Home visits to prevent nursing home admission and functional decline in elderly people - Systematic review and meta-regression analysis

Context The effects of home visitation programs to prevent functional decline in elderly persons have been inconsistent, and the value of these programs is controversial. Objective To evaluate the effect of preventive home visits on functional status, nursing home admission, and mortality. Data Sources Studies published in English, French, German, Italian, or Spanish reporting randomized trials of the effects of preventive in-home visits in older people (mean age >70 years) living in the community were identified through searches of MEDLINE, PSYCHINFO, and EMBASE (January 1985-November 2001). We also searched the Cochrane Controlled Trials Register, checked reference lists of earlier reviews and book chapters, searched conference proceedings and specialty journals, and contacted experts. Study Selection We screened 1349 abstracts and excluded those that did not test in-home interventions or in which the mean age of the study population was younger than 70 years. After further exclusions, 17 articles describing 18 trials were analyzed. Data Extraction Two reviewers independently screened abstracts. Discrepancies were resolved by consensus with a third reviewer. For each included trial, we extracted data on the study population and the characteristics of the intervention. Two of us extracted information on 3 end points: nursing home admissions, mortality, and functional status. One of us assessed trial quality, including an examination of the method of randomization, blinding of caregivers and research staff ascertaining outcomes, and proportion of patients included in analyses of the 3 end points. Data Synthesis The 18 trials included 13447 individuals aged 65 years and older. The effect on nursing home admissions depended on the number of visits performed during follow-up. The pooled relative risk (RR) was 0.66 (95% confidence interval [CI], 0.48-0.92) for trials in the upper tertile (>9 visits) but was 1.05 (95% Cl, 0.85-1.30) in the lower tertile (0-4 visits). Functional decline was reduced in trials that used multidimensional assessment with follow-up (RR, 0.76; 95% Cl, 0.64-0.91) but not in other trials (RR, 1.01; 95% Cl, 0.92-1.11). Functional decline was reduced (RR, 0.78; 95% Cl, 0.64-0.95) in trials with a control group mortality rate in the lower tertile (3.4%-5.8%) but not (RR, 0.98; 95% CI, 0.84-1.13) in those with a control-group mortality rate in the upper tertile (8.3%-10.7%). A beneficial effect on mortality was evident in younger study populations (RR, 0.76; 95% Cl, 0.65-0.88 for ages 72.7-77.5 years) but not in older study populations (RR, 1.09; 95% Cl, 0.92-1.28 for ages 80.2-81.6 years). Conclusion Preventive home visitation programs appear to be effective, provided the interventions are based on multidimensional geriatric assessment and include multiple follow-up home visits and target persons at lower risk for death. Benefits on survival were seen in young-old rather than old-old populations.