Hospital at home early discharge
Abstract
Background
'Early discharge hospital at home' is a service that provides active treatment by health care professionals in the patient's home for a condition that otherwise would require acute hospital in‐patient care. If hospital at home were not available then the patient would remain in an acute hospital ward.
Objectives
To determine, in the context of a systematic review and meta‐analysis, the effectiveness and cost of managing patients with early discharge hospital at home compared with in‐patient hospital care.
Search methods
We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register , MEDLINE (1950 to 2008), EMBASE (1980 to 2008), CINAHL (1982 to 2008) and EconLit through to January 2008. We checked the reference lists of articles identified for potentially relevant articles.
Selection criteria
Randomised controlled trials recruiting patients aged 18 years and over. Studies comparing early discharge hospital at home with acute hospital in‐patient care. Evaluations of obstetric, paediatric and mental health hospital at home schemes are excluded from this review.
Data collection and analysis
Two authors independently extracted data and assessed study quality. Our statistical analyses were done on an intention‐to‐treat basis. We requested individual patient data (IPD) from trialists, and relied on published data when we did not receive trial data sets or the IPD did not include the relevant outcomes. For the IPD meta‐analysis, where at least one event was reported in both study groups in a trial, Cox regression models were used to calculate the log hazard ratio and its standard error for mortality and readmission separately for each data set. The calculated log hazard ratios were combined using fixed‐effect inverse variance meta‐analysis.
Main results
Twenty‐six trials were included in this review [n = 3967]; 21 were eligible for the IPD meta‐analysis and 13 of the 21 trials contributed data [1899/2872; 66%]. For patients recovering from a stroke and elderly patients with a mix of conditions there was insufficient evidence of a difference in mortality between groups (adjusted HR 0.79, 95% CI 0.32 to 1.91; N = 494; and adjusted HR 1.06, 95% CI 0.69 to 1.61; N = 978). Readmission rates were significantly increased for elderly patients with a mix of conditions allocated to hospital at home (adjusted HR 1.57; 95% CI 1.10 to 2.24; N = 705). For patients recovering from a stroke and elderly patients with a mix of conditions respectively, significantly fewer people allocated to hospital at home were in residential care at follow‐up (RR 0.63; 95% CI 0.40 to 0.98; N = 4 trials; RR 0.69, 95% CI 0.48 to 0.99; N =3 trials). Patients reported increased satisfaction with early discharge hospital at home. There was insufficient evidence of a difference for readmission between groups in trials recruiting patients recovering from surgery. Evidence on cost savings was mixed.
Authors' conclusions
Despite increasing interest in the potential of early discharge hospital at home services as a cheaper alternative to in‐patient care, this review provides insufficient objective evidence of economic benefit or improved health outcomes.
PICOs
Plain language summary
Services for patients discharged home early
There continues to be, in some countries, more demand for acute care hospital beds than there are beds. One way to free up beds to make room for other people being admitted is to discharge patients home early. But the patients who are discharged still need acute care. Therefore, special home services have been developed. These services are usually provided by a team of health care professionals, such as doctors, nurses and physiotherapists. The team visits the home of people who have been discharged early to provide them with acute hospital care in their homes.
A review of the effect of services for patients discharged home early was conducted. After searching for all relevant studies, 26 studies were identified. The studies looked at the effect of these services in patients with different types of conditions: patients who had a stroke, patients who had surgery, and elderly patients who had different types of conditions.
There was insufficient evidence that providing services to people at home after being discharged home early may increase the risk of death or readmission; or adversely effect quality of life or the completion of daily activities (such as dressing or daily chores). Patients who had a stroke or elderly patients may have less risk of being admitted to residential care if they are discharged home early with hospital at home services.
Patients may also be more satisfied with their care at home, and at the same time their carers, in most cases, did not report additional burden. However, there is little evidence of cost savings to the health care system of discharging patients home early to hospital at home care.
