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Study flow diagram.
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Figure 1

Study flow diagram.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 At‐home versus institutional long‐term care, Outcome 1 Mortality.
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Analysis 1.1

Comparison 1 At‐home versus institutional long‐term care, Outcome 1 Mortality.

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Comparison 1 At‐home versus institutional long‐term care, Outcome 2 Number of patients with a hospital admission.
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Analysis 1.2

Comparison 1 At‐home versus institutional long‐term care, Outcome 2 Number of patients with a hospital admission.

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Home or foster home versus institutional long‐term care for functionally dependent older people

Patient or population: older adults with functional dependence

Settings: long‐term care

Intervention: long‐term home care

Comparison: long‐term institutional care

Outcomes

Relative effect
(95% CI)

No of participants
(studies)

Certainty of evidence
(GRADE)

Comments

Mortality (6 months)

It is uncertain whether long‐term home care compared to nursing home care decreases mortality risk

Estimates ranged from a relative increase in risk of mortality of RR 2.89 (95% CI 1.57 to 5.32) to a relative reduction in risk of RR 0.38 (95% CI 0.17 to 0.61).

314*
(2 studies)

⊕⊝⊝⊝
Very lowa,b,c

Data were not pooled due to the high degree of statistical heterogeneity for this outcome (I2 = 94%)

Physical function

(3‐6 months)

It is uncertain whether long‐term home care compared to nursing home care improves physical function

Estimates ranged from and improvement in activities of daily living of MD −0.25 points (95% CI −0.44 to −0.06) to MD −1.90 (95% CI −2.18 to −1.62)

1295*
(5 studies)

⊕⊝⊝⊝
Very lowa,b,c

3 studies reporting data used the Katz Index of ADLs or a variation of this measure

2 studies did not provide usable post or change‐score data.

1 study reported no between‐group difference in change in ADLs. 2 studies reported improvements in ADLs for participants receiving home LTC compared to nursing home LTC

Quality of life

(3‐6 months)

It is uncertain whether long‐term home care compared to nursing home care improves happiness (RR 1.97, 95% CI 1.27 to 3.04) or general satisfaction

114
(2 studies)

⊕⊝⊝⊝
Very lowa,b,c

Both studies used proxy items for this outcome.

While both variables were assessed using continuous measures, authors further dichotomised the outcome for reporting, precluding meta‐analysis.

Hospital admissions

It is uncertain whether long‐term home care compared to nursing home care decreases hospital admissions

Estimates ranged from a relative increase in risk of a hospitalisation of RR 2.75 (95% CI 2.59 to 2.92) to a relative reduction in risk of RR 0.82 (95% CI 0.72 to 0.93).

14,853 (3 studies)

⊕⊝⊝⊝
Very lowa,b,c

This outcome described the number of participants having at least one hospital admission. Data were not pooled due to the high degree of statistical heterogeneity for this outcome (I2 = 99%)

Number of adverse health outcomes

The extent to which long‐term home care was associated to more or fewer adverse health outcomes than nursing home care was not reported.

‐‐‐

‐‐‐

‐‐‐

ADL: activities of daily living; CI: confidence interval; LTC: long‐term care; RR: risk ratio.

GRADE Working Group grades of evidence
High certainty: further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low certainty: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low certainty: we are very uncertain about the estimate.

aDowngraded due to study design.
bDowngraded due to risk of bias.
cDowngraded due to inconsistency.

* For Chuang 2005, only participants receiving institutional or home/community‐based care were included; participants receiving family care were not included.

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Table 1. Description of long‐term home care interventions

Study

Service Location (home / community)

Type of services

Dose (how many services and their frequency of provision)

Provider

Condelius 2010

Home

Help with laundry, shopping, cleaning, and personal care. Excluded meals on wheels or transport services

≥ 4 home visits per month

Not reported

Mitchell 1978

Home

Medical care and ancillary services in participant's own home. A potential caregiver (friend, relative, or hired caretaker) must be living in the patient's home and able to assume responsibility for care.

Not reported

Home care team (physician, nurse, dietician, social worker)

Challis 1991

Home

Darlington Care Project: case management service, which could include any number of medical services based on client needs (speech therapy, stoma care, catheter care, change of dressing). Personal care (bathing, dressing, toileting, feeding, hand/nail care), physical care, (assist with walking, lifting/transferring). Social and recreational activities and therapeutic exercises

Not reported

Case manager likely a nurse? Other HCPs as needed

Wilson 2005

Home

Not reported

Not reported

Not reported

Wysocki 2014

Home or community

Not reported

Not reported

Not reported

Chuang 2005

Home or community

Not reported

Not reported

Not reported

Braun 1987

Home or community

Nursing Home Without Walls (NHWW) provides an array of services including case management, skilled nursing, personal care, adult day health, home delivered meals, nutritional counselling, transportation, respite, emergency alarms, moving assistance, rehabilitation, home maintenance, environmental modifications, homemakers

Not reported

Nurse

Sherwood 1986

Community

Counselling, transportation, meals, recreational activities, information/referral, and monitoring services. Based on a patient assessment, the programme could provide medication monitoring, and/or arrange for various types of therapies

Not reported

Social worker/nurse
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Table 1. Description of long‐term home care interventions
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Table 2. Description of long‐term geriatric foster care interventions

Study

Service Location

Type of services

Provider

Oktay 1987

Room in a foster home

Caregivers provided the patient with meals, laundry, assistance with personal and instrumental ADLS, 24‐hour supervision and nursing tasks as needed (e.g. monitoring medication, injections and behavioural modification)

Caregivers were trained by the Johns Hopkins Hospital

Sherwood 1986

Foster home care

Caregivers provided personal care services, 24‐hour supervision, and meal, laundry and household services

Caregivers were a part of a certification and monitoring programme

Braun 1987

Foster care home

Community Care Program: families provide 24‐hour supervision, room and board, homemaker services, personal care including assistance with ADLs, medication, range of motion and other exercises, and in some cases, tube feeding, dressing changes, insulin injections, catheter irrigations, transportation to medical and social outings

Families are trained and supervised by social worker/nurse teams to adopt and care for 1‐2 patients

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Table 2. Description of long‐term geriatric foster care interventions
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Table 3. Mortality: data for all included studies reporting this outcome

Study

Time‐point

Type of long‐term care

Sample size

Results

Relative effect RR (95% CI)

Home care

Nursing home

Braun 1991

6 months

Blended

352

8% (18/221)

16% (21/131)

0.51 (0.28 to 0.92)

Challis 1991

6 months

Home care

214

34% (31/101)

11% (12/113)

2.89 (1.57 to 5.32)

Chuang 2005

6 months

Home care

474

poststroke

6% (24/408)

18% (12/66)

0.38 (0.17 to 0.61)

Challis 1991

12 months

Home care

214

40% (40/101)

31% (35/113)

1.28 (0.89 to 1.84)

Oktay 1987

12 months

Foster care

112

29% (17/59)

32% (17/53)

0.90 (0.51 to 1.57)

CI: confidence interval; RR: risk ratio.

RR: risk ratio.

Figuras y tablas -
Table 3. Mortality: data for all included studies reporting this outcome
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Table 4. Physical function: data for all included studies reporting this outcome

Study

Time point

Sample size

Measure

D/Ca

Results

Relative effectb (95% CI)

Home care

Nursing home

Home care

Mitchell 1978c

3 months

195

ADLd (change)

—

—

—

—

Braun 1987

3 months

98

ADLe

C

Post: 13.02

Post: 13.16

—

Braun 1987

3 months

98

ADL (mobility)e

C

−1.02

−1.05

—

Chuang 2005

6 months

210

ADLe

—

—

—

—

Sherwood 1986

9 months

98

ADL

performance assessment

?

—

—

−0.25 (−0.44 to −0.06)

Condelius 2010f

Unclear

694

ADLg

C

3.0 (1.2)

3.9 (0.4)

−0.9 (−1.02 to −0.78)

Condelius 2010f

Unclear

694

ADLh

C

1.4 (1.7)

3.4 (1.9)

−1.90 (−2.18 to −1.62)

Foster care

Oktay 1987

12 months

53

ADLd (improved/maintained)

D

79% (22/28)

60% (15/25)

0.19 (−0.07 to 0.43)

Oktay 1987

12 months

53

ADLg

(improved/maintained)

D

75% (21/28)

68% (17/25)

0.07 (−0.17 to 0.31)

Sherwood 1986

9 months

62

ADL

performance assessment

—

—

—

—

Braun 1987

Unclear

—

—

—

—

—

—

Blended

Braun 1991

6 months

352

ADLe (pre‐post)

C

Pre: 12.87

Post: 12.16

Pre: 14.43

Post: 13.78

—

Braun 1991

6 months

352

ADLe (change)

0.71

0.65

—

ADL: activities of daily living; CI: confidence interval; RR: risk ratio.

aD: dichotomous outcome; C: continuous outcome.
bFor dichotomous outcomes, the relative effect is reported as a risk ratio (RR).
cNo post‐test data provided for this study. Pre‐test Functional Status Index mean (SD): home care (HC) 8.12 (3.9), institution (hospital): 10.48 (3.3).
dADLs were assessed with theFunction Status Index (FSI). This measure evaluates people on the extent to which they can perform everyday activities and socially defined roles. The self‐care dimension was expanded to include an item (continence) not in the original FSI. Continence used in ADL‐ Katz total FSI scores ranges from a 0 to 17. Higher score worse.
eADLs assessed with theKatz Index of ADLs (Katz 1963). This measures function in eight activities: bathing, dressing, transfer, toileting, continence, feeding, ambulation, house confinement. ADL is first 6 items summed for total score (range: 6 to 18). Mobility is final 2 items summed for total score (range: 2 to 9) We are using the ADL score. Higher scores worse.
fIn this study, there were no pre‐post measures reported; it appears these data are cross‐sectional, and it is unclear at what time point they were taken.
gADL: Activities of daily living were assessed with the Instrumental Activities of Daily Living (IADL) including cooking, transportation, cleaning and shopping. The IADL sum score ranges from 0 (independent in all activities) to 6 (dependent in all activities).
hADL: Activities of daily living were assessed with thePersonal Activities of Daily Living (PADL) including bathing, dressing, going to the toilet, transferring, continence and feeding. The PADL sum score ranges from 0 (independent in all activities) to 4 (dependent in all activities).

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Table 4. Physical function: data for all included studies reporting this outcome
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Table 5. Quality of Life: data for all included studies reporting this outcome

Study

Time point

Type of long‐term care

Sample Size

Measure

D/Ca

Results

Relative effectb

(95% CI)

Favours

Home care

Nursing home

Home care

Braun 1987

3 months

Community care

132

Reported level of happinessc

D

67% (59/88)

34% (15/44)

1.97 (1.27 to 3.04)

Home care

Challis 1991

6 months

Community care

214

General satisfactiond (change)

C

0.79

0.08

—

Home care

Challis 1991

6 months

Community care

214

Well‐being – moraled (change)

C

0.79

0.21

—

Home care

Challis 1991

6 months

Community care

214

Well‐being – depressiond (change)

C

0.33

−1.05

—

Home care

Foster care

Oktay 1987

12 months

Foster care

53

Life satisfaction (improved/maintained)

D

46% (13/28)

72% (18/25)

RR: 0.64 (0.40 to 1.03)

Nursing

Oktay 1987

12 months

Foster care

53

Perceived health (improved/maintained)

D

68% (19/28)

84% (21/25)

RR: 0.81 (0.59 to 1.10)

Nursing

Oktay 1987

12 months

Foster care

53

Mental status (improved/maintained)

D

64% (18/28)

60% (15/25)

RR: 1.07 (0.70 to 1.64)

CI: confidence interval; RR: risk ratio.

aD: dichotomous outcome; C: continuous outcome.
bFor dichotomous outcomes, the relative effect is reported as a risk ratio (RR).
cA single item question, "Are you happy here?" with a 3 point response: 1 = rarely, 2 = sometimes, 3 = often. They report raw response data on each point and then dichotomise data as happy or not. Higher score = better.
dA single item was used but not described. Mean change score at 6 month is reported. SD were not provided. Higher scores are assumed to be better.

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Table 5. Quality of Life: data for all included studies reporting this outcome
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Table 6. Hospital admissions: data for all included studies reporting this outcome

Study

Time‐point

Type of long‐term care

Sample Size

Measure

Results

Relative effect: RR (95% CI)

Favours

Home care

Nursing

home

Wilson 2005

Observational

(data set)

Home care

11,803

Hospital admissiona

55%

(3880/7029)

20%

(958/4774)

2.75 (2.59 to 2.92)

Nursing

home?

Wilson 2005

Observational (dataset)

Home care

11,803

Emergency room visitsb

70.1%

(4992/70290

34.8%

(1662/4774)

—

Nursing

home?

Wysocki 2014

Observational

(dataset)

Home/community care

2338

Preventable

hospitalisationc

11.4%

(133/1169)

9.7%

(113/1169)

—

Nursing

home?

Wysocki 2014

Observational

(dataset)

Home/community care

2338

Any hospitalisationd

35.8%

(419/1169)

25.4%

(297/1169)

1.41

(1.25, 1.60)

Nursing

home?

Condelius 2010e

unclear

Home care

694

Hospital staysf

53.6%

(228/425)

65.4%

(176/269)

0.82

(0.72, 0.93)

Home care?

CI: confidence interval; RR: risk ratio.

aNumber admitted to hospital at least once.
bNumber of patients having ≥ 1 emergency room visits.
cNumber of patients with at least one potentially preventable hospitalisation.
dNumber of patients with at least one any type hospitalisation.
eIn this study, there were no pre‐post measures reported; it appears these data are cross‐sectional, and it is unclear at what time point they were taken.
fNumber of patients with 1 hospital stay.

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Table 6. Hospital admissions: data for all included studies reporting this outcome
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Comparison 1. At‐home versus institutional long‐term care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Mortality Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2 Number of patients with a hospital admission Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected
Figuras y tablas -
Comparison 1. At‐home versus institutional long‐term care
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