Effectiveness of intermediate care in nursing‐led in‐patient units

Peter Griffiths; Margaret Edwards; Angus Forbes; Ruth Harris; Gill Ritchie

doi:10.1002/14651858.CD002214.pub2

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Analysis 1.1

Comparison 1 NLU vs general inpatient care, Outcome 1 Inpatient mortality.

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Analysis 1.2

Comparison 1 NLU vs general inpatient care, Outcome 2 Early post discharge death (4‐6 weeks).

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Analysis 1.3

Comparison 1 NLU vs general inpatient care, Outcome 3 Mortality within 3 months of admission (12 weeks / 90 days).

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Analysis 1.4

Comparison 1 NLU vs general inpatient care, Outcome 4 Mortality within 6 months of admission (24 weeks / 180 days).

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Analysis 1.5

Comparison 1 NLU vs general inpatient care, Outcome 5 Mortality to longest follow up (within 6 months).

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Analysis 1.6

Comparison 1 NLU vs general inpatient care, Outcome 6 Discharge to institutional care.

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Analysis 1.7

Comparison 1 NLU vs general inpatient care, Outcome 7 Independent at discharge.

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Analysis 1.8

Comparison 1 NLU vs general inpatient care, Outcome 8 Institutional care to longest follow up.

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Analysis 1.9

Comparison 1 NLU vs general inpatient care, Outcome 9 Functional Status at discharge.

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Analysis 1.10

Comparison 1 NLU vs general inpatient care, Outcome 10 Change in functional Status (admission to discharge).

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Analysis 1.11

Comparison 1 NLU vs general inpatient care, Outcome 11 Best measure of functional status.

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Analysis 1.12

Comparison 1 NLU vs general inpatient care, Outcome 12 Length of stay to first discharge from hospital setting.

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Analysis 1.13

Comparison 1 NLU vs general inpatient care, Outcome 13 Length of stay to first discharge home.

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Analysis 1.14

Comparison 1 NLU vs general inpatient care, Outcome 14 Early readmission (within 30 days).

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Analysis 1.15

Comparison 1 NLU vs general inpatient care, Outcome 15 Quality of life / health status.

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Analysis 1.16

Comparison 1 NLU vs general inpatient care, Outcome 16 Quality of life / health status change scores only.

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Analysis 1.17

Comparison 1 NLU vs general inpatient care, Outcome 17 Psychological wellbeing.

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Analysis 1.18

Comparison 1 NLU vs general inpatient care, Outcome 18 Satisfaction.

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Analysis 2.1

Comparison 2 NLU vs ICU, Outcome 1 Inpatient mortality.

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Analysis 2.2

Comparison 2 NLU vs ICU, Outcome 2 Mortality to longest follow up (Up to 24 months).

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Analysis 2.3

Comparison 2 NLU vs ICU, Outcome 3 Discharge to institutional care.

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Analysis 2.4

Comparison 2 NLU vs ICU, Outcome 4 Length of stay to first discharge home.

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Analysis 2.5

Comparison 2 NLU vs ICU, Outcome 5 Early readmission (within 30 days).

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Table 1. Summary of study validity

Study ID	Method	Concealment	Follow Up	Blinded assessment	Baseline	Reliable assessment	Contamination	Intention to treat	Number (3‐7) 'done'
Bowcutt 2000	RCT	Unclear	Done	*	Unclear	*	Done	Unclear	2 /5
Daly 1995	CCT	Not done	Done	Unclear	Done	Done	Done	Unclear	4/7
Davies 1994	CBA		Unclear		Unclear	Unclear	Unclear		0/4
Griffiths 1995	RCT	Not done	Done	Not done	Not done	Not done	Done	Done	3/7
Griffiths 2000	RCT	Not done	Done	Not done	Done	Done	Done	Done	5/7
Griffiths 2001	RCT	Done	Done	Not done	Done	Done	Done	Done	6/7
Hall 1975	CCT	Unclear	Done	Not done	Not done	Unclear	Unclear	Done	2/7
Pearson 1988a	RCT	Done	Done	Not done	Not done	Unclear	Done	Unclear	3/7
Pearson 1988b	RCT	Done	Done	Not done	Not done	Unclear	Done	Not done	3/7
Steiner 2001	RCT	Not done	Done	Unclear	Done	Unclear	Done	Done	4/7
Walsh 1999	RCT	Done	Done	Unclear	Unclear	Unclear	Done	Done	4/7

Table 1. Summary of study validity

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Table 2. Costs of care ‐ in‐patient

Study id	Costs considered	Treatment cost	Control cost	Notes
Griffiths 2001	In‐patient costs to service providers (from study entry)	£5144 per stay	£4100 per stay	Comprehensive range of resources used identified and costed directly or estimated. Used a variety of methods to estimate total inpatient costs (including medical and nursing care). Cost differences were subjected to a sensitivity analysis and were not sensitive to assumptions. Main driver of costs is length of stay.
Griffiths 2000	In‐patient costs to service providers (from study entry)	High estimate £ 10,278, Low estimate £8,544 per stay	£7,757	Comprehensive range of resources used identified and costed directly or estimated. Used two methods to estimate cost of medical care for NLU. Magnitude of cost difference varied depending on this but NLU more expensive. Main driver of costs is length of stay.
Bowcutt 2000	Direct hospital costs ‐ unspecified	$9,445.06	$19.,320.87	No detail given on costs other than nursing staff
Pearson 1988a	Cost per hospital stay (including acute stay) to service providers	£1267.3 (£1323.6*)	£1311.9	No detail given on costs other than nursing staff. *Figure in brackets recalculated from data given in paper.
Pearson 1988b	Cost per hospital stay (including acute stay) to service providers	£1476.36	£1431.42	Costing based on staff cost and average cost per bed (estimated)
Daly 1995	In‐patient costs to service providers (total stay)	$76,077	$81,212	Comprehensive range of resources used identified and costed directly or estimated..

Table 2. Costs of care ‐ in‐patient

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Table 3. Costs of care post discharge

Study ID	Costs considered	Treatment cost	Control cost	Notes
Griffiths 2001	Community health and social services cost and post discharge institutional charges to public providers	£374.91 per week	£401.60 per week	Comprehensive range of service provider costs identified. Resource use estimated based on planned resource use identified in patients discharge plan
Griffiths 2000	Health and social services cost and post discharge institutional charges to public providers in the month after discharge	All costs £990, community health and social services only £162	All costs £1,259, community health and social services only £253	Comprehensive range of service provider costs identified. Resource use determined directly from a sample supplemented by estimates based on planned resource use identified in patients discharge plan. Total costs include costs of readmissions

Table 3. Costs of care post discharge

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Comparison 1. NLU vs general inpatient care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Inpatient mortality Show forest plot	7	953	Odds Ratio (M‐H, Random, 95% CI)	1.10 [0.56, 2.16]

1.1 Stronger studies	4	607	Odds Ratio (M‐H, Random, 95% CI)	1.52 [0.86, 2.68]
1.2 Weaker studies	3	346	Odds Ratio (M‐H, Random, 95% CI)	0.68 [0.13, 3.46]
2 Early post discharge death (4‐6 weeks) Show forest plot	4	892	Odds Ratio (M‐H, Random, 95% CI)	0.63 [0.25, 1.62]

2.1 Stronger studies	1	153	Odds Ratio (M‐H, Random, 95% CI)	0.44 [0.08, 2.49]
2.2 Weaker studies	3	739	Odds Ratio (M‐H, Random, 95% CI)	0.74 [0.24, 2.24]
3 Mortality within 3 months of admission (12 weeks / 90 days) Show forest plot	3	885	Odds Ratio (M‐H, Random, 95% CI)	1.60 [0.93, 2.75]

3.1 Stronger studies	2	352	Odds Ratio (M‐H, Random, 95% CI)	1.52 [0.82, 2.82]
3.2 Weaker studies	1	533	Odds Ratio (M‐H, Random, 95% CI)	1.88 [0.61, 5.80]
4 Mortality within 6 months of admission (24 weeks / 180 days) Show forest plot	3	946	Odds Ratio (M‐H, Random, 95% CI)	0.96 [0.63, 1.47]

4.1 Stronger studies	2	413	Odds Ratio (M‐H, Random, 95% CI)	0.95 [0.58, 1.56]
4.2 Weaker studies	1	533	Odds Ratio (M‐H, Random, 95% CI)	1.00 [0.46, 2.20]
5 Mortality to longest follow up (within 6 months) Show forest plot	6	1350	Odds Ratio (M‐H, Random, 95% CI)	0.92 [0.65, 1.29]

5.1 Stronger studies	3	590	Odds Ratio (M‐H, Random, 95% CI)	1.08 [0.71, 1.65]
5.2 Weaker studies	3	760	Odds Ratio (M‐H, Random, 95% CI)	0.70 [0.37, 1.34]
6 Discharge to institutional care Show forest plot	7	952	Odds Ratio (M‐H, Random, 95% CI)	0.44 [0.22, 0.89]

6.1 stronger studies	4	529	Odds Ratio (M‐H, Random, 95% CI)	0.83 [0.41, 1.67]
6.2 Weaker studies	3	423	Odds Ratio (M‐H, Random, 95% CI)	0.24 [0.12, 0.49]
7 Independent at discharge Show forest plot	6	861	Odds Ratio (M‐H, Fixed, 95% CI)	0.71 [0.53, 0.95]

7.1 stronger studies	4	586	Odds Ratio (M‐H, Fixed, 95% CI)	1.04 [0.72, 1.50]
7.2 Weaker studies	2	275	Odds Ratio (M‐H, Fixed, 95% CI)	0.36 [0.22, 0.59]
8 Institutional care to longest follow up Show forest plot	3	411	Odds Ratio (M‐H, Random, 95% CI)	0.97 [0.60, 1.58]

8.1 Stronger studies	3	411	Odds Ratio (M‐H, Random, 95% CI)	0.97 [0.60, 1.58]
9 Functional Status at discharge Show forest plot	6	762	Std. Mean Difference (IV, Random, 95% CI)	0.37 [0.20, 0.54]

9.1 Stronger studies	4	540	Std. Mean Difference (IV, Random, 95% CI)	0.27 [0.10, 0.44]
9.2 Weaker studies	2	222	Std. Mean Difference (IV, Random, 95% CI)	0.61 [0.34, 0.88]
10 Change in functional Status (admission to discharge) Show forest plot	4	426	Std. Mean Difference (IV, Random, 95% CI)	0.38 [0.10, 0.67]

10.1 Strong	3	328	Std. Mean Difference (IV, Random, 95% CI)	0.24 [0.02, 0.46]
10.2 Weak	1	98	Std. Mean Difference (IV, Random, 95% CI)	0.77 [0.35, 1.18]
11 Best measure of functional status Show forest plot	6	762	Std. Mean Difference (IV, Random, 95% CI)	0.37 [0.20, 0.54]

11.1 Strong	4	540	Std. Mean Difference (IV, Random, 95% CI)	0.27 [0.10, 0.44]
11.2 Weak	2	222	Std. Mean Difference (IV, Random, 95% CI)	0.61 [0.34, 0.88]
12 Length of stay to first discharge from hospital setting Show forest plot	9	1669	Mean Difference (IV, Random, 95% CI)	7.37 [2.86, 11.88]

12.1 Stroger studies	4	607	Mean Difference (IV, Random, 95% CI)	13.41 [8.54, 18.29]
12.2 Weaker Studies	5	1062	Mean Difference (IV, Random, 95% CI)	4.08 [‐0.97, 9.13]
13 Length of stay to first discharge home Show forest plot	8	1478	Mean Difference (IV, Random, 95% CI)	5.13 [‐0.50, 10.76]

13.1 Stroger studies	4	607	Mean Difference (IV, Random, 95% CI)	8.78 [2.93, 14.63]
13.2 Weaker Studies	4	871	Mean Difference (IV, Random, 95% CI)	‐1.37 [‐13.52, 10.79]
14 Early readmission (within 30 days) Show forest plot	5	1126	Odds Ratio (M‐H, Random, 95% CI)	0.52 [0.34, 0.80]

14.1 Stronger studies	3	493	Odds Ratio (M‐H, Random, 95% CI)	0.63 [0.36, 1.12]
14.2 Weaker studies	2	633	Odds Ratio (M‐H, Random, 95% CI)	0.40 [0.21, 0.76]
15 Quality of life / health status Show forest plot	5	448	Std. Mean Difference (IV, Random, 95% CI)	0.28 [0.09, 0.48]

15.1 Stronger studies	2	238	Std. Mean Difference (IV, Random, 95% CI)	0.33 [‐0.01, 0.67]
15.2 Weaker studies	3	210	Std. Mean Difference (IV, Random, 95% CI)	0.22 [‐0.07, 0.51]
16 Quality of life / health status change scores only Show forest plot	3	275	Std. Mean Difference (IV, Random, 95% CI)	0.22 [‐0.15, 0.59]

16.1 Stronger studies	2	238	Std. Mean Difference (IV, Random, 95% CI)	0.33 [‐0.01, 0.67]
16.2 Weaker studies	1	37	Std. Mean Difference (IV, Random, 95% CI)	‐0.30 [‐1.12, 0.53]
17 Psychological wellbeing Show forest plot	3	280	Std. Mean Difference (IV, Random, 95% CI)	0.36 [‐0.03, 0.74]

17.1 Stronger studies	2	244	Std. Mean Difference (IV, Random, 95% CI)	0.25 [‐0.03, 0.52]
17.2 Weaker studies	1	36	Std. Mean Difference (IV, Random, 95% CI)	1.04 [0.17, 1.90]
18 Satisfaction Show forest plot	4	335	Std. Mean Difference (IV, Random, 95% CI)	0.22 [‐0.03, 0.46]

18.1 Stronger studies	2	175	Std. Mean Difference (IV, Random, 95% CI)	0.19 [‐0.11, 0.48]
18.2 Weaker Studies	2	160	Std. Mean Difference (IV, Random, 95% CI)	0.29 [‐0.15, 0.72]

Comparison 1. NLU vs general inpatient care

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Comparison 2. NLU vs ICU

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Inpatient mortality Show forest plot	1	220	Odds Ratio (M‐H, Random, 95% CI)	0.62 [0.35, 1.10]

2 Mortality to longest follow up (Up to 24 months) Show forest plot	1	152	Odds Ratio (M‐H, Random, 95% CI)	0.80 [0.40, 1.59]

3 Discharge to institutional care Show forest plot	1	145	Odds Ratio (M‐H, Random, 95% CI)	0.61 [0.30, 1.25]

4 Length of stay to first discharge home Show forest plot	1	220	Mean Difference (IV, Random, 95% CI)	‐2.0 [‐10.96, 6.96]

5 Early readmission (within 30 days) Show forest plot	1	145	Odds Ratio (M‐H, Random, 95% CI)	0.33 [0.12, 0.94]

Comparison 2. NLU vs ICU

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