Interventions to reduce unplanned hospital admission: a series of systematic reviews Funded by National Institute for Health Research Research for Patient Benefit no. PB-PG-1208-18013 Sarah Purdy, University of Bristol Shantini Paranjothy, Cardiff University Alyson Huntley, University of Bristol Rebecca Thomas, Cardiff University Mala Mann, Cardiff University Dyfed Huws, Cardiff University Peter Brindle, NHS Bristol Glyn Elwyn, Cardiff University Final Report June 2012 Acknowledgements Advisory group Karen Bloor Senior research fellow, University of York Tricia Cresswell Deputy medical director of NHS North East Helen England Vice chair of the South of England Specialised Commissioning Group and chairs the Bristol Research and Development Leaders Group Martin Rowland Chair in Health Services Research, University of Cambridge Will Warin Professional Executive Committee Chair, NHS Bristol. Frank Dunstan Chair in Medical Statistics, Department of Epidemiology, Cardiff University Patient & public involvment group In association with Hildegard Dumper Public Involvement Manager at Bristol Community Health With additional support from Rosemary Simmonds Research associate University of Bristol Library support Lesley Greig and Stephanie Bradley at the Southmead Library & Information Service, Southmead Hospital, Westbury-on-Trym, Bristol and South Plaza library, NHS Bristol and Bristol Community Health, South Plaza, Marlborough Street, Bristol. Additional support David Salisbury assistance with paper screening. Funding This research was funded by the National Institute for Health Research, Research for Patient Benefit programme (grant PB-PG-1208-18013). This report presents independent research commissioned by the National Institute of Health Research (NIHR). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Contents Executive summary 6 1. General introduction 9 2. Methods 10 Inclusion and exclusion criteria 10 Searches 10 Data collection and analysis 10 Data synthesis 11 Patient & public involvement 12 3. Results 15 Priorisation of topis areas 15 Structure of report 16 A. Case Management 17 Background 17 Definitions 17 Results 17 Risk of bias 18 Economic evaluation 19 Previous reviews 23 Summary 25 B. Specialist clinics 26 Background 26 Definitions 26 Results 26 Risk of bias 30 Previous reviews 32 Summary 33 C. Community interventions 35 Background 35 Results 35 Risk of bias 35 Previous reviews 35 Summary 37 D. Care pathways & guidelines 38 Background. 38 Results 38 Previous reviews 39 Most recent studies 41 Summary 41 Interventions to reduce unplanned hospital admission:a series of systematic reviews Page 3 E. Medication review 42 Background 42 Results 42 Risk of bias 43 Summary 46 F. Education & self-management 47 Background 47 Definitions 47 Results 47 Summary 51 G. Excercise & rehabilitation 52 Background & definitions 52 Results 52 Summary 57 H. Telemedicine 58 Background 58 Definitions 58 Previous review 58 Most recent studies 58 Summary 58 I. Finance schemes 59 Background 59 Previous reviews 59 Recent studies 59 Summary 59 J. Emergency department interventions 60 Background 60 Results 60 Previous Reviews 60 Recent studies 60 Summary 61 K. Continuity of care 62 Background 62 Previous Reviews 62 Summary 64 L. Vaccine programmes. 65 Background. 65 Results 65 Summary 66 M. Hospital at home. 67 Background 67 Definition 67 Previous review(s) 67 More recent studies 67 Summary 67 Interventions to reduce unplanned hospital admission:a series of systematic reviews Page 4 4. Summary 68 Appendices Appendix 1: general tables & figures 71 Appendix 2: tables of study characteristics 78 Appendix 3: Risk of bias tables 151 Appendix 4: Forest plots 161 Interventions to reduce unplanned hospital admission:a series of systematic reviews Page 5 Executive summary Background Approximately 40% of hospital admissions in England are unplanned admissions (2009/10). Unplanned hospital admissions (UHA) are a problem for health systems internationally as they are costly and disruptive to elective health care, and increase waiting lists. Recent policy in the UK and elsewhere has focused on reducing UHA. To reduce the burden on elective health care and resource use in the long term, it is therefore important to manage UHA. In order to do this we need to fully understand which interventions are effective in reducing UHA. There have been a small number of community or societal level public health or policy interventions aimed at reducing UHA. These approaches have been variable and generally inconclusive. Therefore there was a need for a series of comprehensive systematic literature reviews that would identify interventions that address organisation of care and access for the purpose of reducing UHA. The overall aim of this series of systematic reviews was to evaluate the effectiveness and cost-effectiveness of interventions to reduce UHA. Our primary outcome measures of interest were reduction in risk of unplanned admission or readmission to a secondary care acute hospital, for any speciality or condition. We planned to look at all controlled studies namely randomised trials (RCTs), controlled clinical trials, controlled before and after studies and interrupted time series. If applicable, we planned to look at the cost effectiveness of these interventions. Key findings Case management: RCTs found by our searches covered older people, heart failure and COPD patients. Overall case management did not have any effect on UHA although we did find three positive heart failure studies in which the interventions involved specialist care from a cardiologist. Specialist clinics: RCTs found by our searches covered heart failure, asthma and older people. Overall specialist clinics for heart failure patients, which included clinic appointments and monitoring over a 12 month period reduced UHA. There was no evidence to suggest that specialist clinics reduced UHA in asthma patients or in older people. Community interventions: A small number of RCTs based on home visits were found by our searches and covered older people, mother and child health and heart disease. Overall, Interventions to reduce unplanned hospital admission:a series of systematic reviews Page 6 the evidence is too limited to make definitive conclusions. However, there is a suggestion that visiting acutely at risk populations may result in less UHA e.g. failure to thrive infants, heart failure patients. Care pathways and guidelines: Care pathway systematic reviews have been conducted across conditions as well as for specific diseases such as gastrointestinal surgery, stroke and asthma. Guidelines have been reviewed similarly across conditions. There is no convincing evidence to make any firm conclusions regarding the effect of these approaches on UHA, although it is important to point out that data are limited for most conditions. Medication review: RCTs found by our searches covered the older people, heart failure and asthma. There was no evidence of an effect on UHA in older people, and on those with heart failure or asthma carried out by clinical, community or research pharmacists. It is important to note that the evidence was limited to two studies for asthma patients. Education & self-management: This was a topic covered by recent Cochrane reviews. Our searches found RCTs covering asthma, COPD and heart disease. Cochrane reviews concluded that education with self-management reduced UHA in adults with asthma, and in COPD patients but not in children with asthma. There is weak evidence for the role of education in reducing UHA in heart failure patients. Exercise & rehabilitation: This was a topic covered by recent Cochrane reviews. Our searches found RCTs covering COPD, heart disease, stroke and older people. Cochrane reviews conclude that pulmonary rehabilitation is a highly effective and safe intervention to reduce UHA in patients who have recently suffered an exacerbation of COPD, exercise- based cardiac rehabilitation for coronary heart disease is effective in reducing UHA in shorter term studies, therapy based rehabilitation targeted towards stroke patients living at home did not appear to improve UHA and there were limited data on the effect of fall prevention interventions for at risk older people. The data that were available suggest they did not influence UHA. Telemedicine: Telemedicine has been extensively researched in primary studies as well as extensively assessed in systematic reviews and meta-analysis. A recent programme of work called the Healthlines study carried out in the School of Social and Community Medicine at the University of Bristol in collaboration with the Universities of Sheffield and Southampton included a meta-review of home-based telehealth for the management of long term conditions. Whilst the focus of their work was not specifically the reduction of UHA, their final report included relevant systematic reviews or meta-analyses which described the effect of Interventions to reduce unplanned hospital admission:a series of systematic reviews Page 7 telehealth on UHA. Telemedicine is implicated in reduced UHA for heart disease, diabetes, hypertension and the older people. Vaccine programs: We identified a series of Cochrane reviews looking at the effect of influenza vaccinations on a variety of vulnerable patients. A review on asthma patients reported both asthma-related and all cause hospital admissions. No effects on admissions were reported. A review on seasonal influenza vaccination in people aged