Outcomes of coordinated and integrated interventions targeting frail elderly people: a systematic review of randomised controlled trials

Authors:
EKLUND Kajsa, WIHELMSON Katarina
Journal article citation:
Health and Social Care in the Community, 17(5), September 2009, pp.447-458.
Publisher:
Wiley

This systematic review examined randomised controlled trials on integrated and coordinated interventions targeting frail elderly people living in the community, their outcome measurements and their effects on the client, the caregiver and healthcare utilisation. A literature search of PubMed, AgeLine, Cinahl and AMED was carried out with the following inclusion criteria: original article; integrated intervention including case management or equivalent coordinated organisation; frail elderly people living in the community; randomised controlled trials; in the English language, and published in refereed journals between 1997 and July 2007. The final review included nine articles, each describing one original integrated intervention study. Of these, one was from Italy, three from the USA and five from Canada. Seven studies reported at least one outcome measurement significantly in favour of the intervention, one reported no difference and one was in favour of the control. Five of the studies reported at least one outcome on client level in favour of the intervention. Only two studies reported caregiver outcomes, both in favour of the intervention for caregiver satisfaction, but with no effect on caregiver burden. Outcomes focusing on healthcare utilisation were significantly in favour of the intervention in five of the studies. Five of the studies used outcome measurements with unclear psychometric properties and four used disease-specific measurements. This review provides some evidence that integrated and coordinated care is beneficial for the population of frail elderly people and reduces health care utilisation. There is a lack of knowledge about how integrated and coordinated care affects the caregiver. This review pinpoints the importance of using valid outcome measurements and describing both the content and implementation of the intervention.

Extended abstract:
Author

EKLUND Kajsa; WILHELMSON Katarina;

Outcomes of coordinated and integrated interventions targeting frail elderly people: a systematic review of randomised controlled trials.

Journal citation/publication details

Health and Social Care in the Community, 17(5), September 2009, pp447-458.

Summary

The nine studies included in this review were variable in design and used a wide range of outcome measures, some of which were not validated. There is some evidence that integrated and coordinated care is beneficial in a frail elderly population and can reduce healthcare utilisation. There is a lack of data on the effects on caregivers. The authors discuss the limitations of the studies, in particular the lack of valid outcome measurements and poor reporting of the details of the interventions and the care given to control groups.

Context

Frail elderly people are at high risk of adverse outcomes that could be prevented by a coordinated approach to early detection, treatment and rehabilitation. 'The aim of this study was to review randomised controlled trials on integrated and coordinated interventions targeting frail elderly people living in the community, their outcome measurements and their effects on the client, the caregiver and healthcare utilisation.'

Methods

What sources were searched?
The following databases were searched: PubMed, AgeLine, CINAHL and AMED.

What search terms/strategies were used?
Searches were carried out using MeSH descriptors only: 'frail elderly' in combination with 'health promotion', or 'case management' or 'intervention studies' or 'satisfaction' (including 'personal satisfaction' or 'life satisfaction').

What criteria were used to decide on which studies to include?
Original articles on randomised controlled trials of integrated interventions, including studies of case management or related coordinated approaches, in frail elderly people over 65 years old living in the community that were published, in English, in peer reviewed journals between 1997 and July 2007 were eligible for inclusion. Trials carried out in Africa, Asia and South America were excluded on the basis that different cultural settings would result in a wide variation in views and definitions of dependency and limit the comparability of studies.

Who decided on their relevance and quality?
Both authors examined the titles and abstracts of the retrieved articles against the inclusion/exclusion criteria and the full text of those that were identified as being possibly relevant. The quality of the included studies was assessed using criteria based on the guidelines for systematic reviews produced by the Cochrane Collaboration Back Review Group (Table 3). 

How many studies were included and where were they from?
The literature search yielded 233 articles, 49 of which were examined in full. Nine studies were included in the systematic review: five from Canada, three from the US and one set in Italy. The number of articles identified at each stage from each of the four databases searched is presented in Table 1.

How were the study findings combined?
The review is narrative with details of the inclusion criteria and participants, study design, intervention, and outcomes presented in Table 2. The studies were too diverse to allow meta-analysis of the outcomes.

Findings of the review

The quality rating of the studies ranged from 4 to 7; none of the studies achieved the maximum score of eleven. A lack of reported information to allow assessment of a criterion was the main reason for low quality ratings. The number of participants ranged from 164 to 3079; the mean age was 81 or 82 years in six of the nine studies. The proportion of female participants varied from 48% to 77%. Follow-up occurred at three and six months, respectively, in two studies and after 10 to 12 months in the remaining seven studies.

A case manager undertook an initial assessment, by telephone or in person, in all but one of the studies; in five of the studies the case manager cooperated with a team. A variety of outcome measures were used and they are tabulated separately for each study and categorised as 'client', 'caregiver' or 'health care utilisation' (Table 5). They included measures of perceived health, depression, quality of life, physical function, activities of daily living, and cognitive function in clients. Four studies used disease-specific measurements and five used outcome measurements with unclear psychometric properties.

Five of the nine studies reported at least one statistically significant client related outcome in favour of the intervention. Both of the studies focusing on caregiver outcomes found an increase in caregiver satisfaction related to the intervention but no significant effect on caregiver burden. Five studies reported at least one beneficial healthcare utilisation outcome in favour of the intervention, mainly as a reduction in the number of days spent in hospital. An increase in home and health service use was reported for the control in two studies. Only one of the four studies which measured health care costs was in favour of the intervention.
 

Authors' conclusions

The review 'provides some evidence that integrated and coordinated care is beneficial for the frail elderly population' and 'can decrease healthcare utilisation'. There is little evidence on how such interventions affect informal caregivers.

Implications for policy or practice

None is discussed.

Subject terms:
integrated services, intervention, randomised controlled trials, very old people, case management;
Content type:
systematic review
Link:
Journal home page
ISSN online:
1365-2524
ISSN print:
0966-0410

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