Shepperd, Sasha
University of Oxford
United Kingdom
A multi-centre randomised controlled trial of Comprehensive Geriatric Assessment in an admission avoidance hospital at home setting
NIHR
3,128,429
01/07/2014
4.0
Alzheimer's disease & other dementias
BACKGROUND Evidence is needed on how to provide high quality acute hospital level care to older adults in greater numbers with a fixed or shrinking hospital resource (1). OBJECTIVE We will test the cost-effectiveness of hospital at home (HaH) with comprehensive geriatric assessment (CGA) compared with hospital admission with CGA. DESIGN A multi-centre randomised controlled trial (RCT), a parallel economic evaluation and interview study comparing CGA in an admission avoidance HaH setting with hospital admission with CGA; an update of the Cochrane Review of HaH. SETTING HaH and inpatient hospitals in England, Wales and Scotland. LITERATURE REVIEW We will update the Cochrane Review of admission avoidance HaH. TARGET POPULATION Older people with markers of frailty or prior dependence, this will include patients presenting with delirium, functional decline, dependence, falls, immobility or a background of dementia presenting with physical disease. We will exclude patients with acute coronary syndrome, requiring acute surgical assessment, a suspected stroke, refusing HaH or considered by the clinical staff to be too high risk for home based care. INTERVENTION Admission avoidance HaH with CGA provides active treatment by healthcare professionals for a condition that otherwise would require acute in-patient care. CGA is a specialist led service providing multi-level assessment and management, a tailored management plan and co-ordinated care. Usual care will be hospital-based inpatient CGA. MEASUREMENT OF COSTS AND OUTCOMES Primary outcome: living at home (the inverse of death or living in a residential care setting). Secondary outcomes: incidence of delirium (2), mortality, new long-term residential care, cognitive impairment (3), activities of daily living (4), quality of life and quality adjusted survival (EQ-5D) (5), length of stay, readmission or transfer to hospital, resource use, costs and cost-effectiveness. Follow-up will be at 6 and 12 months. SAMPLE SIZE With 90% power, a two tailed test of significance at the level of 0.05, we will need to recruit 1552 participants to detect a 10% absolute difference in the primary outcome living at 12 months, assuming a control group event rate at 12 months of 50% (1). PROJECT TIMETABLE This will be a two phase trial; in phase one (18 months) we will establish feasibility of recruitment, randomisation and data collection; if successful we will continue in phase 2 (30 months). An update of the Cochrane Review will start in year 2 and be completed in year 4. (1)Shepperd S et al. Hospital at home admission avoidance. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD007491. DOI: 10.1002/14651858. (2)Inouye SK et al et al, Clarifying Confusion: The Confusion Assessment Method. A New Method for Detection of Delirium. Ann Intern Med. 1990; 113:941-8 (3)Nasreddine ZS et al. The Montreal Cognitive Assessment (MoCA): A Brief Screening Tool For Mild Cognitive Impairment. J Amer Ger Soc 53:695-699, 2005 (4)Wade D, et al. The Barthel ADL Index: A standard measure of physical disability. Int Dis Studies 1988;10(2):64-7. (5)EuroQol-a new facility for the measurement of health-related quality of life. Health Policy 1990;16:199-20