Home nursing visits for elderly after hospitalization may reduce short term mortality

1. In this double-blind, multicenter, randomized clinical trial performed in the Netherlands, elderly patients’ ability to perform activities of daily living (ADLs) after a medical hospitalization did not differ if they received an in-hospital comprehensive geriatric assessment (CGA) (standard of care) versus the CGA coupled with a transitional care bridge program by a registered nurse, which included regularly scheduled home visits.

2. However, the combination of the CGA and the transitional care bridge program did lead to decreased mortality at one and six months. The results may have been more robust if the inclusion criteria were stricter, implying that there may be subset of this population that may particularly benefit from structured home nursing visits.

Evidence Rating Level: 1 (Excellent) 

Study Rundown: Older adults who are discharged home or to a nursing home after a medical admission are often greatly debilitated. A significant portion of these older adults lose essential activities of daily living (ADLs), are readmitted, or die. Care models, such is in-hospital comprehensive geriatric assessment (CGA) and in-home transitional care, have been developed to improve the transition from the hospital to the home. This study, conducted in the Netherlands, was done to determine whether hospital-to-home transitional interventions provided any significant benefit for the patients.

The results of this double-blind, multicenter, randomized clinical trial showed that employing a CGA followed by transitional care bridge program by a registered nurse, which included regularly scheduled home visits, did not have any significant effect on patients’ abilities to perform ADLs at six months compared to just employing the in-hospital CGA (which was standard of care). However, the combination intervention did lead to decreased mortality at one and six months. The strength of the study was in it’s design and having meaningful endpoints. However, using this structured intervention in the US may be significantly different than in the Netherlands, so the results may not be generalizable. Also, this intervention may have had a stronger effect in a more debilitated population rather than the general elderly population.

Click to read the study, published today in JAMA Internal Medicine

Relevant Reading: Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials.

In-Depth [randomized controlled trial]: This study was conducted from 2010 to 2014 in the Netherlands at three hospitals which were affiliated with home care organizations. All hospitals had a geriatric consultant team to carry out the comprehensive geriatric assessment (CGA), and each of the home care organizations had community care registered nurses (CCRN) who would provide the transitional care for the intervention group. Patients chosen for the study were those age 65 years or older admitted for at least 48 hours on the Internal Medicine service and were at risk for functional decline (determined via a validated risk system). The qualifying patients were randomized into two groups: systematic CGA or systemic CGA plus the transitional care bridge program facilitated by the CCRN. The transitional care bridge program consisted of the following: in-person handover from CGA team to CCRN, and home visits at <2 days after discharge, 2 weeks, 6 weeks, 12 weeks, and 24 weeks.

Primary endpoint was ability to perform ADLs at six months, and secondary endpoints included mortality at one month and six months after admission. A little over 300 patients were included in each arm of the study, with a mean age of 80 years and a mean of 1.8 preexisting ADL disabilities. At the conclusion of the study, there was no significant difference identified between the control and intervention for the primary endpoint of changes in ADLs at six months. However, the intervention group did have decreased mortality at one month (HR 0.63; 95%CI 0.39–0.99) and six months (HR 0.75; 95%CI 0.56–0.99). No changes in short term readmissions were identified between the two groups.

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