Alternatives to acute hospital care for people over 65 years of age at risk of potentially avoidable admission: a systematic review

Problem

There are some older patients who are ‘at the decision margin’ of admission. This systematic review sought to address this issue with the following objectives:

What are the defining characteristics of those older patients for whom the decision to admit to hospital may be unclear?

What admission alternatives are there for these older patients and are they effective, acceptable, safe and cost-effective?

Approach

The systematic protocol is registered at PROSPERO (CRD42015020371). Any controlled studies of people ≥65 years who were at risk of an unplanned admission and offered an alternative to admission which were published between 2005-April 2015 were included. Outcomes of interest were reduction in secondary care use, patient-related outcomes and costs. Studies were assessed using the Cochrane risk of bias tool and results presented narratively.

Findings

Nineteen studies were identified which recruited patients with both specific and mixed chronic and acute conditions: hospital at home (n=9), hospital in care/nursing home (n=2), paramedic/emergency care practitioner (n=3), community hospital (n=2) and ED-based interventions (n=3). These studies were described in context with any high quality systematic reviews published 2010-2015.

Consequences

The profile of older patients for which the decision to admit is uncertain includes age ≥75 years, co/multi-morbidities, home situation, social support, individual coping abilities and dementia. Data suggest that alternatives to admission appear safe with potential to reduce a) secondary care use, b) length of time care needed and c) extra community resource use. There is a lack of patient-related outcomes and cost data.