PL04: Effectiveness of hospital avoidance interventions among elderly patients: a systematic review

Introduction: Overuse of acute care services, particularly emergency department (ED) use, is an important topic for healthcare providers and policy makers within Canada and abroad. Prior work has shown that frail elderly patients with complex medical needs and limited personal and social resources are heavy users of ED services and are often admitted when they present to the ED. Updated information on the most effective strategies to avert ED presentation and hospital admission focused specifically on elderly patients is needed. Methods: This systematic review addressed the question: what interventions have demonstrated effectiveness in decreasing ED use and hospital admissions in elderly patients? Comprehensive literature searches were conducted in databases including Ovid Medline, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials with no language or date restrictions. Citations were limited to interventional studies. Grey literature and reference list searches, as well as communication with experts in the field were performed. Consensus or a third reviewer resolved any disagreements. Original research regarding interventions conducted in populations 65 years or older with acute illness, either living in community or facility-living were included. Primary outcomes were ED visits and hospital admissions. Secondary outcomes included: mortality, cost, and patient-reported outcomes such as health-related quality of life and functional status. Results: Forty-three relevant studies were identified including 22 randomized controlled trials (RCT), 2 cluster-RCT, 2 trials with non-random allocation, 4 before-after studies, 6 quasi-experimental studies, and 7 cohort studies. Intervention settings included: home visits (22), long-term care (7), outpatient or primary care clinics (8), and ED (3) or inpatient (3). Data characterization revealed that home-based, outpatient and/or primary care-based strategies reduced ED visits and hospitalizations, particularly those which included comprehensive geriatric assessments, home visits or regular face-to-face contact and interdisciplinary teams. Hospital-based models generally showed no difference in ED or inpatient service utilization. There was, however, considerable variability across individual studies with respect to reporting of outcomes, statistical analyses performed, and overall risk of bias. Conclusion: Various interventional strategies have been studied to avert ED presentation and hospital admission for frail elderly patients. More rigorous methodology and standardization of outcome measures is needed to quantitatively assess the effects of these programs.

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Effectiveness of hospital avoidance interventions among elderly patients: A systematic review

CJEM ◽

10.1017/cem.2020.4 ◽

2020 ◽

Vol 22 (4) ◽

pp. 504-513

Author(s):

Caillie Pritchard ◽

Alyssa Ness ◽

Nicola Symonds ◽

Michael Siarkowski ◽

Michael Broadfoot ◽

...

Keyword(s):

Systematic Review ◽

Older Patients ◽

Hospital Admissions ◽

Complex Interventions ◽

Home Visits ◽

Care Utilization ◽

Controlled Trials ◽

Cochrane Central Register ◽

Patient Reported ◽

Ed Visits

ABSTRACTObjectiveOlder patients with complex care needs and limited personal and social resources are heavy users of emergency department (ED) services and are often admitted when they present to the ED. Updated information is needed regarding the most effective strategies to appropriately avoid ED presentation and hospital admission among older patients.MethodsThis systematic review aimed to identify interventions that have demonstrated effectiveness in decreasing ED use and hospital admissions in older patients. We conducted a comprehensive literature search within Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials from database inception to July 2019 with no language restrictions. Interventional study designs conducted in populations of 65 years and older were included. Primary outcomes were ED visits and hospital admissions. Secondary outcomes included hospital readmission, mortality, cost, and patient-reported outcomes.ResultsOf 7,943 citations reviewed for eligibility, 53 studies were included in our qualitative synthesis, including 26 randomized controlled trials (RCT), 8 cluster-RCTs, and 19 controlled before-after studies. Data characterization revealed that community-based strategies reduced ED visits, particularly those that included comprehensive geriatric assessments and home visits. These strategies reported decreases in mean ED use (for interventions versus controls) ranging from -0.12 to -1.32 visits/patient. Interventions that included home visits also showed reductions in hospital admissions ranging from -6% to -14%. There was, however, considerable variability across individual studies with respect to outcome reporting, statistical analyses, and risk of bias, which limited our ability to further quantify the effect of these interventions.ConclusionVarious interventional strategies to avoid ED presentations and hospital admissions for older patients have been studied. While models of care that include comprehensive geriatric assessments and home visits may reduce acute care utilization, the standardization of outcome measures is needed to further delineate which parts of these complex interventions are contributing to efficacy. The potential effects of multidisciplinary team composition on patient outcomes also warrant further investigation.

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Impact of integrating pharmacists into primary care teams on health systems indicators: a systematic review

British Journal of General Practice ◽

10.3399/bjgp19x705461 ◽

2019 ◽

Vol 69 (687) ◽

pp. e665-e674 ◽

Cited By ~ 6

Author(s):

Benedict Hayhoe ◽

Jose Acuyo Cespedes ◽

Kimberley Foley ◽

Azeem Majeed ◽

Judith Ruzangi ◽

...

Keyword(s):

Systematic Review ◽

Primary Care ◽

Health System ◽

Quality Assessment ◽

Observational Studies ◽

Assessment Tool ◽

Risk Of Bias ◽

Controlled Trials ◽

Cochrane Central Register ◽

Quality Assessment Tool

BackgroundEvidence suggests that pharmacists integrated into primary care can improve patient outcomes and satisfaction, but their impact on healthcare systems is unclear.AimTo identify the key impacts of pharmacists’ integration into primary care on health system indicators, such as healthcare utilisation and costs.Design and settingA systematic review of literature.MethodEmbase, MEDLINE, Scopus, the Health Management Information Consortium, CINAHL, and the Cochrane Central Register of Controlled Trials databases were examined, along with reference lists of relevant studies. Randomised controlled trials (RCTs) and observational studies published up until June 2018, which considered health system outcomes of the integration of pharmacists into primary care, were included. The Cochrane risk of bias quality assessment tool was used to assess risk of bias for RCTs; the National Institute of Health National Heart, Lung, and Blood Institute quality assessment tool was used for observational studies. Data were extracted from published reports and findings synthesised.ResultsSearches identified 3058 studies, of which 28 met the inclusion criteria. Most included studies were of fair quality. Pharmacists in primary care resulted in reduced use of GP appointments and reduced emergency department (ED) attendance, but increased overall primary care use. There was no impact on hospitalisations, but some evidence of savings in overall health system and medication costs.ConclusionIntegrating pharmacists into primary care may reduce GP workload and ED attendance. However, further higher quality studies are needed, including research to clarify the cost-effectiveness of the intervention and the long-term impact on health system outcomes.

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The impact of medication reviews conducted in primary care on hospital admissions and mortality - a randomized controlled trial

10.21203/rs.2.11674/v1 ◽

2019 ◽

Author(s):

Veronica Milos Nymberg ◽

Cecilia Lenander ◽

Beata Borgström Bolmsjö

Keyword(s):

Primary Care ◽

Elderly Patients ◽

Usual Care ◽

Frail Elderly ◽

Hospital Admissions ◽

Intervention Group ◽

Control Group ◽

Randomized Controlled ◽

Medication Reviews ◽

The Impact

Abstract Background Drug-related problems among the elderly population are common and increasing. Multi-professional medication reviews (MR) have arisen as a method to optimize drug therapy for frail elderly patients. Research has not yet been able to show conclusive evidence of the effect of MRs on mortality or hospital admissions. Aim The aim of this study was to assess the impact of MRs’ on hospital admissions and mortality after six and 12 months in a frail population of 369 patients in primary care in a randomized controlled study. Methods Patients were blindly randomized to an intervention group (receiving MRs) and a control group (receiving usual care). Descriptive data on mortality and hospital admissions at six and 12 months were collected. Survival analysis was performed for time to death and time to the first hospital admission within 12 months. Results Of the total number of 369 included patients, 182 were randomized to the intervention group and 187 to the control group. Most of the patients (75%) were females and lived in nursing homes. At six months, 50 patients of the baseline population (27%) in the control group had been admitted to hospital at least once, compared to 40 patients (21%) in the intervention group. At 12 months, the percentage had increased to 70 (37%) in the control group compared to 53 (29%) in the intervention group. Compared to usual care, we found that MRs reduced the risk of hospital admissions within 12 months by 36% (HR = 0.64, 95% CI 0.45-0.90), but found no difference on mortality (HR = 1.12, 95% CI 0.78-1.61) between the groups. Conclusion We suggest that MRs should be recommended in the care of frail elderly patients with expected benefits on hospital admissions.

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A systematic review of interventions to prevent suicidal behaviors and reduce suicidal ideation in older people

International Psychogeriatrics ◽

10.1017/s1041610217001430 ◽

2017 ◽

Vol 29 (11) ◽

pp. 1801-1824 ◽

Cited By ~ 32

Author(s):

Chukwudi Okolie ◽

Michael Dennis ◽

Emily Simon Thomas ◽

Ann John

Keyword(s):

Systematic Review ◽

Older Adults ◽

Primary Care ◽

Suicidal Ideation ◽

Older People ◽

Suicidal Behavior ◽

Depression Screening ◽

Controlled Trials ◽

Cochrane Central Register ◽

Suicide Attempted

ABSTRACTBackground:Older people have a high risk of suicide but research in this area has been largely neglected. Unlike for younger age groups, it remains unclear what strategies for prevention exist for older adults. This systematic review assesses the effectiveness of interventions to prevent suicidal behavior and reduce suicidal ideation in this age group.Methods:MEDLINE, EMBASE, PsycINFO, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for relevant publications from their dates of inception until 1 April 2016. Studies included in this review report effectiveness data about interventions delivered to older adults to prevent suicidal behavior (suicide, attempted suicide, and self-harm without suicidal intent) or reduce suicidal ideation. A narrative synthesis approach was used to analyze data and present findings.Results:Twenty one studies met the criteria for inclusion in the study. Most programs addressed risk predictors, specifically depression. Effective interventions were multifaceted primary care-based depression screening and management programs; treatment interventions (pharmacotherapy and psychotherapy); telephone counseling for vulnerable older adults; and community-based programs incorporating education, gatekeeper training, depression screening, group activities, and referral for treatment. Most of the studies were of low quality apart from the primary care-based randomized controlled trials.Conclusions:Multifaceted interventions directed at primary care physicians and populations, and at-risk elderly individuals in the community may be effective at preventing suicidal behavior and reducing suicidal ideation in older adults. However, more high quality trials are needed to demonstrate successful interventions.

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Effectiveness of non-pharmacological strategies in the management of type 2 diabetes in primary care: a protocol for a systematic review and network meta-analysis

BMJ Open ◽

10.1136/bmjopen-2019-034481 ◽

2020 ◽

Vol 10 (1) ◽

pp. e034481 ◽

Cited By ~ 2

Author(s):

Renata Giacomini Oliveira Ferreira Leite ◽

Luísa Rocco Banzato ◽

Julia Simões Corrêa Galendi ◽

Adriana Lucia Mendes ◽

Fernanda Bolfi ◽

...

Keyword(s):

Systematic Review ◽

Type 2 Diabetes ◽

Primary Care ◽

Latin American ◽

Meta Analysis ◽

Biomedical Literature ◽

Blood Glucose Monitoring ◽

Controlled Trials ◽

Cochrane Central Register

IntroductionDespite the increasing number of drugs and various guidelines on the management of type 2 diabetes mellitus (T2DM), several patients continue with the disease uncontrolled. There are several non-pharmacological treatments available for managing T2DM, but various of them have never been compared directly to determine the best strategies.ObjectiveThis study will evaluate the comparative effects of non-pharmacological strategies in the management of T2DM in primary care or community settings.Methods and analysisWe will perform a systematic review and network meta-analysis (NMA), and will include randomised controlled trials if one of the following interventions were applied in adult patients with T2DM: nutritional therapy, physical activity, psychological interventions, social interventions, multidisciplinary lifestyle interventions, diabetes self-management education and support (DSMES), technology-enabled DSMES, interventions delivered only either by pharmacists or by nurses, self-blood glucose monitoring in non-insulin-treated T2DM, health coaching, benchmarking and usual care. The primary outcome will be glycaemic control (glycated haemoglobin (HbA1c) (%)), and the secondary outcomes will be weight loss, quality of life, patient satisfaction, frequency of cardiovascular events and deaths, number of patients in each group with HbA1c <7, adverse events and medication adherence. We have developed search strategies for Embase, Medline, Latin American and Caribbean Health Sciences Literature, Cochrane Central Register of Controlled Trials, Trip database, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature Australasian Medical Index and Chinese Biomedical Literature Database. Four reviewers will assess the studies for their eligibility and their risk of bias in pairs and independently. An NMA will be performed using a Bayesian hierarchical model, and the treatment hierarchy will be obtained using the surface under the cumulative ranking curve. To determine our confidence in an overall treatment ranking from the NMA, we will follow the Grading of Recommendations Assessment, Development and Evaluation approach.Ethics and disseminationAs no primary data collection will be undertaken, no formal ethical assessment is required. We plan to present the results of this systematic review in a peer-reviewed scientific journal, conferences and the popular press.PROSPERO registration numberCRD42019127856.

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The impact of medication reviews conducted in primary care on hospital admissions and mortality - an observational follow up of a randomized controlled trial

10.21203/rs.2.11674/v2 ◽

2020 ◽

Author(s):

Veronica Milos Nymberg ◽

Cecilia Lenander ◽

Beata Borgström Bolmsjö

Keyword(s):

Primary Care ◽

Elderly Patients ◽

Usual Care ◽

Frail Elderly ◽

Hospital Admissions ◽

Intervention Group ◽

Control Group ◽

Randomized Controlled ◽

Medication Reviews ◽

The Impact

Abstract Background Drug-related problems among the elderly population are common and increasing. Multi-professional medication reviews (MRs) have arisen as a method to optimize drug therapy for frail elderly patients. Research has not yet been able to show conclusive evidence of the effect of MRs on mortality or hospital admissions. Aim The aim of this study was to assess the impact of MRs’ on hospital admissions and mortality after six and 12 months in a frail population of 369 patients in primary care in a randomized controlled study. Methods Patients were blindly randomized to an intervention group (receiving MRs) and a control group (receiving usual care). Descriptive data on mortality and hospital admissions at six and 12 months were collected. Survival analysis was performed for time to death and time to the first hospital admission within 12 months. Results Of the total number of 369 included patients, 182 were randomized to the intervention group and 187 to the control group. Most of the patients (75%) were females and lived in nursing homes. At six months, 50 patients of the baseline population (27%) in the control group had been admitted to hospital at least once, compared to 40 patients (21%) in the intervention group. At 12 months, the percentage had increased to 70 (37%) in the control group compared to 53 (29%) in the intervention group. Compared to usual care, we found that MRs reduced the risk of hospital admissions within 12 months by 42% (HR = 0.58, 95% CI 0.37-0.92), but found no difference on mortality (HR = 1.12, 95% CI 0.78-1.61) between the groups. Conclusion We suggest that MRs should be recommended in the care of frail elderly patients with expected benefits on delayed hospital admissions.

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Effectiveness of strategies for nutritional therapy for patients with type 2 diabetes and/or hypertension in primary care: protocol of a systematic review of randomised controlled trials

BMJ Open ◽

10.1136/bmjopen-2019-030450 ◽

2019 ◽

Vol 9 (9) ◽

pp. e030450 ◽

Cited By ~ 1

Author(s):

Julia Simões Corrêa Galendi ◽

Renata Giacomini Occhiuto Ferreira Leite ◽

Adriana Lúcia Mendes ◽

Vania dos Santos Nunes-Nogueira

Keyword(s):

Systematic Review ◽

Type 2 Diabetes ◽

Primary Care ◽

Latin American ◽

Randomised Controlled Trials ◽

Controlled Trials ◽

Cochrane Central Register ◽

Registration Number ◽

Randomised Controlled

IntroductionDespite the increasing number of drugs available and various guidelines on the management of type 2 diabetes mellitus (T2DM) and hypertension, an expressive number of patients continue with these diseases uncontrolled. Nutrition therapy (NT) plays a fundamental role in the prevention and management of these comorbidities, as well as in the prevention of complications related to them. The objective of this review is to evaluate the effectiveness of NT strategies in the management of patients with T2DM and/or hypertension in primary care. The selected strategies did not substitute pharmaceutical treatment but instead focused on preventing a sedentary lifestyle and stimulating healthy nutrition.Methods and analysisWe will perform a systematic review according to Cochrane methodology of randomised controlled trials, wherein patients with T2DM and/or hypertension were allocated into one of the two groups: NT strategy, which may be of dietary quality or energy restriction, and conventional treatment. The primary outcomes will be glycaemic and blood pressure (BP) control, measured by final glycosylated hemoglobin (HbA1c) (%) and BP (mm Hg), respectively. Four general and adaptive search strategies have been created for the Embase, Medline, Latin American and Caribbean Health Sciences Literature (LILACS) and Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases. Two reviewers will independently select eligible studies, assess the risk of bias and extract data from the included studies. Similar outcomes measured in at least two trials will be plotted in the meta-analysis using Review Manager V.5.3. The quality of evidence of the effect estimate of the intervention will be generated according to the Grading of Recommendations Assessment, Development, and Evaluation Working Group.Ethics and disseminationAs no primary data collection will be undertaken, formal ethical assessment is not required. We plan to present the results of this systematic review in a peer-reviewed scientific journal, conferences and the popular press.PROSPERO registration numberOur systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 20 December 2018 (Registration number CRD42018118117).

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The effectiveness of psychoanalytic/psychodynamic psychotherapy for reducing suicide attempts and self-harm: systematic review and meta-analysis

The British Journal of Psychiatry ◽

10.1192/bjp.2019.33 ◽

2019 ◽

Vol 214 (06) ◽

pp. 320-328 ◽

Cited By ~ 8

Author(s):

Stephen Briggs ◽

Gopalakrishnan Netuveli ◽

Nick Gould ◽

Antigone Gkaravella ◽

Nicole S. Gluckman ◽

...

Keyword(s):

Systematic Review ◽

Psychosocial Functioning ◽

Suicide Attempts ◽

Hospital Admissions ◽

Well Being ◽

Controlled Trials ◽

Cochrane Central Register ◽

Number Of Patients ◽

Self Harm ◽

Psychodynamic Psychotherapies

BackgroundPreventing suicide and self-harm is a global health priority. Although there is a growing evidence base for the effectiveness of psychoanalytic and psychodynamic psychotherapies for a range of disorders, to date there has been no systematic review of its effectiveness in reducing suicidal and self-harming behaviours.AimsTo systematically review randomised controlled trials of psychoanalytic and psychodynamic psychotherapies for suicidal attempts and self-harm.MethodWe searched PubMed, PsycINFO, Psycharticles, CINAHL, EMBASE and the Cochrane Central Register of Controlled Trials for randomise controlled trials of psychoanalytic and psychodynamic psychotherapies for reducing suicide attempts and self-harm.ResultsTwelve trials (17 articles) were included in the meta-analyses. Psychoanalytic and psychodynamic therapies were effective in reducing the number of patients attempting suicide (pooled odds ratio, 0.469; 95% CI 0.274–0.804). We found some evidence for significantly reduced repetition of self-harm at 6-month but not 12-month follow-up. Significant treatment effects were also found for improvements in psychosocial functioning and reduction in number of hospital admissions.ConclusionsPsychoanalytic and psychodynamic psychotherapies are indicated to be effective in reducing suicidal behaviour and to have short-term effectiveness in reducing self-harm. They can also be beneficial in improving psychosocial well-being. However, the small number of trials and moderate quality of the evidence means further high-quality trials are needed to confirm our findings and to identity which specific components of the psychotherapies are effective.Declaration of interestNone.

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Impact on hospital admissions of an integrated primary care model for very frail elderly patients

Archives of Gerontology and Geriatrics ◽

10.1016/j.archger.2014.01.005 ◽

2014 ◽

Vol 58 (3) ◽

pp. 350-355 ◽

Cited By ~ 22

Author(s):

Matthieu de Stampa ◽

Isabelle Vedel ◽

Jean-François Buyck ◽

Liette Lapointe ◽

Howard Bergman ◽

...

Keyword(s):

Primary Care ◽

Elderly Patients ◽

Frail Elderly ◽

Hospital Admissions ◽

Integrated Primary Care ◽

Care Model ◽

Primary Care Model

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Effective Parental intervention strategies to reduce screen time among preschool-aged children: A systematic review (Preprint)

10.2196/preprints.25774 ◽

2020 ◽

Author(s):

Diana Raj ◽

Halimatus Sakdiah Minhat ◽

Nor Afiah Mohd. Zulkefli ◽

Norliza Ahmad

Keyword(s):

Systematic Review ◽

Preschool Children ◽

Young Children ◽

Screen Time ◽

Mode Of Delivery ◽

Intervention Strategies ◽

Controlled Trials ◽

Cochrane Central Register ◽

Negative Consequences ◽

Parental Intervention

BACKGROUND The increasing screen time exposure among young children in general and the reported negative consequences associated with excessive ST, calls for focused strategies to reduce ST, especially among young children. OBJECTIVE This systematic review aimed to identify effective parental intervention strategies to reduce ST among preschool children. METHODS A total of five databases, namely Cochrane Central Register of Controlled Trials, CINAHL, Medline Complete, PubMed, and Scopus, were searched for randomised controlled trials that involved intervention strategies in ST reduction among preschool children. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines were used. RESULTS A total of nine studies were assessed. The results showed that besides providing knowledge and awareness regarding ST, having restrictive practices, offering alternative activities to parents, and removal of screen from child’s bedroom were the most common strategies used by studies that reported successful intervention. Intervention duration of between six to eight weeks was sufficient to produce ST reduction. Face-to-face method was the commonest mode of delivery. Theoretical constructs that aimed at increasing parental self-efficacy, listing outcome expectations, and offering reinforcement of strategies that targeted both the parents and home environment were beneficial in reducing ST. CONCLUSIONS By offering appropriate strategies to parents, a reduction in the amount of ST was observed among the children. Future intervention studies could benefit in exploring culturally adapted strategies, especially in developing countries. Trials of higher quality would also facilitate the drawing of conclusions in future research. CLINICALTRIAL PROSPERO No: CRD42020199398

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