Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Opportunistic Screening is more effective.
- Andrew M Thornett (19 March 2000)
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75+ Health Assessments
- Jonathan Newbury (24 March 2000)
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Review of preventive home visits to elderly people: Is vote counting the answer?
- Andreas Stuck (11 April 2000)
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Effects of preventive home visits to elderly people living in the community: systematic review.
- Astrid Fletcher (11 April 2000)
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Preventive home visits to those over 75
- Joy Townsend (19 April 2000)
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Discussion about review of preventive home visits to elderly people living in the community.
- Jolanda van Haastregt (9 May 2000)
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Re-analysis of results of included studies does not support original review conclusions.
- Chris Hyde (5 April 2001)
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Andrew M Thornett, Clinical Assistant Arnewood Practice, New Milton, Hampshire
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I read with interest the article by van Haastregt et al on preventive home visits to elderly people1. As a general practitioner in an area with a large elderly population, I have experienced personally the advantages of thorough assessment of individuals during home visits. This leads to the detection of significant amounts of previously undiagnosed pathology, much of which might be potentially serious if left untreated. Many of these individuals have few social contacts and their quality of life is improved by the personal interaction provided by health professionals. Other advantages gained by these visits include the support provided to family and carers. Under the red book regulations, general practitioners should offer each patient over the age of 75 years a consultation and a domiciliary visit annually. However, formal screening of all elderly individuals in general practice is an expensive undertaking2, and may not be cost- effective. There is some evidence that screening produces an increase in use of health care services, but only a minimal change in health state3. A high proportion of this population are seen by their general practitioner each year for acute needs, and the benefits of this care are probably best provided by opportunistic screening. Reference List 1. van Haastregt JCM, Diederiks JPM, van Rossum E, de Witte LP, Crebolder HFJM. Effects of preventive home visits to elderly people living in the community: systemic review. 2000. 2. Wallis JB,.Barber JH. The effect of a system of geriatric screening and assessment on general practice workload. Health Bull (Edinb) 1982;40:125-32. 3. Tulloch AJ,.Moore V. A randomised controlled trial of geriatric screening and surveillance in general practice. J.R.Coll.Gen.Pract. 1979;29:733-42. |
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Jonathan Newbury, Lecturer, Dept. of General Practice University of Adelaide
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“75+ Health Assessment in Australia.” The systematic review by Van Haastregt et al of trials of preventive home visit for the elderly (65+) reported that “no clear evidence was found in favour” of such visits (1) . Some of the trials reviewed found favourable effects in some of the five main outcome measures (physical functioning, psychosocial functioning, falls, admissions to institutions and mortality) but most found no effect. However, van Haarstregt’s review demonstrates, but does not comment on, the observation that favourable outcomes were more prevalent in studies conducted in older subjects (75+). Table 1 is constructed from the analysis they report.
Table 1
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Number of Number (%)
favourable of these
studies favourable
studies in 75+
people
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Physical functioning 5 1 (20)
Psychosocial functioning 1 1 (100)
Falls 2 1 (50)
Admission to institution 2 2 (100)
Mortality 3 2 (67)
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Physical functioning outcomes are the exception with only 1 of the 5 favourable studies being in 75+ people. This is not unexpected. The ability to improve physical functioning may be easier in the 65+ group generally than in the 75+ group specifically. General practitioners in Australia have recently been funded for “75+ Health Assessments”. We have just concluded a randomised controlled trial of “75+ Health
Assessments”. The protocol for the trial was briefly described in a
previous letter (2) . A nurse visited 100 community living elderly people
twice, one year apart (50 control, 50 intervention). No interval
assessment nor reminder was included in the protocol.
Initial analysis includes:
Our study is consistent with the other published trials, demonstrating modest improvement in the measured outcomes in the 75+ age group. Van Haarstregt et al call for either improved effectiveness of preventive home visits or their discontinuation. Their data support, as do our initial results, that annual preventive home visits are most useful in the 75+ age group. A BMJ editorial 12 years ago also made the point that 65 is too young to start preventive home visits . Evaluation of the Australian “75+ Health Assessments” will establish if they have a beneficial effect on outcome. Dr. Jonathan Newbury
(1) Van Haarstregt JCM, Diederiks JPM, van Rossum E, de Witte LP, Crebolder HFJM. Effects of preventive home visits to elderly people living in the community: systematic review. BMJ 2000; 320: 754-758. (2) Newbury J, Marley J. eLetter BMJ www.bmj.com/cgi/content/abstract/319/7211/683#responses (3) Buckley EG, Williamson J. What sort of "health checks" for older people? BMJ 1988; 296:1145. |
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Andreas Stuck, medical director Zieglerspital, Bern
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EDITOR - Haastregt et al conclude that there is little evidence supporting the effectiveness of preventive home visits to elderly people living in the community (1). Their review is timely but methodological shortcomings limit its usefulness. The principal method of analysis consisted of "vote counting": adding up the number of studies showing statistically significant effects. This procedure is a sad relic from the times of unsystematic, narrative reviews, ignoring sample size, effect size, type of intervention and methodological quality (2). For example, it is important to distinguish between preventive home visits that included multidimensional geriatric assessment with follow-up and interventions that did not (3). Assessment of the quality of trials was also problematic. Empirical research has shown that the scale used by Haastregt et al, and scales in general, may produce misleading results (4). Rather than calculating a summary score the methodological aspects that are important in a given context should be identified and assessed individually. Some of the items included by Haastregt et al are not relevant in this context ("co- interventions" are an integral part of preventive home visits), others do not measure the quality of a trial (adverse effects are an important outcome but not a measure of methodological quality), while important dimensions of quality (for example, concealment of allocation) were lacking from the list of items. Three of us (AS, JCB, CM) were involved in a randomised trial of preventive home visits which was conducted in Berne, Switzerland (5). The findings from this trial, which was published after the review by Haastregt et al appeared showed that preventive home visits can reduce disability, which in a 3-year period may save up to 1400 US $ per person per year (5). In a planned subgroup analysis we found that the effect of the intervention depended on the base-line risk status of trial participants (disability was reduced among persons at low-risk at base- line, but not among high-risk participants). In addition, the professional experience of the person visiting was an important factor determining programme efficacy. These findings indicate that the composition of the study population and the type and quality of the intervention are important factors which may explain the discrepant results obtained from randomised trials of preventive home visits. Although there are conflicting results between individual trials of preventive home visits, some trials clearly demonstrate that home visits can substantially reduce or delay the onset of disability. Thus, research is needed to explicitly define the conditions for cost-effective programmes for reducing disability among older people. We agree with Haastregt et al that it is often inappropriate to combine a heterogeneous set of trials. However, vote counting cannot identify the factors introducing heterogeneity. Further meta-analytic and trial research is required to clarify what components of this complex intervention work in which population groups. Andreas Stuck, medical director
Matthias Egger, senior lecturer in epidemiology and public health
medicine
Christoph E. Minder, senior biostatistician
Steve Iliffe, reader in general practice
John C. Beck, MD, professor of medicine (geriatrics),
References (1) Van Haastregt JCM, Diederiks JPM, van Rossum et al. Effects of preventive home visits to elderly people living in the community: systematic review. BMJ 2000;320:754-8. (2) Egger M, Davey Smith G. Rationale, potentials and promise. In: Egger M, Davey Smith G, Altman DG. Systematic Reviews in Health Care: Meta -Analysis in Context. London: BMJ Books (in press). (3) Stuck AE, Walthert J, Nikolaus T, Büla CJ, Hohmann C, Beck JC. Risk factors for functional status decline in community-dwelling elderly people: a systematic literature review. Soc Sci Med 1999; 48:445-469. (4) Jüni P, Witschi A, Bloch R, Egger M. The hazards of scoring the quality of clinical trials for meta-analysis. JAMA 1999; 282:1054-1060 (5) Stuck AE, Minder CE, Peter-Wüest I, Gillmann G, Egli C, Kesselring A, Leu RE, Beck JC. A randomized trial of in-home visits for disability prevention in community-dwelling older people at low and at high risk for nursing home admission. Arch Intern Med 2000 . Arch Intern Med 2000; 160:977-986 |
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Astrid Fletcher
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Dear Sir - The authors (1) rightly point out that a formal pooling of the results of the RCTs on preventive home visits was not appropriate given the "considerable heterogeneity of the interventions". However the information they provide is uninformative: they present only the results for selected outcomes in terms of being "significant" or "non significant" with no information on the estimates of effect or the confidence intervals. This information is essential to understand the magnitude of possible benefits, and the precision of estimates of benefit. Lack of power is one of the major limitations of most of the studies reviewed especially for mortality outcomes. Their review also misses some other important methodological problems (2). The studies in general practice used within practice individual randomisation and this may have resulted in 'contamination' of the control group. Most European trials suffered from "black box" interventions while the US trials had low participation rates and over-represented high-income fit elderly. In none of the trials was there adequate information regarding the cost-effectiveness of multidimensional assessment. We agree with the authors' conclusions that there is currently limited evidence for the benefit of multidimensional assessment of older people. These concerns are more than "academic" since regular health checks for the over 75s were introduced by the DOH in 1990 as a contractual obligation of GPs. Not surprisingly, most general practitioners view the policy unfavourably while nurses and elderly people are enthusiastic about the health checks and consider them to be of value (3-5). The current situation is unsatisfactory but abandoning the health checks is not a sensible option at the present time. Within the UK there are some models of good practice and ongoing research. A large trial is in progress, which will provide important data on the cost effectiveness of different methods of assessment and management of elderly people within the context of the 1990 contract of service. The trial, funded by the MRC and Department of Health has been designed to have adequate power to detect benefits in mortality, hospital admissions and quality of life. 106 General Practices and 33,000 elderly people from the MRC GP Research Framework are participating with results expected in 2001. There are strong arguments for regular assessment of elderly people on the basis of their special needs. The UK policy was introduced prematurely in the absence of evidence of benefit. It would be equally premature to withdraw the policy based on the results of the small, low powered studies, with a mixed and uncertain bag of interventions, described in this review. Astrid Fletcher,
Christopher Bulpitt,
on behalf of the MRC Trial of Assessment and Management of elderly people in the community 1. van Haastregt JCM, Diederiks JPM, van Rossum E, de Witte LP, Crebolder HFJM. Effects of preventive home visits to elderly people living in the community: systematic review. BMJ 2000;320:754-8 2. Fletcher AE. Multidimensional assessment of elderly people. British Medical Bulletin 1998; 1998;54:945-960. 3. Tremellen J Assessment of patients aged over 75 in general practice. BMJ 1992;305:621-624 4. Chew CA, Wilkin D, Glendenning C. Annual assessment of patients aged 75 years and over; general practitioners and practice nurses views and experiences. Br J Gen Pract 1994;44:263-7 5. McIntosh IB, Power KG. Elderly people's views of an annual screening assessment. Br J Gen Prac1993;43:189-192 |
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Joy Townsend
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Dear Sir - We were interested to see your systematic review on preventive home visits from a care attendant to elderly people (1). One specific area in which such visits have been found to be of significant value is to those over 75 years at hospital discharge. We evaluated a scheme in which elderly patients were visited at home by a care attendant immediately after hospital discharge irrespective of apparent need; and followed up 903 patients for 18 months in a randomised controlled trial, half receiving only standard discharge care (2). The scheme aimed to provide a safety net to include patients assessed as not needing care and to check gaps in provision or failure to implement services. This age group has a high readmission rate with half being readmitted at least once within the year. Those receiving visits had significantly fewer multiple readmissions (7% v 14% twice or more in 18 months) and emergency readmissions (3). Hospital days were reduced particularly for those living alone (17 days v 31 days over 18 months). The scheme cost £26 000 per 100 000 population with short-term savings of £115 000 and much higher long-term savings (1985/6 values). The NHS successfully implemented and evaluated schemes in four centres in North Thames (Waltham Forest, Basildon, Enfield and Tower Hamlets) based on this research. Similar results to the original research were reported together with clear evidence that they were highly valued by the patients, health and social services staff (4). It seems that at least one home visit immediately after discharge of an elderly individual from hospital, in addition to usual assessment, is highly beneficial and cost effective. Joy Townsend Andrew Frank Mary Piper References 1. van Haastregt, JCM, Diederiks JPM, van Rossum E, de Witte LP, Crebolder HFJM. Effects of preventive home visits to elderly people living in the community: systematic review. BMJ 2000; 320: 754-8 2. Townsend J, Piper M, Frank AO, Dyer S, North WRS, Meade TW. Reduction in hospital readmission stay of elderly patients by a community- based hospital discharge scheme: a randomised controlled trial. BMJ 1988; 297: 544-7 3. Townsend J, Dyer S, Cooper J, Piper M, Frank AO. Emergency hospital admissions and readmissions of patients aged over 75 years and the effects of a community-based discharge scheme. Health Trends 1992; 24(4): 136-9 4. Townsend J. Hospital Aftercare Service for older people (care attended scheme) implementation study. Report to NHSE North Thames, November 1997. |
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Jolanda van Haastregt, health scientist Institute for Rehabilitation Research
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EDITOR - In their response to our review of preventive home visits to community-living elderly persons [1], Stuck [2] and Fletcher [3] criticised several aspects of our study. Stuck discussed our method of analysis, which he considers to be inadequate. As we reported in our paper, we seriously considered statistical pooling of the data of the included trials. However, owing to the large clinical heterogeneity of our set of trials, statistically pooling the data of these fifteen trials is extremely hazardous and in our opinion inappropriate. Only when clinically homogeneous subsets could be generated from this set of trials, data pooling could be justified and potentially useful. Yet, in our opinion, it is not possible to distinguish such homogeneous subsets, mainly owing to the large clinical heterogeneity of the interventions. In addition, considerable differences exist between subjects, outcome measures, timing of outcome measurement and the health care settings in which the interventions were performed. We therefore chose for a more generic approach by performing a detailed qualitative systematic review of the effects of this diverse set of preventive home visit programmes. Fletcher stated that lack of power is one of the major limitations of most of the trials included in our review. It can be observed however that ten of the fifteen studies we reviewed, included between 200 and 700 subjects per group which makes it highly unlikely that a lack of power could have seriously influenced the results of these studies. Moreover, when we seperately analyse the results of these ten large studies, we still come to the same conclusion: no clear evidence exist in favour of the effectiveness of preventive home visits to elderly people living in the community. With regard to our methodological quality assessment, Stuck stated
that rather than calculating a summary score, the methodological aspects
that are important should have been identified and assessed individually.
That is what we did in our study: identify methodologically relevant
aspects and assess them individually.
Currently, we think it is not possible to properly distinguish the active components from the total set of components of preventive home visit programmes, because of the 'black box' character of the intervention programmes. However, with regard to future research we certainly agree with Stuck that researchers should aim at clarifying what components of preventive home visits work in which population groups. This could possibly improve consensus in this field of study and hopefully may result in the development of more effective interventions. [1] van Haastregt JCM, Diederiks JPM, van Rossum E, de Witte LP, Crebolder HFJM. Effects of preventive home visits to elderly people living in the community: systematic review. BMJ 2000;320:754-8. [2] Stuck AE. Review of preventive home visits to elderly people: Is vote counting the answer? Response published on BMJ website: 11 april 2000. [3] Fletcher A. Effects of preventive home visits to elderly people living in the community: systematic review. Response published on BMJ website: 11 april 2000. |
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Chris Hyde, Senior Lecturer in Public Health ARIF, Dept of Public Health & Epidemiology, University of Birmingham
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Dear Editor As part of a teaching exercise for a session on an MPH course the students and I recently examined the article by van Haastregt et al. This was chosen at random, without any suspicion that it contained errors. To illustrate problems associated with data extraction and analysis in systematic reviews, we obtained the original papers for the 15 included studies and looked in detail at two of the outcomes considered in the original review - falls and mortality. These two outcomes were chosen for reasons of feasibility. When we did this, considering the full data presented in the original reports, we uncovered a pattern of small effects that generally favoured the preventive home visit arms of the included trials. This is illustrated for the mortality data in the odds ratio diagram below, but also applied to data on falls: http://www.bham.ac.uk/arif/preventive2.jpg I would highlight three issues arising from the re-analysis performed. First, problems associated with vote-counting as a method of analysis in systematic reviews were highlighted in correspondence following the original article. This concern seems to be vindicated as the vote-counting technique employed in the original review, seems to have over-looked the possibility of drawing conclusions on the basis of consistent, small effects, few of which are statistically significant. Quantitative summary (meta-analysis) is the obvious way to identify such a pattern, but qualitative synthesis which records and considers the direction of the results and the sizes of any effects where quantified would also work. There appears to be an urgent need to re-examine the results of all outcomes of the included studies in the original systematic review using such approaches. Second, even ahead of such fuller re-analysis, the mortality data alone seem to challenge the conclusion reached by van Haastregt et al, "No clear evidence was found in favour of the effectiveness of preventive home visits to elderly people living in the community". Although there is some statistical heterogeneity in the mortality results, there is reasonably clear evidence of a small beneficial effect on mortality in most trials which demands that consideration continue to be given to preventive health visits as a useful health intervention. Even if it is thought that the effect of the given intervention on mortality is unlikely by virtue of biological implausibility, the fact that the effect has been observed empirically suggests further investigation is essential. This is completely at odds with the bottom-line offered by van Haastregt et al that, "It seems essential that the effectiveness of such visits is improved, but if this cannot be achieved consideration should be given to discontinuing these visits." Finally, the case in question alerts to the fallibility of standard practice in implementing the results of systematic reviews (and other research). In this we have come to assume that provided articles meet standard critical appraisal criteria they will provide internally valid results which can be safely applied if benefits seem to outweigh disbenefits and costs. Unfortunately the review in question meets commonly used criteria for systematic reviews such as clarity of question, focus on RCTs as the most appropriate study design to assess effectiveness, comprehensiveness of search strategy and assessment of the quality of included studies. The unwary might have been tempted to act on it. Thus, particularly in the context of decisions with far-reaching consequences, this example should remind that greater depth of assessment is essential. In retrospect, the inability to follow the conclusions made in this systematic review back to the results as they would have been presented in the original papers should have raised an alarm. In our view the results of the included studies as summarised were not a true reflection of the data in the original papers. A simple safeguard that would help alert to problems of this sort is to directly scrutinise a selection of the included studies prior to decisions on implementation. We suggest that particularly for health policy and population level health care decisions, this step should become routine. I have no conflicts of interest concerning this topic. |
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