Preventing admission of older people to hospital
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3186 (Published 20 May 2013) Cite this as: BMJ 2013;346:f3186
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Sir, we would like to put forward a number of caveats that will help generate a more balanced argument towards this discussion:
- The authors appear to heavily focus on community based case management models as the main intervention but have not acknowledged the national QIPP LTC model of care which recommends the 3 underpinning drivers for whole system change, of which case management forms only part of it and cannot be prescribed in silo. The ideal model of care has to be redesign of our existing services which should include a number of interventions starting with targeting strategies such as risk stratification, a single assessment framework followed by multi disciplinary meetings where anticipatory care planning is carried out, incorporating systematized self care self management using, among others, assistive technologies in partnership with the third sector and voluntary organisations. All of this need to be commissioned together at pace and scale.
- The authors have not acknowledged the importance of how and when patients should be identified / selected for case management and care coordination which will have an impact on admission avoidance. If frequent fliers are targeted when they are in ‘crisis’, chances are that any reduction of admissions would have occurred irrespective of any intervention due to regression to the mean. Integrated care approach should be implemented before the ‘crisis’ to avert the ‘crisis’ resulting in admission avoidance.
- Understanding urgent care activity is complex and not straightforward. There are a multitude of push and pull factors that contribute to it. A systematic review done by University of Bristol in 2012 looking quality of evidence in reducing unplanned admissions admitted that while most researched interventions, including case management, have demonstrated little benefit, they admit that few research studies include evaluation of system wide approaches, hence the impact of programmes of interventions are rarely reported in the research literature. This highlights the importance of robust evaluation of interventions as they are introduced into health and social care systems. In this regard we recommend that any future whole system phased transformational approach to managing urgent care should be underpinned by a robust rolling evaluation framework using complex adaptive systems theory to account for the dynamic nature and complex inter relationships between different patients, services and their interventions, and organisations rather than relying on specific ‘cause and effect’ associations.
- Finally in light of Roemer’s Law which implies that a hospital bed available is a hospital bed filled, stresses the importance of supply induced demand. Investment into any integrated model of care in the community ultimately needs to be aligned with a concomitant disinvestment in acute care capacity or reduction in hospital beds, to ensure desired outcomes and sustainability of the new model in question. In this regard, the main outcomes will not be unscheduled admissions because any reduction would have been planned at the outset, but rather outcomes on patient safety, impact on other urgent care services such as ambulance call outs, OOH/111 and unscheduled primary care activity.
Competing interests: No competing interests
Sir,
We would like to emphasise that our article was not against investment in community services. Our editorial acknowledged clear evidence that community services are associated with high levels of patient satisfaction and reduced subsequent institutionalisation. Additionally, community care is generally preferred by patients who are eager to be treated closer to home. As geriatricians, we were keen to support local community services that could provide models associated with reduced hospital admissions. We were surprised to discover that there was no intervention that had yet been shown to help reduce admissions to hospital amongst frail older patients. We felt that it was important to highlight this lack of evidence for 2 reasons:
1.A reduction in acute beds in secondary care to fund increases in community services will have a significant impact on the ability of hospitals to provide adequate care for acute problems if the number of admissions fail to reduce.
2.It is unfair to gauge the effectiveness of enhanced community services by their ability to reduce admissions to hospitals when there is clear evidence that this it has not been achieved.
Policy makers and colleagues should accept that frailty is a very unstable condition and that an acute crisis requiring hospital admission is often an unavoidable part of the patient journey. There should be more focus on community enhancements that facilitate early supported discharge from hospital. The integration of health and social care within the ‘Torbay Model’ and recent work on improving the flow of frail older inpatients in Sheffield have demonstrated reduced acute bed usage whilst preserving patient satisfaction.[1][2]
References
1. Candace Imison, Emmi Poteliakhoff, James Thompson. Older People and emergency bed use: Exploring Variation. The Kings Fund. August 2012
2. Health Foundation. Improving the flow of older people. The Flow cost quality improvement programme
Competing interests: Authors of the orginal Editorial- Preventing Admission of Older People to Hospital
There are a few flaws in the current assumptions driving the strategic planning and funding of the care of Elderly patients all over the world, namely:
1. Blind faith in the "Supply-Demand" theory: If one reduce the number of hospital beds, the number of Elderly patients requiring a hospital bed will also go down
2. Elderly patients can be assessed comprehensively by numbers: does not matter who carry-out these assessments
3. Elderly patients are never "really" ill
4. Chronic diseases do not need "direct" specialists input
5. Computers and technology can "do" the work of carers, therapists, nurses and doctors
Those of us in the front-line working at the coal-face knows otherwise. The following are what we see:
1. Elderly people hate hospitals. They will never come to hospital if they can help it, and rightly so.
2. Assessment tools are just that. Tools. Comprehensive Geriatric Assessment needs tools, but more than that, it needs Clinical Skills to recognise symptoms and elicit signs, experience to know when a patient is well, ill or in between, and knowledge of "what is the best thing to do next". Sometimes, this is nothing. Sometimes, it is everything.
In reality, Elderly Patients do badly when assessed or treated solely by numbers.
3. When the Elderly falls ill, they do so at neck-breaking speed with disastrous outcomes if not recognised and given appropriate assessment and treatment, earlier rather than later.
4. Chronic diseases have different stages which requires different types and intensity of treatment. Also, they frequently exist not in isolation, but in complex interactions with other equally challenging chronic diseases, leading to extremely complex therapeutic and secondary prevention challenges and conundrums.
5. No studies to date have shown that this is possible. Computers and technology are good for numbers. Ill Elderly patients requires good clinical judgement borne out of years of clinical experience, good nursing skills and nurturing, in addition to the unquantifiable benefits of the multi-disciplinary team in order to get well, return to and continue with an independent life.
Technology alone can keep humans alive, but it alone cannot get patients better.
The challenge for us in the future it seems is not:
"How do we keep patients out of hospital".
It is "How best do we manage patients whom are old and have multiple co-morbidities and get them better".
Someone once told me that the answer to every complex problem in life is simple, straight forward and wrong, and this has been proven true on many occasions.
However, some approaches to the complex problems of the ill Edlderly with multimorbidity have been explored in the following American Geriatric Society publications:
1. Advancing Evidence-Based Clinical Care for Older Adults with Multimorbidity. Annals of Long-Term Care:Clinical Care and Aging. 2012;20(9):12
2. Guiding Principles for the Care of Older Adults with Multimorbidity: An Approach for Clinicians. J Am Geriatr Soc 60:E1–E25, 2012.
3. Patient-Centered Care for Older Adults With Multiple Chronic Conditions, A Stepwise Approach from the American Geriatrics Society. J Am Geriatr Soc 60:1957–1968, 2012.
Also, the recent systematic review by Smith et al is timely. It suggests that like the management of recurrent fallers, a targeted approach is the only way forward to achieve measurable clinical benefits.
In general, organisational interventions such as case management or how care is delivered in primary care and community settings have not produced expected favourable outcomes in terms of hospital admission rates, physical activity, patient reported functional health outcomes or even costs of care:
Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. BMJ 2012;345:e5205
The current focus of medical care for the Elderly is on what we know we can do best. Secondary prevention.
However, treating numbers at all costs is intrinsicly counter-intuitive as we know that each secondary prevention measure carries with it its own weight of side-effects. Add 3 or more of these weights and the patient at extreme age may well cease to be able to carry on an independent life, but will however likely live longer. Gurthrie et al elaborates on these issues in their paper entitled:
Adapting clinical guidelines to take account of multimorbidity. BMJ 2012;345:e6341
We seemed to have left by the way-side the once often quoted adage in Medicine: Compression of Morbidity, Not Prolongation of Life.
This is not unexpected as the former is much harder to do, requiring good public health policies, accessible comprehensive public health care systems like the former National Heath Service, investments in primary prevention efforts, tight regulation of alcohol and tobacco consumption and a pragmatic approach to end of life.
Furthermore, it is unlikely that the idea of regular, sustained, long-term physical activity which would be an important part of this paradigm will become popular anytime soon with the masses. It is much easier to pop pills.
The following article gives an interesting account of this forgotten paradigm:
1. Physical activity, the compression of morbidity, and the health of the elderly. Fries F James. J R Soc Med 1996;89:64-68
I suspect if one asks those at the extreme of age (>80) what is important to them in the foreseeable future, they will likely say:
1. The ability to walk and live independently
One could argue that in order to achieve this simple goal, it is likely that elderly person who becomes ill will
need to be seen urgently and managed by a generalist who has been trained to look after this special group of people.
Instead of keeping ill Elderly people at home, the outcome is conceivablely better if they are admitted to a Geriatric Specialised Hospital staffed by Geriatricans with Special Interests in Organ Specialties.
And if they are found to be well, they can then be confidently sent home without burden of in-patient iatrogenicity, at the point of assessment, supported by community and outpatient services as required.
The later already exist in the form of Special Interest Groups (SIG) in the British Geriatric Society.
The former is not and will unlikely to manifest itself anytime soon in the current climate of commercialisation of healthcare, as those who needs care the most are often also the one least able to afford it.
Perhaps, as the world population demographics change and the affluent young and middle age becomes the elderly with abundant wealth, this vision may one day become a reality.
A lot more Geriatricians will also be needed then.
Competing interests: No competing interests
We share D’Souza’s concerns that community initiatives may not reduce admissions in frail older people (1). Political strategy and the current climate of austerity have resulted in a reduction in acute inpatient beds. If this shortfall cannot be countenanced by community care and initiatives, we risk placing further strain on secondary care services. Further improvements in hospital length of stay and readmissions may have negligible benefit. Inpatient care has already moved to a more consultant-centric service. Even resource intensive interventions such as twice daily consultant rounds do not affect readmission rates (2). Large studies of factors influencing readmission rates showed they were closely linked to overall admission rates. Therefore, efforts to improve transitional care to the community may only have minimal effect and the focus should be on factors linked to admission (3).Fundamentally, policies to reduce the need for hospitalisation should also decrease the readmission rates.
We may be approaching a crucial saturation point in secondary care efficiency improvements regarding length of stay and readmission. A reduction in beds without compensatory gains through community initiatives could have deleterious effects. Early identification of de-compensation in chronic disease is a potential area of exploration; however the initial promise of telemedicine has yet to be fulfilled (4). We are concerned that the paucity of evidence in community admission prevention programmes in the frail elderly population may extend to other specialities and chronic diseases. This has wide reaching ramifications and the decision to redistribute acute beds to overstated community initiatives may be a miscalculation. Commissioning groups will need to consider the evidence rather than the intentions.
1. D’Souza S, Guptha S. Preventing admission of older people to hospital. BMJ 2013;346:f3186
2. Ahmad A, Purewal T, Sharma D, Weston P. The impact of twice-daily consultant ward rounds on the length of stay in two general medical wards. Clinical medicine 2011;11:524-8
3. Epstein A, Jha A, Orav J. The relationship between hospital admission rates and rehospitalizations. N Engl J Med 2011;365:2287-95
4. Henderson C, Knapp M, Fernandez JL et al. Cost effectiveness of teleheath for patients with long term conditions (whole systems demonstrator telehealth questionnaire study): nested economic evaluation in a pragmatic, cluster randomised controlled trial. BMJ 2013;346:f1035
Competing interests: No competing interests
Sir,
Souza and Guptha provide a provocative overview of admission prevention strategies in the elderly. There needs however to be some clarity of language and definition in this complex area as well as a little care in some of the common assumptions.
There is a widely held belief that chronic disease management strategies are a suitable proxy for the prevention of acute crisis related to frailty. Long term conditions management may be a key to better health but are not synonymous with frailty. We have also learned that the crisis that confronts an older adult with frailty can be quicker, more profound and more prolonged as a consequence (2). For this reason it may in its nature be unpredictable.
Secondly there is a danger in assuming that all community approaches are comparable and this may not be the case.
Thirdly there needs to be clarity regarding the definition of comprehensive geriatric assessment (CGA). It is in fact not a tool but a complex intervention composed of personnel and key processes to deliver multidimensional care across multiple domains. It cannot therefore be compared with a screening tool. It is also not of equal effectiveness in all situations as recent reviews have demonstrated (3).
Fourthly the assumption that the key to preventing admission is the identification of frailty still assumes you can predict sudden decompensation and avoid it. This as we have seen has yet to be proven.
In fact the prevention of frailty and multiple comorbidity will not rest on a single intervention. It is likely to require a multifactorial approach. This might include the promotion of activity, changing societal attitudes to dementia, the prevention and management of chronic diseases, anticipatory care planning, responsive community services, tackling polypharmacy and alternatives to hospital admission. Such multifaceted approaches are as much about public health, public policy and media influences as they are about integration, and health and social care interventions. Further such a broad range of initiatives may not deliver dividends rapidly.
It is right to ask for a critical evaluation of policy direction and to question the assumptions or even the confidence on which health care management decisions are based. Nevertheless there are reasons to be positive. The prevention of admission to long-term residential care may be more important to patients and their carers than admission to a hospital. Not only that but community rehabilitation programmes also appear to prevent decline and dependence (4). Importantly however some alternatives to admission have suggested significant potential benefits to mortality, patient acceptability and cost that need to be explored further (5).
Necessity requires us to innovate and evaluate. This area of public health needs focus now more than ever before. Certainly the current economic climate brings inevitable change, however we need to be able to address these challenges head on or face being condemned to push rocks uphill forever.
1) D’Souza S, Guptha S. Preventing admission of older people to hospital
BMJ 2013; 346:f3186
2) Clegg A, Young J, Illiffe S, Rikkert MO, Rockwood K. Frailty in elderly people.
Lancet 2013;381:752-62
3) Ellis G, Whitehead MA, O'NeillD, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD006211. DOI: 10.1002/14651858.CD006211.pub2.
4) Beswick AD, Rees K, Dieppe P, Ayis S, Gooberman-Hill R, Horwood J, Ebrahim S. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet. 2008 Mar 1;371(9614):725-35. doi: 10.1016/S0140-6736(08)60342-6.
5) Shepperd S, Doll H, Angus RM, Clarke MJ, Iliffe S, Kalra L, Ricauda
NA, Wilson AD. Hospital at home admission avoidance. Cochrane Database
of Systematic Reviews 2008, Issue 4. Art. No.: CD007491. DOI:
10.1002/14651858.CD007491
Competing interests: No competing interests
D'souza and Guptha are right in criticising policy makers who believe without adequate evidence that bed numbers for older people can be reduced through interventions in the community.
They are selective in quoting Purdy's Kings Fund 2010 report in support of their case but, for example, ignoring her clear statement in favour of hospital at home schemes.
The reality is that many attempts to case manage in the community have been "parachuted" in as "stand-alone" interventions, rather then evolving through integrated working between primary, community and secondary care staff.
Systematic use of risk management techniques in Germany, for example, where primary and community care can be rewarded for achieving improvements in morbidity and mortality over what would be predicted, has become an important part of routine healthcare.
In my area (Eastern Devon), where we have a population structure which is equivalent to what is predicted for England in 2035, there are striking and consistent differences in standardized admission rates between areas which have developed a pro-active approach able to intervene within 4 hours when patients are at high risk of admission, as well as using predictive modelling as a focus for multi-disciplinary discussions and action to reduce developing risk, and areas which have not embraced this approach.
When, as Purdy recommends, 'avoidable" admissions such as those in the standardised ACSC (ambulatory care sensitive conditions) are the focus then sustained differences in admission rates are even more striking.
Teams working in this way can also "pull" patients out of hospital as soon as their diagnostic and treatment planning phase is complete.
This way of working has not needed extra resources except for the cost of the predictive modelling (which I would not regard as a key intervention in itself).
I hope that colleagues on reading this piece will understand that it is an argument against bed reductions without integration between primary community and secondary care staff to create systems of care which can allow frail older people only to be in hospital when and for as long as they need. Babies and bathwater come to mind.
Competing interests: Eastern Devon Locality Commissioning Lead for Healthcare for Older People
The desire to reduce hospital admissions is understandable but as these authors illustrate the provision of increased service in the community has yet to show that it can reduce the demand for admission. The eagerly awaiting London integrated care pilot has also so far failed to demonstrate a reduction in admissions or use of unscheduled care by older people or by diabetics.1 Claims that admissions can be reduced by 20% or more are mostly based on theoretical modelling rather than actual practice.2
International comparisons show that, contrary to popular assumption, the UK has fewer acute hospital beds per capita than the OECD median and fewer admissions per head of population.3
Within the NHS, increases in admissions have occurred across all age groups, but the increase is confined to those staying less than 48 hours, who include relatively fewer older patients.4 55% of bed days are accounted for by the 20% of admissions who stay more than 2 weeks who are mostly frail elderly. A focus by community services on facilitating discharge in this group could be more efficient and cost effective than targeting a reduction intotal numbers ofadmissions.
Although a hospital may currently be the most efficient way of pooling diagnostic technology, clinical and therapeutic expertise in one place, frail older people are not well served by long spells in hospital with increased risk of morbidity and reduction in mobility associated with prolonged stay.5 We should continue to seek alternatives. We are aware of several innovative models which are being developed to try and achieve this with rapid assessment and intervention from specialist geriatric teams.6
The demand for medical services from older people, with multiple complex health needs, often living alone, will continue to rise. We may never be able to prevent the insult and injury that precipitate unscheduled care in the elderly but the whole system of health and social care must adapt to ensure that their needs are met swiftly and they are returned to function as quickly as possible. At the Royal College of Physicians, we are committed to ensuring the service we offer meets the needs of these and all patients. The Future hospital commission, which reports in the autumn, is exploring new ways for medical teams to work, to promote more joined up care, and deploying expertise in the most effective way.7
1. Iacobucci BMJ 2013;346:f3255
2.Mytton OT, Oliver D, Mirza N, Lippett J, Chatterjee A, Ramcharitar K, Maxwell J. Avoidable acute hospital admission in older people. Brit J of Healthcare Management 2012;18 (11) 597-603
3. http://www.oecd.org/health/health-systems/oecdhealthdata2012.htm
4. E Potiliakhoff, Thomson J.Emergency bed use: what the numbers tell us. Kings Fund 2011
5. Covinsky KE, Palmer RM, Fortinsky RH et al. Loss of independence in activities of daily living in older adults hospitalised with medical illnesses: increase vulnerability with age. J Am GeriatrSoc 51:451-8
6. Health Foundation. Improving the flow of older people. The Flow cost quality improvement programme. 2013
7. http://www.rcplondon.ac.uk/projects/future-hospital
Competing interests: We are members of the operational group of the Future Hospital Comission, hosted by the RCP.
Sir, Gupta et al provide a useful summary of the published evidence of admission avoidance schemes through attempts to enhance community care.
However they fail to make a critical analysis of the data; we are dealing with high levels of complexity for individual patients and the systems that care for them; measuring the effectiveness of complex interventions both in and out of hospital must require huge sample sizes and a lengthy follow up for any meaningful result to arise.
The assumption is that the path of least resistance should continue, that is for someone to ring an ambulance when a frail elderly person decompensates. This cannot be an appropriate response given the changing demographics. It is also very disruptive for such patients, leading often to prolonged admissions that increase dependency on health and social care (unpublished, multiple narrative examples from primary care).
Remember the Oxcheck study 1 ? This looked at using nurses to collect data and give advice relevant to cardiovascular risk. The initial publication gave support to those rejecting the development of primary care teams reliant on nurses for this proactive care, however delayed follow up 2 showed an extension of the benefit, even before the widespread use of statins for primary prevention.
Since then UK primary care has embedded nurses within its teams, and UK practices are fighting to maintain good working relationships with community (aka district) nursing teams, and we have to learn how to develop a multidisciplinary approach along with geriatricians, social care commissioners and the third (voluntary) sector.
So let's look beyond the evidence and see how we can hone the growing expertise, towards providing a more holistic risk assessment. The concept of care planning is growing in primary care; we should embrace the idea of shared decision making, and the development of tools for enhanced self-care. The ingredients are there; what is needed is the political will to support the shift of resources from secondary care to fund this process adequately and to move away from a narrow focus that looks for in year savings through acute admission avoidance.
And we could also start using our experience to highlight some of the changes in society that make caring for your nearest and dearest for a couple of days so hard. We may have to accept that the state can no longer provide all necessary care, but employers should support brief compassionate leave, such as having a couple of days off work to stay and give the much needed fluids and antibiotics.
Dr Charles Heatley GMC 3117127
GP, Birley Health Centre, Sheffield S12 3BP
Member, Commissioning Executive Group, NHS Sheffield Clinical Commissioning Group
charles.heatley@nhs.net
1 J Muir, D Mant, L Jones, P Yudkin, “Effectiveness of health checks conducted by nurses in primary care: results of the OXCHECK study after one year” BMJ1994;308doi: http://dx.doi.org/10.1136/bmj.308.6924.308(Published 29 January 1994)
Cite this as:BMJ1994;308:308
2 Imperial Cancer Research Fund OXCHECK Study Group, “Effectiveness of health checks conducted by nurses in primary care: final results of the OXCHECK study” BMJ1995;310doi: http://dx.doi.org/10.1136/bmj.310.6987.1099(Published 29 April 1995)
Competing interests: I am a member of the NHS Sheffield Clinical Commissioning Group Commissioning Executive Team. My practice has a share in Primary Provider Limited, a not for profit company.
Sir, The recent editorial by de Sousa and Guptha [1] makes the very valid point that frail old people who are unwell need hospital admission to investigate the cause and provide immediate treatment. However, while we endorse the sentiment expressed that closing hospital beds to pay for isolated community care is folly, we feel there is more cause for optimism in terms of what active community services can achieve than the editorial suggests.
The success of community services cannot be judged purely on the extent to which hospital admissions are prevented. A multidisciplinary community care team which works in an integrated way across health, including older people's mental health services, and social care can offer support to reduce admissions in far more ways than simply case management. Perhaps more significantly, they can also reduce occupied bed days. This can be done by community services pulling older people along a pathway of care and back into the community before during and after a crisis. This can be achieved by the provision of genuine alternatives to admission when appropriate; sharing information about care and support plans to shorten hospital admission when admission is needed; and then effecting rapid exit back to the community as soon as a patient is ready for discharge.
Alternatives to hospital admission, which include appropriate medical and diagnostic care, are unlikely to provide cost savings. However, the same Kings Fund review [2] quoted by the authors highlights that hospital at home services may help to manage some of the crises which precipitate admissions. The alternatives to admission which they offer may be preferable for patients with multimorbidity who have well established care and support packages and who do not want the upheaval of hospital admission. Likewise for patients with dementia, for whom hospital admission can be bewildering and have adverse effects (even in dementia friendly units).
We believe geriatricians can be a lynchpin of integration as they can provide a bridge between hospitals and community teams and there are increasing numbers of community based geriatricians. Across the UK geriatricians are involved in the development of integrated services and models in Leeds, Southampton, Leicester, Sheffield and Warwick are bearing results. The work in Warwick has been described by Ian Philp [3)
The active management of advance care planning in care homes helps care homes to manage crises better, active working with the ambulance services to jointly plan for crisis intervention around issues like falls management can reduce admissions and, at a basic level, the sharing of information between services so that, when a crisis does occur, risk is shared more appropriately and not avoided (by admitting the patient to hospital).
Rather than constantly pitting the acute sector and community services against one another, the focus should be on ensuring the appropriate distribution and sharing of resources (financial and workforce) so that older people have access to specialist health and supportive care when and where they need it. This will provide a better experience all around.
Yours
Professor Paul Knight, BGS President
Dr Gill Turner, BGS Vice President Clinical Quality
[1]D’Souza, S and Guptha S. Preventing Admission of Older People to Hospital BMJ 2013;346:f3186 doi: 10.1136/bmj.f3186 (Published 20 May 2013)
[2] Purdy S. Avoiding hospital admissions. What does the research evidence say? King’s Fund, 2010.
www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-P....
[3] Philp, I. The principles behind integrated care for older people. HSJ 30 Nov 2012.
Competing interests: No competing interests
Re: Preventing admission of older people to hospital
We write to contest the claim made by D’Souza and Guptha that “no convincing evidence exists that increases in the provision of community services reduce the length of stay for frail older people”.
There are two commonly used markers of the effectiveness of a programme of this sort in older patients – the number of institutional referrals and time spent in institutional care. The ultimate objective of care in this field is to keep these vulnerable old people active and independent for as long as possible. Thus the effectiveness of these measures is best reflected by any reduction in the number of bed days of institutional care rather than the number of institutional referrals.
The authors make a case for the above claim using the number of hospital referrals only as an indicator. At the same time they ignore studies which used bed days of inpatient care as their marker of effectiveness. The first randomised controlled trial in this connection was done in general practice in Bicester1 It showed that the programme did not improve health significantly but study group patients spent significantly less time in institutional care. Over the next fourteen years a further seven RCTs were done in Europe and, of the total of eight, six used time spent in hospital or institutional care as an indicator of outcome. All six showed a reduction in bed days in the study group when compared with the control group and the difference was statistically significant in four of the six studies. Thereafter a variety of similar studies were done which were surveyed comprehensively by Beswick et al2 in what is the most important paper published in this field in recent years. In their meta-analysis they reviewed no less than 89 studies and concluded that a preventive care programme would produce a reduction in number of bed days of institutional care, in hospital referrals and in number of falls. Physical function was also better in the intervention groups. Yet D’Souza and Guptha ignored this study, of which they must be aware, and this has led them to make claims which are simply untenable on the limited evidence they provided.
The authors also claim that “no validated tool has been proved to be useful in reducing admissions and readmissions among frail older people”. We are aware of one such tool designed in Wales which is in current use in two practices in Cirencester3.
We think it was very sad that the authors should paint such a negative picture of the value of providing a more active interventionist programme of care for vulnerable old people. At a time when the number of patients in this category is rising steadily and the number of hospital geriatric beds for these patients is being reduced we simply must find a way to keep these subjects active and independent in the community for longer. Otherwise the already heavy burden on carers will simply lead to breakdown of the system.
Towards this end general practitioners must learn to organise and deliver care to these vulnerable subjects in a manner appropriate to their needs. A demand led care programme alone is not enough if patients are to be kept active and independent for as long as possible.
References
1 Tulloch A J, Moore V. A randomised controlled trial of geriatric screening and surveillance in general practice. J. Roy. Coll. Gen. Practit. 1979 29 : 355-359
2 Beswick AD, Rees K et al. Complex interventions to improve physical function and maintain independent living in elderly people : a systematic review and meta-analysis Lancet 2008 March : 371 (9614) : 725-735
3 Pathy MS, Bayer A, Harding K, Dibble A. Randomised trial of case finding and surveillance of elderly people at home. Lancet 1992 Oct 10 340 (8824) : 890-3
A J Tulloch and D L Beales, retired general practitioners with 40 years experience of running geriatric clinics for vulnerable old people in general practice
Competing interests: No competing interests