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Nursing home residents are often characterized by longevity, multiple chronic illnesses and a low level of physical and mental function. These characteristics contribute to nursing home residents’ vulnerability for acute and deteriorating illness. When occurring, the decision of whether to hospitalize makes an important and complex part of the clinical decision making. The aim of this report was to give a systematic review of the effect of interventions to reduce hospitalizations from nursing homes. We emphasize that hospital admissions from nursing homes can be both appropriate and essential for the elderly to receive the best possible health care. The focus of this report is on reducing unnecessary admissions, i.e. where there are medically sound alternatives to hospitalization in the nursing home. We included four systematic reviews and five primary studies in this review. In total there were eleven unique interventions that were evaluated, gathered in three main categories. Interventions to standardize treatment and care: Four out of seven interventions for structuring and standardizing treatment and care yielded fewer hospital admissions for the intervention groups. The results for mortality, however, were unclear. The quality of the evidence was assessed as being low or very low. Geriatric specialist services: Geriatric specialist teams compared with usual care demonstrated fewer hospital admissions in the intervention groups. The quality of the evidence was judged as being very low. Influenza vaccination: Promoting influenza vaccination of health personnel in nursing homes demonstrated unclear results for hospital admissions, but yielded fewer deaths for the intervention group. The quality of the evidence was judged as low. Influenza vaccination of nursing home residents showed fewer hospital admissions and fewer cases of influenza-like illness and deaths for the intervention group, but for laboratory confirmed influenza the result was unclear. The quality of the evidence was judged as very low. Overall there were relatively few studies evaluating the effects of interventions to reduce hospital admissions from nursing homes. Although the results of the evaluation of several of the interventions showed a reduction in admissions, the evidence for these results was graded as of low or very low quality. Our confidence in the results corresponds to this, which means that we cannot draw any definitive conclusions for the effect of any of the interventions.
Background Nursing homes are first and foremost a service for society’s oldest and frailest and with the highest level of dependency. Several chronic diseases, old age and a low level of function are characteristics of nursing home residents that make them vulnerable to acute flares in their health condition. During the clinical assessment of acute illness, the decision of whether or not to hospitalize constitutes an important part of treatment and care. Several studies have shown that hospitalizations from nursing homes are common, in Norway as well as in other countries. At the same time it is well established that hospitalizations of frail and old people may have unwarranted effects on their physical and mental functional levels. Often, hospitalization is necessary for the nursing home resident to receive the best available treatment and care. However, in the research literature it is implied that some hospital admissions are due to clinical problems that could have been treated in the nursing home, provided that the nursing home has the necessary capacity. A shift of tasks from specialist to primary care is in accordance with the current political guidance in Norway. We have conducted a systematic review of research studies of the effects of interventions to reduce acute hospital admissions from nursing homes, commissioned by the the Centre for Evidence-Based Practice, Bergen University College. Objective The objective of this report is to systematically review the available research evidence that evaluates the effects of interventions to reduce hospitalizations from nursing homes. Method We searched systematically for studies that evaluated the effect of interventions to reduce hospitalizations from nursing homes in Cochrane Library, PubMed, MEDLINE, EMBASE, CINAHL and ISI Web of Science in the period June – October 2012. Additionally we searched for ongoing or planned studies. All titles and abstracts retrieved through the literature searches were screened independently by two researchers to identify references that fulfilled the inclusion criteria for this review. Potentially relevant publications were ordered in full-text and assessed for inclusion or exclusion. All systematic review articles that fulfilled the inclusion criteria were appraised using the Norwegian Knowledge Centre’s check list for judging quality in systematic reviews. Only reviews of high quality were included. We used the review authors’ assessment of risk of bias for the studies that we selected from the reviews. For other primary studies we used the Cochrane Collaboration’s tool for assessing bias. Two persons independently of one another decided upon inclusion or exclusion of studies according to inclusion criteria and then assessed the primary studies that had been included. The quality of overall documentation for each outcome was first graded by one person and then checked by another. Results The literature searches generated 5 762 individual hits and of these, we included four systematic reviews of high quality and five primary studies. All in all, eleven different interventions were evaluated. We classified these into three categories of interventions. Two reviews and three primary studies were classified to the category Standardization of treatment and care, two primary studies to the category Geriatric specialist care and two reviews to the category Influenza vaccination. Interventions to structure and standardize treatment and care Four out of seven interventions for structuring and standardizing treatment and care (educating health personnel in advance care planning as a single intervention or combined with hospital-in-the-nursing-home, intervention to increase the use of hospice services and a clinical care pathway intervention) yielded fewer hospitalizations for the intervention groups, but for mortality as an outcome the results were unclear. For the three remaining interventions, none of the results were statistically significant (educating social workers in advance care planning, educational intervention supported by change agents for implementing guidelines and implementing a care protocol for the treatment of chronic obstructive pulmonary disease). The quality of documentation was judged as low or very low. Geriatric specialist care Geriatric specialist services compared to usual care demonstrated fewer hospital admissions in the intervention groups. The quality of the documentation was assessed as very low. Influenza vaccination Promoting influenza vaccination of health personnel in nursing homes demonstrated unclear results for hospital admissions, but yielded fewer incidences of influenza-like illness and fewer deaths for the intervention group. The quality of the documentation was judged as low. Influenza vaccination of nursing home residents showed fewer hospitalizations and fewer incidences of influenza-like illness and deaths for the intervention group, but for laboratory verified influenza the results were unclear. The quality of the documentation was judged as very low. Discussion This report shows that there are few research studies that have evaluated the effect of interventions to reduce hospitalizations from nursing homes. All evidence in this report was judged as being of low or very low quality. This is mainly due to the primary studies being few and small, that they had methodological shortcomings and/or that they were insufficiently reported. It is claimed in several studies that some of the hospitalizations from nursing homes are avoidable, however, the proportions claimed to be avoidable vary substantially. These claims may have had an impact on the political guidelines which is directed at providing more treatment and care in the community. It is worth noting that the interventions to structure and standardize treatment and care presented here, is not only about determining beforehand conditions for which the resident should be treated in the nursing home, but also about adding additional resources in the form of teaching, hospice team, additional personnel or specialist services. Conclusion Among the interventions identified, several of the studies reported fewer hospitalizations from the evaluation. However, the documentation for these results is of low and very low quality and it is not possible to draw firm conclusions. If somebody in the Norwegian nursing home setting would want to implement any of these interventions, this should be done under systematic monitoring and evaluation and integrated with an overall judgment of the nursing home’s capacity to carry out an adaption to increased local treatment and care.