What Is the Evidence for the Effectiveness of Managing the Hospital / Community Interface for Older People?
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NZHTA REPORT February 2004 Volume 7 Number 1 What is the evidence for the effectiveness of managing the hospital / community interface for older people? A critical appraisal of the literature Wasan Ali Patricia Rasmussen New Zealand Health Technology Assessment Department of Public Health and General Practice Christchurch School of Medicine and Health Sciences Christchurch, New Zealand Division of Health Sciences, University of Otago NEW ZEALAND HEALTH TECHNOLOGY ASSESSMENT (NZHTA) Department of Public Health and General Practice Christchurch School of Medicine and Health Sciences Christchurch, New Zealand What is the evidence for the effectiveness of managing the hospital / community interface for older people? A critical appraisal of the literature Wasan Ali Patricia Rasmussen NZHTA REPORT February 2004 Volume 7 Number 1 This report should be referenced as follows: Ali, W. and Rasmussen P. What is the evidence for the effectiveness of managing the hospital / community interface for older people. NZHTA Report 2004; 7(1). 2004 New Zealand Health Technology Assessment (NZHTA) ISBN 1-877235-52-0 ISSN 1174-5142 i CONTRIBUTION BY AUTHORS This report was authored by Dr Wasan Ali (Assistant Research Fellow) who conducted the critical appraisals and prepared the report project. Mrs Patricia Rasmussen (Assistant Research Fellow) provided the descriptive review section on the key components of published specialist geriatric service protocols and guidelines. ACKNOWLEDGEMENTS Mr Peter Day (Research Fellow) and Dr Ray Kirk (Director) provided comment on various drafts and coordinated the overall project. Mrs Susan Bidwell (Information Specialist Manager) developed and undertook the search strategy and coordinated retrieval of documents. Ms Becky Mogridge and Mrs Philippa Monkman assisted with the retrieval of documents. Mrs Ally Reid (Administrative Secretary) provided document formatting. The Canterbury Medical Library assisted with the retrieval of articles. NZHTA is a Research Unit of the University of Otago funded under contract to the Ministry of Health. This report was commissioned by Ms Pam Fletcher, Senior Analyst, Health of Older People, Sector Policy Directorate of New Zealand’s Ministry of Health. We also thank Pam for assisting us in developing the scope of the review and providing background material for the review. Dr Matthew Parsons from the Clinical Trials Research Unit, Faculty of Medical and Health Sciences, University of Auckland provided peer review comment on the document. DISCLAIMER New Zealand Health Technology Assessment (NZHTA) takes great care to ensure the information supplied within the project timeframe is accurate, but neither NZHTA, the University of Otago, nor the contributors involved can accept responsibility for any errors or omissions. The reader should always consult the original database from which each abstract is derived along with the original articles before making decisions based on a document or abstract. All responsibility for action based on any information in this report rests with the reader. NZHTA and the University of Otago accept no liability for any loss of whatever kind, or damage, arising from reliance in whole or part, by any person, corporate or natural, on the contents of this report. This document is not intended as personal health advice. People seeking individual medical advice are referred to their physician. The views expressed in this report are those of NZHTA and do not necessarily represent those of the University of Otago or the New Zealand Ministry of Health. COPYRIGHT This work is copyright. Apart from any use as permitted under the Copyright Act 1994 no part may be reproduced by any process without written permission from New Zealand Health Technology Assessment. Requests and inquiries concerning reproduction and rights should be directed to the Director, New Zealand Health Technology Assessment, Christchurch School of Medicine and Health Sciences, P O Box 4345, Christchurch, New Zealand. WHAT IS THE EVIDENCE FOR THE EFFECTIVENESS OF MANAGING THE HOSPITAL / COMMUNITY INTERFACE FOR OLDER PEOPLE? ii CONTACT DETAILS New Zealand Health Technology Assessment (NZHTA) Department of Public Health and General Practice Christchurch School of Medicine and Health Sciences PO Box 4345 Christchurch New Zealand Tel: +64 3 364 3696 Fax: +64 3 364 3697 Email: [email protected] Web Site: http://nzhta.chmeds.ac.nz/ WHAT IS THE EVIDENCE FOR THE EFFECTIVENESS OF MANAGING THE HOSPITAL / COMMUNITY INTERFACE FOR OLDER PEOPLE? iii EXECUTIVE SUMMARY 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: C provide evidence for the effectiveness of services managing the hospital / community interface and C 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. WHAT IS THE EVIDENCE FOR THE EFFECTIVENESS OF MANAGING THE HOSPITAL / COMMUNITY INTERFACE FOR OLDER PEOPLE? iv 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.