What is the effectiveness of interventions to reduce acute hospital admissions from nursing homes?

The literature search is led by a research librarian at the Norwegian Knowledge Centre for the Health Services, Oslo. The final search strategy will be posted once finalised. Databases that will be searched are: The Cochrane Central, Embase, Medline, ISI Web of Science and Cinahl. Initially there will be no restrictions to language, but decisions about translation will be made if articles in languages other than English present in the literature search.

Initially, we will search for pre-existing SRs and RCTs. If we find RCTs and these are of low (or very low) quality, then we will search for and include other experimental designs, such as quasi-randomised studies, controlled before-and-after design and interrupted time-series design.

The pilot search resulted in no previously published SRs. If screening of the final search results should reveal a relevant systematic review we will consider updating this.

Nursing home residents are prone to acute incidences due to frailty, multimorbidity and polypharmacy, which in turn often result in hospitalisations. Hospitalisation of this population is, however, associated with unfavourable outcomes, and some may be potentially avoidable if interventions are implemented at a lower level of health care. Thus, it is of interest to systematically review the evidence of interventions that may reduce acute hospitalisations from nursing homes.

Nursing home residents, age > 65 years.

Exclusion criteria:

Nursing home residents age < 65 (because our population of interest is the typical geriatric nursing home resident).

Geriatric population living outside nursing home facilites.

Any intervention aimed at reducing acute hospitalisations from nursing homes

(including quality improvement interventions like educational support, implementing evidence-based guidelines, improving shared decision making)

Care as usual or another intervention.

Studies undertaken in residential care facilities of different levels (skilled nursing care homes, intermediate care homes etc).

Primary outcomes

Acute hospitalisation.

Hospitalisation rates, number of hospitalisations at any time of follow-up.

Secondary outcomes

Secondary outcomes:

1) Length of stay in hospital.

Because avoidance of hospitalisation is not always possible, particularly due to unavailability of diagnostic procedures, it is of interest to see if certain interventions may aid the coordination between hospital and nursing home so that the length of stay in hospital can be as short as possible.

2) Mortality.

3) Morbidity.

The last two secondary outcomes are included so that several aspects of the intervention may be assessed, in parallell to the primary outcome.

Measured in any way at any time of follow-up.

Two persons will independently assess titles and abstracts from the literature search and decide upon selection of full-text articles based on inclusion and exclusion criteria. Any disagreement or discrepancy will be resolved by involving a third person. The following data will be extracted from primary studies: A complete reference, the number of participants in the study, data on population, intervention, control intervention, outcomes and results. For dichotomous outcomes, such as the number of individuals with at least one hospitalisation, if possible, we will express the results as risk ratio (RR) with 95% confidence interval (CI). For continous outcomes, we will use the average difference between groups (MD).

Risk of bias will be assessed for each of the individual studies, according to the Risk-of-Bias table in the Cochrane Handbook. For studies with interrupted time series as study design, we will use a checklist developed by the Norwegian knowledge Centre for Health Services, available on their website: www.kunnskapssenteret.no. Each study will be assessed independently by at least two researchers, and any discrepancy will be resolved by involving at least one researcher more. We will not remove poor quality studies.

We will assess clinical heterogeneity by looking at the population, intervention and outcome. To assess statistical heterogeneity, we will use the I-squared test and Chi-square test. A significance level of p <0.1 will be considered to indicate heterogeneity. I-squared values of 25% or less will be considered to indicate low heterogeneity and values of 75% or more we will be regarded as a high heterogeneity (25). If we consider the studies to be similar enough, we will conduct a meta-analysis using the program RevMan 5, otherwise, we will make a descriptive analysis. For any meta-analysis, we will use "random-effects method" with "inverse-variance approach" that adjusts the weighting of the study in accordance with the degree of variation in the certainty of the effect estimate.

The quality of the overall evidence for each of the outcome measures will be assessed using the program GRADE. The grading provides an overall assessment of the confidence we have in the results presented in the studies. We describe the quality of the evidence as high, medium, low or very low.

None planned.

Two end products are planned for this synthesis:

1) Report published on the Norwegian Knowledge Centre's website: www.kunnskapssenteret.no

2) Systematic review published in a peer-reviewd journal

Birgitte Graverholt

Centre for Evidence-Based Practice, Postboks 7030, 5020 Bergen, Norway

bgra@hib.no

The Norwegian Knowledge Centre for the Health Services and Centre for Evidence-Based Practice, Bergen University College

http://www.kunnskapssenteret.no/Home

Mrs Birgitte Graverholt, Bergen University College
Dr Louise Forsetlund, The Norwegian Knowledge Centre
Dr Gro Jamtvedt, The Norwegian Knowledge Centre

This is the protocol for the first edition.

04 June 2012

11 March 2013

This SR is an assignment given to the Norwegian Knowledge Centre for the Health Services. The Knowledge Centre will manage and finance the development and work of the review. Unique project number in the organisation's portfolio is 723. Two end products are anticipated; one report published on the website of the Knowledge Centre (in Norwegian language) and as a peer-reviewed published article in English.

None known

The Norwegian Knowledge Centre for the Health Services, Oslo, Norway. Unique identification number in this organisation is 723.

English, Norway

Norway

Subject indexing assigned by CRD

Hospitalization; Humans; Nursing Homes

http://www.kunnskapssenteret.no/Prosjekter/Tiltak+for+%C3%A5+redusere+akutte+sykehusinnleggelser+av+sykehjemsbeboere.15542.cms

20 September 2012

20 September 2012