient over the age of 75 years a consultation and a domiciliary
visit annually. However, formal screening of all elderly individuals in
general practice is an expensive undertaking2, and may not be cost-
effective. There is some evidence that screening produces an increase in
use of health care services, but only a minimal change in health state3. A
high proportion of this population are seen by their general practitioner
each year for acute needs, and the benefits of this care are probably best
provided by opportunistic screening.
Reference List
1. van Haastregt JCM, Diederiks JPM, van Rossum E, de Witte LP,
Crebolder HFJM. Effects of preventive home visits to elderly people living
in the community: systemic review. 2000.
2. Wallis JB,.Barber JH. The effect of a system of geriatric
screening and assessment on general practice workload. Health Bull (Edinb)
1982;40:125-32.
3. Tulloch AJ,.Moore V. A randomised controlled trial of geriatric
screening and surveillance in general practice. J.R.Coll.Gen.Pract.
1979;29:733-42.
Competing interests: No competing interests
Re-analysis of results of included studies does not support original review conclusions.
Dear Editor
As part of a teaching exercise for a session on an MPH course the
students and I recently examined the article by van Haastregt et al. This
was chosen at random, without any suspicion that it contained errors. To
illustrate problems associated with data extraction and analysis in
systematic reviews, we obtained the original papers for the 15 included
studies and looked in detail at two of the outcomes considered in the
original review - falls and mortality. These two outcomes were chosen for
reasons of feasibility. When we did this, considering the full data
presented in the original reports, we uncovered a pattern of small effects
that generally favoured the preventive home visit arms of the included
trials. This is illustrated for the mortality data in the odds ratio
diagram below, but also applied to data on falls:
http://www.bham.ac.uk/arif/preventive2.jpg
I would highlight three issues arising from the re-analysis
performed.
First, problems associated with vote-counting as a method of analysis
in systematic reviews were highlighted in correspondence following the
original article. This concern seems to be vindicated as the vote-counting
technique employed in the original review, seems to have over-looked the
possibility of drawing conclusions on the basis of consistent, small
effects, few of which are statistically significant. Quantitative summary
(meta-analysis) is the obvious way to identify such a pattern, but
qualitative synthesis which records and considers the direction of the
results and the sizes of any effects where quantified would also work.
There appears to be an urgent need to re-examine the results of all
outcomes of the included studies in the original systematic review using
such approaches.
Second, even ahead of such fuller re-analysis, the mortality data
alone seem to challenge the conclusion reached by van Haastregt et al, "No
clear evidence was found in favour of the effectiveness of preventive home
visits to elderly people living in the community". Although there is some
statistical heterogeneity in the mortality results, there is reasonably
clear evidence of a small beneficial effect on mortality in most trials
which demands that consideration continue to be given to preventive health
visits as a useful health intervention. Even if it is thought that the
effect of the given intervention on mortality is unlikely by virtue of
biological implausibility, the fact that the effect has been observed
empirically suggests further investigation is essential. This is
completely at odds with the bottom-line offered by van Haastregt et al
that, "It seems essential that the effectiveness of such visits is
improved, but if this cannot be achieved consideration should be given to
discontinuing these visits."
Finally, the case in question alerts to the fallibility of standard
practice in implementing the results of systematic reviews (and other
research). In this we have come to assume that provided articles meet
standard critical appraisal criteria they will provide internally valid
results which can be safely applied if benefits seem to outweigh
disbenefits and costs. Unfortunately the review in question meets commonly
used criteria for systematic reviews such as clarity of question, focus on
RCTs as the most appropriate study design to assess effectiveness,
comprehensiveness of search strategy and assessment of the quality of
included studies. The unwary might have been tempted to act on it. Thus,
particularly in the context of decisions with far-reaching consequences,
this example should remind that greater depth of assessment is essential.
In retrospect, the inability to follow the conclusions made in this
systematic review back to the results as they would have been presented in
the original papers should have raised an alarm. In our view the results
of the included studies as summarised were not a true reflection of the
data in the original papers. A simple safeguard that would help alert to
problems of this sort is to directly scrutinise a selection of the
included studies prior to decisions on implementation. We suggest that
particularly for health policy and population level health care decisions,
this step should become routine.
I have no conflicts of interest concerning this topic.
Competing interests: No competing interests