Young Camilla, Hall Amanda M, Gonçalves-Bradley Daniela C, Quinn Terry J, Hooft Lotty, van Munster Barbara C, Stott David J
Institute of Cardiovascular and Medical Sciences, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, Glasgow, UK, G4 0SF.
Faculty of Medicine, Memorial University of Newfoundland, St. John's, Canada.
Cochrane Database Syst Rev. 2017 Apr 3;4(4):CD009844. doi: 10.1002/14651858.CD009844.pub2.
Changing population demographics have led to an increasing number of functionally dependent older people who require care and medical treatment. In many countries, government policy aims to shift resources into the community from institutional care settings with the expectation that this will reduce costs and improve the quality of care compared.
To assess the effects of long-term home or foster home care versus institutional care for functionally dependent older people.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library, MEDLINE, Embase, CINAHL, and two trials registers to November 2015.
We included randomised and non-randomised trials, controlled before-after studies and interrupted time series studies complying with the EPOC study design criteria and comparing the effects of long-term home care versus institutional care for functionally dependent older people.
Two reviewers independently extracted data and assessed the risk of bias of each included study. We reported the results narratively, as the substantial heterogeneity across studies meant that meta-analysis was not appropriate.
We included 10 studies involving 16,377 participants, all of which were conducted in high income countries. Included studies compared community-based care with institutional care (care homes). The sample size ranged from 98 to 11,803 (median N = 204). There was substantial heterogeneity in the healthcare context, interventions studied, and outcomes assessed. One study was a randomised trial (N = 112); other included studies used designs that had potential for bias, particularly due lack of randomisation, baseline imbalances, and non-blinded outcome assessment. Most studies did not select (or exclude) participants for any specific disease state, with the exception of one study that only included patients if they had a stroke. All studies had methodological limitations, so readers should interpret results with caution.It is uncertain whether long-term home care compared to nursing home care decreases mortality risk (2 studies, N = 314, very-low certainty evidence). Estimates ranged from a nearly three-fold increased risk of mortality in the homecare group (risk ratio (RR) 2.89, 95% confidence interval (CI) 1.57 to 5.32) to a 62% relative reduction (RR 0.38, 95% CI 0.17 to 0.61). We did not pool data due to the high degree of heterogeneity (I = 94%).It is uncertain whether the intervention has a beneficial effect on physical function, as the certainty of evidence is very low (5 studies, N = 1295). Two studies reported that participants who received long-term home care had improved activities of daily living compared to those in a nursing home, whereas a third study reported that all participants performed equally on physical function.It is uncertain whether long-term home care improves happiness compared to nursing home care (RR 1.97, 95% CI 1.27 to 3.04) or general satisfaction because the certainty of evidence was very low (2 studies, N = 114).The extent to which long-term home care was associated to more or fewer adverse health outcomes than nursing home care was not reported.It is uncertain whether long-term home care compared to nursing home care decreases the risk of hospital admission (very low-certainty evidence, N = 14,853). RR estimates ranged from 2.75 (95% CI 2.59 to 2.92), showing an increased risk for those receiving care at home, to 0.82 (95% CI 0.72 to 0.93), showing a slightly reduced risk for the same group. We did not pool data due to the high degree of heterogeneity (I = 99%).
AUTHORS' CONCLUSIONS: There are insufficient high-quality published data to support any particular model of care for functionally dependent older people. Community-based care was not consistently beneficial across all the included studies; there were some data suggesting that community-based care may be associated with improved quality of life and physical function compared to institutional care. However, community alternatives to institutional care may be associated with increased risk of hospitalisation. Future studies should assess healthcare utilisation, perform economic analysis, and consider caregiver burden.
人口结构的变化导致需要护理和治疗的功能依赖型老年人数量不断增加。在许多国家，政府政策旨在将资源从机构护理环境转移到社区，期望这样能降低成本并提高护理质量。
评估长期居家或寄养家庭护理与机构护理对功能依赖型老年人的影响。
我们通过Cochrane图书馆、MEDLINE、Embase、CINAHL以及两个试验注册库检索了截至2015年11月的Cochrane对照试验中心注册库（CENTRAL）。
我们纳入了符合EPOC研究设计标准、比较长期居家护理与机构护理对功能依赖型老年人影响的随机和非随机试验、前后对照研究以及中断时间序列研究。
两名评价员独立提取数据并评估每项纳入研究的偏倚风险。由于研究间存在实质性异质性，我们以叙述方式报告结果，不进行Meta分析。
我们纳入了10项研究，涉及16377名参与者，所有研究均在高收入国家进行。纳入研究将社区护理与机构护理（养老院）进行了比较。样本量从98到11803不等（中位数N = 204）。在医疗背景、研究干预措施和评估结局方面存在实质性异质性。一项研究为随机试验（N = 112）；其他纳入研究采用的设计存在偏倚可能性，特别是由于缺乏随机化、基线不平衡和非盲法结局评估。大多数研究未针对任何特定疾病状态选择（或排除）参与者，只有一项研究仅纳入中风患者。所有研究均存在方法学局限性，因此读者应谨慎解读结果。与养老院护理相比，长期居家护理是否能降低死亡风险尚不确定（2项研究，N = 314，证据确定性极低）。估计范围从居家护理组死亡风险增加近三倍（风险比（RR）2.89，95%置信区间（CI）1.57至5.32）到相对降低62%（RR 0.38，95%CI 0.17至0.61）。由于异质性程度高（I² = 94%），我们未合并数据。由于证据确定性极低（5项研究，N = 1295），干预措施对身体功能是否有有益影响尚不确定。两项研究报告称，接受长期居家护理的参与者与养老院参与者相比，日常生活活动有所改善，而第三项研究报告称所有参与者在身体功能方面表现相当。与养老院护理相比，长期居家护理是否能提高幸福感（RR 1.97，95%CI 1.27至3.04）或总体满意度尚不确定，因为证据确定性极低（2项研究，N = 114）。未报告长期居家护理与养老院护理相比，不良健康结局更多或更少的程度。与养老院护理相比，长期居家护理是否能降低住院风险尚不确定（证据确定性极低，N = 14853）。RR估计范围从2.75（95%CI 2.59至2.92），表明居家接受护理者风险增加，到0.82（95%CI 0.72至0.93），表明同一组风险略有降低。由于异质性程度高（I² = 99%），我们未合并数据。
没有足够的高质量已发表数据来支持针对功能依赖型老年人的任何特定护理模式。在所有纳入研究中，基于社区的护理并非始终有益；有一些数据表明，与机构护理相比，基于社区的护理可能与生活质量改善和身体功能改善相关。然而，机构护理的社区替代方案可能与住院风险增加相关。未来研究应评估医疗保健利用情况、进行经济分析并考虑照顾者负担。
