SYSTEMATIC REVIEW PROTOCOL

Effectiveness of home visit nursing for improving

patient-related clinical outcomes in older people: an
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umbrella review protocol

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Sameh Eltaybani  Kiyomi Kawase  Risako Kato  Asa Inagaki  Masumi Shinohara  Noriko Yamamoto-Mitani
Department of Gerontological Homecare and Long-Term Care Nursing, Division of Health Sciences and Nursing, Graduate School of Medicine,
The University of Tokyo, Tokyo, Japan

ABSTRACT

Objective: The objective of this review is to synthesize systematic reviews on the effectiveness of home visit
nursing for improving patient-related outcomes in older people.
Introduction: Home care for older people covers a wide range of services and is provided by an array of health
professionals. Reviews on the effectiveness of home care services differ in definition and scope, and the unique
contribution of home visit nursing services for older people has not been clearly identified.
Inclusion criteria: This review will consider systematic reviews of quantitative studies assessing the effectiveness
of home visit nursing for older people. Home visit nursing will include the provision of preventive, promotive,
curative, or rehabilitative services in the home. This will be compared with usual care, alternative therapeutic
interventions, or no intervention. The outcomes of interest are hospitalization, institutionalization, mortality, patient
satisfaction, and quality of life. Systematic reviews with and without meta-analyses will be eligible for inclusion.
Methods: This review will follow the JBI methodology. MEDLINE, CINAHL Plus with Full Text, PsycINFO, the
Cochrane Database of Systematic Reviews, Epistemonikos, ProQuest Dissertations and Theses, PROSPERO, and Grey
Literature Report will be searched. The authors will hand-search reference lists of the included reviews. There will be
no restrictions on the publication date or country of origin of the review. Only systematic reviews with full text
published in English will be considered. Screening of articles, assessment of methodological quality, and data
extraction will be performed independently by two reviewers. Quality of evidence will be assessed using the
Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Data will be summa-
rized in a narrative format with supporting tables.
Scoping review registration: Open Science Framework (https://osf.io/3fexj)
Keywords: aged; home care services; home visits; house calls; visiting nursing services
JBI Evid Synth 2022; 20(8):2071–2078.

Introduction enable older people to remain in their own

ith a growing aging population, home care homes.1-3 Home visits cover a wide range of services,
W programs have become part of the national
policy in several countries.1-3 These programs
including health promotion, preventive care, surveil-
lance, screening, comprehensive assessment, refer-
mainly involve home visits, although they may ral, health education, social support, psychological
include online and telephone support. The aim of support, coordinating community services, treating
home visits is to decrease institutionalized care (eg, observed problems, case management, respite care,
in hospitals, nursing homes, and residential care follow-up, rehabilitation, and care for caregivers.1,4
facilities) and expand community-based care to Home visit services may be provided by volunteers or
health care professionals, such as social workers,
Correspondence: Sameh Eltaybani, [email protected] geriatricians, general practitioners, health visitors,
The authors declare no conflict of interest. and nurses. The latter may include community,
DOI: 10.11124/JBIES-21-00343 public health, primary care, district, hospital, and

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home care nurses.4,5 Despite the extensive work to of a specific illness,8 whereas some reviews have
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investigate the effectiveness of home care services, focused on patients with specific conditions, such
the unique contribution of home visit nursing has yet as mental illness.9 Some reviews have examined the
to be adequately synthesized in the literature. effectiveness of home visiting for patients with spe-
Markle-Reid et al.1 and Elkan et al.4 evaluated the cific medical conditions, such as asthma,10 diabe-
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effectiveness of home visit programs that offer health tes,11 and hypertension,12 regardless of the age
promotion and preventive care to older people. of participants.
Markle-Reid et al.1 concluded that home visit inter- Insight into whether home visit nursing for older
ventions carried out by nurses can favorably affect people is effective is essential for implementation
health and functional status, mortality rates, use of and future research. Because of the heterogeneity of
hospitalization and nursing homes, and costs. This previous studies and reviews with respect to defini-
review included only randomized controlled trials tion, scope, provider qualification, participant selec-
(RCTs) of interventions provided by a registered tion, and outcome of home visit services, the unique
nurse or equivalent, alone or as part of a team, contribution of home visit nursing services for older
and excluded home visits for therapeutic or rehabili- people cannot be clearly identified. It is important to
tative purposes (eg, dementia support), although summarize the review evidence of the effectiveness of
they did not conduct or report a meta-analysis. A home visit nursing for older people available to date
meta-analysis by Elkan et al.4 found that home to inform clinicians, clinical practice guidelines, and
visiting was associated with a significant reduction future research.13
in mortality and admissions to long-term care, but A preliminary search in July 2021 of PubMed,
no significant reduction in admissions to hospital, Cochrane Database of Systematic Reviews, PROS-
health status, or activities of daily living. This review PERO, and JBI Evidence Synthesis found no recent
included both RCTs and quasi-experimental studies, umbrella reviews or protocols on the topic. The
and excluded studies in which the home visitor was a objective of this umbrella review is to synthesize
specialist in a branch of nursing other than health systematic reviews of the effectiveness of home visit
visiting (eg, district nursing). nursing for older people (aged  60 years) with
Another meta-analysis by Stuck et al.2 revealed respect to five patient-related clinical outcomes,
that preventive home visit programs are effective in namely hospitalization, institutionalization, mortal-
reducing nursing home admission, functional ity, patient satisfaction, and quality of life. There will
decline, and mortality, provided that the interven- be no limitation on the condition of the care recip-
tions are based on multidimensional geriatric assess- ients or the scope and content of the care services.
ment, include multiple follow-up visits, and target The five outcomes of interest were selected because
persons at lower risk of death. Providers of home of their clinical and economic importance for both
visits in this review included nurses, geriatricians, care recipients and care providers. Outcomes not
physical therapists, physicians, health visitors, lay covered by the current review are not less worthy.
community workers, social workers, and volunteers.
Bouman et al.5 assessed the effectiveness of intensive
Review question
home visit programs targeting older people with
poor health or with other functional impairments. What is the effectiveness of home visit nursing,
The review concluded that home visit programs compared with usual care, alternative therapeutic
appear to not be beneficial for older people with interventions, or no intervention, for improving
poor health within the health care setting of Western patient-related clinical outcomes (ie, hospitalization,
countries. This review was limited to RCTs and institutionalization, mortality, patient satisfaction,
included studies in which home visits were carried and quality of life) in older people?
out by nurses or other health professionals (eg,
geriatricians). Inclusion criteria
Geographically, while some reviews have focused Participants
on a particular country,6 other reviews have The umbrella review will consider systematic
excluded studies conducted in specific countries.7 reviews that include studies of older people (female
Some reviews have excluded patients on the basis and male). Previous reviews related to older people

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defined their population differently. For instance, the results related to ongoing long-term care services
older people were defined as those aged  60 years
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are clearly identified in the review without referring

by Renz and Meinck14;  65 years by Bouman to the original studies. Reviews on the effectiveness
et al.,5 Markle-Reid et al.,1 and Elkan et al.4; mean of home-based hospitalization (ie, in-home hospital
age > 70 years by Stuck et al.2; and >75 years by care) will be excluded.
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Tappenden et al.6 With the aim of including studies

from different societies, this proposed umbrella Comparators
review defines older people as those aged  60 years. Reviews will be included if the effectiveness of home
No exclusion will be made based on the participants’ visit nursing is compared with usual care, alternative
country of residence, sex, or specific medical con- therapeutic interventions, or no intervention.
ditions. Reviews with mixed populations (ie, differ-
ent age groups) will be included if the studies related Outcomes
to older people are clearly identified in the review This review will examine the effectiveness of home
without referring to the original studies. visit nursing using five patient-related clinical out-
comes: hospitalization, institutionalization, mortal-
Interventions ity, patient satisfaction, and quality of life. Mortality
The intervention covered by this umbrella review is is the number or rate of study participants who died.
home visit nursing, which is defined as visiting older Hospitalization is defined as being admitted to a
persons at their home to provide preventive, promo- hospital and does not include emergency department
tive, curative, or rehabilitative services by nurses. visits or receiving consultation from the hospital,
These services include, but are not limited to, physi- and is not defined by the length of hospitalization.
cal activity; multifactorial intervention; psychosocial Institutionalization is defined as admission to nurs-
intervention; health and social care provision; and ing homes or other types of residential care facilities.
cognitive, nutrition, or medical maintenance adher- Patient satisfaction and quality of life will be
ence-focused interventions. A nurse is a licensed included whether they are patient- or proxy-
health care professional who undertakes remuner- reported. Health economic outcomes (eg, cost-effec-
ated work for which formal nursing education tiveness) are not covered by the current review.
is required.
Reviews will be eligible if they report an assess- Types of studies
ment of the effectiveness of the home visit nursing This umbrella review will consider systematic
services provided at patients’ homes on an ongoing reviews of quantitative studies on the effectiveness
(ie, more than once) long-term basis. Studies will be of home visit nursing for older people. A review will
excluded if the duration of intervention is less than be eligible if it provides i) an explicit, clearly focused
three months. Reviews covering temporary services review question; ii) clearly defined eligibility criteria
(eg, transitional care programs, temporary post-dis- to select primary studies; iii) an explicit method that
charge care, short-term follow-up visits) or remote includes a clearly articulated search strategy, includ-
services (eg, telephone-based care, online support) ing at least one bibliographic database; and iv)
will be excluded. Reviews on case management evidence of critical appraisal/assessment of the risk
interventions (eg, care planning, care coordination) of bias.
or nurse-led/mediated interventions will be included Systematic reviews including RCTs and non-
only if home visits are explicitly stated to be solely RCTs with intervention study designs and control
done by nurses. group (quasi-experimental studies, non-randomized
Reviews with mixed settings (eg, home care and trials, and controlled before and after studies) will be
institutional care settings) and reviews with services included. Systematic reviews including mixed
provided by multiple professionals (eg, integrated method and multi-method studies will be eligible
care) will be included if the results related to home if the quantitative results of the included studies are
care and nursing services, respectively, are clearly clearly identified in the overall findings of the review
identified in the review without referring to the without referring to the original studies. Systematic
original studies. Reviews covering ongoing long- reviews with and without meta-analyses will
term care and temporary care will be included if be eligible.

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Systematic reviews of qualitative studies, with- PA, USA), and duplicates will be removed. Titles and
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drawn or retracted publications, case reports, earlier abstracts will then be screened by two independent
versions of updated systematic reviews, books, and reviewers for assessment against the inclusion crite-
primary research will be excluded. Systematic reviews ria for the review. Potentially relevant papers will be
will be eligible only if the full text is available (eg, retrieved, and their full text will be assessed in detail
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reviews available only as abstracts are excluded). against the inclusion criteria by two independent
reviewers. Reasons for exclusion of full-text articles
Methods that do not meet the inclusion criteria will be
The umbrella review will be conducted using JBI recorded and reported in the final report. Any dis-
methodology.15 This umbrella review protocol has agreements that arise between the reviewers at each
been registered in Open Science Framework (https:// stage of the selection process will be resolved
osf.io/3fexj). through discussion. Where systematic reviews con-
taining the same primary studies are identified, we
will include both reviews. A citation matrix will be
Search strategy included in the review to depict the primary study
Eight bibliographic databases will be searched: overlap within the systematic reviews, and the cor-
MEDLINE (PubMed), CINAHL Plus with Full Text rected covered area index, a metric that provides a
(EBSCO), PsycINFO (EBSCO), Cochrane Database percentage of overlap of the primary studies, will be
of Systematic Reviews (Ovid), Epistemonikos, Pro- calculated.17,18 The results of the search will be
Quest Dissertations and Theses (ProQuest), PROS- reported in full in the final report and presented in
PERO, and Grey Literature Report. Search strategies a Preferred Reporting Items for Systematic Reviews
suggested by Aromataris et al.15 and Aromataris and Meta-analyses (PRISMA) flow diagram.19
et al.16 will be followed. First, an initial logic grid
aligned with the current review participants, con- Assessment of methodological quality
cept, and context will be constructed. Second, an Eligible reviews will be critically appraised by two
initial search of two databases (MEDLINE and independent reviewers. Overall methodological
CINAHL Plus with Full Text) will be performed, quality will be appraised using the standard JBI
followed by an analysis of the text words contained critical appraisal instrument for systematic reviews
in the title and abstract of retrieved papers, and of and research syntheses.13 Any disagreements
the index terms used to describe the articles. Third, between the reviewers will be resolved through dis-
the initial logic grid will be updated; a second search cussion. The results of the critical appraisal will be
using all identified keywords and index terms will be reported in narrative and tabular forms in the final
undertaken across all included databases with no report. All reviews, regardless of methodological
limitation on the date. Appendix I presents an exam- quality, will undergo data extraction and synthesis
ple of the search strategy. to summarize the current literature and quality of
We will also search reference lists of included existing studies in systematic reviews to date.
systematic reviews for potentially relevant records
that may have been missed in the previous search. Data extraction
Where an umbrella review is found, we will screen Using the standardized JBI data extraction tool,15
the included reviews for potentially relevant records. data extraction will be conducted by two reviewers
Systematic reviews not published in English will be independently. Any disagreements between the
excluded due to limited resources that do not allow for reviewers will be resolved through discussion. Three
screening and translation of studies in other languages. researchers will independently extract data from the
Nevertheless, systematic reviews that meet the previ- first review using the data extraction form and meet
ously stated eligibility criteria will be included regard- to determine whether their approach to data extrac-
less of the language of included primary studies. tion is consistent with the research question and
purpose. Any disagreements between the reviewers
Study selection will be resolved through discussion. The data chart-
Following the search, all identified citations will be ing form will be refined and updated if needed, and
uploaded into EndNote v.X8 (Clarivate Analytics, modifications will be detailed in the final review

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report. All reviews will be extracted by three Acknowledgments

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researchers (two independent reviewers). Data Professor Carolina Weller, Monash University,
extraction will be limited to the data presented in Australia, for her guidance and support.
the reviews, and primary studies will not be
reviewed. Authors of reviews will be contacted on
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up to two occasions over one month to request Funding

missing or additional data, where required. NYM is supported by Health Labour Sciences
Research Grant (21GA1002). The funder has no role
Data synthesis in the design of this study, execution, analyses, inter-
This umbrella review will rely on the analyses pre- pretation of the data, or decision to submit results.
sented in the included reviews and we will not
undertake any re-analysis of the outcome data pro- References
vided in the reviews. On the final report, the data 1. Markle-Reid M, Browne G, Weir R, Gafni A, Roberts J,
extracted from selected reviews will be summarized, Henderson SR. The effectiveness and efficiency of home-
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Tabulated information from the included reviews 2. Stuck AE, Egger M, Hammer A, Minder CE, Beck JC. Home
will include the number of studies that inform the visits to prevent nursing home admission and functional
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studies, study and population characteristics, and
3. Duan-Porter W, Ullman K, Rosebush C, et al. Interventions
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A summary of evidence will be provided for each adults with impairments-a systematic review of reviews. J
outcome utilizing a three-color traffic light system, Gen Intern Med 2020;35(7):2118–29.
symbolizing the strength of the evidence of effective- 4. Elkan R, Kendrick D, Dewey M, Hewitt M, Robinson J, Blair M,
ness. Green will represent an effective intervention, et al. Effectiveness of home based support for older people:
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pared to a control intervention, and red will repre- (7315):719–25.
sent a detrimental intervention or one that is less 5. Bouman A, van Rossum E, Nelemans P, Kempen GI, Knips-
effective than the comparator.15 A narrative discus- child P. Effects of intensive home visiting programs for
sion of the effectiveness with respect to the scope and older people with poor health status: a systematic review.
BMC Health Serv Res 2008;8:74.
content of the home visit nursing, participants’ char-
6. Tappenden P, Campbell F, Rawdin A, Wong R, Kalita N. The
acteristics, examined outcomes, and methodological
clinical effectiveness and cost-effectiveness of home-
quality of reviews, including consideration of study based, nurse-led health promotion for older people: a
design, will be provided. systematic review. Health Technol Assess 2012;16(20).
7. Eklund K, Wilhelmson K. Outcomes of coordinated and
Assessing certainty in the findings integrated interventions targeting frail elderly people: a
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Development and Evaluation (GRADE) approach Soc Care Community 2009;17(5):447–58.
for establishing the certainty of evidence20 will be 8. Apóstolo J, Cooke R, Bobrowicz-Campos E, Santana S,
followed, and a ranking of the quality of the evidence Marcucci M, Cano A, et al. Effectiveness of interventions
will be presented as reported in the included reviews. to prevent pre-frailty and frailty progression in older adults:
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The GRADE concept is based on an assessment of
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four criteria: quality of primary studies, design of
9. Van Citters AD, Bartels SJ. A systematic review of the
primary studies, consistency, and directness. A four- effectiveness of community-based mental health outreach
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the evidence: high, moderate, low, and very low. A 49.
Summary of Findings will be provided and will 10. Muneswarao J, Hassali MA, Ibrahim B, et al. Effectiveness of
included the five outcomes covered by the current home visits in adult patients with asthma: a systematic
review (ie, hospitalization, institutionalization, mor- review of randomized controlled trials. J Allergy Clin Immu-
tality, patient satisfaction, and quality of life). nol Pract 2020;8(9):3036–55.

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11. Han L, Ma Y, Wei S, Tian J, Yang X, Shen X, et al. Are home Adelaide: JBI; 2020 [cited 2021 Dec 16]. Available from:
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visits an effective method for diabetes management? A https://synthesismanual.jbi.global.

quantitative systematic review and meta-analysis. J Diabe- 16. Aromataris E, Riitano D. Constructing a search strategy and
tes Investig 2017;8(5):701–8. searching for evidence. A guide to the literature search for a
12. Ma Y, Lu H, Zhang Y, Wang Y, Li S, Yan F, et al. Effectiveness systematic review. Am J Nurs 2014;114(5):49–56.
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of home visiting on patients with hypertension: a system- 17. Hennessy EA, Johnson BT. Examining overlap of included
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2021;100(10):e24072. covered area index. Res Synth Methods 2020;11(1):134–45.
13. Aromataris E, Fernandez R, Godfrey CM, Holly C, Khalil H, 18. Pieper D, Antoine SL, Mathes T, Neugebauer EA, Eikermann
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2015;13(3):132–40. 19. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffman TC,
14. Renz JC, Meinck M. [Effectiveness of preventive house visits Mulrow CD, et al. The PRISMA 2020 statement: an updated
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Appendix I: Search strategy

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MEDLINE (PubMed)
Date searched: February 8, 2022
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# Query Records retrieved

1 aged[MeSH Terms] 3,367,334
2 aged, 80 and over[MeSH Terms] 998,501
3 elderly[MeSH Terms] 3,367,334
4 geriatric nursing[MeSH Terms] 13,786
5 health services for the aged[MeSH Terms] 18,133
6 elder[Title/Abstract] 252,856
7 “older people”[Title/Abstract] 30,060

8 “older person ”[Title/Abstract] 11,568
9 gerontologic[Title/Abstract] 3462
10 geriatric[Title/Abstract] 64,169
11 senior[Title/Abstract] 39,676
12 “older adult”[Title/Abstract] 84,249
13 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR 11 OR #12 3,472,810
14 home care services[MeSH Terms] 49,661
15 house calls[MeSH Terms] 3969
16 homecare[Title/Abstract] 2271
17 “home care”[Title/Abstract] 18,899
18 “home visit”[Title/Abstract] 8920
19 “visiting nursing service”[Title/Abstract] 88
20 “home healthcare”[Title/Abstract] 1396

21 “home nurs ”[Title/Abstract] 1793
22 “district nurs”[Title/Abstract] 1782
23 “community nurs”[Title/Abstract] 3590
24 “home based support”[Title/Abstract] 49
25 “home-based support”[Title/Abstract] 49
26 “home based car”[Title/Abstract] 1043
27 “home-based car”[Title/Abstract] 1043
28 “home based healthcare”[Title/Abstract] 41
29 “home-based healthcare”[Title/Abstract] 41
30 “home based health care”[Title/Abstract] 31
31 “home-based health care”[Title/Abstract] 31
32 #14 OR #15 OR #16 OR 17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR 71,745
#30 OR #31
33 hospitalization[MeSH Terms] 273,625
34 hospital[Title/Abstract] 1,272,429
35 admission[Title/Abstract] 220,351
36 institutionalization[MeSH Terms] 8729

37 institution [Title/Abstract] 279,297
38 facility[Title/Abstract] 68,007
39 facilities[Title/Abstract] 99,382

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(Continued)
# Query Records retrieved
40 residential[Title/Abstract] 32,398
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41 nursing homes[MeSH Terms] 42,476

42 homes for the aged[MeSH Terms] 14,583
43 elderly home[Title/Abstract] 247
44 care home[Title/Abstract] 3938
45 nursing home[Title/Abstract] 31,049
46 mortality[MeSH Terms] 414,482
47 death[MeSH Terms] 157,564
48 mortalit[Title/Abstract] 767,615
49 death[Title/Abstract] 828,492
50 patient satisfaction[MeSH Terms] 96,659
51 satisfact[Title/Abstract] 262,415
52 quality of life[MeSH Terms] 232,799
53 quality of life[Title/Abstract] 268,863
54 quality-of-life[Title/Abstract] 268,863
55 QoL[Title/Abstract] 38,360
56 life quality[Title/Abstract] 7300
57 #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR #39 OR #40 OR #41 OR #42 OR #43 OR #44 OR #45 OR #46 OR #47 OR #48 OR 3,630,171
#49 OR #50 OR #51 OR #52 OR #53 OR #54 OR #55 OR #56
58 systematic[sb] 181,028
59 Systematic Review[Publication Type] 180,779
60 Systematic Reviews as Topic[MeSH Terms] 7445
61 review[Publication Type] 2,683,966
62 systematic[Title] 164,823
63 systemic[Title] 105,763
64 review[Title] 470,997
65 meta[Title] 856,841

66 synthes [Title] 268,315
67 #58 OR #59 OR #60 OR #61 OR #62 OR #63 OR #64 OR #65 OR #66 3,918,613
68 #13 AND #32 AND #57 AND #67 991
69 Filter to #68: Text availability: Full Text 818
70 Filter to #69: Language: English 743

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