Reducing hospital bed use by frail older people: results from a systematic review of the literature

Introduction Numerous studies have been conducted in developed countries to evaluate the impact of interventions designed to reduce hospital admissions or length of stay (LOS) amongst frail older people. In this study, we have undertaken a systematic review of the recent international literature (2007-present) to help improve our understanding about the impact of these interventions. Methods We systematically searched the following databases: PubMed/Medline, PsycINFO, CINAHL, BioMed Central and Kings Fund library. Studies were limited to publications from the period 2007-present and a total of 514 studies were identified. Results A total of 48 studies were included for full review consisting of 11 meta-analyses, 9 systematic reviews, 5 structured literature reviews, 8 randomised controlled trials and 15 other studies. We classified interventions into those which aimed to prevent admission, interventions in hospital, and those which aimed to support early discharge. Conclusions Reducing unnecessary use of acute hospital beds by older people requires an integrated approach across hospital and community settings. A stronger evidence base has emerged in recent years about a broad range of interventions which may be effective. Local agencies need to work together to implement these interventions to create a sustainable health care system for older people.

Systematic review (M) Systematic reviewof interventions intended to reduce admission to hospital of older people.
E Evidence for reducing hospitalisation rates was equivocal. The most effective was provided by established, integrated teams in the patient's home. The review had some methodological limitations and caution is warranted when interpreting the author's conclusions. [4] Systematic review and meta-analysis of randomised controlled trials (H) 108,838 people; 110 randomised controlled trials -21 incorporated in meta-analysis Review of randomised controlled trials evaluating 'complex' social and medical interventions that may help maintain independence in older people. P There was an overall benefit of complex interventions in helping older people to live at home, explained by reduced nursing home admissions rather than death rates. Hospital admissions and falls were also reduced in intervention groups. Benefits were largely restricted to earlier studies, perhaps reflecting general improvements in health and social care for older people. was better in the intervention groups than in other groups. Benefit for any specific type or intensity of intervention was not noted.
[6] a Literature review (M) Review of randomised controlled trials and observational studies Overview of the effectiveness of different strategies for reducing hospital demand that may be viewed as primarily targeting the hospital sectorincreasing capacity and throughput and reducing readmissions -or the nonhospital sector -facilitating early discharge or reducing presentations and admissions to hospital. P In regards to the non-hospital sector, potentially the biggest gains in reducing hospital demand will come from improved access to residential care, rehabilitation services and domiciliary support. More widespread use of acute care and advance care planning within residential care facilities and population-based chronic disease management programmes can also assist. [  (2) with the standard average stay in the corresponding autonomous region.

P
The mean length of stay in the acute geriatric unit was 8-19% shorter than that of similar patients in other medical departments. In one hospital, the reduction in the mean length of stay was 21% in patients older than 80 years. In three of the four hospitals where comparisons with the standard average stay in the corresponding autonomous region were performed, the mean length of stay in the acute geriatric unit showed reductions of 7-9%.    Two systematic reviews comparing coordinated multidisciplinary approaches for in-patient rehabilitation of older people versus usual orthopaedic care found no significant difference in mortality.
Mental health liaison [34] Narrative review (M) 13 papers Review of joint geriatric/psychiatric wards as a potential solution to improving care of older patients with both psychiatric and medical illnesses in acute hospitals. E These wards share common characteristics and there is an evidence that they may reduce the length of stay and be cost-effective, but there are no highquality randomised controlled trials. This is a narrative rather than a systematic review because the limited number of studies address different aspects of care in different patient populations and authors did not consider it meaningful to attempt to combine results. Pooled analysis of exercise intervention trials found no effect on the proportion of patients discharged to home or acute hospital length of stay.

Continues
This article is published in a peer reviewed section of the International Journal of Integrated Care   Interventions should commence well before discharge. The research shows there is a direct correlation between the quality of discharge planning and readmission to hospital.
No mention of cost-effectiveness or economic evaluations.
[42] Systematic meta-review (H) 15 reviews Synthesis of the evidence presented in the literature on the effectiveness of interventions aimed to reduce post-discharge problems in adults discharged home from an acute general care hospital.
E Although a statistical significant effect was occasionally found, most review authors reached no firm conclusions that the discharge interventions they studied were effective. We found limited evidence that some interventions may improve knowledge of patients, may help in keeping patients at home or may reduce readmissions to hospital.
Interventions that combine discharge planning and discharge support tend to lead to the greatest effects.
There is little evidence that discharge interventions have an impact on length of stay, discharge destination or dependency at discharge. [43] Quasiexperimental pre-post study design (USA) (L) 237 patients pre intervention; 185 intervention Study of the feasibility and effectiveness of a discharge planning intervention to facilitate the transition of older adults from three hospitals back to their homes. The intervention toolkit had five core elements: admission form with geriatric cues, facsimile to the primary care provider, interdisciplinary worksheet to identify barriers to discharge, pharmacist-physician collaborative medication reconciliation and pre-discharge planning appointments.

Results
A total of 48 studies were included for full review consisting of 11 meta-analyses, 9 systematic reviews, 5 structured literature reviews, 8 randomised controlled trials and 15 other studies (6 before and after studies, 6 non-randomised controlled trials, 1 comparator group study, 1 cohort study with case controls and 1 observational cohort study). With only 1 exception [3], evidence from meta-analyses and systematic reviews was classified as high, from literature reviews and randomised controlled trials as medium and that from 'other' studies as low.
We assessed the impact of the studies based on the reported findings as follows: Positive -statistically significant positive impact on hospital admissions/readmissions and/or length of stay; Equivocal -some positive but not statistically significant impact; Negative -no impact. We classified interventions into those which aimed to prevent admission (Table 1) interventions in hospital (Table 2), and those which aimed to support early discharge (Table 3).
We found evidence for the effectiveness of care coordination, preventive health checks and care home liaison in the prevention of admission to hospital. Within the hospital setting, there was an evidence for the effectiveness of geriatric assessment units and orthogeriatric units targeting frail older people in reducing the length of stay. For services which linked hospital-and community-based care, including discharge planning, information sharing and rehabilitation services provided in the person's home, there was an evidence of effectiveness in reducing length of stay and preventing readmission to hospital.
There were a series of interventions where there was no evidence of impact on hospital bed use. These included multi-factorial falls prevention services, day hospital services, medication reviews, exercise programmes in the community, nutritional enhancement in hospital and nurse-led transitional care units. This review provides insufficient objective evidence of economic benefit or improved health outcomes for early discharge hospital at home services.

Discussion
Our search for peer-reviewed publications about interventions for reducing hospital bed use by frail older people published since 2007 revealed a large number of studies. There may be further studies which were not captured by our search terms. As the majority of studies we identified were secondary reviews, our study covers a substantial body of evidence from peer-reviewed research on this topic.
We have found that the evidence base has strengthened for many interventions in hospital and community settings. These include: targeted preventive health checks, care coordination for frail older people, when embedded within integrated health and social care teams, hospital geriatric assessment and orthogeriatric units, community-based rehabilitation services and better integration of acute and post-acute care through discharge planning and joined up information systems.
We have found no evidence to support multi-factorial falls prevention services, community-based medicines reviews, day hospital services, exercise interventions in hospital and nurse-led transitional care, but there were fewer studies of these interventions. It may be that with further development, some of these interventions may prove effective. Studies of association have shown that falls [51], polypharmacy [52], poor nutrition [53][54][55] and lack of exercise [56] are all associated with increased hospital bed use in older people, so interventions targeted on these areas have the potential to reduce hospital bed use.
Despite huge expectations, telehealth and telecare have not been shown to be effective in the randomised trials. In a recently published randomised trial of telehealth [57] (the Whole Systems Demonstrator telehealth trial), compared with usual care, telehealth was not more effective and did not improve quality of life or psychological outcomes for patients with chronic obstructive pulmonary disease, diabetes or heart failure over 12 months [58]. Reassuringly, no deleterious effects on the service users were noted with the telehealth. Similarly, a cluster randomised trial comparing telecare (as implemented in the Whole Systems Demonstrator trial) with usual care did not show significant reductions in service use over 12 months [59].
Effective interventions had common features including anticipatory care targeting older people at risk of adverse outcomes in all settings and well-integrated multidisciplinary practice and inter-agency working. We conclude that services should be developed as a whole system including preventive care, acute hospital care and community care. A shared information system should be created to support patient flow through the system.

Conclusion
Reducing unnecessary use of acute hospital beds by older people requires an integrated approach across hospital and community settings. A stronger evidence base has emerged in recent years about a broad range of interventions which may be effective. Local agencies need to work together to implement these interventions to create a sustainable health care system for older people.