Here is the standardised PICO analysis for the twenty-fourth uploaded article:
Full Title
Which interventions are effective at decreasing or increasing emergency department attendances or hospital admissions from long-term care facilities? A systematic review
Authors: Ben Searle, Robert O. Barker, Daniel Stow, Gemma F. Spiers, Fiona Pearson, Barbara Hanratty
Journal: BMJ Open, 2023; 13:e064914
DOI: 10.1136/bmjopen-2022-064914
Type of Study
Systematic review of randomised controlled trials (RCTs)
PICO Summary
Population (P)
- Residents of long-term care facilities (LTCFs)
- Population focus was on older adults, typically frail, with high hospital utilisation
- Excluded: private homes, supported living, hospice settings
Intervention (I)
- 43 RCTs categorised by intervention type, including:
- Advance care planning (ACP) and goals of care discussions
- Influenza vaccination or antiviral management
- Prescribing interventions (deprescribing, medication review, education)
- Nurse practitioner/specialist input
- Palliative or geriatric specialist care
- IV fluids/antibiotics delivered in LTCF
- Various single or multifaceted interventions (e.g. hand hygiene, SBAR, simulation)
Comparison (C)
- Usual care or alternative intervention arm in the same LTCF setting
- Studies included were RCTs only (no observational or non-randomised studies)
Outcomes (O)
Health system outcomes (primary):
- Hospitalisations (n=36 studies)
- Emergency department attendances (n=10)
- Hospital readmissions (n=3)
- Proportion of residents treated in hospital (n=1)
Findings:
- ACP: 5 of 6 studies showed reduced hospitalisations; GRADE = low
- Influenza vaccination: consistently reduced hospitalisations; GRADE = very low due to risk of bias
- Nurse practitioner/specialist input: all studies showed reduction in hospital/ED use; only 1 statistically significant
- Prescribing: mixed results; some non-significant increases in hospital use noted
- Palliative care and geriatrician input: inconsistent; often bundled with ACP, limiting attribution
- IV therapy in facility: 1 study showed significant reduction in hospital transfers, despite high risk of bias
Findings Summary
This review confirms the effectiveness of ACP and influenza vaccination in reducing unscheduled hospital use in LTCFs. Interventions involving nurse specialists or IV therapy access may also reduce hospitalisations but lack consistent robust evidence. Prescribing reviews and secondary care outreach have inconclusive effects. Due to heterogeneity and complexity, the authors suggest that combinations of interventions will likely be required to meaningfully reduce hospital admissions across this population.
GRADE assessments were generally low or very low, with many studies limited by risk of bias, underpowered samples, and implementation challenges. No meta-analysis was conducted due to intervention diversity.
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