Rural and urban differences in quality of dementia care of persons with dementia and caregivers across all domains: a systematic review.

BACKGROUND: There are challenges in healthcare service delivery in rural areas, and this may be especially true for persons with dementia, who have higher needs to access to the healthcare system, and may have difficulties to commute easily and safely to these services. There is a growing body of literature regarding geographical disparities, but there is no comprehensive systematic review of geographical differences in persons with dementia across all domains of care quality. Therefore, the objective of this study is to conduct a systematic review of the literature on rural and urban differences in quality of dementia care outcomes of persons with dementia across all quality-of-care domains. METHODS: We performed a digital search in Ovid MEDLINE on July 16, 2019, updated on May 3, 2021, for French or English records. We selected studies that reported outcome from at least one domain of quality of dementia care (Access, Integration, Effective Care, Efficient Care, Population Health, Safety, and Patient-Centered) in both rural and urban persons with dementia or caregivers. We used rigorous, systematic methods for screening, selection, data extraction and we analyzed outcomes reported by at least two studies using vote counting and appraised the certainty of evidence. Finally, we explored sources of heterogeneity. RESULTS: From the 38 included studies, we found differences in many dementia care domains. Rural persons with dementia had higher mortality rates (Population Health), lower visits to any physicians (Access), more hospitalizations but shorter stays (Integration), higher antipsychotic medications (Safety), lower use of home care services and higher use of nursing home (Patient-Centered Care) compared to urban persons with dementia. CONCLUSIONS: This comprehensive portrait of rural-urban differences in dementia care highlights possible geographically based inequities and can be used by researchers and decision makers to guide development of more equitable dementia care policies.

Research protocol of the Laval-ROSA Transilab: a living lab on transitions for people living with dementia.

BACKGROUND: The Laval-ROSA Transilab is a living lab that aims to support the Laval Integrated Health and Social Services Centres (Quebec, Canada) in consolidating the Quebec Alzheimer Plan. It aims to improve care transitions between different settings (Family Medicine Groups, home care, and community services) and as such improve the care of people living with dementia and their care partners. Four transition-oriented innovations are targeted. Two are already underway and will be co-evaluated: A) training of primary care professionals on dementia and interprofessional collaboration; B) early referral process to community services. Two will be co-developed and co-evaluated: C) developing a structured communication strategy around the dementia diagnosis disclosure; D) designation of a care navigator from the time of dementia diagnosis. The objectives are to: 1) co-develop a dashboard for monitoring transitions; 2) co-develop and 3) co-evaluate the four targeted innovations on transitions. In addition, we will 4) co-evaluate the impact and implementation process of the entire Laval-ROSA Transilab transformation, 5) support its sustainability, and 6) transfer it to other health organizations. METHODS: Multi-methods living lab approach based on the principles of a learning health system. Living labs are open innovation systems that integrate research co-creation and knowledge exchange in real-life settings. Learning health systems centers care improvement on developing the organization's capacity to learn from their practices. We will conduct two learning cycles (data to knowledge, knowledge to practice, and practice to data) and involve various partners. We will use multiple data sources, including health administrative databases, electronic health records data, surveys, semi-structured interviews, focus groups, and observations. DISCUSSION: Through its structuring actions, the Laval-ROSA Transilab will benefit people living with dementia, their care partners, and healthcare professionals. Its strategies will support sustainability and will thus allow for improvements throughout the care continuum so that people can receive the right services, at the right time, in the right place, and from the right staff.

Improving dementia care: insights from audit and feedback in interdisciplinary primary care sites.

BACKGROUND: Many primary care sites have implemented models to improve detection, diagnosis, and management of dementia, as per Canadian guidelines. The aim of this study is to describe the responses of clinicians, managers, and staff of sites that have implemented these models when presented with audit results, their insights on the factors that explain their results, their proposed solutions for improvement and how these align to one another. METHODS: One audit and feedback cycle was carried out in eight purposefully sampled sites in Ontario, Canada, that had previously implemented dementia care models. Audit consisted of a) chart review to assess quality of dementia care indicators, b) questionnaire to assess the physicians' knowledge, attitudes and practice toward dementia care, and c) semi-structured interviews to understand barriers and facilitators to implementing these models. Feedback was given to clinicians, managers, and staff in the form of graphic and oral presentations, followed by eight focus groups (one per site). Discussions revolved around: what audit results elicited more discussion from the participants, 2) their insights on the factors that explain their audit results, and 3) solutions they propose to improve dementia care. Deductive content and inductive thematic analyses, grounded in causal pathways models' theory was performed. FINDINGS: The audit and feedback process allowed the 63 participants to discuss many audit results and share their insights on a) organizational factors (lack of human resources, the importance of organized links with community services, clear roles and support from external memory clinics) and b) clinician factors (perceived competency practice and attitudes on dementia care), that could explain their audit results. Participants also provided solutions to improve dementia care in primary care (financial incentives, having clear pathways, adding tools to improve chart documentation, establish training on dementia care, and the possibility of benchmarking with other institutions). Proposed solutions were well aligned with their insights and further nuanced according to contextual details. CONCLUSIONS: This study provides valuable information on solutions proposed by primary care clinicians, managers, and staff to improve dementia care in primary care. The solutions are grounded in clinical experience and will inform ongoing and future dementia strategies.

Interprofessional primary care: indispensable for family physicians yet invisible to older patients.

There is growing consensus that interprofessional primary care is key to delivering timely, coordinated, and comprehensive care, especially in the older patient population who often live with complex and chronic needs. Despite significant investments in reforming health systems toward interprofessional primary care, there is a paucity of evidence describing the importance of interprofessional primary care for older patients and physicians. This qualitative descriptive study aimed to understand the use and utility of interprofessional primary care for older patients and family physicians from the perspective of different stakeholders within primary care in Ontario, Canada. Twenty-five semi-structured interviews (including 16 older patients, six family physicians, three primary care managers) and a focus group with 13 patient representatives were conducted. Our study found that while the benefits of interprofessional primary care teams for family physicians were clearly emphasized, stakeholders consistently reported that older patients often appeared to be unaware of the presence of, or roles played by, non-physician healthcare professionals in their clinic. Better transparency and education regarding available services and roles of different care providers may allow for more optimal use of interprofessional family medicine clinics by patients.

Sex differences in the management of persons with dementia following a subnational primary care policy intervention.

BACKGROUND: The influence of sex and gender on the risk of dementia, its clinical presentation and progression is increasingly being recognized. However, current dementia strategies have not explicitly considered sex and gender differences in the management of dementia to ensure equitable care. The objective of this study was to examine the moderating effect of sex on the quality of care following the implementation of the Quebec Alzheimer Plan (QAP). METHODS: We conducted a secondary analysis of the evaluation of the QAP consisting of a retrospective chart review of 945 independent, randomly-selected patient charts of males and females 75+ years old with dementia and a visit to one of 13 participating Family Medicine Groups before (October 2011-July 2013) and after (October 2014 - July 2015). The quality of dementia care score, based on Canadian and international recommendations and consensus guidelines, consisted of documented assessments in 10 domains. We used a mixed linear regression model to measure the interaction between sex and the implementation of the QAP on the quality of dementia care score, adjusting for age and number of medications. RESULTS: We found that improvements in the quality of dementia care following the QAP were larger for men than women (mean difference = 4.97; 95%CI: 0.08, 9.85). We found that men had a larger improvement in four indicators (driving assessments, dementia medication management, Alzheimer Society referrals, and functional status evaluation), while women had a smaller improvement in three (home care needs, behavioural and psychological symptoms of dementia, and weight). Men were prescribed fewer anticholinergics post-QAP, while women were prescribed more. Cognitive testing improved in men but decreased for women following the QAP; the opposite was observed for caregiver needs. CONCLUSION: While the overall quality of care improved after the implementation of the QAP, this study reveals differences in dementia management between men and women. While we identified areas of inequalities in the care received, it is unclear whether this represents inequities in access to care and health outcomes. Future research should focus on better understanding sex and gender-specific needs in dementia to bridge this gap and better inform dementia strategies.

Le Plan Alzheimer québécois, un plan basé sur les soins primaires.

Many countries have answered the call from the World Health Organization, and developed or implemented Alzheimer Plans. Some plans anchored the majority of the care for persons living with dementia in specialized care settings, while others anchored it in primary care. In this article we present the Quebec Alzheimer Plan, which is being implemented in Family Medicine Groups, primary care interdisciplinary clinics, across the Canadian province. The Quebec Alzheimer Plan aims to enable primary healthcare teams of physicians, nurses and/or social workers to provide access to personalized, coordinated assessment and treatment services for people living with dementia and their caregivers. The Quebec Alzheimer Plan enables and empowers primary care clinicians to detect, diagnose, treat and follow-up the vast majority of patients/caregivers. A major strength of the Quebec Alzheimer Plan strategy is the embedded evaluation to inform implementation and its flexibility to allow local adaptations. We are discussing that it is feasible and advantageous to anchor dementia care in an interprofessional primary care setting.

Rural-Urban Differences in Healthcare Use in Persons With Dementia Between 2000 and 2019: A Quebec Population-Based Study.

Background: Rural persons with dementia face medical services gaps. This study compares the health service utilization of rural and urban community-dwelling individuals with incident dementia. Methods: This study used a repeated annual cross-sectional cohort design spanning a period from 2000 to 2019 analyzing age-adjusted rates for 20 indicators of service use and mortality one year after diagnosis in Quebec administrative databases. Results: Of 237,259 persons, 20.1% were rural. Most rural persons had more emergency department visits and hospitalizations, shorter stays, less alternate level of care and fewer family physicians' and cognition specialists' visits. All groups had similar long-term care and mortality rates. Conclusion: Policy implications of these disparities are discussed.

Sex Differences in Healthcare Utilization in Persons Living with Dementia Between 2000 and 2017: A Population-Based Study in Quebec, Canada.

Objectives: Describe sex differences in healthcare utilization and mortality in persons with new dementia in Quebec, Canada. Methods: We conducted a repeated cohort study from 2000 to 2017 using health administrative databases. Community-dwelling persons aged 65+ with a new diagnosis of dementia were included. We measured 23 indicators of healthcare use across five care settings: ambulatory care, pharmacological care, acute hospital care, long-term care, and mortality. Clinically meaningful sex differences in age-standardized rates were determined graphically through expert consultations. Results: Women with dementia had higher rates of ambulatory care and pharmacological care, while men with dementia had higher acute hospital care, admission to long-term care, and mortality. There was no meaningful difference in visits to cognition specialists, antipsychotic prescriptions, and hospital death. Discussion: Men and women with dementia demonstrate differences in healthcare utilization and mortality. Addressing these differences will inform decision-makers, care providers and researchers and guide more equitable policy and interventions in dementia care.

Dashboards to Support Implementation of the Quebec Alzheimer Plan: Evaluation Study With Regional and Professional Considerations.

BACKGROUND: Health organizations face the critical task of executing and overseeing comprehensive health care. To address the challenges associated with this task, evidence-based dashboards have emerged as valuable tools. Since 2016, the regional health organizations of Quebec, Canada, have been responsible for ensuring implementation of the Quebec Alzheimer Plan (QAP), a provincial plan that aims to reinforce the capacity of primary care services to detect, diagnose, and treat persons with dementia. Despite the provincial scope of the QAP, the diverse material and human resources across regions introduce variability in the interest, utility, and specific needs associated with these dashboards. OBJECTIVE: The aim of this study was to assess the interest and utility of dashboards to support the QAP implementation, as well as to determine the needs for improving these aspects according to the perspectives of various types of professionals involved across regions. METHODS: An evaluative study using qualitative methods was conducted within a collaborative research approach involving different stakeholders, including the ministerial advisor and the four project managers responsible for supporting the implementation of the QAP, as well as researchers/scientific advisors. To support these organizations, we developed tailored, 2-page paper dashboards, detailing quantitative data on the prevalence of dementia, the use of health services by persons with dementia, and achievements and challenges of the QAP implementation in each organization's jurisdiction. We then conducted 23 focus groups with the managers and leading clinicians involved in the implementation of the QAP of each regional health organization. Real-time notes were taken using a structured observation grid. Content analysis was conducted according to different regions (organizations with university mandates or nearby organizations, labeled "university/peripheral"; organizations for which only part of the territory is in rural areas, labeled "mixed"; and organizations in remote or isolated areas, labeled "remote/isolated") and according to different types of participants (managers, leading clinicians, and other participants). RESULTS: Participants from organizations in all regions expressed interest in these dashboards and found them useful in several ways. However, they highlighted the need for indicators on orphan patients and other health care providers. Differences between regions were observed, particularly in the interest in continuity of care in university/peripheral regions and the need for diagnostic tools adapted to the culture in remote/isolated regions. CONCLUSIONS: These dashboards support the implementation of an Alzheimer Plan and contribute to the emergence of a learning health care system culture. This project allows each region to increase its monitoring capacity for the implementation of the QAP and facilitates reflection among individuals locally carrying out the implementation. The perspectives expressed will guide the preparation of the next iteration of the dashboards.

The brain-in-motion study: effect of a 6-month aerobic exercise intervention on cerebrovascular regulation and cognitive function in older adults.

BACKGROUND: Aging and physical inactivity are associated with declines in some cognitive domains and cerebrovascular function, as well as an elevated risk of cerebrovascular disease and other morbidities. With the increase in the number of sedentary older Canadians, promoting healthy brain aging is becoming an increasingly important population health issue. Emerging research suggests that higher levels of physical fitness at any age are associated with better cognitive functioning and this may be mediated, at least in part, by improvements in cerebrovascular reserve. We are currently conducting a study to determine: if a structured 6-month aerobic exercise program is associated with improvements or maintenance of both cerebrovascular function and cognitive abilities in older individuals; and, the extent to which any changes seen persist 6 months after the completion of the structured exercise program. METHODS/DESIGN: Two hundred and fifty men and women aged 55-80 years are being enrolled into an 18-month combined quasi-experimental and prospective cohort study. Participants are eligible for enrollment into the study if they are inactive (i.e., not participating in regular physical activity), non-smokers, have a body mass index <35.0 kg/m(2), are free of significant cognitive impairment (defined as a Montreal Cognitive Assessment score of 24 or more), and do not have clinically significant cardiovascular, cerebrovascular disease, or chronic obstructive pulmonary airway disease. Repeated measurements are done during three sequential six-month phases: 1) pre-intervention; 2) aerobic exercise intervention; and 3) post-intervention. These outcomes include: cardiorespiratory fitness, resting cerebral blood flow, cerebrovascular reserve, and cognitive function. DISCUSSION: This is the first study to our knowledge that will examine contemporaneously the effect of an exercise intervention on both cerebrovascular reserve and cognition in an older population. This study will further our understanding of whether cerebrovascular mechanisms might explain how exercise promotes healthy brain aging. In addition our study will address the potential of increasing physical activity to prevent age-associated cognitive decline.

Autobiographical memory in mild cognitive impairment and Alzheimer's disease: a comparison between the Levine and Kopelman interview methodologies.

Previous studies have produced inconsistent results concerning the two components of autobiographical memory--personal semantic memory and episodic memory. Results in subjects with mild cognitive impairment (MCI) and dementia of Alzheimer's type (DAT) have varied concerning the existence of a temporal gradient in retrograde amnesia. These results have important theoretical implications regarding multiple trace theory versus standard consolidation models of long-term memory (LTM). We investigated whether this variability arises from differences in the methods used in assessing autobiographical memory. We examined patterns of memory impairment in 20 healthy elderly controls, 20 MCI subjects, and 10 DAT subjects using the Autobiographical Memory Interview (AMI) of Kopelman and the Autobiographical Interview (AI) of Levine. Both the AMI and AI were modified to allow for the test scores to be derived from a single interview without fatiguing the subjects. On the AMI, DAT subjects were significantly impaired on both components of autobiographical memory--episodic memory and personal semantics--with episodic memory showing a significant though gentle temporal gradient sparing childhood memories. Using the AI test, subjects with DAT showed impaired recall of episodic details (but not personal semantics), again with a gentle temporal gradient. Differences between the two interview methods (fewer epochs in the AMI; fewer memories per epoch in the AI) were found to have a significant impact on the pattern of findings; fewer epochs in the AMI brought out the temporal gradient, and fewer memories per epoch (in the AI) diminished it. These data show the importance of technical details of the different tests in favouring one versus another LTM theory. The data are not purely compatible with either theory.

Word reading threshold and mild cognitive impairment: a validation study.

BACKGROUND: It was previously found, in a pilot study, that Word Reading Threshold (WRT) test is abnormally prolonged in individuals with Alzheimer's disease (AD) and Mild Cognitive Impairment (MCI), with high sensitivity and specificity. This validation study examines the WRT test as a prognostic tool in MCI individuals. We wish to confirm in a larger group the sensitivity and specificity of the WRT test and determine whether it is influenced by deterioration on other cognitive domains. METHODS: We measured WRT in 60 MCI individuals, 29 AD patients, and 33 normal elderly control (NE). We followed the MCI individuals over 8 years to monitor who progressed to dementia. RESULTS: We found a statistically significant difference in WRT scores between the three groups. However, using the same cutoff of 85 milliseconds suggested by Massoud and his colleagues, we found lower diagnostic sensitivity (72%) and specificity (76%) when comparing NC and AD. Furthermore, the test did not clearly differentiate MCI individuals who progressed to dementia from those who did not. WRT was found to correlate to some degree with other cognitive domains, especially attention. CONCLUSIONS: We conclude that the WRT is insufficient alone as a diagnostic tool for prodromal AD.

Description of organizational and clinician characteristics of primary dementia care in Canada: a multi-method study.

BACKGROUND: Organizational and clinician characteristics are important considerations for the implementation of evidence-based recommendations into primary care practice. The introduction of Canadian dementia practice guidelines and Alzheimer strategies offers a unique context to study which of the organizational and clinician characteristics align with good quality care in primary care practices. METHODS: To evaluate the quality of dementia care, we carried out a retrospective chart review in randomly selected patients with a diagnosis of dementia and who had a visit during a 9-month period in 33 primary care practices. We collected data on indicators that were based on existing Canadian evidence-based recommendations to measure a quality of dementia care score. In addition, four questionnaires were administered: two questionnaires to evaluate the organizational characteristics of the practices (dementia-specific and general organization) and two to evaluate the clinician characteristics (one for family physicians and one for nurses). Primary care practices were stratified into tertiles based on their average quality of dementia care score (low, moderate, high). The differences between the groups organizational and clinician questionnaires scores were analyzed descriptively and visually. RESULTS: The mean overall scores for each questionnaire were higher in the high quality of dementia care group. When looking at the breakdown of the overall score into each characteristic, the high-quality group had a higher average score for the dementia-specific organizational characteristics of "access to and coordination with home and community services", "financial support", "training", "coordination and continuity within the practice", and "caregiver support and involvement". The characteristic "Leadership" showed a higher average score for the moderate and high-quality groups than the low-quality group. In both clinician questionnaires, the high group scored better in "attitudes towards the Alzheimer's plan" than the other two groups. CONCLUSIONS: These results suggest that investing in organizational characteristics specifically aimed at dementia care is a promising avenue to improve quality of dementia care in primary care. These results may be useful to enhance the implementation of evidence-based practices and improve the quality of dementia care.

The association between the level of institutional support for dementia care in primary care practices and the quality of dementia primary care: A retrospective chart review.

INTRODUCTION: Institutional support, encompassing financial and training support, as well as interdisciplinary teams, may be important for the quality of dementia primary care for persons living with dementia. The aim of this study was to measure the association between the level of institutional support provided to primary care practices and the quality of dementia care. METHODS: This was a cross-sectional chart review in 33 Canadian primary care practices to measure the quality of dementia primary care using a quality of follow-up score. The score was based on the assessment of 10 indicators. Practices were chosen using a purposeful sampling method with varying levels of institutional support for dementia primary care (e.g., financial support, training, interdisciplinary team). A linear mixed-effect model was used to measure the association between the level of institutional support and the quality of dementia care. RESULTS: There was a significant association between the level of institutional support and the quality of dementia care (mean difference = 23.5, 95% confidence interval: 16.4, 30.6). DISCUSSION: Providing more institutional support for primary care practices could be a promising avenue to improve the care of persons living with dementia.

Chronic stress, cognitive functioning and mental health.

This review aims to discuss the evidence supporting the link between chronic stress, cognitive function and mental health. Over the years, the associations between these concepts have been investigated in different populations. This review summarizes the findings that have emerged from older populations as well as from populations suffering from pathological aging, namely Mild Cognitive Impairment and Alzheimer's Disease. Although older adults are an interesting population to study in terms of chronic stress, other stress-related diseases can occur throughout the lifespan. The second section covers some of these stress-related diseases that have recently received a great deal of attention, namely burnout, depression, and post-traumatic stress disorder. Given that chronic stress contributes to the development of certain pathologies by accelerating and/or exacerbating pre-existing vulnerabilities that vary from one individual to the other, the final section summarizes data obtained on potential variables contributing to the association between chronic stress and cognition.

A transdisciplinary perspective of chronic stress in relation to psychopathology throughout life span development.

The allostatic load (AL) model represents an interdisciplinary approach to comprehensively conceptualize and quantify chronic stress in relation to pathologies throughout the life cycle. This article first reviews the AL model, followed by interactions among early adversity, genetics, environmental toxins, as well as distinctions among sex, gender, and sex hormones as integral antecedents of AL. We next explore perspectives on severe mental illness, dementia, and caregiving as unique human models of AL that merit future investigations in the field of developmental psychopathology. A complimenting transdisciplinary perspective is applied throughout, whereby we argue that the AL model goes beyond traditional stress-disease theories toward the advancement of person-centered research and practice that promote not only physical health but also mental health.

Validation of a Questionnaire for Family Physicians: Knowledge, Attitude, Practice on Dementia Care.

Our study objective was to develop and validate a questionnaire assessing the knowledge, attitude, and practice (KAP) of family physicians regarding dementia care and dementia strategies in Canada. Using a multistage process with a panel of experts, we developed and distributed an 83-item questionnaire to 542 eligible family physicians in 42 interdisciplinary primary care teams participating in the Quebec Alzheimer Plan implementation. Altogether, 369 physicians (68%) returned questionnaires. Median item-specific non-response rate was 0.8 per cent (0.3%-8.1%). Exploratory factor analyses and scale correlation supported the questionnaire validity. The final questionnaire contained five factors and 31 items. The KAP questionnaire has proved to be a reliable instrument for assessing the KAP of family physicians regarding dementia care and dementia strategies. This questionnaire provides researchers, clinicians, managers, and decision-makers with a tool to assess an intervention, a program, or a policy change implemented in primary health care for patients with dementia.

Hospital-at-Home Interventions vs In-Hospital Stay for Patients With Chronic Disease Who Present to the Emergency Department: A Systematic Review and Meta-analysis.

Importance: Hospitalizations are costly and may lead to adverse events; hospital-at-home interventions could be a substitute for in-hospital stays, particularly for patients with chronic diseases who use health services more than other patients. Despite showing promising results, heterogeneity in past systematic reviews remains high. Objective: To systematically review and assess the association between patient outcomes and hospital-at-home interventions as a substitute for in-hospital stay for community-dwelling patients with a chronic disease who present to the emergency department and are offered at least 1 home visit from a nurse and/or physician. Data Sources: Databases were searched from date of inception to March 4, 2019. The databases were Ovid MEDLINE, Ovid Embase, Ovid PsycINFO, CINAHL, Health Technology Assessment, the Cochrane Library, OVID Allied and Complementary Medicine Database, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. Study Selection: Randomized clinical trials in which the experimental group received hospital-at-home interventions and the control group received the usual in-hospital care. Patients were 18 years or older with a chronic disease who presented to the emergency department and received home visits from a nurse or physician. Data Extraction and Synthesis: Risk of bias was assessed, and a meta-analysis was conducted for outcomes that were reported by at least 2 studies using comparable measures. Risk ratios (RRs) were reported for binary outcomes and mean differences for continuous outcomes. Narrative synthesis was performed for other outcomes. Main Outcomes and Measures: Outcomes of interest were patient outcomes, which included mortality, long-term care admission, readmission, length of treatment, out-of-pocket costs, depression and anxiety, quality of life, patient satisfaction, caregiver stress, cognitive status, nutrition, morbidity due to hospitalization, functional status, and neurological deficits. Results: Nine studies were included, providing data on 959 participants (median age, 71.0 years [interquartile range, 70.0-79.9 years]; 613 men [63.9%]; 346 women [36.1%]). Mortality did not differ between the hospital-at-home and the in-hospital care groups (RR, 0.84; 95% CI, 0.61-1.15; I2 = 0%). Risk of readmission was lower (RR, 0.74; 95% CI, 0.57-0.95; I2 = 31%) and length of treatment was longer in the hospital-at-home group than in the in-hospital group (mean difference, 5.45 days; 95% CI, 1.91-8.97 days; I2 = 87%). In addition, the hospital-at-home group had a lower risk of long-term care admission than the in-hospital care group (RR, 0.16; 95% CI, 0.03-0.74; I2 = 0%). Patients who received hospital-at-home interventions had lower depression and anxiety than those who remained in-hospital, but there was no difference in functional status. Other patient outcomes showed mixed results. Conclusions and Relevance: The results of this systematic review and meta-analysis suggest that hospital-at-home interventions represent a viable substitute to an in-hospital stay for patients with chronic diseases who present to the emergency department and who have at least 1 visit from a nurse or physician. Although the heterogeneity of the findings remained high for some outcomes, particularly for length of treatment, the heterogeneity of this study was comparable to that of past reviews and further explored.