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Meta-Analysis

Hospital Elder Life Program: Systematic Review and Meta-analysis of Effectiveness

Tammy T Hshieh et al. Am J Geriatr Psychiatry. 2018 Oct.

Abstract

Background: Delirium, defined as an acute disorder of attention and cognition with high morbidity and mortality, can be prevented by multicomponent nonpharmacological interventions. The Hospital Elder Life Program (HELP) is the original evidence-based approach targeted to delirium risk factors, which has been widely disseminated.

Objective: To summarize the current state of the evidence regarding HELP and to highlight its effectiveness and cost savings.

Methods: Systematic review of Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from 1999 to 2017, using a combination of controlled vocabulary and keyword terms.

Results: Of the 44 final articles included, 14 were included in the meta-analysis for effectiveness and 30 were included for examining cost savings, adherence and adaptations, role of volunteers, successes and barriers, and issues in sustainability. The results for delirium incidence, falls, length of stay, and institutionalization were pooled for meta-analyses. Overall, 14 studies demonstrated significant reductions in delirium incidence (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.37-0.59). The rate of falls was reduced by 42% among intervention patients in three comparative studies (OR 0.58, 95% CI 0.35-0.95). In nine studies on cost savings, the program saved $1600-$3800 (2018 U.S. dollars) per patient in hospital costs and over $16,000 (2018 U.S. dollars) per person-year in long-term care costs in the year following delirium. The systematic review revealed that programs were generally successful in adhering to or appropriately adapting HELP (n = 13 studies) and in finding the volunteer role to be valuable (n = 6 studies). Successes and barriers to implementation were examined in 6 studies, including ensuring effective clinician leadership, finding senior administrative champions, and shifting organizational culture. Sustainability factors were examined in 10 studies, including adapting to local circumstances, documenting positive impact and outcomes, and securing long-term funding.

Conclusion: The Hospital Elder Life Program is effective in reducing incidence of delirium and rate of falls, with a trend toward decreasing length of stay and preventing institutionalization. With ongoing efforts in continuous program improvement, implementation, adaptations, and sustainability, HELP has emerged as a reference standard model for improving the quality and effectiveness of hospital care for older persons worldwide.

Keywords: Delirium prevention; Hospital Elder Life Program; multicomponent nonpharmacological intervention.

Copyright © 2018 Elsevier Ltd. All rights reserved.

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Conflict of interest statement

Financial Disclosures: No Disclosures to Report; no conflicts of interest.

Figures

Figure 1.
Figure 1.. Literature Identification, Review and Selection for Inclusion

Databases searched included Ovid MEDLINE, EMBASE, The Cochrane Central Register of Controlled Trials, and The Cochrane Database of Systematic Reviews from January 1999 and December 2017. Reference lists from published narrative review articles and systematic reviews were further reviewed to identify additional studies. The following MeSH terms and free words were used: “delirium prevention,” “multicomponent intervention,” “non-pharmacological intervention” and “Hospital Elder Life Program.” Utilizing our systematic literature search strategy, 3275 articles were found. Of these, 3202 were excluded based on our screening criteria for relevance, language, age range, or non-human study subjects; full-text articles of the remaining 73 studies were retrieved for further assessment according to the inclusion criteria. A total of 14 studies were included in meta-analysis and an additional 30 were included as cost-savings studies, methodological papers, and qualitative studies.

Figure 2.
Figure 2.. Meta-analysis of Outcome of Delirium Incidence

Twelve studies of the HELP model measured delirium incidence. In total, the meta-analysis involved 3,605 patients and showed that the odds of delirium were 53% lower in the intervention group compared with controls (OR 0.47; 95% CI, 0.37–0.59, I2 = 28%). Stratified by study type (RMT versus non-RMT), HELP-based delirium interventions lowered the odds of delirium by 45% (OR 0.55; 95% CI, 0.39–0.78, I2 = 10%) among 1,267 patients included in 2 RMTs and by 58% (OR 0.42; 95% CI, 0.32–0.57, I2 = 34%) among 2,378 intervention patients included in 10 non-RMTs. The numbers needed to treat (NNTs) were 16.7 (95% CI, 10.0–33.3) among RMTs and 12.5 (95% CI, 10.0–20.0) among non-RMTs.

Figure 3.
Figure 3.. Meta-analysis of Outcome of Falls

Three studies examined number of falls per patient-day. The meta-analysis showed that the odds of falling was 42% lower (OR 0.58, 95% CI 0.35–0.95, I2 =0%) among subjects in 3 non-RMT studies (Figure 3).

Comment in

  • The Hospital Elder Life Program: Past and Future.

    Scheunemann LP, Girard TD, Skidmore ER, Resnick NM. Scheunemann LP, et al. Am J Geriatr Psychiatry. 2018 Oct;26(10):1034-1035. doi: 10.1016/j.jagp.2018.08.002. Epub 2018 Aug 6. Am J Geriatr Psychiatry. 2018. PMID: 30146370 Free PMC article. No abstract available.

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