Impact of health service interventions on acute hospital use in community-dwelling persons with dementia: A systematic literature review and meta-analysis

Abstract

Background Persons with dementia have twice the acute hospital use as older persons without dementia. In addition to straining overburdened healthcare systems, acute hospital use impacts patient and caregiver quality of life and is associated with increased risk of adverse outcomes including death. Reducing avoidable acute hospital use in persons with dementia is thus a global healthcare priority. However, evidence regarding the impact of health service interventions as defined by the Effective Practice and Organization of Care Cochrane Group on acute hospital use is scant and inconclusive. The aim of this systematic review and meta-analysis was to synthesize available evidence on the impact of health service interventions on acute hospital use in community-dwelling persons with dementia compared to usual care. Methods Data Sources: MEDLINE, EMBASE, CINAHL and Cochrane CENTRAL (from 01/1995 to 08/2017). Study eligibility criteria: Randomised controlled trials measuring the impact of health service interventions on acute hospital use (proportion and mean number of emergency department visits and hospitalisations, mean number of hospital days, measured at 12 months, and at longest follow-up) in community-dwelling persons with dementia, compared to usual care. Study selection, appraisal and synthesis methods: Reviewers independently identified studies, extracted data, and assessed the risk of bias, with the Cochrane risk of bias tool. Authors of relevant trials were queried about unpublished data. Random effects model was used for meta-analyses. Effect heterogeneity was assessed through prediction intervals, and explored using sub-group analyses. Findings Seventeen trials provided data on 4,549 persons. Unpublished data were obtained for 13 trials, representing 65% of synthesized data. Most interventions included a case management or a self-management component. None of the outcome comparisons provided conclusive evidence supporting the hypothesis that these interventions would lead to a decrease in acute hospital use. Furthermore, prediction intervals indicated possible and important increased service use associated with these interventions, such as emergency department visits, hospital admissions, and hospital days. Subgroup analyses did not favour any type of intervention. A limitation of this study is the inclusion of any type of health service intervention, which may have increased the observed heterogeneity. Conclusion Despite a comprehensive systematic review and meta-analysis, including predominantly unpublished data, no health service intervention beyond usual care was found to reduce acute hospital use in community-dwelling persons with dementia. An important increase in service use may be associated with these interventions. Further research is urgently needed to identify effective interventions for this vulnerable population to limit rising acute hospital use, associated costs and adverse outcomes. Sy...

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“…Shorter interventions led to better mental functioning scores (Amo‐Setien et al., 2019); longer interventions improved HbA1c levels but not blood pressure (Berntsen et al., 2019). Longer case management interventions in dementia were associated with reduced institutionalisation (Pimouguet et al., 2010), but not for other care models compared to usual care (Godard‐Sebillotte et al., 2019).…”

“…Having a clear focus on self‐management contributed to positive clinical outcomes in LTCs and multimorbidity (Kastner et al., 2018; Reynolds et al., 2018), social support in LTCs (compared to usual care) (Reilly et al., 2015), and reducing admissions in older people at risk of hospitalisation (Tricco et al., 2014); but did not influence the effectiveness of case management over usual care upon acute hospital use for people with dementia (Godard‐Sebillotte, Le Berre, Schuster, Trottier, & Vedel, 2019).…”

“…In those at risk of hospitalisation, patient education reduced admissions (Tricco et al., 2014). However, intervention characteristics including education had no effect upon use of acute hospital services for people with dementia compared to usual care (Godard‐Sebillotte et al., 2019). Teaching patients in nurse‐led interventions did not impact upon mental functioning (which includes vitality, social and emotional functioning and mental health) in LTCs (Amo‐Setien et al., 2019).…”

2021 Alzheimer's disease facts and figures

“…Researchers of two recent systematic reviews, however, have found little evidence to support health services interventions successfully reducing acute hospitalizations or emergency department visits. One group of researchers who conducted a recent systematic review and meta‐analysis of 17 randomized controlled trials from seven countries aimed at reducing avoidable acute hospital care by community‐dwelling individuals with dementia found that none of the interventions reduced acute hospital use, such as emergency department visits, hospital admissions, or hospital days 653 . In another systematic review and meta‐analysis that included some of the same studies, researchers also found no evidence that non‐pharmacological interventions reduced hospital admission for community‐dwelling individuals with dementia 654 .…”

2020 Alzheimer's disease facts and figures

“…Another group of researchers, however, found that a dementia care program that used nurse practitioners and physicians to co‐manage patients was cost neutral after taking into account the costs of the program and cost savings due to fewer long‐term care nursing home admissions 585 . However, in a recent systematic review and meta‐analysis of 17 randomized controlled trials from seven different countries aimed at reducing avoidable acute hospital care by persons with dementia, none of the interventions reduced acute hospital use, such as emergency department visits, hospital admissions, or hospital days 586 …”