Title: Community-based complex interventions to sustain independence in older people, stratified by frailty: a systematic review and network meta-analysis
Funder: Department of Health and Social Care

Abstract: Challenges for the NHS:_x000D_ The number of older people in the UK is increasing. Older people, particularly those with long-term health problems and frailty, are core users of NHS and social care services. It is expected that use of health and social care services by the growing older population will increase over the next ten years._x000D_ _x000D_ The UK government have recently published the NHS Long Term Plan. This sets out how the NHS will change over the next ten years to meet the needs of the population. A key focus of the NHS Long Term Plan is to enable older people to age well, and provide community services that improve independence and wellbeing. However, an important problem is that we do not have good evidence for how community services for older people, including people living with frailty, should be organised and provided._x000D_ _x000D_ Our aims:_x000D_ In this project we plan to review findings from previous research studies (clinical trials) that have tested different community services for older people living at home. We will combine information from the previous research studies to find out which community services for older people are most effective. This will produce new information on how services should be organised, which is crucial information for people who develop and provide services. This will help people who run the NHS and social care to decide precisely which services should be offered and who should get them. In turn this should help older people to live longer in their own homes with fewer problems. _x000D_ _x000D_ What will we do?_x000D_ We will assess existing findings using a method called network meta-analysis. This will allow us to compare different services with each other. We will be looking at which kind of service is most effective at helping older people to stay living at home. We will also be looking at which services improve independence and mental health most. We will find out if some services can reduce falls, hospital admission and nursing home admissions more than others. We will also look at how much different services cost and if they are cost-effective._x000D_ _x000D_ We will compare services that differ on key details such as the staff involved, how long the service lasts, and the setting, such as in groups or in people’s homes. This is a major improvement on previous reviews, where usually we only find out if having a service is better than not having the service at all. We will also find out if some services are better suited to people with frailty and others are better suited to the general older population. _x000D_ _x000D_ Patient and public involvement:_x000D_ Our established Frailty Oversight Group (FOG), made up of patients and public, understand the challenges of living with and managing frailty. We have discussed our research plans at our annual consumer research conference. Our FOG recognised the importance of the problem and the need to identify the best treatment options. _x000D_ _x000D_ We will present our work at our regular FOG meetings and work with them to produce plain English summaries and press releases. Members of our FOG will support us to share our work in public meetings, where we will invite feedback on our findings and how they might be best put to use. _x000D_ _x000D_ Impact:_x000D_ This work will provide important and robust information to providers of services so they can deliver the NHS Long Term Plan and improve health and wellbeing in later life.

Lay abstract: Research questions_x000D_ i) Do community-based complex interventions for older people increase living at home, independence and health-related quality of life?_x000D_ ii) Do community-based complex interventions for older people reduce home care requirement, depression, loneliness, falls, hospitalisation, care home admission, costs and mortality?_x000D_ iii) How should interventions be grouped for network meta-analysis (NMA)?_x000D_ iv) What is the optimal configuration of community-based complex interventions for older people?_x000D_ v) Do intervention effects differ by frailty level (not frail; pre-frailty; frailty)?_x000D_ _x000D_ Background_x000D_ The 2019 NHS Long Term Plan emphasises development of community services to help people age well and maintain independence, including people living with frailty. However, there is insufficient guidance for policymakers, commissioners and providers about which services should be implemented._x000D_ _x000D_ Aim_x000D_ To synthesise evidence on the effectiveness of community-based complex interventions to sustain independence for older people, including the effect of frailty and pre-frailty, and group interventions to identify the best configurations._x000D_ _x000D_ Methods_x000D_ -Review design_x000D_ Systematic review with NMA, following Cochrane methods, Confidence in network meta-analysis (CINeMA), Grading of Recommendations Assessment, Development and Evaluation (GRADE) adapted for NMA and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) NMA guidance._x000D_ _x000D_ -Eligibility criteria_x000D_ Randomised controlled trials (RCTs) and cluster RCTs of community-based complex interventions to sustain independence for older people living at home (mean age 65+), compared with usual care, placebo, or another eligible complex intervention. _x000D_ _x000D_ -Study selection/data collection_x000D_ Two independent researchers will assess title/abstract, study eligibility, and extract data, resolving disagreements by consensus._x000D_ _x000D_ -Data items_x000D_ Primary outcome:_x000D_ Living at home_x000D_ _x000D_ Secondary outcomes:_x000D_ Activities of daily living_x000D_ Health status/health-related quality of life_x000D_ Home care requirement_x000D_ Depression_x000D_ Loneliness_x000D_ Falls_x000D_ Hospitalisation_x000D_ Care home admission_x000D_ Mortality_x000D_ Costs_x000D_ Cost-effectiveness_x000D_ _x000D_ -Risk of bias_x000D_ Two independent reviewers will assess risk of bias (RoB) using Cochrane’s RoB 2 tool, including additional criteria for cluster RCTs._x000D_ _x000D_ -Summary measures_x000D_ For continuous outcomes, we will calculate intervention effect as mean difference. For binary outcomes, we will calculate risk ratios/odds ratios. For survival (time-to-event) outcomes, hazard (rate) ratios will be extracted._x000D_ _x000D_ -Analysis_x000D_ Random-effects meta-analyses, to allow for potential between-study heterogeneity in each intervention effect. A NMA will then be conducted using a multivariate random-effects meta-analysis framework._x000D_ _x000D_ -Assessment of inconsistency_x000D_ Consistency will be examined for each treatment comparison where there is direct and indirect evidence, and across the whole network using ‘design-by-treatment interaction’ models._x000D_ _x000D_ -Risk of bias across studies_x000D_ Funnel plots will be presented to examine potential publication bias._x000D_ _x000D_ -Additional analyses_x000D_ Meta-analysis results will be presented by different levels of frailty (not frail; pre-frailty; frailty), and by extending the standard and NMA to a meta-regression._x000D_ _x000D_ Timelines_x000D_ -6-0m: Run searches; screen records; obtain papers; assess eligibility._x000D_ 1-9m: Summarise studies; extract data; intervention grouping & frailty assessment._x000D_ 10-15m: Synthesise data in meta-analysis/NMA._x000D_ 15-18m: Write-up/dissemination._x000D_ _x000D_ Impact and dissemination_x000D_ Potential for major impact, supporting delivery of the NHS Long Term Plan, with dissemination to policymakers, commissioners, health/social care professionals, older people and researchers.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: GENERIC HEALTH RELEVANCE