Preventive interventions to improve older people's health outcomes: systematic review and meta-analysis

Abstract

Background: Systematic reviews of preventive, non-disease-specific primary care trials for older people often report effects according to what is thought to be the intervention's active ingredient.

Aim: To examine the effectiveness of preventive primary care interventions for older people and to identify common components that contribute to intervention success.

Design and setting: A systematic review and meta-analysis of 18 randomised controlled trials (RCTs) published in 22 publications from 2009 to 2019.

Method: A search was conducted in PubMed, MEDLINE, Embase, Web of Science, CENTRAL, CINAHL, and the Cochrane Library. Inclusion criteria were: sample mainly aged ≥65 years; delivered in primary care; and non-disease-specific interventions. Exclusion criteria were: non-RCTs; primarily pharmacological or psychological interventions; and where outcomes of interest were not reported. Risk of bias was assessed using the original Cochrane tool. Outcomes examined were healthcare use including admissions to hospital and aged residential care (ARC), and patient-reported outcomes including activities of daily living (ADLs) and self-rated health (SRH).

Results: Many studies had a mix of patient-, provider-, and practice-focused intervention components (13 of 18 studies). Studies included in the review had low-to-moderate risk of bias. Interventions had no overall benefit to healthcare use (including admissions to hospital and ARC) but higher basic ADL scores were observed (standardised mean difference [SMD] 0.21, 95% confidence interval [CI] = 0.01 to 0.40) and higher odds of reporting positive SRH (odds ratio [OR] 1.17, 95% CI = 1.01 to 1.37). When intervention effects were examined by components, better patient-reported outcomes were observed in studies that changed the care setting (SMD for basic ADLs 0.21, 95% CI = 0.01 to 0.40; OR for positive SRH 1.17, 95% CI = 1.01 to 1.37), included educational components for health professionals (SMD for basic ADLs 0.21, 95% CI = 0.01 to 0.40; OR for positive SRH 1.27, 95% CI = 1.05 to 1.55), and provided patient education (SMD for basic ADLs 0.28, 95% CI = 0.09 to 0.48). Additionally, admissions to hospital in intervention participants were fewer by 23% in studies that changed the care setting (incidence rate ratio [IRR] 0.77, 95% CI = 0.63 to 0.95) and by 26% in studies that provided patient education (IRR 0.74, 95% CI = 0.56 to 0.97).

Conclusion: Preventive primary care interventions are beneficial to older people's functional ability and SRH but not other outcomes. To improve primary care for older people, future programmes should consider delivering care in alternative settings, for example, home visits and phone contacts, and providing education to patients and health professionals as these may contribute to positive outcomes.

Keywords: activities of daily living; aged; aged, 80 and over; general practice; healthcare use; patient reported outcome measures.

Figure 1.

Flow diagram of the review. RCT = randomised controlled trial.

Figure 2.

Effect of preventive primary care interventions for older people on healthcare use (n = 13). Data in the final column in brackets are 95% confidence intervals. ^aHigh and unclear risk of bias in domains assessed are marked using the conventional style: – for high risk of bias and ? for unclear risk (>1 – or ? reflects bias in >1 domain). 1P = provider-focused domain only. 2P = provider- and practice-focused domains for van Hout et al (2010); provider- and patient-focused domains for Blom et al (2016). 3P = includes patient-, provider-, and practice-focused intervention components. %, LTC home = proportion admitted to long-term care home. dur = duration. ed = education. F = financial components. IRR = incidence rate ratio. MDT = multidisciplinary team. OR = odds ratio.

Figure 3.

Effect of preventive primary care interventions for older people on functional ability (n = 11). Data in the final column in brackets are 95% confidence intervals. ^aHigh and unclear risk of bias in domains assessed are marked using the conventional style: – for high risk of bias and ? for unclear risk (>1 – or ? reflects bias in >1 domain). 1P = provider-focused domain only. 2P = provider- and practice-focused domains for van Hout et al (2010); provider- and patient-focused domains for Blom et al (2016). 3P = includes patient-, provider-, and practice-focused intervention components. ADL = Activities of Daily Living. Barthel = Barthel Index of Activities of Daily Living. d = SMD, standardised mean difference. ed = education. F = financial components. GARS = Groningen Activity Restriction Scale. IADL = Instrumental Activities of Daily Living. MDT = multidisciplinary team. Modified Katz = modified Katz Activities of Daily Living. NEADL = Nottingham Extended Activities of Daily Living. OARS ADL = Older Americans Resources and Services Activities of Daily Living scale. SF-36 PF subscale = 36-Item Short Form Health Survey Physical Functioning subscale.

Figure 4.

Effect of preventive primary care interventions for older people on quality of life (n = 15): a) single item and index scores; b) multidomain scores. Data in the final column in brackets are 95% confidence intervals. ^aHigh and unclear risk of bias in domains assessed are marked using the conventional style: – for high risk of bias and ? for unclear risk (>1 – or ? reflects bias in >1 domain). 1P = provider-focused domain only. 2P = provider- and practice-focused domains for van Hout et al (2010); provider- and patient- focused domains for Blom et al (2016). 3P = includes patient-, provider-, and practice-focused intervention components. Cantril = Cantril’s Ladder. CASP-19 = Control, Autonomy, Self-Realization and Pleasure scale. d = SMD, standardised mean difference. ed = education. EQ-5D = EuroQOL five dimensions summary index for quality of life. F = financial components. MDT = multidisciplinary team. OR = odds ratio. SF = Short Form Health Survey. SRH = self-rated health. WHOQOL-BREF = brief version of the World Health Organization Quality of Life assessment tool. 1P = provider-focused domain only. 2P = provider- and practice-focused domains for van Hout et al (2010); provider- and patient-focused domains for Blom et al (2016). 3P = includes patient-, provider-, and practice-focused intervention components.