The clinical effectiveness and cost-effectiveness of home-based, nurse-led health promotion for older people: a systematic review

Identification of studies

A comprehensive literature search was undertaken across 12 different databases and research registers between February and March 2011. Information on the provider and coverage dates of the sources are detailed in Table 1.

Where applicable, sensitive search filters were applied to identify three study designs: (1) randomised controlled trials (RCTs), (2) systematic reviews and (3) economic evaluations (Table 2; see also Appendix 1). MEDLINE and MEDLINE in Process & Other Non-Indexed Citations, EMBASE and the Web of Science were searched for all three study designs. Completed and unpublished studies were identified through searches in the Health Technology Assessment (HTA) database and two web-based research registers, including the UK Clinical Research Network (CRN) Portfolio Database and ClinicalTrials.gov. Searches for economic evaluations were supplemented by searching MEDLINE and EMBASE, HTA database, NHS Health Economic Evaluation Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE) and Cumulative Index to Nursing and Allied Health Literature (CINAHL).

It was agreed among the research team that the searches would be limited by date from 2001 onwards and that an English-language limit would also be applied as only UK-specific studies were relevant to the scope of the assessment. Other studies published prior to this date were identified by hand-searching existing systematic reviews. RCT filters were not applied to searches in The Cochrane Library [HTA and Cochrane controlled trials reports (CCTR)] and research registers (UK CRN and ClinicalTrials.gov), as these are trial-based sources. Similarly, the economic evaluation filter was not applied to the NHS EED and the Health Economic Evaluations Database (HEED) as these constitute the largest collection of economic evaluations. Given that the largest number of records was retrieved from the RCT searches compared with the systematic reviews and economic evaluation searches, a geographic filter was applied to identify studies that were related to the UK setting.

All citations were imported into Reference Manager, version 12 (Thomson Reuters, Philadelphia, PA, USA) software and duplicates were removed. Titles and abstracts of all unique citations were then screened by one reviewer (FC) using the inclusion criteria outlined in Chapter 3 (see Inclusion/exclusion criteria). Any uncertainty regarding possible inclusion of studies was resolved by discussion between the members of the research team, or through retrieval and subsequent examination of the full study publication. The full papers of all potentially relevant citations were retrieved to enable an in-depth assessment concerning study inclusion in the review. In the event that published papers did not report potentially relevant data, corresponding authors were contacted by e-mail; where further relevant data were made available through this route, they were included in the analysis.

Inclusion/exclusion criteria

The inclusion criteria for the systematic review of clinical effectiveness were as follows:

• Population Older people (> 75 years or > 70 years when considered a vulnerable population on the basis of age) with long-term medical or social needs at risk of admission to hospital, residential or nursing care.

• Interventions Structured home-based, nurse-led health promotion.

• Comparators Standard care including joint health and social assessment. Health promotion delivered in a different setting or not delivered by a nurse.

• Setting Interventions delivered in the home setting, undertaken in the UK.

• Outcomes Admission to hospital, residential or nursing care, mortality, morbidity including depression, falls, accidents, deteriorating health status, patient satisfaction.

• Study design RCTs.

Studies were excluded from the review if the effectiveness of the intervention was not assessed within a UK setting, if the intervention was not predominantly delivered by nurses, if the population did not include a substantial proportion of individuals aged over 75 years, or if the intervention did not include any discernible elements of health promotion. In instances whereby all inclusion criteria were met except for the age-restriction criterion, this was sometimes relaxed based on subjective judgement and discussions among the research team. Non-randomised studies were also excluded from the review.

Data extraction strategy

Data were extracted independently by one reviewer using a standardised data extraction form.

Quality assessment strategy

The methodological quality of studies included in the review was assessed using the Cochrane Risk of Bias tool (available from www.cochrane.org/). In particular, consideration of study quality included the following factors:

1. timing, duration and length of follow-up of the study

2. method of randomisation

3. method of allocation concealment

4. blinding

5. numbers of participants randomised, excluded and lost to follow-up (LTFU)

6. whether or not intention-to-treat (ITT) analysis has been performed.

Methods of analysis and evidence synthesis

Data from included studies were tabulated and discussed in a narrative review. Where appropriate, statistical meta-analysis was undertaken to estimate a summary measure of effect on relevant outcomes based on ITT analyses. Meta-analysis was undertaken using random-effects models using Review Manager (RevMan) software, version 5.0 (The Cochrane Collaboration, Nordic Cochrane Centre, Copenhagen, Denmark). The results of these analyses were reported as odds ratios (ORs). Heterogeneity was explored through consideration of the study populations, methods and interventions, by visualisation of analysis results and through consideration of the I²-statistic.

Quantity and quality of research available

Following the removal of duplicate citations, the systematic searches for RCTs and systematic reviews identified 2068 potentially relevant records. Of these, 38 were retrieved for a more detailed inspection. Of these, 26 studies were excluded from the review. In total, 11 studies were included in the final review of clinical effectiveness. This information is summarised in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram presented in Figure 1.

FIGURE 1.

The PRISMA flow diagram.

Mortality

Eight studies21,22,25–31 reported mortality rates, with a total of 4583 participants included in the analysis. Random-effects meta-analysis (Figure 2) suggests that the intervention significantly reduced the risk of death [odds ratio (OR) = 0.80, 95% confidence interval (CI) 0.68 to 0.95]. There was little heterogeneity present in this analysis (I² = 9%).

FIGURE 2.

Random-effects meta-analysis results for mortality.

Exclusion of the two studies – Cunliffe et al. 31 and Vetter et al. 30 – from the above random-effects meta-analysis (Figure 3) did not differ significantly in reducing the overall risk of death (OR = 0.80, 95% CI 0.65 to 0.99). However, the degree of heterogeneity increased in this analysis (I² = 16%).

FIGURE 3.

Random-effects meta-analysis results for mortality (excluding Cunliffe et al. 31 and Vetter et al. 30).

Falls

Four studies25–28 reported the number of falls experienced within the intervention and control groups. Assessment of risk and health promotion activities designed to reduce future falls were objectives of these studies. A total of 1392 participants were included in this analysis (Figure 4). Although there appears to be a trend favouring the intervention, with fewer falls occurring in the intervention group compared with usual care, this difference was not statistically significant at the 95% level (OR = 0.51, 95% CI 0.19 to 1.36). There was evidence of considerable heterogeneity in this analysis (I² = 89%).

FIGURE 4.

Random-effects meta-analysis results for incidence of falls.

Measures of independence

Four studies24,26,28,31 reported outcomes using the Barthel Index (Table 6). The results were not presented in sufficient detail across the trials to enable meta-analysis to be performed. Two studies24,28 reported a significant difference, with those participating in the intervention group demonstrating greater independence than those in the control group. Spice et al. 26 and Cunliffe et al. 31 did not report a significant difference between the intervention and control groups. The differences in these findings are not attributable to the baseline conditions of the participants or the frequency of contact with the nurse during the intervention period.

Other outcomes

A number of other outcomes were measured and recorded in the included studies (Table 7). These included admission to hospital, moving to residential care, leg ulcer recurrence, the Nottingham Health Profile, the Beck Depression Inventory, Caregiver Strain Index, the General Health Questionnaire (GHQ) and Short Form questionnaire-36 items (SF-36). Brooks et al. 23 found a significant reduction in leg ulcer recurrence in participants in the intervention group (4% vs 36%, p = 0.004). During the intervention, participants were encouraged to perform leg exercises and to keep his or her legs elevated for a prescribed period during the day. Interventions were also successful in improving Nottingham Health Profile scores,24 reducing caregiver strain,24 improving health and well-being as measured by the GHQ,31 and using a global health question. 22

Study inclusion/exclusion criteria for review of economic evaluations

Identification of relevant studies

All citations were imported into Reference Manager version 12 and duplicates were removed. UK-specific citations were identified; the abstracts of these were then sifted to identify any potentially relevant economic evaluation studies for inclusion in the review. In addition, the studies included in the review of clinical effectiveness (see Chapter 3) were also scrutinised to identify any potentially relevant economic studies missed by the economic searches. Full papers of potentially relevant studies were retrieved and scrutinised in greater detail by two reviewers (PT and AR). Subjective judgement on the part of the reviewers was required with respect to the application of certain inclusion criteria, in particular the age distribution of study subjects (the proportion of subjects ≥ 75 years and < 75 years, and the extent to which this is reported), the extent to which the intervention involves health promotion rather than care, and the extent of nurse involvement in the delivery of the intervention. Studies that included a slightly younger patient population were given additional consideration (substantial proportion subjects ≥ 70 years of age) if all of the other inclusion criteria were met. All sifting was undertaken by two reviewers (PT and AR) and disagreements were resolved through discussion among the research team.

Number and type of included studies

The systematic searches for economic evaluations identified 1988 potentially relevant citations, excluding duplicated records. Following an initial sift of abstracts and titles, full papers of 49 studies were retrieved for more detailed inspection. Forty-five of these studies failed to meet the inclusion criteria and were hence excluded from the review. The most common reasons for study exclusion were (1) the inclusion of younger age groups; (2) the absence of any substantive nursing element within the description of the intervention; (3) the absence of any form of health promotion in the definition of the intervention; or (4) the failure to undertake a comparative economic evaluation. In many instances, studies were excluded for more than one reason. In total, only three studies, reported across four papers, met the inclusion criteria for the review. Further hand-searching of included studies and web-based searching did not result in the retrieval of any additional relevant studies. An abridged PRISMA diagram is shown in Figure 5.

Table 8 presents a summary of the characteristics of the economic studies included in the review. Table 9 summarises the main resource components included within each study. Table 10 presents the results of the critical appraisal.

FIGURE 5.

PRISMA diagram for systematic review of cost-effectiveness.

Bakerly et al.

The study reported by Bakerly et al. 34 presents the methods and results of a cost minimisation analysis based on the results of a non-randomised prospective study of an early discharge and integrated care protocol for patients admitted to hospital with acute exacerbations of chronic obstructive pulmonary disease (COPD). This study was not included in the review of clinical effectiveness (see Chapter 3) owing to its non-randomised design. Although the authors purport to have adopted a NHS perspective, PSS costs were also included within the analysis. Costs were valued at year 2007 prices.

The population within the intervention group included 130 out of 546 patients who were admitted to hospital with acute exacerbations of COPD and who consented to the integrated care intervention during the period August 2003 to August 2004. The comparator group for the economic analysis comprised 95 out of 662 patients who were admitted to hospital with acute exacerbations of COPD between August 2002 and August 2003, and who stayed in hospital for the full duration of his or her treatment. Members of the control population were selected to match members of the intervention population in terms of age, gender and postcode.

The average age of patients who were allocated to the intervention group was 70 years [standard deviation (SD) = 8 years] and the average age of patients within the retrospective comparator group was 68 years (SD = 11 years). The intervention assessed within this study was an early discharge and integrated care protocol in which patients discharged from hospital early were visited at home by specialist respiratory nurses until they were totally discharged. The Acute COPD Assessment Service (ACAS) was able to provide short-term nebulisers and oxygen to patients. The ACAS team was staffed by three full-time specialist respiratory nurses and a middle-grade physician, who dedicated 40% of his time to the programme. During the last visit, patients and their carers were educated regarding COPD and its causes, how to prevent ill health as a result of the disease and how to manage suspected COPD exacerbations, and were given advice on exercise, healthy living and smoking cessation. In addition, patients were also given a written self-management plan (in conjunction with their GPs), and were given steroids and antibiotics to initiate at home when required. Patients were assessed in clinic 60 days after the index episode and a comprehensive management plan was agreed with the patient and communicated to their GP. Patients who were deemed unfit for early discharge were followed up daily in the hospital by programme nurses until they were well enough to be discharged with or without integrated care support. The comparator group received inpatient hospital care until the patients were considered well enough for discharge.

The objective of the study was to determine any cost savings that could be achieved by the introduction of an early discharge and integrated care protocol. Within the analysis, outcomes for the ACAS programme were assumed to be equivalent between the intervention and control groups. Although the authors did refer to a previous systematic review reported by Ram et al. 37 as evidence that the intervention was safe, the study did not involve the prospective collection or analysis of evidence regarding health-related quality of life (HRQoL), survival or other intermediate clinical outcomes.

Resource use was measured for patients receiving the early discharge and integrated care protocol and for patients within the retrospective control group. Resource components included the original hospital admission and length of stay, emergency ambulance transfers, and accident and emergency visits prior to their original hospital admission. Additional resource-use components recorded within the intervention group included visits by specialist respiratory nurses, emergency home visits, contact with various health-care professionals, accident and emergency visits following discharge, hospital readmissions, and outpatient clinic visits. Unit costs used to value resource use were obtained from appropriate reference sources, including NHS Reference Costs 2007/0838 and Curtis et al. 39

The authors did not report the results of any sensitivity analysis to examine the impact of costing assumptions on the likely cost savings of the protocol. The use of discounting was not reported; although this may be considered appropriate given the short time horizon for resource measurement (60 days), the potential resource and cost differences beyond this time point remain subject to considerable uncertainty.

The results of the analysis reported by Bakerly et al. 34 are summarised in Table 11.

The results of the economic analysis suggest that the early discharge and integrated care protocol for patients admitted to hospital with acute exacerbations of COPD may generate substantial cost savings compared with usual inpatient care. However, it should be noted that the study design adopted by Bakerly et al. 34 used a non-randomised design without any form of blinded allocation to the groups under assessment. In particular, although the prospective intervention and historical control groups were selected for inclusion in the study using a case-matching approach, subjects were matched only on the basis of age, gender and postcode. Prognostic factors and other baseline characteristics were not included as part of this process. Consequently, the study may be at risk of selection bias.

Hurwitz et al./Jarman et al.

The study reported by Hurwitz et al. 35 and Jarman et al. 22 presents the methods and results of an economic analysis of a RCT of community-based nursing for patients with Parkinson’s disease. The authors describe the economic analysis as a cost minimisation analysis and report primary economic outcomes in terms of the cost difference between the intervention and control arms of the trial. However, the study would be more accurately described as a cost–consequence analysis, as disease-specific clinical outcomes and HRQoL outcomes are also reported within both papers. 22,35 The perspective adopted for the analysis was not clearly reported in either paper; however, the types of resource components included within the analysis include those that would typically fall on the NHS (although some local authority costs were also included such as institutional and respite care). Costs were valued at year 1996 prices.

Within the RCT, patients were randomly assigned either to a community-based nursing intervention (n = 1041) or standard care (n = 818). The study population consisted of patients identified as suffering from Parkinson’s disease by 438 general practices in nine randomly selected health authorities in England. The intervention was delivered by nurses who had no previous experience of nursing patients with Parkinson’s disease in the community. However, some of the nurses did have experience of nursing patients with Parkinson’s disease in a hospital setting. All of the nurses attended a course on meeting the needs of people with Parkinson’s disease and their carers. The clinical position of the nurses during the trial was not clinically autonomous; rather they worked in an advisory role to GPs and consultants. The nurses counselled and educated patients and carers about Parkinson’s disease, monitored the clinical well-being of patients and their response to treatment at least twice a year, and reported the results back to GPs or consultants as appropriate. The nurses also investigated options for respite or day hospital care, visited patients in hospital and liaised with hospital staff on discharge, assessed social security benefit entitlement, and, where appropriate, liaised with members of local multidisciplinary primary care teams regarding ongoing assessment and therapy. The nurses also provided drug information to patients under the auspices of GPs and consultants. Although the nurses were not empowered to change patient medication, they could make suggestions to GPs about altering a patient’s dose regimen. The comparator intervention was defined as standard care; however, patients allocated to the control arm were offered a single assessment by a Parkinson’s disease nurse specialist at the end of the 2-year intervention period. Further details of this trial are included in Chapter 3 of this report.

A number of primary and secondary clinical and health-related quality-of-life outcomes were measured. The primary outcomes include the results from the stand-up test and the dot-in-square test, the proportion of patients sustaining fracture and HRQoL as measured using the European Quality of Life-5 Dimensions (EQ-5D) questionnaire. Patient well-being was also measured using the PDQ-39 (Parkinson’s disease-specific measure of health status questionnaire) and a self-perceived global health question asking patients to rate their change in general health over the previous year on a scale from 0 (much better) to 4 (much worse). Outcomes assessments were undertaken during interviews between patients and non-professional interviewers employed by the National Centre for Social Research. Interviewers had received prior training. Other secondary outcomes included the median dose of l-dopa in each group, the proportion of patients on l-dopa controlled-release medication, the proportion of patients on a combination of pharmaceuticals, the proportion of patients referred to ancillary therapy, and the proportion of patients referred to a Parkinson’s disease specialist. Again, these secondary outcomes were measured during interviews. Patient mortality for each group was obtained from the NHS Central Registry.

All of the patients in the study were interviewed to estimate NHS resources used. Resource components included institutional, respite, hospital and day care, community and general practitioner care, social security benefits, home aids, adaptations and pharmaceuticals. Unit cost estimates were obtained from appropriate reference sources including the Monthly Index of Medical Specialities (MIMS)40 and Netten et al. 41 The authors calculated that, including administrative costs and car hire, the intervention would cost approximately £200 per patient per year.

The authors did not report the results of any sensitivity analysis. Although the authors used non-parametric bootstrapping to check the assumptions of their mean estimates, a comprehensive analysis of decision uncertainty was not reported. Even though the intervention period was 2 years, there is no evidence that discounting of future costs was undertaken. The headline economic results for the study are summarised in Table 12. Although the economic study design adopted here is reported to be that of a cost minimisation analysis, EQ-5D scores were actually reported to be non-significantly lower in the intervention arm (mean EQ-5D difference = –0.02). On the basis of the total direct NHS costs for each group in those completing the study, and absolute EQ-5D differences between the groups, the nurse-led intervention appears to be dominated by standard care (less effective and more expensive). However, this is subject to considerable uncertainty.

Miller et al.

Miller et al. 36 present the methods and results of an economic evaluation conducted alongside a RCT to estimate the cost-effectiveness of an early discharge and rehabilitation service for older patients admitted to hospital. The analysis adopted a NHS and PSS perspective. The formal price year was unspecified within the paper; however, it appears from the cost sources used that costs were valued at year 2000 prices.

Within the RCT, patients were randomly assigned to one of two groups: (1) an early discharge and rehabilitation service (n = 185) or (2) standard social services home care and outpatient rehabilitation (n = 185). The study population consisted of patients who had been admitted to hospital for acute care; the most frequent reasons for admission were fracture (28%), neurological conditions including stroke (26%) and cardiorespiratory illness (14%). The median age of patients was 80 years, although the trial was open to any patient aged ≥ 65 years who was medically ready for discharge, had rehabilitation needs that could be met at home and did not need 24-hour care. Of the patients recruited to the trial, 246 were female (67%) and 247 lived alone (67%). The median hospital length of stay was 13.5 days. The intervention comprised a home care and rehabilitation service that was delivered by a team of nurses, physiotherapists, occupational therapists and rehabilitation assistants during up to four visits per day for up to 4 weeks. Patients who were allocated to the comparator arm received standard care, which included social services home care and rehabilitation delivered through an outpatient department.

European Quality of Life-5 Dimensions HRQoL estimates were elicited at 12-month follow-up using postal questionnaires. Sixty-six patients died before follow-up and were assigned a zero score. The remaining 32 patients withdrew consent or declined follow up. EQ-5D estimates were obtained for 272 patients of the recruited who were still alive at 12 months. Importantly, the authors do not report whether or not EQ-5D assessments were undertaken at baseline; hence, the methods used to estimate incremental QALYs between the groups are not entirely clear. This may affect the credibility of the results of the economic analysis.

Resource costs were measured for all participants in both the intervention arm and the control arm; these included the costs of the intervention, the costs of the acute hospital stay following randomisation, the costs of any readmissions to hospital or outpatient visits, and the costs of any nursing home admissions or any contact with GPs, community health services or social services within the 12-month follow-up period. Total resource use for each patient was estimated using data collected from service providers over the follow-up period. The cost of the intervention was based on recorded client contact time with members of the early discharge rehabilitation service. Hospital inpatient admissions were costed according to the length of stay and clinical specialty. Outpatient attendances were also costed according to clinical specialty. The cost of contact with GPs was based on the recorded number of face-to-face and telephone consultations. The cost of contact with community health service professionals was based on recorded contact time. Unit costs were obtained from standard references sources including the NHS Reference Costs 2000/0142 and Netten et al. 43 The cost of nursing and residential home admission was based on duration of stay multiplied by the average cost obtained from Netten et al. 43 The cost of referrals to social services professionals was based on the assumption of 1 hour of contact time per visit, with the hourly rate being obtained from Netten et al. 43 The costs of local authority funded social services were based on recorded contact time.

Uncertainty surrounding costs and health outcomes was explored using a paired bootstrapping technique developed by Barber and Thompson. 44 The patient-level data set was resampled 2000 times to generate estimates of variance. Uncertainty surrounding unit cost estimates does not appear to have been considered within the analysis. The results of the uncertainty analysis were presented as cost-effectiveness planes and cost-effectiveness acceptability curves. However, the authors do not actually report mean (expected) incremental quality-adjusted life-years (QALYs) gained or an expected incremental cost-effectiveness ratio (ICER; i.e. the incremental cost per QALY gained).

The paper does not mention the use of discounting to adjust for time preferences in the accrual of future costs and health benefits. Given the short time horizon of the RCT, this may be considered methodologically appropriate, but does raise questions concerning potential longer-term differences in costs and outcomes between the groups.

The main results presented by Miller et al. 36 are summarised in Table 13 and Figures 6 and 7.

FIGURE 6.

Cost-effectiveness plane for early discharge and rehabilitation vs standard care. (Reproduced with permission from Miller et al. 36)

FIGURE 7.

Cost-effectiveness acceptability curve for early discharge and rehabilitation vs standard care. (Reproduced with permission from Miller et al. 36) EDRS, Early Discharge and Rehabilitation Service.

The authors used three different alternative estimators of the population mean to control for the skewed nature of the cost data and found that in each case this technique yielded an increase in the cost savings that was attributable to the intervention. The results presented on the cost-effectiveness plane demonstrate that the majority of the sample points fell below the horizontal axis, which indicates that the intervention was likely to result in cost savings. However, the QALY estimates appear to be fairly evenly distributed around the vertical axis; this indicates considerable uncertainty around whether or not the service offered any incremental health gain. As such, there appears to be a marked possibility that the intervention was less effective than standard care. Overall, there remains uncertainty, in both the short and longer term, about the actual benefit of the intervention.

Summary of main findings

The main findings of the three included studies are summarised below:

• One cost minimisation study, by Bakerly et al. ,34 reported cost savings of approximately £600 per patient, associated with an early discharge and integrated care protocol for patients admitted to hospital with acute exacerbations of COPD. This analysis was based on a case-matching exercise involving historical control subjects and prospectively identified subjects within the intervention arm. This study may be open to potential bias as a result of the case-matching exercise, as this did not include any baseline prognostic factors. Furthermore, the economic analysis assumes equivalent effectiveness between the intervention and usual care groups and adopts a very short time horizon for resource-use data collection (60 days).

• The second study22,35 reports a cost–consequence analysis of community-based nursing versus standard care for patients with Parkinson’s disease. This study reported increased costs in the intervention arm compared with standard care; however, the mean increase in costs over 2 years was £266 lower for the intervention group than the standard care group. Although the economic study design adopted here is reported to be that of a cost minimisation analysis, EQ-5D scores were actually reported to be non-significantly lower in the intervention arm (mean EQ-5D difference = –0.02). On the basis of the total direct NHS costs for each group in those completing the study, and absolute EQ-5D differences between the groups, the nurse-led intervention appears to be dominated by standard care (less effective and more expensive). Of particular concern are the short time horizon adopted within this study (2 years) and the potentially perverse assumption of equivalence between the intervention and comparator groups.

• The third study36 reported a cost–utility analysis of an early discharge and rehabilitation service compared with usual care. The authors reported a high probability that the Early Discharge and Rehabilitation Service (EDRS) would be cost-effective. However, reporting within this study was problematic and the authors did not report expected ICERs. Judging from the presentation of probabilistic sensitivity analysis, although there is a high likelihood that the intervention offers cost savings, there also appears to be a strong possibility that the EDRS offered little or no incremental QALY gain over usual care. As with the other two included studies, the time horizon for this economic analysis is very short (1 year).

Other non-UK economic analyses of home-based, nurse-led health promotion

During the process of preparing the economic review, a number of other non-UK economic analyses of home-based, nurse-led health promotion were identified. Although these studies did not meet the inclusion criteria for this review, as they do not relate to home-based, nurse-led programmes implemented within the UK context, they do provide some notion of the alternative types of programme that have been assessed elsewhere. Generally speaking, these studies fall into one of three groups – studies in which the home-based, nurse-led programme is:

1. widely implemented solely on the basis of older age (e.g. Sahlen et al. 45 and Kronborg et al. 46) – there is no equivalent evidence from the UK perspective

2. targeted at individuals with some non-comorbid increased risk factor (e.g. history of falls47,48)

3. targeted at individuals with increased risk owing to the presence of an incurable disease.

It is difficult, however, to draw any firm conclusions from these studies, as the clinical effectiveness and patterns of resource use for the home-based, nurse-led intervention and standard care may differ markedly by geographical location.

Clinical effectiveness findings

The systematic review of clinical effectiveness included 11 studies, comprising a total of 5761 participants. There was considerable heterogeneity between the studies in terms of the study populations and the nature, purpose and composition of the interventions. There were also marked differences between studies in terms of the level of training of the nurses delivering the interventions. All but one of the included studies were judged to be at medium or low risk of bias.

Random-effects meta-analysis of eight studies suggested a statistically significant mortality benefit for the home-based nursing groups, whereas a meta-analysis of four studies suggested non-significant benefits in terms of improvement in falls. Positive outcomes for home-based nursing interventions were also reported within individual studies: these outcomes included the Barthel Index (although this finding was not consistent across all studies), leg ulcer recurrence, the Nottingham Health Profile, the Caregiver Strain Index, the GHQ and a global health question. The following outcomes failed to demonstrate a statistically significant difference: admission to hospital, the number of subjects moving into residential care, SF-36 quality of life and the Beck Depression Inventory scores.

Four existing systematic reviews8,10,14,32 reported a meta-analysis of included studies. These were reviews of home- or community-based interventions to support in older people. The reviews were not limited to nurse-led interventions and were not focused solely on the UK context. Three reviews8,14,32 did not find a significant reduction in mortality. However, the results reported by Elkan et al. 10 concur with the findings of this review, as the authors also reported a significant reduction in mortality (OR = 0.76, 95% CI 0.64 to 0.97). 8,14 Both of these reviews reported statistically significant benefits for the intervention group in terms of reduced nursing home admissions, risk of hospital admissions, falls and functional decline. However, Stuck et al. 8 found that the effect on functional decline depended on the number of home visits performed during follow-up. The positive effects seen in these reviews are mirrored in our review, supporting the conclusion that home visits to older people can reduce mortality and appears to improve the health and well-being of those in the intervention group compared with the control group.

On the basis of the evidence included in this systematic review, home-based, nurse-led health promotion may offer clinical benefits across a number of important health dimensions. However, it is generally unclear from the available studies that components of this type of complex intervention contribute towards individual aspects of benefit. This is particularly so when nurses are working within a multidisciplinary team; determining the effect of the nursing intervention distinct from that of other professionals or trained non-professionals is difficult to elicit.

Owing to time and resource constraints for this short report, data from the included clinical studies were extracted by a single reviewer. This should be noted as a possible limitation of the systematic review.

Cost-effectiveness findings

The systematic review of existing economic evaluation studies highlights a dearth of relevant economic evidence supporting the use of home-based, nurse-led health promotion for older people. A total of three studies were included in the cost-effectiveness review. This evidence base is comprised of one cost minimisation analysis based on non-randomised case matching, and two economic evaluations undertaken alongside RCTs. Two of the included studies involved an intervention targeted specifically at patients with a known underlying incurable disease (COPD and Parkinson’s disease), whereas the third study examined the clinical effectiveness and cost-effectiveness of early discharge in patients with a range of conditions including fractures, neurological conditions and cardiorespiratory conditions.

Each of the three studies indicated some likelihood that home-based, nurse-led health promotion may offer cost savings to the NHS (and potentially associated sectors such as social services). However, one study did not report any health outcomes and simply assumed equivalence between the intervention and comparator, whereas the other two studies suggested at best a negligible benefit in terms of preference-based HRQoL measures. Within these last two studies, there is a marked possibility that the intervention offers cost savings but no discernable positive health benefits. The level of uncertainty surrounding measured quality-of-life outcomes suggests that there is also a possibility that the interventions assessed result in a lower aggregate level of health gain compared with standard care. Clearly, these findings are inconsistent with those arising from the clinical review. The critical appraisal of available economic studies highlighted a number of methodological concerns associated with the available studies, which, to some degree, may explain the conflicting findings of the clinical and economic reviews presented here.

Recommendations for the evaluation of home-based, nurse-led health promotion programmes

The evaluation of health promotion programmes requires consideration not only of health outcomes accrued by the recipient, and the costs of generating these, but also whether or not the intervention has wider indirect impacts on other individuals (e.g. carers) and other resources incurred outside of the health service. As a consequence, the full range of opportunity costs may be difficult to identify, measure and value. Although the available UK economic evidence base reviewed in Chapter 4 is sparse, there is some evidence of variability concerning the inclusion of relevant resource costs (see Table 9). It has previously been argued that an intersectoral approach is required to identify the broad range of costs and benefits of public health interventions;51 as such, this goes far beyond the standard methods recommended by existing economic reference cases for cost–utility analysis. 52 For instance, Weatherly et al. 51 suggest that the social care and/or health service sector may pay for the social care services and any of the sectors including social care, health service, voluntary or private may provide such services. These issues create an additional layer of complexity to the evaluation of health promotion programmes. The design of future health promotion studies should include prospective consideration of the following issues:

• The definition of the comparator for evaluation may be subject to geographical heterogeneity and may differ according to the particular population risk group under evaluation. Future research should take in ensuring that the comparisons assessed are meaningful from a policy perspective.

• Standard reference cases for economic analysis in the UK typically recommend the adoption of a NHS and PSS perspective, whereby relevant health outcomes are defined as those accrued by NHS patients and relevant costs are those borne by the NHS. Consideration should be given to wider societal costs and benefits. 51,53

• As health promotion is a complex intervention, it is difficult to associate changes in any particular set of disease events as a direct or indirect result of the intervention on health outcomes. Future research should ensure that preference-based HRQoL instruments (e.g. the EQ-5D) are used as a matter of course and that any potential mortality impacts are also captured. It should also be noted that the QALY may fail to capture other multidimensional aspects of health promotion interventions; Weatherly et al. 51 suggest the development of sector-specific generic outcomes outside of health (e.g. a carer QALY).

• Future studies should ensure that the duration of the study follow-up period is sufficient to capture all relevant costs and outcomes between intervention and comparator groups.

• Future studies should also seek to characterise the full range of uncertainty relevant to the policy decision; hence, the use of cost minimisation should be avoided.

MEDLINE(R) In-Process & Other Non-Indexed Citations and MEDLINE(R): Ovid 1950–present

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2. “aged, 80 and over”/

3. frail elderly/

4. aged.tw.

5. aging.tw.

6. geriatric.tw.

7. elder$.tw.

8. senior$.tw.

9. pensioner$.tw.

10. (over 65 or over sixty-five$ or over sixty five$).tw.

11. (old$ adj20 (adult$ or person or people)).tw.

12. or/1–11

13. Health Education/

14. health education.tw.

15. Health Promotion/

16. (health adj (promotion$ or campaign$ or prevention$ or protection)).tw.

17. wellness program$.tw.

18. primary prevention.tw.

19. or/13–18

20. (nurse led or nurse-led or home or community based or community-based).tw.

21. 19 and 20

22. ((home-based or home based or home) adj nursing).tw.

23. Home Care Services/

24. home care service$.tw.

25. Home Nursing/

26. Health Services for the Aged/

27. House Calls/

28. house call$.tw.

29. (home visit$ or house visit$).tw.

30. Geriatric Nursing/

31. geriatric health service$.tw.

32. Community Health Nursing/

33. (community adj (health or nursing)).tw.

34. Public Health Nursing/

35. public health nursing.tw.

36. Specialties, Nursing/

37. specialist nurse$.tw.

38. district nurs$.tw.

39. visiting nurse$.tw.

40. health visitor$.tw.

41. advanced practitioner$.tw.

42. Nurse Practitioners/

43. nurse practitioner$.tw.

44. Nurse Clinicians/

45. clinical nurse specialist$.tw.

46. or/22–42

47. 12 and (21 or 46)

EMBASE: Ovid 1980–present

1. aged/

2. FRAIL ELDERLY/

3. aged.tw.

4. aging.tw.

5. geriatric.tw.

6. elder$.tw.

7. senior$.tw.

8. pensioner$.tw.

9. (over 65 or over sixty-five$ or over sixty five$).tw.

10. (old$ adj20 (adult$ or person or people)).tw.

11. or/1–10

12. health education/

13. health education.tw.

14. health promotion/

15. (health adj (promotion$ or campaign$ or prevention$ or protection)).tw.

16. wellness program$.tw.

17. primary prevention/

18. primary prevention.tw.

19. or/12–18

20. (nurse led or nurse-led or home or community based or community-based).tw.

21. 19 and 20

22. ((home-based or home based or home) adj nursing).tw.

23. home care/

24. home care service$.tw.

25. elderly care/

26. house call$.tw.

27. (home visit$ or house visit$).tw.

28. geriatric nursing/

29. geriatric health service$.tw.

30. community health nursing/

31. (community adj (health or nursing)).tw.

32. public health nursing.tw.

33. nursing discipline/

34. specialist nurse$.tw.

35. district nurs$.tw.

36. visiting nurse$.tw.

37. health visitor$.tw.

38. nurse practitioner/

39. nurse practitioner$.tw.

40. nurse clinician$.tw.

41. clinical nurse specialist$.tw.

42. or/22–41

43. 11 and (21 or 42)

Science Citation Index: Web of Science 1899–present

1. # 10 #8 AND #7

   Refined by: Publication Years =thinsp;(2009 OR 2008 OR 2002 OR 2006 OR 2001 OR 2004 OR 2005 OR 2010 OR 2003 OR 2007)

2. # 9 #8 AND #7

3. # 8 Topic =thinsp;(“cost–benefit analysis” or “economic value of life” or “quality-adjusted life years” or “economic model*” or “cost utilit*” or “cost benefit*” or “cost minim*” or “cost effect*” or “economic evaluation*”)

4. # 7 #6 AND #1

5. # 6 #5 OR #4

6. # 5 Topic =thinsp;(“home-based nursing” or “home based nursing” or “home nursing”) OR Topic =thinsp;(“home care service*” or “health services for the aged” or “house call*” or “home visit*” or “house visit*” or “geriatric nursing” or “geriatric health service*” or “community health” or “community nursing” or “public health nursing” or “specialities nursing”) OR Topic =thinsp;(“specialist nurse*” or “district nurs*” or “visiting nurse*” or “health visitor*” or “advanced practitioner*” or “nurse practitioner*” or “nurse clinician*” or “clinical nurse specialist*”)

7. # 4 #3 AND #2

8. # 3 Topic =thinsp;(“nurse led” or nurse-led or home or “community based” or community-based)

9. # 2 Topic =thinsp;(“health education” or “health promotion*” or “health campaign*” or “health prevention*” or “health protection” or “wellness program*” or “primary prevention”)

10. # 1 Topic =thinsp;(aged or aging or geriatric or elder* or senior* or pensioner*) OR Topic =thinsp;(“over 65” or “over sixty-five*” or “over sixty five*”) OR Topic =thinsp;(old* SAME20 (adult* or person or people))

Cochrane Database of Systematic Reviews: Wiley InterScience 1996–present; Cochrane Central Register of Controlled Trials: Wiley InterScience 1898–present; NHS Economic Evaluation Database: Wiley InterScience 1995–present; Health Technology Assessment Database: Wiley InterScience 1995–present; Database of Abstracts of Reviews of Effects: Wiley InterScience 1995–present

1. #1 MeSH descriptor Aged explode all trees

2. #2 (aged):ti,ab

3. #3 (aging):ti,ab

4. #4 (geriatric):ti,ab

5. #5 (elder*):ti,ab

6. #6 (senior*):ti,ab

7. #7 (pensioner*):ti,ab

8. #8 (over 65 or over sixty-five* or over sixty five*):ti,ab

9. #9 (old* NEAR/20 (adult* or person or people)):ti,ab

10. #10 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9)

11. #11 MeSH descriptor Health Education, this term only

12. #12 (health education):ti,ab

13. #13 MeSH descriptor Health Promotion explode all trees

14. #14 (health NEXT (promotion* or campaign* or prevention* or protection)):ti,ab

15. #15 (wellness program*):ti,ab

16. #16 (primary prevention):ti,ab

17. #17 (#11 OR #12 OR #13 OR #14 OR #15 OR #16)

18. #18 (nurse led or nurse-led or home or community based or community-based):ti,ab

19. #19 (#17 AND #18)

20. #20 (home-based or home based or home) NEXT nursing:ti,ab

21. #21 MeSH descriptor Home Care Services, this term only

22. #22 (home care service*):ti,ab

23. #23 MeSH descriptor Home Nursing explode all trees

24. #24 MeSH descriptor Health Services for the Aged, this term only

25. #25 MeSH descriptor House Calls, this term only

26. #26 (house call*):ti,ab

27. #27 (home visit* or house visit*):ti,ab

28. #28 MeSH descriptor Geriatric Nursing, this term only

29. #29 (geriatric health service*):ti,ab

30. #30 MeSH descriptor Community Health Nursing, this term only

31. #31 (community NEXT (health or nursing)):ti,ab

32. #32 MeSH descriptor Public Health Nursing, this term only

33. #33 (public health nursing):ti,ab

34. #34 MeSH descriptor Specialties, Nursing, this term only

35. #35 (specialist nurse*):ti,ab

36. #36 (district nurs*):ti,ab

37. #37 (visiting nurse*):ti,ab

38. #38 (health visitor*):ti,ab

39. #39 (advanced practitioner*):ti,ab

40. #40 MeSH descriptor Nurse Practitioners, this term only

41. #41 (nurse practitioner*):ti,ab

42. #42 MeSH descriptor Nurse Clinicians, this term only

43. #43 (clinical nurse specialist*):ti,ab

44. #44 (#20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR #39 OR #40 OR #41 OR #42 OR #43)

45. #45 (#19 OR #44)

46. #46 (#10 AND #45)

47. #47 (#46), from 2001 to 2011

CINAHL: EBSCO 1982–present

1. S39 S5 and S12 and S37 Limiters – Published Date from: 20020101–20111231

2. S38 S5 and S12 and S37

3. S37 S15 or S16 or S17 or S18 or S19 or S20 or S21 or S22 or S23 or S24 or S25 or S26 or S27 or S28 or S29 or S30 or S31 or S32 or S33 or S34 or S35 or S36

4. S36 TI “clinical nurse specialist*” or AB “clinical nurse specialist*”

5. S35 (MH “Clinical Nurse Specialists”)

6. S34 TI “nurse practitioner*” or AB “nurse practitioner*”

7. S33 (MH “Nurse Practitioners”)

8. S32 TI “advanced practitioner*” or AB “advanced practitioner*”

9. S31 TI “health visitor*” or AB “health visitor*”

10. S30 TI “visiting nurse*” or AB “visiting nurse*”

11. S29 TI “district nurs*” or AB “district nurs*”

12. S28 TI “specialist nurse*” or AB “specialist nurse*”

13. S27 (MH “Specialties, Nursing”)

14. S26 TI public health nursing or AB public health nursing

15. S25 TI ((community N2 health) or (community N2 nursing)) or AB ((community N2 health) or (community N2 nursing))

16. S24 (MH “Community Health Nursing”)

17. S23 TI geriatric health service* or AB geriatric health service*

18. S22 (MH “Gerontologic Nursing”)

19. S21 TI (“house call*” or “home visit*” or “house visit*”) or AB (“house call*” or “home visit*” or “house visit*”)

20. S20 (MH “Home Visits”)

21. S19 (MH “Health Services for the Aged”)

22. S18 (MH “Home Nursing”)

23. S17 TI “home care service*” or AB “home care service*”

24. S16 (MH “Home Health Care”)

25. S15 TI (“home-based nursing” or “home based nursing” or “home nursing”) or AB (“home-based nursing” or “home based nursing” or “home nursing”)

26. S14 S12 and S13

27. S13 TI (“nurse led” or nurse-led or home or “community based” or community-based) or AB (“nurse led” or nurse-led or home or “community based” or community-based)

28. S12 S6 or S7 or S8 or S9 or S10 or S11

29. S11 TI primary prevention or AB primary prevention

30. S10 TI wellness program* or AB wellness program*

31. S9 TI ((health N2 promotion*) or (health N2 campaign*) or (health N2 prevention*) or (health N2 protection)) or AB ((health N2 promotion*) or (health N2 campaign*) or (health N2 prevention*) or (health N2 protection))

32. S8 (MH “Health Promotion”)

33. S7 TI health education or AB health education

34. S6 (MH “Health Education”)

35. S5 S1 or S2 or S3 or S4

36. S4 TI ((old* N20 adult*) or (old* N20 person) or (old* N20 people)) or AB ((old* N20 adult*) or (old*N20 person) or (old* N20 people))

37. S3 TI (“over 65” or “over sixty-five*” or “over sixty five*”) or AB (“over 65” or “over sixty-five*” or “over sixty five*”)

38. S2 TI (aged or aged or geriatric or elder* or senior* or pensioner*) or AB (aged or aged or geriatric or elder* or senior* or pensioner*)

39. S1 (MH “Aged”) OR (MH “Aged, 80 and Over”) OR (MH “Frail Elderly”)

UK Clinical Research Network: NIHR 2001–present

http://public.ukcrn.org.uk/search/

• Home based nursing

• Home-based nursing

• Home nursing

• Nursing.

Clinical Trials.gov: US-National Institutes of Health (US-NIH) 2000–present

http://clinicaltrials.gov/ct2/search

• Found 92 studies with search of: home based nursing | Senior | received from 1 January 2001 to 1 March 2011.

Health Economic Evaluations Database: OHE-IFPHA 1967–present

1. AX =thinsp;(aged) or (aging) or (geriatric) or (elder*) or (senior*) or (pensioner*) or (old people)

2. AX =thinsp;(nurse led) or (nurse-led) or (home) or (community based) or (community-based)

3. AX =thinsp;(primary prevention) or (health education) or (health protection)

4. CS =thinsp;2 and 3

5. AX =thinsp;(home-based nursing) or (home based nursing) or (home nursing)

6. AX =thinsp;(geriatric nursing) or (community health) or (community nursing) or (public health nursing)

7. CS =thinsp;4 or 5 or 6

8. CS =thinsp;1 and 7

9. JD> =thinsp;2001

10. CS =thinsp;8 and 9

Randomised controlled trial including UK filter, e.g. in MEDLINE

1. Randomized controlled trials as Topic/

2. Randomized controlled trial/

3. Random allocation/

4. randomized controlled trial.pt.

5. Double blind method/

6. Single blind method/

7. Clinical trial/

8. exp Clinical Trials as Topic/

9. controlled clinical trial.pt.

10. or/1–9

11. (clinic$adj25 trial$).ti,ab.

12. ((singl$ or doubl$ or treb$ or tripl$) adj (blind$ or mask$)).tw.

13. Placebos/

14. Placebo$.tw.

15. (allocated adj2 random).tw.

16. or/11–15

17. 10 or 16

18. Case report.tw.

19. Letter/

20. Historical article/

21. or/18–20

22. exp Animals/

23. Humans/

24. 22 not 23

25. 21 or 24

26. 17 not 25

27. 26 and 47 (last statement of MEDLINE strategy)

28. exp Great Britain/

29. (britain or england or uk or united kingdom or scotland or wales or british or northern ireland or gb).af.

30. 28 or 29

31. 27 and 30

Systematic reviews filter, e.g. in MEDLINE

1. meta-analysis as topic/

2. (meta analy$ or metaanaly$).tw.

3. Meta-Analysis/

4. (systematic adj (review$1 or overview$1)).tw.

5. “Review Literature as Topic”/

6. or/1–5

7. (cochrane or embase or psychlit or psyclit or psychinfo or psycinfo or cinahl or cinhal or science citation index or bids or cancerlit).ab.

8. ((reference adj list$) or bibliograph$ or hand-search$ or (relevant adj journals) or (manual adj search$)).ab.

9. ((selection adj criteria) or (data adj extraction)).ab.

10. “review”/

11. 9 and 10

12. comment/or editorial/or letter/

13. Animals/

14. Humans/

15. 13 and 14

16. 13 not 15

17. 12 or 16

18. 6 or 7 or 8 or 11

19. 18 not 17

20. 19 and 47 (last statement of MEDLINE strategy)

Economic filter, e.g. in MEDLINE

1. Cost–benefit analysis/

2. Economic value of life/

3. Quality-adjusted life years/

4. exp models, economic/

5. cost utilit$.tw.

6. cost benefit$.tw.

7. cost minim$.tw.

8. cost effect$.tw.

9. economic evaluation$.tw.

10. or/1–9

11. 10 and 47 (last statement of MEDLINE strategy)

Research Question

What is the clinical and cost-effectiveness of nurse-led health promotion intervention delivered at home for older people at risk of admission to hospital, residential or nursing care in the UK?

Intervention

Structured home-based nurse led health promotion.

Patient population

Frail older people (>75 years) with long-term medical or social needs at risk of admission to hospital, residential or nursing care.

Setting

In the home or community.

Relevant comparators

Standard care including joint health and social assessment. Health promotion delivered in a different setting or not delivered by a nurse.

Design

An evidence synthesis in the form of a systematic review of studies undertaken in the UK, including older people with longer-term medical or social needs and at risk of admission to hospital, residential or nursing care. A decision analytic model will be developed to investigate the cost-effectiveness of nurse-led, home- or community-based health promotion.

Outcomes

The systematic review will summarise the evidence for home-based nurse-led interventions designed to promote health and prevent the deterioration of health. The review will look at the components of the review and seek to identify factors that contribute to the clinical effectiveness of particular programmes.

Key factors to be addressed

Do home-based nurse-led interventions work, and if so what do they prevent or promote? If these interventions work effectively, what features of the interventions are crucial to their effectiveness and do these represent good value for money for the NHS?

Population

Frail older people (>75 years) with long-term medical or social needs at risk of admission to hospital, residential or nursing care.

Interventions

Structured home based nurse-led health promotion.

Comparators

Standard care including joint health and social assessment. Health promotion delivered in a different setting or not delivered by a nurse.

Outcomes

Admission to hospital, residential or nursing care, mortality, morbidity including depression, falls, accidents, deteriorating health status, patient satisfaction.

Search Strategy

The search will be limited by date from 2001 to 2010. The Stuck et al (2002) review will be used as a source for identifying studies publishing earlier prior to 2002 (their search was conducted from January 1985 to November 2001). Bibliographies of previous systematic reviews, review articles and included studies will be handsearched to identify any other relevant studies.

The search strategy will comprise the following elements:

• Searching of electronic databases

• Handsearching of bibliographies of retrieved papers

• Contact with experts in the field.

Databases to be searched include the following:

• MEDLINE

• MEDLINE in Process (last 12 months)

• EMBASE

• CINAHL

• The Cochrane Library including the Cochrane Systematic Reviews Database, Cochrane Controlled Trials Register, DARE, NHS EED and HTA databases

• Science Citation Index (via Web of Science)

• National Research Register

• www.clinicaltrials.gov.

Inclusion Criteria

Studies will be included if they were conducted in the UK. They will be included if they evaluated a nurse-led health promoting intervention delivered in a home or community setting. Studies will only be included if they adopted an RCT design.

Exclusion Criteria

Non-randomised studies, non-English-language papers and reports published as meeting abstracts only where insufficient methodological details are reported to allow critical appraisal of study quality. Non-UK studies and interventions led by professionals other than nurses.

Data Extraction Strategy

Data will be extracted by one reviewer (FC).

Quality Assessment Strategy

Quality will be assessed using the Cochrane Risk of Bias tool. In particular, consideration of study quality will include the following factors:

Methods of analysis/synthesis

Data will be tabulated and discussed in a narrative review. Where appropriate, meta-analysis will be employed to estimate a summary measure of effect on relevant outcomes based on intention to treat analyses. Meta-analysis will be undertaken using fixed and random effects models, using Revman software. Heterogeneity will be explored through consideration of the study populations, methods and interventions, by visualisation of results and by the I² statistic.

Where available data is sufficient, subgroup analysis will be conducted to explore factors identified in earlier work as being significant in influencing intervention effectiveness including risk factors associated with the elderly person, the number of visits and the nature of the initial assessment. Sensitivity analysis will be used to explore the impact of study design on measures of effectiveness.

Methods for estimating quality of life

Studies describing relevant health-related quality of life outcomes will be identified from published sources as deemed appropriate from the definition of the decision problem.

TAR Centre

The ScHARR Technology Assessment Group (ScHARR-TAG) undertakes reviews of the effectiveness and cost-effectiveness of healthcare interventions for the NHS R&D Health Technology Assessment Programme on behalf of a range of policymakers in a short timescale, including the National Institute for Health and Clinical Excellence. The group has extensive expertise in information retrieval, systematic reviewing and health economic modelling.

Contributions of team members:

Appendix 1– MEDLINE search strategy

1. aged/

2. “aged, 80 and over”/

3. frail elderly/

4. aged.tw.

5. aging.tw.

6. geriatric.tw.

7. elder$.tw.

8. senior$.tw.

9. pensioner$.tw.

10. (over 65 or over sixty-five$ or over sixty five$).tw.

11. (old$ adj20 (adult$ or person or people)).tw.

12. or/1–11

13. Health Education/

14. health education.tw.

15. Health Promotion/

16. (health adj (promotion$ or campaign$ or prevention$ or protection)).tw.

17. wellness program$.tw.

18. primary prevention.tw.

19. or/13–18

20. (nurse led or nurse-led or home or community based or community-based).tw.

21. 19 and 20

22. ((home-based or home based or home) adj nursing).tw.

23. Home Care Services/

24. home care service$.tw.

25. Home Nursing/

26. Health Services for the Aged/

27. House Calls/

28. house call$.tw.

29. (home visit$ or house visit$).tw.

30. Geriatric Nursing/

31. geriatric health service$.tw.

32. Community Health Nursing/

33. (community adj (health or nursing)).tw.

34. Public Health Nursing/

35. public health nursing.tw.

36. Specialties, Nursing/

37. specialist nurse$.tw.

38. district nurs$.tw.

39. visiting nurse$.tw.

40. health visitor$.tw.

41. advanced practitioner$.tw.

42. Nurse Practitioners/

43. nurse practitioner$.tw.

44. Nurse Clinicians/

45. clinical nurse specialist$.tw.

46. or/22–42

47. 12 and (21 or 46)

Searches will be limited by year from 2001 to present. A highly sensitive filter will be applied to limit searches by publication (reviews, RCTs and economic studies).

Appendix 2 – Sample data extraction form

Prioritisation Group

1. Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

2. Professor Imti Choonara, Professor in Child Health, Academic Division of Child Health, University of Nottingham

   Chair – Pharmaceuticals Panel

3. Dr Bob Coates, Consultant Advisor – Disease Prevention Panel

4. Dr Andrew Cook, Consultant Advisor – Intervention Procedures Panel

5. Dr Peter Davidson, Director of NETSCC, Health Technology Assessment

6. Dr Nick Hicks, Consultant Adviser – Diagnostic Technologies and Screening Panel, Consultant Advisor–Psychological and Community Therapies Panel

7. Ms Susan Hird, Consultant Advisor, External Devices and Physical Therapies Panel

8. Professor Sallie Lamb, Director, Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick

   Chair – HTA Clinical Evaluation and Trials Board

9. Professor Jonathan Michaels, Professor of Vascular Surgery, Sheffield Vascular Institute, University of Sheffield

   Chair – Interventional Procedures Panel

10. Professor Ruairidh Milne, Director – External Relations

11. Dr John Pounsford, Consultant Physician, Directorate of Medical Services, North Bristol NHS Trust

    Chair – External Devices and Physical Therapies Panel

12. Dr Vaughan Thomas, Consultant Advisor – Pharmaceuticals Panel, Clinical

    Lead – Clinical Evaluation Trials Prioritisation Group

13. Professor Margaret Thorogood, Professor of Epidemiology, Health Sciences Research Institute, University of Warwick

    Chair – Disease Prevention Panel

14. Professor Lindsay Turnbull, Professor of Radiology, Centre for the MR Investigations, University of Hull

    Chair – Diagnostic Technologies and Screening Panel

15. Professor Scott Weich, Professor of Psychiatry, Health Sciences Research Institute, University of Warwick

    Chair – Psychological and Community Therapies Panel

16. Professor Hywel Williams, Director of Nottingham Clinical Trials Unit, Centre of Evidence-Based Dermatology, University of Nottingham

    Chair – HTA Commissioning Board

    Deputy HTA Programme Director

HTA Commissioning Board

1. Professor of Dermato-Epidemiology, Centre of Evidence-Based Dermatology, University of Nottingham

2. Department of Public Health and Epidemiology, University of Birmingham

3. Professor of Clinical Pharmacology, Director, NIHR HTA programme, University of Liverpool

1. Professor Ann Ashburn, Professor of Rehabilitation and Head of Research, Southampton General Hospital

2. Professor Judith Bliss, Director of ICR-Clinical Trials and Statistics Unit, The Institute of Cancer Research

3. Professor Peter Brocklehurst, Professor of Women’s Health, Institute for Women’s Health, University College London

4. Professor David Fitzmaurice, Professor of Primary Care Research, Department of Primary Care Clinical Sciences, University of Birmingham

5. Professor John W Gregory, Professor in Paediatric Endocrinology, Department of Child Health, Wales School of Medicine, Cardiff University

6. Professor Steve Halligan, Professor of Gastrointestinal Radiology, University College Hospital, London

7. Professor Angela Harden, Professor of Community and Family Health, Institute for Health and Human Development, University of East London

8. Dr Martin J Landray, Reader in Epidemiology, Honorary Consultant Physician, Clinical Trial Service Unit, University of Oxford

9. Dr Joanne Lord, Reader, Health Economics Research Group, Brunel University

10. Professor Stephen Morris, Professor of Health Economics, University College London, Research Department of Epidemiology and Public Health, University College London

11. Professor Dion Morton, Professor of Surgery, Academic Department of Surgery, University of Birmingham

12. Professor Gail Mountain, Professor of Health Services Research, Rehabilitation and Assistive Technologies Group, University of Sheffield

13. Professor Irwin Nazareth, Professor of Primary Care and Head of Department, Department of Primary Care and Population Sciences, University College London

14. Professor E Andrea Nelson, Professor of Wound Healing and Director of Research, School of Healthcare, University of Leeds

15. Professor John David Norrie, Chair in Clinical Trials and Biostatistics, Robertson Centre for Biostatistics, University of Glasgow

16. Dr Rafael Perera, Lecturer in Medical Statisitics, Department of Primary Health Care, University of Oxford

17. Professor Barney Reeves, Professorial Research Fellow in Health Services Research, Department of Clinical Science, University of Bristol

18. Professor Peter Tyrer, Professor of Community Psychiatry, Centre for Mental Health, Imperial College London

19. Professor Martin Underwood, Professor of Primary Care Research, Warwick Medical School, University of Warwick

20. Professor Caroline Watkins, Professor of Stroke and Older People’s Care, Chair of UK Forum for Stroke Training, Stroke Practice Research Unit, University of Central Lancashire

21. Dr Duncan Young, Senior Clinical Lecturer and Consultant, Nuffield Department of Anaesthetics, University of Oxford

1. Dr Tom Foulks, Medical Research Council

2. Dr Kay Pattison, Senior NIHR Programme Manager, Department of Health

HTA Clinical Evaluation and Trials Board

1. Director, Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick and Professor of Rehabilitation, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford

2. Professor of the Psychology of Health Care, Leeds Institute of Health Sciences, University of Leeds

3. Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

1. Professor Keith Abrams, Professor of Medical Statistics, Department of Health Sciences, University of Leicester

2. Professor Martin Bland, Professor of Health Statistics, Department of Health Sciences, University of York

3. Professor Jane Blazeby, Professor of Surgery and Consultant Upper GI Surgeon, Department of Social Medicine, University of Bristol

4. Professor Julia M Brown, Director, Clinical Trials Research Unit, University of Leeds

5. Professor Alistair Burns, Professor of Old Age Psychiatry, Psychiatry Research Group, School of Community-Based Medicine, The University of Manchester & National Clinical Director for Dementia, Department of Health

6. Dr Jennifer Burr, Director, Centre for Healthcare Randomised trials (CHART), University of Aberdeen

7. Professor Linda Davies, Professor of Health Economics, Health Sciences Research Group, University of Manchester

8. Professor Simon Gilbody, Prof of Psych Medicine and Health Services Research, Department of Health Sciences, University of York

9. Professor Steven Goodacre, Professor and Consultant in Emergency Medicine, School of Health and Related Research, University of Sheffield

10. Professor Dyfrig Hughes, Professor of Pharmacoeconomics, Centre for Economics and Policy in Health, Institute of Medical and Social Care Research, Bangor University

11. Professor Paul Jones, Professor of Respiratory Medicine, Department of Cardiac and Vascular Science, St George‘s Hospital Medical School, University of London

12. Professor Khalid Khan, Professor of Women’s Health and Clinical Epidemiology, Barts and the London School of Medicine, Queen Mary, University of London

13. Professor Richard J McManus, Professor of Primary Care Cardiovascular Research, Primary Care Clinical Sciences Building, University of Birmingham

14. Professor Helen Rodgers, Professor of Stroke Care, Institute for Ageing and Health, Newcastle University

15. Professor Ken Stein, Professor of Public Health, Peninsula Technology Assessment Group, Peninsula College of Medicine and Dentistry, Universities of Exeter and Plymouth

16. Professor Jonathan Sterne, Professor of Medical Statistics and Epidemiology, Department of Social Medicine, University of Bristol

17. Mr Andy Vail, Senior Lecturer, Health Sciences Research Group, University of Manchester

18. Professor Clare Wilkinson, Professor of General Practice and Director of Research North Wales Clinical School, Department of Primary Care and Public Health, Cardiff University

19. Dr Ian B Wilkinson, Senior Lecturer and Honorary Consultant, Clinical Pharmacology Unit, Department of Medicine, University of Cambridge

1. Ms Kate Law, Director of Clinical Trials, Cancer Research UK

2. Dr Morven Roberts, Clinical Trials Manager, Health Services and Public Health Services Board, Medical Research Council

Diagnostic Technologies and Screening Panel

1. Scientific Director of the Centre for Magnetic Resonance Investigations and YCR Professor of Radiology, Hull Royal Infirmary

2. Professor Judith E Adams, Consultant Radiologist, Manchester Royal Infirmary, Central Manchester & Manchester Children’s University Hospitals NHS Trust, and Professor of Diagnostic Radiology, University of Manchester

3. Mr Angus S Arunkalaivanan, Honorary Senior Lecturer, University of Birmingham and Consultant Urogynaecologist and Obstetrician, City Hospital, Birmingham

4. Dr Diana Baralle, Consultant and Senior Lecturer in Clinical Genetics, University of Southampton

5. Dr Stephanie Dancer, Consultant Microbiologist, Hairmyres Hospital, East Kilbride

6. Dr Diane Eccles, Professor of Cancer Genetics, Wessex Clinical Genetics Service, Princess Anne Hospital

7. Dr Trevor Friedman, Consultant Liason Psychiatrist, Brandon Unit, Leicester General Hospital

8. Dr Ron Gray, Consultant, National Perinatal Epidemiology Unit, Institute of Health Sciences, University of Oxford

9. Professor Paul D Griffiths, Professor of Radiology, Academic Unit of Radiology, University of Sheffield

10. Mr Martin Hooper, Public contributor

11. Professor Anthony Robert Kendrick, Associate Dean for Clinical Research and Professor of Primary Medical Care, University of Southampton

12. Dr Nicola Lennard, Senior Medical Officer, MHRA

13. Dr Anne Mackie, Director of Programmes, UK National Screening Committee, London

14. Mr David Mathew, Public contributor

15. Dr Michael Millar, Consultant Senior Lecturer in Microbiology, Department of Pathology & Microbiology, Barts and The London NHS Trust, Royal London Hospital

16. Mrs Una Rennard, Public contributor

17. Dr Stuart Smellie, Consultant in Clinical Pathology, Bishop Auckland General Hospital

18. Ms Jane Smith, Consultant Ultrasound Practitioner, Leeds Teaching Hospital NHS Trust, Leeds

19. Dr Allison Streetly, Programme Director, NHS Sickle Cell and Thalassaemia Screening Programme, King’s College School of Medicine

20. Dr Matthew Thompson, Senior Clinical Scientist and GP, Department of Primary Health Care, University of Oxford

21. Dr Alan J Williams, Consultant Physician, General and Respiratory Medicine, The Royal Bournemouth Hospital

1. Dr Tim Elliott, Team Leader, Cancer Screening, Department of Health

2. Dr Joanna Jenkinson, Board Secretary, Neurosciences and Mental Health Board (NMHB), Medical Research Council

3. Professor Julietta Patrick, Director, NHS Cancer Screening Programme, Sheffield

4. Dr Kay Pattison, Senior NIHR Programme Manager, Department of Health

5. Professor Tom Walley, CBE, Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

6. Dr Ursula Wells, Principal Research Officer, Policy Research Programme, Department of Health

Disease Prevention Panel

1. Professor of Epidemiology, University of Warwick Medical School, Coventry

2. Dr Robert Cook, Clinical Programmes Director, Bazian Ltd, London

3. Dr Colin Greaves, Senior Research Fellow, Peninsula Medical School (Primary Care)

4. Mr Michael Head, Public contributor

5. Professor Cathy Jackson, Professor of Primary Care Medicine, Bute Medical School, University of St Andrews

6. Dr Russell Jago, Senior Lecturer in Exercise, Nutrition and Health, Centre for Sport, Exercise and Health, University of Bristol

7. Dr Julie Mytton, Consultant in Child Public Health, NHS Bristol

8. Professor Irwin Nazareth, Professor of Primary Care and Director, Department of Primary Care and Population Sciences, University College London

9. Dr Richard Richards, Assistant Director of Public Health, Derbyshire County Primary Care Trust

10. Professor Ian Roberts, Professor of Epidemiology and Public Health, London School of Hygiene & Tropical Medicine

11. Dr Kenneth Robertson, Consultant Paediatrician, Royal Hospital for Sick Children, Glasgow

12. Dr Catherine Swann, Associate Director, Centre for Public Health Excellence, NICE

13. Mrs Jean Thurston, Public contributor

14. Professor David Weller, Head, School of Clinical Science and Community Health, University of Edinburgh

1. Ms Christine McGuire, Research & Development, Department of Health

2. Dr Kay Pattison, Senior NIHR Programme Manager, Department of Health

3. Professor Tom Walley, CBE, Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

External Devices and Physical Therapies Panel

1. Consultant Physician North Bristol NHS Trust

2. Reader in Wound Healing and Director of Research, University of Leeds

3. Professor Bipin Bhakta, Charterhouse Professor in Rehabilitation Medicine, University of Leeds

4. Mrs Penny Calder, Public contributor

5. Dr Dawn Carnes, Senior Research Fellow, Barts and the London School of Medicine and Dentistry

6. Dr Emma Clark, Clinician Scientist Fellow & Cons. Rheumatologist, University of Bristol

7. Mrs Anthea De Barton-Watson, Public contributor

8. Professor Nadine Foster, Professor of Musculoskeletal Health in Primary Care Arthritis Research, Keele University

9. Dr Shaheen Hamdy, Clinical Senior Lecturer and Consultant Physician, University of Manchester

10. Professor Christine Norton, Professor of Clinical Nursing Innovation, Bucks New University and Imperial College Healthcare NHS Trust

11. Dr Lorraine Pinnigton, Associate Professor in Rehabilitation, University of Nottingham

12. Dr Kate Radford, Senior Lecturer (Research), University of Central Lancashire

13. Mr Jim Reece, Public contributor

14. Professor Maria Stokes, Professor of Neuromusculoskeletal Rehabilitation, University of Southampton

15. Dr Pippa Tyrrell, Senior Lecturer/Consultant, Salford Royal Foundation Hospitals’ Trust and University of Manchester

16. Dr Nefyn Williams, Clinical Senior Lecturer, Cardiff University

1. Dr Kay Pattison, Senior NIHR Programme Manager, Department of Health

2. Dr Morven Roberts, Clinical Trials Manager, Health Services and Public Health Services Board, Medical Research Council

3. Professor Tom Walley, CBE, Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

4. Dr Ursula Wells, Principal Research Officer, Policy Research Programme, Department of Health

Interventional Procedures Panel

1. Professor of Vascular Surgery, University of Sheffield

2. Consultant Colorectal Surgeon, Bristol Royal Infirmary

3. Mrs Isabel Boyer, Public contributor

4. Mr Sankaran Chandra Sekharan, Consultant Surgeon, Breast Surgery, Colchester Hospital University NHS Foundation Trust

5. Professor Nicholas Clarke, Consultant Orthopaedic Surgeon, Southampton University Hospitals NHS Trust

6. Ms Leonie Cooke, Public contributor

7. Mr Seumas Eckford, Consultant in Obstetrics & Gynaecology, North Devon District Hospital

8. Professor Sam Eljamel, Consultant Neurosurgeon, Ninewells Hospital and Medical School, Dundee

9. Dr Adele Fielding, Senior Lecturer and Honorary Consultant in Haematology, University College London Medical School

10. Dr Matthew Hatton, Consultant in Clinical Oncology, Sheffield Teaching Hospital Foundation Trust

11. Dr John Holden, General Practitioner, Garswood Surgery, Wigan

12. Dr Fiona Lecky, Senior Lecturer/Honorary Consultant in Emergency Medicine, University of Manchester/Salford Royal Hospitals NHS Foundation Trust

13. Dr Nadim Malik, Consultant Cardiologist/Honorary Lecturer, University of Manchester

14. Mr Hisham Mehanna, Consultant & Honorary Associate Professor, University Hospitals Coventry & Warwickshire NHS Trust

15. Dr Jane Montgomery, Consultant in Anaesthetics and Critical Care, South Devon Healthcare NHS Foundation Trust

16. Professor Jon Moss, Consultant Interventional Radiologist, North Glasgow Hospitals University NHS Trust

17. Dr Simon Padley, Consultant Radiologist, Chelsea & Westminster Hospital

18. Dr Ashish Paul, Medical Director, Bedfordshire PCT

19. Dr Sarah Purdy, Consultant Senior Lecturer, University of Bristol

20. Dr Matthew Wilson, Consultant Anaesthetist, Sheffield Teaching Hospitals NHS Foundation Trust

21. Professor Yit Chiun Yang, Consultant Ophthalmologist, Royal Wolverhampton Hospitals NHS Trust

1. Dr Kay Pattison, Senior NIHR Programme Manager, Department of Health

2. Dr Morven Roberts, Clinical Trials Manager, Health Services and Public Health Services Board, Medical Research Council

3. Professor Tom Walley, CBE, Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

4. Dr Ursula Wells, Principal Research Officer, Policy Research Programme, Department of Health

Pharmaceuticals Panel

1. Professor in Child Health, University of Nottingham

2. Senior Lecturer in Clinical Pharmacology, University of East Anglia

3. Dr Martin Ashton-Key, Medical Advisor, National Commissioning Group, NHS London

4. Dr Peter Elton, Director of Public Health, Bury Primary Care Trust

5. Dr Ben Goldacre, Research Fellow, Division of Psychological Medicine and Psychiatry, King’s College London

6. Dr James Gray, Consultant Microbiologist, Department of Microbiology, Birmingham Children’s Hospital NHS Foundation Trust

7. Dr Jurjees Hasan, Consultant in Medical Oncology, The Christie, Manchester

8. Dr Carl Heneghan, Deputy Director Centre for Evidence-Based Medicine and Clinical Lecturer, Department of Primary Health Care, University of Oxford

9. Dr Dyfrig Hughes, Reader in Pharmacoeconomics and Deputy Director, Centre for Economics and Policy in Health, IMSCaR, Bangor University

10. Dr Maria Kouimtzi, Pharmacy and Informatics Director, Global Clinical Solutions, Wiley-Blackwell

11. Professor Femi Oyebode, Consultant Psychiatrist and Head of Department, University of Birmingham

12. Dr Andrew Prentice, Senior Lecturer and Consultant Obstetrician and Gynaecologist, The Rosie Hospital, University of Cambridge

13. Ms Amanda Roberts, Public contributor

14. Dr Gillian Shepherd, Director, Health and Clinical Excellence, Merck Serono Ltd

15. Mrs Katrina Simister, Assistant Director New Medicines, National Prescribing Centre, Liverpool

16. Professor Donald Singer, Professor of Clinical Pharmacology and Therapeutics, Clinical Sciences Research Institute, CSB, University of Warwick Medical School

17. Mr David Symes, Public contributor

18. Dr Arnold Zermansky, General Practitioner, Senior Research Fellow, Pharmacy Practice and Medicines Management Group, Leeds University

1. Dr Kay Pattison, Senior NIHR Programme Manager, Department of Health

2. Mr Simon Reeve, Head of Clinical and Cost-Effectiveness, Medicines, Pharmacy and Industry Group, Department of Health

3. Dr Heike Weber, Programme Manager, Medical Research Council

4. Professor Tom Walley, CBE, Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

5. Dr Ursula Wells, Principal Research Officer, Policy Research Programme, Department of Health

Psychological and Community Therapies Panel

1. Professor of Psychiatry, University of Warwick, Coventry

2. Consultant & University Lecturer in Psychiatry, University of Cambridge

3. Professor Jane Barlow, Professor of Public Health in the Early Years, Health Sciences Research Institute, Warwick Medical School

4. Dr Sabyasachi Bhaumik, Consultant Psychiatrist, Leicestershire Partnership NHS Trust

5. Mrs Val Carlill, Public contributor

6. Dr Steve Cunningham, Consultant Respiratory Paediatrician, Lothian Health Board

7. Dr Anne Hesketh, Senior Clinical Lecturer in Speech and Language Therapy, University of Manchester

8. Dr Peter Langdon, Senior Clinical Lecturer, School of Medicine, Health Policy and Practice, University of East Anglia

9. Dr Yann Lefeuvre, GP Partner, Burrage Road Surgery, London

10. Dr Jeremy J Murphy, Consultant Physician and Cardiologist, County Durham and Darlington Foundation Trust

11. Dr Richard Neal, Clinical Senior Lecturer in General Practice, Cardiff University

12. Mr John Needham, Public contributor

13. Ms Mary Nettle, Mental Health User Consultant

14. Professor John Potter, Professor of Ageing and Stroke Medicine, University of East Anglia

15. Dr Greta Rait, Senior Clinical Lecturer and General Practitioner, University College London

16. Dr Paul Ramchandani, Senior Research Fellow/Cons. Child Psychiatrist, University of Oxford

17. Dr Karen Roberts, Nurse/Consultant, Dunston Hill Hospital, Tyne and Wear

18. Dr Karim Saad, Consultant in Old Age Psychiatry, Coventry and Warwickshire Partnership Trust

19. Dr Lesley Stockton, Lecturer, School of Health Sciences, University of Liverpool

20. Dr Simon Wright, GP Partner, Walkden Medical Centre, Manchester

1. Dr Kay Pattison, Senior NIHR Programme Manager, Department of Health

2. Dr Morven Roberts, Clinical Trials Manager, Health Services and Public Health Services Board, Medical Research Council

3. Professor Tom Walley, CBE, Director, NIHR HTA programme, Professor of Clinical Pharmacology, University of Liverpool

4. Dr Ursula Wells, Principal Research Officer, Policy Research Programme, Department of Health