¿Cuál es la evidencia de la efectividad de manejo de la interfaz del hospital / de la comunidad para las personas mayores

BACKGROUND:

It is generally agreed that there is often a service gap for people who are frail or have complex or multiple conditions between short-stay hospital care and the support they need to manage in the community. The Ministry of Health, in conjunction with DHBNZ and ACC is aiming to develop an integrated service model for specialist geriatric and geriatric psychiatry services to bridge the gap. With the growing body of literature about options for bridging that gap, a critical appraisal of literature on managing the hospital / community interface for older people was carried out. This will contribute to the evidence base for developing a service framework for specialist health services for older people in order to meet the objectives of the Health of Older People Strategy.

OBJECTIVE:

This review was conducted to: • provide evidence for the effectiveness of services managing the hospital / community interface and
• provide the evidence base for the Ministry of Health’s work to assess the options for intermediate-level care to bridge the gap between the hospital and home-based care.

METHODS:

The aim of the search strategy was to provide as comprehensive retrieval as possible of published studies relating to intermediate care. Literature retrieval focused on obtaining studies of higher quality and levels of evidence (i.e., systematic reviews, meta-analyses, and randomised controlled trials) as first preference followed by lower level evidence.

DATA SOURCES:

The literature was searched using the following bibliographic databases: Medline, Embase, Current Contents, Cochrane Controlled Trials Register, Index New Zealand, web of Science, PsychInfo, and Cinahl. Other electronic and library catalogue sources searched included: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness (DARE), HTA database, ACP Journal Club, TRIP database. Other sources include Scottish Intercollegiate Guidelines Network, US National Guidelines Clearinghouse, UK National Coordinating Centre for Health Technology Assessment, Australian Department of Health & Ageing (including subsites and related links), Health
Canada (including subsites and related links) and World Health Organisation. Searches were limited to English language and were not restricted by date. These searches generated 747 citations. A separate systematic method of literature searching and selection was employed in the preparation of service delivery guideline protocols and specified expert opinion literature. Searches were limited to English language material with no date restriction. The searches were completed on 9 May 2003. Additional searches on slow-stream rehabilitation (nurse-led units), and case-management services were also carried out in December 2003. Professional associations and health systems with a focus on geriatrics in New Zealand, Australia, UK, Canada and the United States were also searched.

SELECTION CRITERIA:

Study selection: Studies were included if they were published between 1980 to 2003, used one of these designs (systematic review, meta-analysis, randomised controlled trials, controlled clinical trials, quasi- experimental, or descriptive) and intended to evaluate or describe any intermediate care service for older patients of 65 years and over with complex comorbidities who need services between general hospital and home support. Some measure of health outcome for the group to whom the service was delivered was required. Excluded studies included articles with abstract only and correspondence as well as studies specifically set in stroke units, studies with less than 50 persons, studies with less than three months of follow-up, and studies, including systematic reviews and meta-analyses, with inadequate methodology. Of 747 articles identified by the search strategy, 201 articles were retrieved as full text. From these a final group of 30 primary data papers, and nine systematic reviews were identified as eligible for appraisal and inclusion. An additional 13 studies were included but not appraised. These provided further detail about services. 134 articles were excluded from the review. A further 40 articles were identified for the section on guidelines / protocols and specified expert opinion literature. Of these, 18 were excluded and 22 were described and included in the evidence tables. Data extraction and synthesis
A single reviewer extracted data and appraised the articles applying a modified checklist based on the Cochrane Effective Practice and Organisation of Care Review (EPOC) of the Cochrane Collaboration and in-house checklists developed by the NZHTA for the appraisal of descriptive studies. Articles were graded according to levels of evidence defined by the National Health and Medical Research Council (NH&MRC, 2000). Information was recorded about each relevant study and a tabular summary of study characteristics was compiled. This included study citation, source and design, study sample, inclusion and exclusion criteria, service design features, interventions, outcomes and study limitations.

KEY RESULTS AND CONCLUSIONS:

Overall, 201 articles were identified. 39 papers met the inclusion criteria for appraisal and 25 studies were used as reference material. Those papers appraised have their results presented separately according to the type of services that manage the hospital / community interface they assess. Additional material was also included as this provided useful information about services provided in a number of systematic reviews. The following conclusions are based on the current evidence available from this report’s critical appraisal and review of the published literature on the topic. In general, the evidence is a mixture of benefit, deficit and uncertainty, due to the complexity and variability of the interventions and methodological problems with the evaluations. Evidence supports intervention programmes that provide services to reduce and prevent falls. The literature provided evidence that discharge planning arrangements showed some beneficial effects on subsequent readmission to hospital. Hospital-at-home schemes as an alternative to acute hospital care are an increasingly popular way of delivering health care and the literature shows that outcomes for selected patients seems to be as good as standard hospital care, although studies have used many different outcome measures. Most of the published data on the care needs of older emergency patients are descriptive with minimal evaluation of the effect of the interventions on patient outcomes. Also, the current disease-oriented and episodic models of emergency care did not provide enough evidence to adequately respond to the complex care needs of older patients experiencing multiple and often interrelated medical, functional, and social problems. The mixed results with the ED-based studies suggest that more appropriate care of older ED patients can achieve better outcomes – therefore, costs can be more or less depending on the nature of the services. Published data around nurse-led units (NLUs) concern hospital-based NLUs, with none on community-based NLUs. No judgements about effectiveness of nurse-led inpatient care for post-acute patients could be made. Various case-management models including a post acute care program (PAC), a short-term case management by an advanced practice nurse, an integrated community care program, case managers for patients discharged from hospital, and integrated home care program guided by a case manager generally showed benefits to patients in the outcomes assessed. The majority of the studies included were set overseas with some conducted among Veterans Affairs, thus differences in health care delivery may limit how applicable these results are in New Zealand. Their generalisability to the New Zealand population and context needs to be considered. There is a need for future research that focuses on service models that are comparable and applicable to New Zealand’s older population. The general consensus from the analyses of service descriptions from published evidence-based service guidelines and protocols supports a continuum of care model which requires a high degree of collaborative, multidisciplinary and interdisciplinary care. Many recommendations were made for research into service development and care models focusing more on prevention and screening, and for comprehensive geriatric services across different care settings and also rehabilitation care. Funding for these services and monitoring and quality improvement systems are needed.