Effects of intensive home visiting programs for older people with poor health status: A systematic review

Home visiting programs have been developed aimed at improving the health and independent functioning of older people. Also, they intend to reduce hospital and nursing home admission and associated cost. A substantial number of studies have examined the effects of preventive home visiting programs on older people living in the community. Since 2000 four systematic reviews [1–4], a literature review [5] and a synthesis of several reviews [6] have been published. Furthermore, a review on the effectiveness of preventive primary care outreach interventions aimed at older people was published, but this review also included trials not based on home visiting programs [7]. The reviews produced inconsistent and conflicting results. Subgroup analyses of the largest meta-analysis showed that effective home-visiting programs include multidimensional assessment, many follow-up visits and targeted people at lower risk of death [3].

A trial in the Netherlands in the 1990s showed that home visits do not seem to be useful for the general population of older people, but subgroup analyses in this study suggested benefits for older people with poor health [8, 9]. To investigate this further, a Dutch trial by Bouman et al. was recently conducted focusing on older people with poor health at baseline [10–13]. The study could not confirm beneficial effects on health status or service use for this target group. It is possible however that these findings constituted an isolated observation. In order to make a more well-founded judgment upon the effectiveness of home visits for this group of older persons, we decided to integrate the evidence from the study by Bouman et al. with evidence from other trials. Here we publish a systematic review to investigate whether the findings from this trial have also been reported by comparable studies targeting older people with poor health, or otherwise with functional impairments ('frail older persons'). Insight into whether home visiting programs for older people with poor health are effective is essential for implementation and future research. An assessment of the methodological quality of the included trials is also presented.

Of the eight randomized controlled trials evaluating the effectiveness of intensive home visiting programs for older people with poor health or otherwise with functional impairments, seven were of sufficient methodological quality according to the predefined standard. Even though nearly all studies were methodologically sound, improvements are still possible in specifying whether co-interventions were avoided or comparable between the intervention and control group, and, for half of the studies, in reporting the compliance with the interventions. The main analysis results from the trials of sufficient methodological quality consistently showed that the home visiting programs had no effect on the health status or service use of older people with poor health. Based on the information provided in these studies, also no differences were found between the intervention and control group in mortality.

In our evaluation, we did not include the results from the trial of insufficient methodological quality [20] and from post hoc subgroup analyses within two trials [8, 22]. These studies reported some positive effects, but the results were based on small sample sizes, and, in the trial of insufficient methodological quality, the outcomes may also have been affected by the large drop-out rate and the dissimilarity of the study groups at baseline. The positive effects from the post hoc subgroup comparison from the earlier Dutch study [8] that indicated the visits to be effective for those with a poor perceived health status at baseline could not be confirmed by the results from a larger replication study [12].

The review consists largely of published information; some unpublished data was obtained from two systematically searched studies [19, 21]. We did not further supplement the database search with expert consultations and it is possible that unpublished data from other trials is available. Studies with significant, positive, results are generally easier to find than those with non-significant or negative results and this could lead to a bias toward a more positive result [26]. Since nearly all studies in our review have negative results, publication bias can not explain the results. To ensure an acceptable standard for design and quality, only randomized controlled trials were included and an assessment of validity items was provided. It is rather striking that the one trial, that provided positive results, was considered to be of poor methodological quality by both reviewers.

In the review by van Haastregt et al. [1] no clear evidence was found in favor of the effectiveness of preventive home visits to older persons. The review and meta-regression analysis by Stuck et al. [3], including 11/15 of the studies from van Haastregt et al. (see Table 1), also showed no effect on mortality, nursing home admissions or functional status. Both reviews included trials with different target populations and interventions. Meta-analytic subgroup analyses in the review by Stuck et al. suggested, however, benefits from home visiting programs for certain types of patients or interventions. For instance, when interventions were targeted at persons with a lower risk for death (defined as annual mortality rates between 3% and 6%), a reduction in functional decline was shown. No reductions were shown for target populations with a mortality rate above 6%. This latter finding is in agreement with the findings in this review, wherein mortality rates were above 6% in most studies. Meta-analyses in the review by Elkan et al. [2], including 8/15 studies from van Haastregt et al., also focused on subgroups of frail older persons: no effects were shown on functional status, but positive effects were shown on mortality and nursing home admissions. However, these findings for frail older persons were based on only four studies, including one nonrandomized controlled trial [27] and one we scored in our review as being of insufficient methodological quality [20].

From the search, a number of home visiting programs targeting frail older persons were not included in our review because the intervention consisted of less than four visits per year and/or the duration of the intervention program was shorter than 12 months. The results of studies on less-intensive interventions are mixed. Five studies out of nine showed positive results: two studies with benefits for the intervention group on fall-related outcomes [28, 29]; one study showing more nursing home admissions in the control group [30]; one study showing improvements in psychosocial functioning for the intervention group [31]; and one study demonstrating a shorter length of stay at the hospital in the intervention group in the younger group (aged 65–74), but not in the older group (aged 75 or older), and better self-rated health scores in the intervention group (no baseline measurements were available) [32]. Four studies out of nine had negative results [33–36]. As most positive trials (5/9) showed benefits for only one parameter, while the other trials were negative (4/9), the overall benefits seem limited. In case we had used different inclusion criteria and added these studies, this would not have exerted a great influence on the findings of our review.

The mean number of visits of the trials presented in Table 3 ranged from 4.5 to 7.5, and, on average, 18.9 hours; for the non-included studies targeting frail older persons this ranged from 1 to approximately 3 [28, 30, 32–36], with the exception of 7.8 visits in the Tinetti et al. study [29] and a median of 5 visits in the Markle-Reid et al. study [31]. The last two studies were not included, because their intervention period lasted 6 months or less. In general, we succeeded in including studies with more-intensive programs. These did not, however, result in more favorable outcomes for the intervention group compared to the control group. Based on our definition of home visiting programs, all included trials reported a multidimensional assessment with follow-up, also with physical examination in the study by Stuck et al. [15]. Of the less-intensive non-included programs for frail older persons, Hebert et al. [36] and Tinetti et al. [29] included a multidimensional assessment with physical examination. There seemed no apparent relationship between characteristics of the assessments and beneficial effects of the programs.

There is still debate on the frailty concept. The definition and identification of frail older persons varies considerably [37, 38]. As there is no consensus yet, we used 'poor health status' as inclusion criteria, but we also referred to 'frail older persons'. Because of the wide use in defining frail populations, we decided that the inclusion could be based on either subjective measures (e.g. self-rated health, which is an overall measure for functional health abilities, including physical, mental and social functioning and has shown predictive validity for mortality and institutionalization among older persons [9, 39]) or on more 'objective' measures (e.g. ADL-scores). Also other measures, e.g. 'at risk for falls' or 'functional impairments', have been described for target populations of frail older persons, and these studies were eligible. The non-included home visiting studies also targeted frail older persons, but did not match our criteria on the intervention program.

The results of the trial by Bouman et al. in the Netherlands have been supported by all methodologically sound studies evaluated in this review [12]. The results from the post hoc subgroup analysis from an earlier Dutch study on which this trial was based, could not be confirmed [8]. The CONSORT statement [40] already made notice of the risk of spurious findings from subgroup analyses [41, 42], and indicated that especially post hoc subgroup comparisons are likely not to be confirmed by further studies. This is in line with the findings of this review. Results from reported post hoc subgroup analyses should therefore be interpreted with great caution.

Contrary to our expectation, the findings of this review suggest that intensive home visiting programs targeted at older people with poor health status are not effective. As half of the included studies were carried out in the Netherlands and the other half in other Western countries, the results may only be applicable in comparable health care settings. There seem to be no arguments to add the home visiting program targeting older persons with poor health status to regular healthcare. In a number of countries, e.g. Japan, Denmark and Australia, preventive home visits are part of the national policy and the visits are incorporated into regular healthcare for older persons. It seems essential, that the programs are judged on their merit again when targeting older persons in poor health. The United Kingdom withdrew this policy in 2004 based on the results of a large national trial, which showed that different forms of multidimensional assessment, targeting either the general population of older persons or frail older persons, offered almost no differences in patient outcomes [35].

Frail older persons may benefit from other types of interventions. In a recent editorial by Stuck and Kane, the authors indicated that older persons at higher risk or those already disabled are likely to benefit from multidimensional interventions that target specific problems [43], e.g. favorable effects were shown by a 6-month intensive home-based physical therapy program (16 visits over 6 months) [44], a chronic disease self-management program including three visits and nine telephone calls [45], and by a nurse-centered discharge plan with follow-up home visits for frail older persons discharged from hospital [46]. The economic arguments for these studies remain to be established however. Collaboration between different professionals involved may be necessary to manage the complex care that is often required by frail older persons. In a large European study (11 countries) it was found that home care service based on a case management approach reduced risk of institutionalization in a population of frail older persons in home care [47]. Although care-coordination can be provided by a case-manager, ideally the health and social services should be more integrated and have coordination between the services to supply the best available options for the individual needs of older persons.

In conclusion, we think that intensive home visiting programs are probably not beneficial for frail older persons within the health care setting of Western countries. Since many older adults prefer to live in their own homes and the population of older adults, including frail adults, is expected to grow, future research is needed to search for alternative approaches to improve the health status of frail older persons.