Challenges of undertaking a systematic review to measure residents’ length of stay in care homes

Collingridge Moore, Danielle and Payne, Sheila and Keegan, Thomas and Froggatt, Katherine (2020) Challenges of undertaking a systematic review to measure residents’ length of stay in care homes. In: EAPC RN & PACE Preconference Seminar, 10th World Research Congress of the EAPC, 2018-06-24 - 2018-06-26.

Abstract

Background: The global population is ageing. It is estimated that in Europe, the proportion of adults aged over 80 years will increase from 5.1% in 2014 to 12.3% by 2080, an increase from 26.0 million to 63.9 million. Care home residents are arguably some of the most vulnerable service users, with higher levels of frailty, comorbidities and cognitive impairment than those residing in the community. Length of stay before death in European care homes is not well documented, demonstrating a need for representative, internationally comparable research. An understanding of anticipated length of stay is important in healthcare resource allocation, developing care plans, and informing the decisions of residents and their relatives. Aims: This paper has two aims; firstly, it will provide a systematic review of factors associated with length of stay, and summarize the strength of evidence to support them. Secondly, it will reflect upon the methodological challenges of conducting the review, including feasibility and quality of data sources. Methods: To identify factors associated with length of stay after admission to a care home, a systematic review of international literature was conducted. Key databases were searched for potential studies, including MEDLINE, EMBASE, PsycINFO, CINAHL, Proquest, the Cochrane Library, Web of Science, the Campbell Library, SCOPUS and Social Care Online. The review focused on older adults, defined as any adult aged 65 years or above. Studies were included in the review if participants resided in a care home or long term care facility. The review focused on one outcome measure, length of stay, measured as length of stay from admission, or any point post admission, to a care home until death. The review was restricted to observational studies, including prospective cohort, cross-sectional and case control studies. Studies that met the inclusion criteria were obtained, data extracted and assessed for quality using tools specifically developed for the review. All factors identified across the studies were grouped into categories based on their association with length of stay (positive, negative or not statistically significant). These findings were then cross-referenced with the quality assessment score for the study. A factor was classed as having strong evidence to support it if there were consistent findings in at least 75% of studies in at least three high quality studies. Moderate evidence was classed as consistent findings in at least 50% of studies in at least two high quality studies. Weak evidence was classed as findings of one high quality study and at least two moderate to low quality studies or consistent findings (≥75%) in at least four or more moderate to low quality studies. Results: Forty-seven studies were included in the systematic review. Two predictors were identified as being supported by strong evidence; oxygen therapy and shortness of breath. Ten predictors were supported by moderate evidence; being male, older age, cancer, poor general health, poor mobility, low BMI or malnutrition, poor physical functioning, presence of pressure ulcers, increased contact with primary care, and admission to a facility providing nursing care. The findings of this review indicate that although cognitive impairment and dementia may be associated with care home admission, neither are associated with shorter lengths of stay. In contrast, functional impairment and characteristics associated with poor physical functioning, such as mobility and pressure ulcers, were identified as having moderate evidence to support them. Unpacking the terms used to describe a care home, and the services offered, was a challenge in conducting the review. The majority of studies only collected data at baseline, it is possible that changes in time dependent characteristics, such as cognitive impairment, or other diagnoses which may deteriorate, were missed. In addition, the review did not capture a resident’s situation prior to admission that may affect the decision to enter a care home. Care home characteristics, such as size and type, were rarely reported. Conclusions: The importance of functional impairment over cognitive impairment in identifying residents with potentially shorter lengths of stay requires further research. Studies which collect data on care home residents prior to admission and continue follow up post admission are required to fully understand the factors which affect length of stay. Few nationally representative observational studies continue to follow up residents post admission, meaning a wealth of data is lost. Research that allows for international comparison will likely progress the understanding of care home residents experience, however a greater appreciation of the national context in which care homes operate is required. This could include reference to local policies, funding for long term care placements and relationships with the wider health care system. In addition, the role of care home characteristics, which may be associated with length of stay, needs exploring.