Study selection
Our search revealed 3271 publications (Fig. 1), and n = 17 met our inclusion criteria (18 publications including two publications of the same study: seven randomized controlled trials and ten qualitative studies).
Study characteristics
Seven RCTs with 1072 participants were included [2, 4, 7, 21–25]. The size of the studies ranged from ten to 400 participants. The cohort study alongside one RCT was not considered in the analysis [7].
Ten qualitative studies [3, 9, 26–33] with a total of 245 participants (range: n = 4 [31] to n = 60 [26]) were included. All the studies used interview techniques, and one additionally used participant observation [32]. Three studies explored perceptions of patients, therapists and older adults in community dwellings with regard to the use of virtual reality (VR) applications in PDHA [9, 28, 29]. One study explored factors considered by the OTs when deciding about stroke patients’ need for a predischarge home assessment visit [33]. One study focused on older adults’ and carers’ perception of and involvement in PDHA decision-making processes [27]. Another study also highlighted the patients’ perspective on PDHA [31]. One study explored the aspects of home modifications, which might be important for patients and families [26], and another study focused on the OTs’ perception of and clinical reasoning in the PDHA process [29]. A summary of characteristics of the included quantitative and qualitative studies is displayed in Table 1.
Table 1
Study characteristics of included studies
Reference | Study design, country, setting | Participants Number, age in years, percent female (♀%) | Intervention description | Outcomes/aim of qualitative research | Outcome measures | FU in mo nths |
Clemson et al., 2016 [2] | RCT Australia Acute care, unspecified | n = 400 Intervention 80.2 (± 6.4, range n.r.) ♀ 59.6% Control 80.7 (± 5.7, range n.r.) ♀ 63.9% | Intervention In-hospital rapport building, interview, ADL-assessment, predischarge home visit, post-discharge home-visit, telephone calls Control Usual care, in-hospital interview, ADL assessment, access visit if required | Functional independence, participation in ADL, unplanned readmissions, emergency department visits, recommendations | NEADL [34], Late Life Disability Index (LLDI) - sub scores: frequency and limitation [52], number of: recommendations, unplanned readmissions, emergency department visits, falls, process outcomes (e.g., number of prescribed and tried equipment; effects not estimated) | 3 |
Drummond et al., 2013 [7] | RCT UK Stroke rehabilitation unit | n = 126 Intervention 70.64 (± 14.29, range 34–88) ♀ 54.7% Control 73.65 (± 16.06, range 41–99) ♀ 47.8% | Intervention One or two predischarge home visit(s) Control Structured home assessment interview | ADL/IADL, mobility, unplanned readmissions, falls, emotional distress in medical settings, depressed mood of clients with stroke and significant aphasia, caregiver strain | NEADL [34], Barthel Index [53], RMI [39], Number of unplanned readmissions, GHQ-28 [42], SADQ-10 [44], Caregiver Strain Index [54] | 1 |
Hagsten et al., 2004 [21] Hagsten et al., 2006 [22] | RCT Sweden Acute care, hip fractures | n = 100 Intervention 81 (± 23, range 68–91) ♀ 84% Control 79 (± 30, range 65–95) ♀ 76% | Intervention Individual daily training, including use of technical aids, single predischarge home visit Control One walking instruction when in hospital | ADL/IADL, health-related quality of life | ADL [55], EQ5D [56], IADL single scales: moving around indoors; performance of light house work; getting in and out of a car, SWED-QUAL [36] subscales | 2 |
Lannin et al., 2007 [57] | RCT Australia Rehabilitation unit, mixed (cardiac, orthopedic trauma, neurological, orthopedic joint surgery, spinal or deconditioned) | n = 10 Intervention 80.0 (± 7, range n.r.) ♀ 100% Control 82.4 (± 7, range n.r.) ♀ 60% | Intervention Single predischarge home visit Control In-hospital consultation prior to discharge | ADL/IADL, mobility, unplanned readmissions, falls, fear of falling, community support, health-related quality of life | NEADL [34], FIM [58], RNLI - Reintegration to Normal Living Index [59], Tinnetti [38], number of unplanned readmissions, number of falls, FES-I [40], EQ5D [56], EQ-5D VAS [37] | 7 |
Nikolaus et al., 2003 [24] | RCT Germany Geriatric acute care, unspecified | n = 360 Intervention 81.2 (± 6.2, range 84.9–87.5) ♀ 72.4% Control 81.9 (± 6.5, range 74.4–88.4) ♀ 74.3% | Intervention Predischarge home visit and post-discharge follow up visit(s), comprehensive in-hospital geriatric assessment Control Comprehensive geriatric assessment and usual care | Falls, recommendations | Number of falls, compliance with recommendations after 12 months | 12 |
Pardessus et al., 2002 [25] | RCT France Geriatric acute care, unspecified | n = 60 Intervention 83.51 (± 9.08, range n.r.) ♀ 76% Control 82.9 (± 6.33, range n.r.) ♀ 80% | Intervention Predischarge home visit Control Usual care | ADL/IADL, Falls, rehospitalization, institutionalization | IADL [60], SMAF subscales [35] ADL subscales [61] number of recurring falls, mean number of fall recurrence in former fallers, number of rehospitalizations, number of institutionalizations | 12 |
Threapleton et al., 2018 [4] | RCT UK Stroke ward, acute care | n = 16 Intervention 72 (± 21.08, range 38–90) ♀ 75% Control 70 (± 12.6, range 46–86) ♀ 37% | Intervention Single predischarge virtual home assessment Control Usual care | ADL/IADL, overall independence, mobility, fear of falling, health-related quality of life | NEADL [34], Barthel- Index [53], MRS [62], Rivermead Mobility Index [39], FES-I [40], EQ5D [56] | 6 |
Aplin et al., 2013 [26] | In-depth interview, semi-structured Australia Clients of home modification service | Patients n = 55, 25–87 years Parents of children receiving services, n = 5 Spouses of clients, n = 13 Carer, friend n = 1 (2%) 25–87 years ♀ 45% across all participants | Intervention Major home modifications | - To explore if the dimensions of home (physical / social / personal / temporal / occupational) are important to clients in the home modification process and whether there were other aspects of the home environment previously not considered; - To understand the aspects of the home environment which affect home modification decision-making | n.a. | n.a. |
Atwal et al., 2008 [27] | Semi-structured interview UK Geriatric acute care | Patients, main carers n = 15 86,46 years (range 73–97) ♀ 60% | Intervention Single predischarge home visit | - To explore older adults’ and carers’ involvement in decisions that were made during the home visit; - To explore older adults´ and carers' perceptions of the home visit process | n.a. | n.a. |
Atwal et al., 2014a [28] | Semi-structured interview; think aloud technique UK Acute care and community care | OTs n = 7 ♀ 71% social services, older persons, mental health, acute care, pediatrics | Intervention Virtual reality predischarge home assessment with interior design application | - To explore occupational therapists’ perceptions of a virtual reality interior design application (VRIDA); - to gain insights into the feasibility of using VRIDA as a tool to aid the predischarge home visit (perceived usefulness, perceived ease of use, actual use) | n.a. | n.a. |
Atwal et al., 2014b [29] | Semi-structured interview UK Acute care, intermediate care, rehabilitation, older patients, mental health (older people) | OTs n = 21 | Intervention Predischarge home visit / access visit | - To explore occupational therapists' perceptions of home visits; - To ascertain occupational therapists’ clinical reasoning with respect to conducting home visits | n.a. | n.a. |
Cameron et al., 2014 [30] | In-depth interview, semi-structured, focus groups Canada Rehabilitation facility, stroke | Patients n = 16 62 years (range 25–87) ♀ 75% Family caregivers n = 15 41 years (range 23–75) ♀ 86,7% Multiple health professionals n = 20 | Intervention Single predischarge home visit or preparation in hospital and single/multiple predischarge weekend passes | - To explore stroke survivors’, caregivers’, and health care professionals’ perceptions of weekend passes offered during inpatient rehabilitation and its role in facilitating the transition home | n.a. | n.a. |
Hibberd, 2008 [31] | Semi-structured interview UK Intermediate care unit | Patients n = 4 65 years and older ♀ 50% | Intervention Predischarge home visit / access visit | Part of an evaluation study; - To gain patient perspectives on home visiting process -to ensure service meets needs | n.a. | n.a. |
Money et al., 2015 [9] | Semi-structured interviews, thinking aloud UK Community dwelling | Community dwelling older people n = 10 56-80 years ♀ 50% | Intervention Virtual reality predischarge home assessment with interior design application | - To explore community dwelling older adults’ perceptions of using a computerized 3D interior design application (perceived usefulness, ease of use, and actual use) - To consider the potential barriers and opportunities of using CIDA as an assistive tool within the predischarge home visits process | n.a. | n.a. |
Nygard et al., 2004 [32] | Interviews, focus groups, participant observation Sweden Geriatric acute care, mixed diagnoses | Patients n = 23 78 years (range 68–86) ♀ 50% Living alone n = 12 OTs n = 9 | Intervention Single predischarge home visit | - To describe and illuminate, from both clients’ and therapists’ perspectives, the occupational therapy interventions and recommendations that were undertaken and followed-up in common practice during predischarge home visits; - To gain insight in the accuracy of expectations of therapists and in perceived usefulness of predischarge home visits to clients | n.a. | n.a. |
Threapleton et al., 2017 [3] | Semi-structured interview UK Acute care, rehabilitation, community, stroke | Patients n = 8 68 years (range 44–92) ♀ 75% Stroke survivors n = 4 70 years (range 61–79) ♀ 75% OTs n = 13 | Intervention Virtual predischarge home visit | - To explore perceptions concerning the acceptability, potential utility and limitations of the use of a virtual reality interior design application from the perspectives of therapists and patients | n.a. | n.a. |
Whitehead et al., 2014 [33] | Semi-structured interview UK Acute, rehabilitation, mixed, hyper acute, stroke | OTs n = 20 | Intervention Predischarge home assessment visits | - To explore what factors occupational therapists consider when deciding which patients with a stroke need a predischarge home assessment visit | n.a. | n.a. |
FU: latest time point of follow-up; n.r.: not reported; n.a.: not applicable |
Setting and participants
Studies were published between 2002 and 2018, and the majority were conducted in the UK [3, 4, 7, 9, 27–29, 31, 33] and Australia [2, 23, 26]. One study each was carried out in Germany [24], France [25] and Canada [30], and two studies were conducted in Sweden [21, 22, 32].
Participants in RCTs were recruited in acute care settings [2, 4, 21, 22, 24, 25] and rehabilitation units [7, 23], and for qualitative studies in the community [9, 26], in rehabilitation [30], in acute care [3, 27] and in intermediate care [31].
In one quantitative study, the diagnoses were mixed [32], and diagnoses were not specified or not sufficiently reported in three studies [24, 25, 32]. In two studies, participants suffered from stroke [4, 7] and from hip fracture in another study [21, 22].
Qualitative studies reported on participants’ views [3, 26, 30–32] and on views of OTs [3, 27, 28, 30, 32, 33], families [26, 30], and older community-dwelling people [9].
Participants’ diagnoses were either stroke [3, 30], mixed [32] or not reported [27, 30].
Types of interventions
Interventions comprised a single predischarge home visit only [4, 7, 23] as well as additional supportive interventions through in-hospital activities [21, 22, 24, 25], including extended assessment [2, 23, 24] and / or extended training [22, 24]. Further intervention components were patient education [4, 7, 23, 25] and post discharge follow-ups [2, 24]. All the PDHAs were conducted by OTs alone, or with additional professionals allied to health (physiotherapists, nurses, social workers) [24, 25]. The patients were present during the home assessment in six out of seven RCTs [2, 4, 7, 21–23, 25]. All but one of the interventions were conducted in the patient's home, including functional assessment [2, 7, 22–24, 26]. Virtual home visits, conducted at the hospital, were investigated in one study [4]. Intervention details are available from the corresponding author.
Types of comparators
Usual care in Australia was described as an in-hospital structured interview with the OT, including two structured assessments and an access visit, if more information was required, such as measurements for rails [2] or additional patient education and information about equipment use and community services [23]. Usual care in the UK was described as structured interviews and general discussions about potential problems and referring to agencies [7]. One study [4] reported additional home / access visits for controls, if required. Usual care in Sweden [21, 22] comprised nursing care and instruction from a physiotherapist for walking aids. Usual care in Germany [24] comprised comprehensive geriatric assessment and recommendations. Usual care in France was not described [25].
Risk of bias within studies
The results of the risk of bias assessment are summarized in Fig. 2 and are presented in more detail in Additional File 3. Risk of selection bias was low in all but one study, where it was unclear [25]. Risk of performance bias was unclear in four of five studies [2, 4, 7, 25], and there was a high risk of performance bias in two of the five studies addressing the outcome IADL/ADL. Risk of performance bias was high in two studies [21–23] and unclear in two of four studies [4, 7]. Risk of readmission and risk of falling were not biased in all five studies addressing this outcome [2, 7, 21–25]. Mobility was detected in two studies with low or unclear performance bias, respectively. The same two studies assessed fear of falling with high or unclear risk of bias, respectively [4, 23, 25]. Risk of detection bias was unclear in two studies [21, 22, 25]. Risk of attrition bias was high in one study and unclear in another study [21, 22]. Risk of other bias was unclear in one study [2].
The quality appraisal of the qualitative studies is shown in Additional File 4. The quality of the studies did not influence the analysis since all the studies were considered as being valuable for our research question.
Effectiveness of PDHA versus usual care
Seven RCTs including 1072 participants compared PDHA with usual care [2, 4, 7, 21–25]. Forest plots for comparisons are displayed in Additional File 6. Meta-analysis was performed for Instrumental Activities of Daily Living (IADL) and Activities of Daily Living (ADL), quality of life (Qol), mobility, fear of falling, risk of falling and risk of readmission. Details on the GRADE judgment are reported in Additional File 5.
The summary of findings for the main outcomes is presented in Table 2.
Table 2
PDHA compared with usual care for adults with any diagnosis at all |
Patients or population: adults with any diagnosis at all (except mental disorders only) Setting: acute / subacute hospital care or rehabilitation unit Intervention: predischarge home assessment Comparison: usual care |
Outcomes | SMD* or MD* or RR, [95% CI], I2, p | Number of participants (number of studies) | GRADE | Comments |
IADL/ADL. Various scales. Including studies with NEADL, NEADL (60), SMAF, SWED-QUAL Subscale Physical function. Higher score indicates better function. Mean duration of follow-up: 14.6 weeks (range 4–48 weeks) | SMD − 0.17 [-0.87, 0.53], I2 = 91% p = 0.64 | 656 (6) | ⨁OOO very lowa | No statistically significant effects. (favors control not significantly, FE and RE applied) |
IADL/ADL. NEADL Score 0–22 points. Higher score indicates better results. Mean duration of follow-up: 6.7 weeks (range 4–12 weeks) | MD -0.32 [-1.26, 0.61], I2 = 7% p = 0.50 | 501 (3) | ⨁⨁OO lowc | No statistically significant effects. (favors control not significantly, FEM and RE applied) |
Quality of life. Various scales: EQ-5D overall score, EQ-5D subscale VAS, SWED-QUAL subscale general health perception. Higher score indicates better health status. Mean duration of follow-up: 7 weeks (range 4–12) | SMD 0.14 [-036, 0.65, I2 = 57% p = 0.57 | 204 (4) | ⨁OOO very lowc | No statistically significant effects. (favors experimental not significantly, FE and RE applied) |
Quality of life. EQ-5D overall score 0–1. Higher score indicates better health status. Mean duration of follow-up: 4 weeks | MD 0.19 [-0.08, 0.46], I2 = 0% p = 0.18 | 109 (2) | ⨁⨁OO lowb | No statistically significant effects. (favors experimental not significantly, FE and RE applied) |
Mobility. Various scales: Tinetti (scale 4–24) and RMI (0–15). Higher scores indicate better mobility. Mean duration of follow-up: 8 weeks (range 4–12) | SMD 1.24 ['-0.69, 3.17], I2 = 78% p = 0.21 | 26 (2) | ⨁OOO very lowb | No statistically significant effects. (favors experimental not significantly, FE and RE applied) |
Fear of falling. FES-I Score 10–100. Higher scores indicate more confidence. Mean duration of follow-up: 8 weeks (range 4–12). | MD -5.42 [-16.07, 5.23], I2 = 27% p = 0.32 | 26 (2) | ⨁OOO very lowc | Significant harm if FE applied (MD -7.26 [-11.91, -2.61], p = 0.002) |
Risk of falling Mean duration of follow-up: 19 weeks (range 4–48). | RR 0.88 [0.69, 1.13], I2 = 0% p = 0.32 | 523 (4) | ⨁⨁⨁Od moderate | No statistically significant effects. (favors experimental not significantly, FE and RE applied) |
Risk of readmission: Mean duration of follow-up: 19 weeks (range 4–48). | RR 1.14 [0.81, 1.62], I2 = 36% p = 0.70 | 563 (4) | ⨁⨁⨁Od moderate | No statistically significant effects. (favors control not significantly, FE and RE applied) |
Adverse effects of intervention | | | | No adverse events reported in studies. |
a downgraded due to unblinded personnel and participants, inconsistency and imprecision of results b downgraded due to inconsistency and high imprecision of results c downgraded due to downgraded due to unblinded participants and personnel and imprecision of results d downgraded due to imprecision of results; FE: fixed effect model, RE: random effects model |
File name
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File format
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Title of data
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Description of data
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Additional File 1
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.docx
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Search strategy and excluded references
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Search terms and search strategy exemplary for MEDLINE via PubMed
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Additional File 2
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.docx
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Outcome hierarchy for ADL IADL measures
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Authors’ prespecified hierarchy of ADL and IADL measures for meta-analysis
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Additional File 3
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.docx
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Detailed ROB single studies
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Risk of bias assessment on single study level, detailed explanation per outcome, additional graphics
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Additional File 4
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.docx
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Quality appraisal qualitative studies
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Quality appraisal on single study level in qualitative studies
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Additional File 5
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.docx
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GRADE pooled effects
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Detailed explanation of GRADE judgment per outcome
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Additional File 6
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.pdf
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Forest plots
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Graphical display of meta-analysis with effects in all pooled outcomes
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Additional File 7
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.docx
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Descriptive themes
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Summary of findings in qualitative studies on level of descriptive themes
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Additional File 8
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.xlsx
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Analytical themes
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Summary of analytical themes from qualitative synthesis with related barriers and facilitators and derived implications
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Additional File 9
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.xlsx
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Integrative synthesis
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Detailed overview on integrated results of meta-analysis and qualitative synthesis
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Assessment of reporting bias through funnel plot analysis was not appropriate due to the small number of studies.
IADL/ADL (Instrumental) Activities of Daily Living (IADL/ADL) were measured in six of seven studies [2, 4, 7, 21–23, 25]. Four studies used the Extended Activities of Daily Living scale (NEADL) [34], another used the Functional Autonomy Measurement System (SMAF) [35], each as a full questionnaire. One study used single items addressing Activities of Daily Living from The Swedish Health-Related Quality of Life Survey (SWED-QUAL) [36]. There was no overall effect in functions of daily living for participants at the latest follow-up after receiving PDHA when measured with various scales (656 participants, SMD − 0.17, 95% CI [-0.87 to 0.53], p = 0.64, I2 = 91%). The quality of evidence was judged to be very low due to concerns about risk of bias (blinding of outcome assessment), inconsistency and imprecision with considerable heterogeneity. A sensitivity analysis of three studies using the same scale (NEADL) confirmed the results (MD -0.32 [-1.26 to 0.61], p = 0.50, I2 = 0%) with very low heterogeneity [2, 4, 7]. GRADE assessment indicated low quality due to high risk of bias (blinding of outcome assessment) and imprecision.
Quality of life (QoL) Two studies used the EQ-5D overall score [37] and another two the subscales of the EQ-5D measure of health status from the EuroQol Group (EQ-5D) or SWED-QUAL [36], respectively. Pooling all studies with any Qol measure [4, 21–23] showed no statistical significant group differences of PDHA compared to usual care with moderate heterogeneity (204 participants, SMD 0.14, 95% CI [-0.36 to 0.65], p = 0.57, I2 = 57%). Applying the GRADE approach, we assessed the quality of the evidence to be low due to risk of bias (unblinded participants and personnel) and imprecision of results. A sensitivity analysis of two studies using the same scale (EQ-5D overall score) did not significantly affect the Qol outcome (109 participants MD 0.19, 95% CI [-9.40 to 9.46], p = 0.18, I2 = 0%). The quality of the evidence for these results is low only due to inconsistency and high imprecision.
Mobility Two studies assessed mobility through Performance-Oriented Assessment of Mobility Problems (Tinetti) or The Rivermead Mobility Index (RMI) rating scale, respectively [38, 39]. Pooling these studies showed no improvement at the latest time points of follow-up at one and three months (26 participants, SMD 1.24, 95% CI [-0.69 to 3.17], p = 0.21, I2 = 78%). However, the quality of the evidence was rated very low due to inconsistency and high imprecision based on a very small number of participants with high heterogeneity.
Two studies measured fear of falling with the Falls Efficacy Scale - International (FES-I) [40]. There might be a slight trend towards an increase of fear of falling in participants who received the PDHA intervention. Applying the fixed effect Model (FEM) resulted in a statistically significant effect in favor of the control group (26 participants, MD -7.26, 95% CI [-11.91 to -2.61], p = 0.002) with moderate heterogeneity (I2 = 27%). When a prespecified random effects model (REM) was used, there was no difference between groups in pooled effects for fear of falling (26 participants, MD -7.26, 95% CI [-11.91 to -2.61], p = 0.32). Using the GRADE approach, we assessed the quality of the evidence for this outcome to be very low due to risk of performance bias (unblinded participants and personnel) and imprecision of results resulting from the very small number of participants.
Risk of falling The overall effect of PDHA on reducing risk of falling was not statistically significant (523 participants, RR 0.88, 95% CI [0.69 to 1.13], p = 0.32), I2 = 0%). Using the GRADE, the quality of evidence was assessed as moderate because considerable harm and benefit were included in confidence intervals of all the studies. Therefore, we had concerns regarding imprecision.
Risk of readmission Pooling four studies showed no statistically significant effect on the reduction of readmissions throughout an average of 16 weeks after receiving PDHA (523 participants, RR 1.13, 95% CI [0.61 to 2.10], p = 0.70, I2 = 36%). Applying the GRADE approach, the quality of evidence was assessed as moderate because significant harm and benefit were included in the confidence intervals of all the studies. For this reason, we had concerns regarding imprecision.
Outcomes from single studies:
Overall independence was assessed with the Modified Ranking Scale [41] in one study with a missing significant difference between the groups at one month after discharge (16 participants, MD -0.20 95% CI [-0.65 to 0.25], p = 0.38) [4].
Psycho-social outcomes
One study reported on three different psycho-social outcomes, although all with missing significant differences at one month after discharge: Emotional distress in medical settings was measured through the GHQ-28 [42, 43] in 85 participants (in the intervention group with median 19; IQR 12.25–23.75 vs. median 23; IQR 15.5–31.5 in the control group; p = 0.10). Depression was measured through The Stroke Aphasic Questionnaire [44] in 85 participants (in the intervention group with median 6; IQR 3.25–9.75 vs. median 7; IQR 4–11 in the control group; p = 0.37). Caregiver strain was measured though the Caregiver Strain Index [7] in 85 participants (in the intervention group with median 5.5; IQR 1.75–7 vs. median 6; IQR 5–8 in the control group; p = 0.11).
Process outcomes
The number of recommendations was reported in one study with a significant increase in the number of modifications in the intervention group compared to the control group at 90 days after discharge (range 0–13 in intervention vs. 0–7 in controls, p = 0.001) [2].
Admissions to hospitals and care facilities
The number of emergency department visits was reported in one study with missing significant differences between the groups at 90 days after discharge (337 participants; RR = 1.06, 95% CI [0.73 to 1.55], p = 0.73 [2].
One study (86 participants) reported missing significant differences in the number of institutionalizations after 12 months (60 participants, RR = 0.58; 95% CI 0.26 to 1.27; p = 0.17) [25].
The number of patients receiving community support was reported by one study. Three months after discharge three patients in total across groups received community support (seven patients across groups received support at baseline) [23].
Qualitative synthesis
Based on four comprehensive descriptive themes, five analytical themes were identified regarding the barriers and facilitators of the PDHA process. Details are reported in Additional File 7 (Summary of the descriptive themes) and Additional File 8 (Overview on analytical themes).
Barriers and facilitators in PDHA process, analytical themes
Safety at home For decisions on home modifications, safety was the most important factor for OTs [26] and patients [26, 30]. OTs are appreciated as experts for safety by the participants. In patient education on safety, virtual reality (VR) applications have proved helpful for understanding the possible hazards [3, 9].
Patients and family carers’ acceptance of home modification and aids Patients had specific demands on modifications and aids. They refused ‘disabled’ or ‘like a hospital’ looks as well as recommendations that might possibly mean that ADL and other meaningful activities could not be performed in the way the patients were used to or that they preferred [26, 27]. Patients wanted to have control over the number and kinds of changes [26]. Patients had their own ideas and solutions for aids and modifications [32]. The needs of family members and visitors in joining in with social activities and performing activities of daily living together with patients were equally important to patients and family carers when planning modifications [26]. For patients and family carers, it was difficult to imagine modifications, adaptations and the logistic requirements [3, 28]. OTs reported on the challenges encountered when trying to propose and communicate potential adaptations to the patient adequately [9]. OTs and older people found the use of visualization with a 3D interior design software application to be helpful for imagining and understanding the assistive technologies and adaptations planned [3, 9, 28] and for involving patients in decision-making on proposed changes [3, 9, 28]. OTs rated the VR applications as being better than drawings and photographs [28] and more helpful for communicating decisions regarding discharge destination, choice of aids and modifications [3].
Appropriateness of information to include patients in the PDHA process Predischarge home assessments were, when conducted as home visits with the OT and the patient, often frightening for the patients [27, 29], particularly when older people initially lacked information regarding the goal and consequences of the PDHA [27, 29, 31]. Therefore, having general and written information beforehand was appreciated [31]. During the home assessment, patients felt excluded from the assessment and planning modifications if the conversation took place only between therapists and carers. Patients appreciated getting feedback about the quality of their performance during the assessment and appreciated the social skills of the OTs in providing support [27]. After the home assessment, patients often did not feel sufficiently informed about the outcome of the assessment, were uncertain about next steps and felt excluded [27, 29].
Involvement in patient goals and meaningful activities in functional assessment. PDHAs were seen as a chance for both the patients and the therapists to gain a realistic view about the patient’s function and limitations in the home environment [27, 29, 32, 33]. The patients felt restrained by the time limitation during the self-assessment at home [27, 31]. Whereas some therapists expressed to take sufficient time for a functional assessment [29], others emphasized that “The clients need to spend some time at home and feel what it really is like before they can recognize what they need” [32], just as the patients emphasized the need to try out their functional abilities in individual meaningful activities at home [30].
Relevant patient conditions in PDHA The levels of impairment and functioning were important factors in decision-making about a home assessment [30, 33]. Moderately impaired patients were seen as most likely to benefit from a PDHA [32, 33], while PDHA was not considered as suitable for severely physically impaired, immobile and medically instable patients for PDHA [30, 33]. PDHA was also not considered as suitable for patients with severe cognitive impairment in contrast to patients with mild cognitive impairments [9, 29]. Further indications were visual and perceptual impairments, new complex needs and diagnoses of hip and knee replacements [29]. A virtual predischarge home assessment app does not seem indicated for patients with bad eyesight, visual impairments, severe cognitive impairments [9], low fine motor function, [3] and or who lack familiarity with the occupational therapy objects shown in the app’s catalogue and have low computer literacy [3, 9]. OTs reported that access visits are sometimes difficult to conduct with patients with mental disorders, when patients were unwilling to let therapists enter the home in the patient’s absence. However, hip and knee replacements were seen as appropriate indications for access visits [29]. Social conditions in terms of a supportive network of family members and outpatient services were considered to be crucial for gaining reliable information about the home environment and for realizing home modifications and aids provision and could possibly avoid the necessity of a PDHA [32, 33].
From these analytical themes, seven implications for PDHA interventions were derived for planning and conducting PDHAs, providing aids and implementing home modifications.
Integrative synthesis
Implications for practice are displayed in Table 3. Further details on the description of the interventions and on the extent to which implications were considered in intervention components of the included RCTs are displayed in additional files (see Additional File 9 for a detailed overview on study interventions, outcomes, effect sizes and implications addressed by study interventions).
Table 3
Synthesis of practice implications and RCT interventions
Implication | Studies addressing implications |
1 | Provide education about environmental hazards in an appropriate manner. | Nikolaus et al., 2003, Drummond et al., 2013, Threapleton et al., 2018, Pardessus et al., 2002 |
2 | Provide tailored adaptations based on shared decision-making and explicitly involve patients’ ideas, solutions and expectations in planning home modifications and adaptations of aids and provide the patient with advice on alternative solutions. | Threapleton et al., 2018, Hagsten et al, 2004/Hagsten et al., 2006, |
3 | Consider needs of family members and friends in home modifications. | Not identified |
4 | Use 3D applications to visualize and discuss modifications (if this method is appropriate for patients). | Threapleton et al., 2018 |
5 | Provide adequate (verbal and written) patient information about the aim, process, assessment, the results and consequences. | Not identified |
6 | Involve patient goals in the PDHA | Clemson et al., 2016 |
7 | Include patients’ levels and kinds of impairments, diagnoses and availability of a supportive network in deciding about if and what kind of predischarge home assessment should be performed. | Not identified |