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. 2000 Aug 19;321(7259):512.

Preventive home visits to elderly people in the community

Visits are most useful for people aged ⩾75

Jonathan Newbury 1,2, John Marley 1,2
PMCID: PMC1118404  PMID: 11012259

Editor—The systematic review by van Haastregt et al of trials of preventive home visits for people aged 65 or over reported that “no clear evidence was found in favour” of such visits.1 Some of the trials reviewed showed 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, the review shows that favourable outcomes were more prevalent in studies conducted in older subjects (⩾75), although it does not comment on this. The table is constructed from the analysis they report.

Outcomes of physical functioning are the exception, with only one of the five favourable studies being in people aged 75 and over. This is not unexpected. It may be easier to improve physical functioning in the group aged 65 or over generally than in the group aged 75 or over specifically.

General practitioners in Australia have recently been funded for “75+ health assessments.” We have just concluded a randomised controlled trial of these assessments. A nurse visited 100 elderly people who were living in the community on two occasions, one year apart (50 control, 50 intervention). No interval assessment nor reminder was included in the protocol.2 Initial analysis found:

  • Fewer people reported falls in the intervention group in the study year (12 v 22, P=0.055)

  • Fewer people died in the intervention group (1 v 5, P=0.2)

  • Physical functioning did not change (measured using Barthel index of activities of daily living)

  • Psychosocial functioning improved (geriatric depression scale 15, Wilcoxon scores (rank sums) P=0.09).

Our study is consistent with the other published trials, showing modest improvement in the measured outcomes in the group aged 75 or over.

Van Haastregt et al call for either improved effectiveness of preventive home visits or their discontinuation. Their data, and our initial results, indicate that annual preventive home visits are most useful in the group aged 75 or over. An editorial in the BMJ 12 years ago also made the point that 65 year olds are too young to receive preventive home visits.3 Evaluation of the Australian 75+ health assessments will establish whether they have a beneficial effect on outcome.

References

BMJ. 2000 Aug 19;321(7259):512.

Studies reviewed have methodical flaws

Astrid Fletcher 1,2, Christopher Bulpitt 1,2

Editor—Van Haastregt et al rightly point out that a formal pooling of the results of the randomised controlled trials on preventive home visits was not appropriate given the “considerable heterogeneity of the interventions.”1-1 However, the information they provide is uninformative: they present the results for selected outcomes only in terms of being “significant” or “non-significant,” with no information on the estimates of effect or the confidence intervals. This information is essential for understanding 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.1-2 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. The American trials had low rates of participation, and the proportion of fit elderly people with a high income was overrepresented. In none of the trials was there adequate information regarding the cost effectiveness of multidimensional assessment.

We agree with van Haastregt et al's conclusions that there is limited evidence that multidimensional assessment is beneficial for older people. These concerns are more than “academic,” as regular health checks for people over 75 were introduced by the UK Department of Health in 1990 as a contractual obligation of general practitioners. Not surprisingly, most general practitioners view the policy unfavourably, whereas nurses and elderly people are enthusiastic about the health checks and consider them to be valuable.1-3–1-5

The situation is unsatisfactory, but abandoning the health checks is not a sensible option at present. In the United Kingdom 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 in the context of the 1990 contract of service. The trial, funded by the Medical Research Council and Department of Health, has been designed to have adequate power to detect benefits in mortality, hospital admissions, and quality of life. Some 106 general practices and 33 000 elderly people from the Medical Research Council's 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 policy in the United Kingdom was introduced prematurely in the absence of evidence of benefit. It would be equally premature to withdraw the policy on the basis of the results of the small, low powered studies, with a mixed and uncertain bag of interventions, described in this review.

Footnotes

On behalf of the MRC trial of assessment and management of elderly people in the community

References

  • 1-1.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;320:754–758. doi: 10.1136/bmj.320.7237.754. . (18 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Fletcher AE. Multidimensional assessment of elderly people. Br Med Bull. 1998;54:945–960. doi: 10.1093/oxfordjournals.bmb.a011740. [DOI] [PubMed] [Google Scholar]
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BMJ. 2000 Aug 19;321(7259):512.

Further research is needed

Andreas Stuck 1,2,3,4,5, Matthias Egger 1,2,3,4,5, Christoph E Minder 1,2,3,4,5, Steve Iliffe 1,2,3,4,5, John C Beck 1,2,3,4,5

Editor—Van Haastregt et al conclude that there is little evidence supporting the effectiveness of preventive home visits to elderly people living in the community.2-1 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.2-2 For example, it is important to distinguish between preventive home visits that included multidimensional geriatric assessment with follow up and interventions that did not.2-3

Assessment of the quality of trials was also problematic. Empirical research has shown that the scale used by van Haastregt et al, and scales in general, may produce misleading results.2-4 Rather than researchers calculating a summary score, the methodological aspects that are important in a given context should be identified and assessed individually.

Three of us (AS, JCB, CEM) were involved in a randomised trial of preventive home visits conducted in Berne, Switzerland.2-5 The findings from this trial, which was published after the review by van Haastregt et al appeared, showed that preventive home visits can reduce disability, which in a three year period may save up to $1400 (£933) per person a year.2-5 In a planned subgroup analysis we found that the effect of the intervention depended on the baseline risk status of trial participants (disability was reduced among people at low risk at baseline but not among participants at high risk). In addition, the professional experience of the person visiting was an important factor in determining the efficacy of the programme.

These findings indicate that the composition of the study population and the type and quality of the intervention are important factors that may explain the discrepant results obtained from previous trials of preventive home visits. Although results from individual trials of preventive home visits conflict, some trials clearly show that home visits can substantially reduce or delay the onset of disability. Thus, research is needed to define explicitly 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, counting votes cannot identify the factors introducing heterogeneity. Further meta-analyses and trials are needed to clarify what components of this complex intervention work in which population groups.

References

  • 2-1.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;320:754–758. doi: 10.1136/bmj.320.7237.754. . (18 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Egger M, Davey Smith G. Rationale, potentials and promise. In: Egger M, Davey Smith G, Altman DG, eds. Systematic reviews in health care: meta-analysis in context. London: BMJ Books (in press).
  • 2-3.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. doi: 10.1016/s0277-9536(98)00370-0. [DOI] [PubMed] [Google Scholar]
  • 2-4.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. doi: 10.1001/jama.282.11.1054. [DOI] [PubMed] [Google Scholar]
  • 2-5.Stuck AE, Minder CE, Peter-Wüest I, Gillmann G, Egli C, Kesselring A, et al. 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;160:977–986. doi: 10.1001/archinte.160.7.977. [DOI] [PubMed] [Google Scholar]
BMJ. 2000 Aug 19;321(7259):512.

Author's reply

Jolanda C M van Haastregt 1

Editor—The respondents to our review of preventive home visits to elderly people living in the community criticise several aspects of our study.3-1 Newbury and Marley criticise the fact that we did not discuss the relation between favourable outcomes and age. We agree that there are indeed (slight) indications that favourable outcomes are more prevalent in studies conducted among people aged 75 years and over. However, on the basis of the slender evidence, we do not think that the conclusion can be justified that preventive home visits are likely to be more effective among older people (⩾75).

Fletcher and Bulpitt state that lack of power is one of the major limitations of most of the trials included in our review. It should be noted, however, that 10 of the 15 studies we reviewed included 200-700 subjects per group. This makes it highly unlikely that the results of these studies could have been seriously influenced by a lack of power. Moreover, when we analyse the results of these 10 large studies separately, we still arrive at the same conclusion: no clear evidence exists in favour of the effectiveness of preventive home visits to elderly people living in the community.

Stuck et al discuss our method of analysis, which they consider to be inadequate. As we reported in our paper, we seriously considered statistical pooling of the data of the trials. However, owing to the large (clinical) heterogeneity of our set of trials, the statistical pooling of the data of these 15 trials is hazardous and, in our opinion, inappropriate. Only if it had been possible to generate more homogeneous subsets from this set of trials could data pooling have been justified and potentially useful.3-2 In our opinion, it is not possible to distinguish such homogeneous subsets, owing to the large heterogeneity of the interventions and the considerable differences that exist between subjects, outcome measures, timing of outcome measurement, and the healthcare setting in which the interventions were performed. We therefore decided to adopt a more generic approach by performing a detailed qualitative systematic review of the effects of this diverse set of preventive home visit programmes.

At the moment, it is not possible to single out the active components adequately from the total set of components of preventive home visit programmes, primarily because of the “black box” character of the intervention programmes. However, with regard to future research we certainly agree with Stuck et al that researchers should aim to clarify what components of preventive home visits work in which population groups. This could probably improve consensus in this field of study and may result in the development of more effective interventions.

References

  • 3-1.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;320:754–758. doi: 10.1136/bmj.320.7237.754. . (18 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-2.Moher D, Olkin I. Meta-analysis of randomized controlled trials: a concern for standards. JAMA. 1995;274:1962–1963. [PubMed] [Google Scholar]

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