Interventions to reduce unplanned hospital admission: a series of systematic reviews

Key findings

Case management: RCTs found by our searches covered older people, heart failure and COPD patients. Overall case management did not have any effect on UHA although we did find three positive heart failure studies in which the interventions involved specialist care from a cardiologist.

Specialist clinics: RCTs found by our searches covered heart failure, asthma and older people. Overall specialist clinics for heart failure patients, which included clinic appointments and monitoring over a 12 month period reduced UHA. There was no evidence to suggest that specialist clinics reduced UHA in asthma patients or in older people.

Community interventions: A small number of RCTs based on home visits were found by our searches and covered older people, mother and child health and heart disease. Overall, the evidence is too limited to make definitive conclusions. However, there is a suggestion that visiting acutely at risk populations may result in less UHA e.g. failure to thrive infants, heart failure patients.

Care pathways and guidelines: Care pathway systematic reviews have been conducted across conditions as well as for specific diseases such as gastrointestinal surgery, stroke and asthma. Guidelines have been reviewed similarly across conditions. There is no convincing evidence to make any firm conclusions regarding the effect of these approaches on UHA, although it is important to point out that data are limited for most conditions.
Medication review: RCTs found by our searches covered the older people, heart failure and asthma. There was no evidence of an effect on UHA in older people, and on those with heart failure or asthma carried out by clinical, community or research pharmacists. It is important to note that the evidence was limited to two studies for asthma patients.

Education & self-management: This was a topic covered by recent Cochrane reviews. Our searches found RCTs covering asthma, COPD and heart disease. Cochrane reviews concluded that education with self-management reduced UHA in adults with asthma, and in COPD patients but not in children with asthma. There is weak evidence for the role of education in reducing UHA in heart failure patients.

Exercise & rehabilitation: This was a topic covered by recent Cochrane reviews. Our searches found RCTs covering COPD, heart disease, stroke and older people. Cochrane reviews conclude that pulmonary rehabilitation is a highly effective and safe intervention to reduce UHA in patients who have recently suffered an exacerbation of COPD, exercise-based cardiac rehabilitation for coronary heart disease is effective in reducing UHA in shorter term studies, therapy based rehabilitation targeted towards stroke patients living at home did not appear to improve UHA and there were limited data on the effect of fall prevention interventions for at risk older people. The data that were available suggest they did not influence UHA.

Telemedicine: Telemedicine has been extensively researched in primary studies as well as extensively assessed in systematic reviews and meta-analysis. A recent programme of work called the Healthlines study carried out in the School of Social and Community Medicine at the University of Bristol in collaboration with the Universities of Sheffield and Southampton included a meta-review of home-based telehealth for the management of long term conditions. Whilst the focus of their work was not specifically the reduction of UHA, their final report included relevant systematic reviews or meta-analyses which described the effect of telehealth on UHA. Telemedicine is implicated in reduced UHA for heart disease, diabetes, hypertension and the older people.

Vaccine programs: We identified a series of Cochrane reviews looking at the effect of influenza vaccinations on a variety of vulnerable patients. A review on asthma patients reported both asthma-related and all cause hospital admissions. No effects on admissions were reported. A review on seasonal influenza vaccination in people aged over 65 years old looked at non-RCTs. The authors concluded that the available evidence is of poor quality and provides no guidance for outcomes including UHA. A review on health workers who work with the elderly showed no effect on UHA.

Hospital at home: This was a topic covered by a recent Cochrane review of hospital at home following early discharge. Readmission rates were significantly increased for older people with a mixture of conditions allocated to hospital at home services.

We found insufficient evidence (a lack of studies) to make any conclusions on the role of finance schemes, emergency department interventions and continuity of care for the reduction of UHA.

Conclusions

This review represents one of the most comprehensive sources of evidence on interventions for unplanned hospital admissions. There was evidence that education/self-management, exercise/rehabilitation and telemedicine in selected patient populations, and specialist heart failure interventions can help reduce unplanned admissions. However, the evidence to date suggests that majority of the remaining interventions included in these reviews do not help reduce unplanned admissions in a wide range of patients. There was insufficient evidence to determine whether home visits, pay by performance schemes, A & E services and continuity of care reduce unplanned admissions.
The results of this review are important for policy makers, clinicians and researchers. Some of the findings may be disappointing but it is important to remember that some of the interventions may have demonstrable impact in other areas, for example case management appears to reduce length of hospital stay. In addition, in many health care economies a number of interventions are introduced across the system. Few research studies include evaluation of system wide approaches, hence the impact of programmes of interventions are rarely reported in the research literature. This highlights the importance of robust evaluation of interventions as they are introduced into health and social care systems.