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Emergency medicine
Research
A systematic review to identify and assess the effectiveness of alternatives for people over the age of 65 who are at risk of potentially avoidable hospital admission
  1. Alyson L Huntley1,
  2. Melanie Chalder1,2,
  3. Ali R G Shaw1,
  4. William Hollingworth3,
  5. Chris Metcalfe1,4,
  6. Jonathan Richard Benger5,6,
  7. Sarah Purdy1
  1. 1 Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
  2. 2 Brunelcare, Saffron Gardens, Bristol, UK
  3. 3 Health Economics at Bristol, School of Social and Community Medicine University of Bristol, Bristol, UK
  4. 4 Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
  5. 5 Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
  6. 6 Department of Emergency Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
  1. Correspondence to Dr Alyson L Huntley; alyson.huntley{at}bristol.ac.uk

Abstract

Background/objectives There are some older patients who are ‘at the decision margin’ of admission. This systematic review sought to explore this issue with the following objective: what admission alternatives are there for older patients and are they safe, effective and cost-effective? A secondary objective was to identify the characteristics of those older patients for whom the decision to admit to hospital may be unclear.

Design Systematic review of controlled studies (April 2005–December 2016) with searches in Medline, Embase, Cinahl and CENTRAL databases. The protocol is registered at PROSPERO (CRD42015020371). Studies were assessed using Cochrane risk of bias criteria, and relevant reviews were assessed with the AMSTAR tool. The results are presented narratively and discussed.

Setting Primary and secondary healthcare interface.

Participants People aged over 65 years at risk of an unplanned admission.

Interventions Any community-based intervention offered as an alternative to admission to an acute hospital.

Primary and secondary outcomes measures Reduction in secondary care use, patient-related outcomes, safety and costs.

Results Nineteen studies and seven systematic reviews were identified. These recruited patients with both specific conditions and mixed chronic and acute conditions. The interventions involved paramedic/emergency care practitioners (n=3), emergency department-based interventions (n=3), community hospitals (n=2) and hospital-at-home services (n=11). Data suggest that alternatives to admission appear safe with potential to reduce secondary care use and length of time receiving care. There is a lack of patient-related outcomes and cost data. The important features of older patients for whom the decision to admit is uncertain are: age over 75 years, comorbidities/multi-morbidities, dementia, home situation, social support and individual coping abilities.

Conclusions This systematic review describes and assesses evidence on alternatives to acute care for older patients and shows that many of the options available are safe and appear to reduce resource use. However, cost analyses and patient preference data are lacking.

  • systematic review
  • emergency medical services
  • aged
  • hospitalization
  • hospital alternative

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjopen-2017-016236

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    Footnotes

    • Contributors ALH: lead systematic reviewer conducting all stages of the review and was responsible for the initial draft of paper. MC: protocol of systematic review is based on outline from National Institute for Health Research Programme Development Grant in which MC had a significant role; specific expertise in patient and public involvement; contributing to discussion as the review progressed; commenting and editing on the drafts of the paper. AH: specific expertise in patient-related outcomes; contributing to discussion as the review progressed; commenting and editing on the drafts of the paper. WH: specific expertise in health economics; contributing to discussion as the review progressed; commenting and editing on the drafts of the paper. CM: specific expertise in trial design and statistical analysis; contributing to discussion as the review progressed; commenting and editing on the drafts of the paper. JB: professor of emergency care; contributing to discussion as the review progressed; commenting and editing on the drafts of the paper. SP: principal investigator; professor of primary health care; third reviewer of data; commenting and editing on the drafts of the paper.

    • Funding This paper presents research funded by the National Institute for Health Research (NIHR) as part of their Programme Development Grant scheme (RP-DG-1213-10004).

    • Disclaimer The views expressed are those of the authors and not necessarily those of the National Health Service, NIHR or the Department of Health.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement This is a systematic review, and all the data we have collected are either in the main text and table or in the appendices and therefore freely available.