Hospital at home admission avoidance
Abstract
Background
Admission avoidance 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, and always for a limited time period. In particular, hospital at home has to offer a specific service to patients in their home requiring health care professionals to take an active part in the patients' care. If hospital at home were not available then the patient would be admitted to an acute hospital ward. Many countries are adopting this type of care in an attempt to reduce the demand for acute hospital admission.
Objectives
To determine, in the context of a systematic review and meta analysis, the effectiveness and cost of managing patients with admission avoidance hospital at home compared with in‐patient hospital care.
Search methods
The following databases were searched through to January 2008: MEDLINE, EMBASE, CINAHL, EconLit and the Cochrane Effective Practice and Organisation of Care Group (EPOC) register. We checked the reference lists of articles identified electronically for evaluations of hospital at home and obtained potentially relevant articles. Unpublished studies were sought by contacting providers and researchers who were known to be involved in this field.
Selection criteria
Randomised controlled trials recruiting patients aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital in‐patient care. The admission avoidance hospital at home interventions may admit patients directly from the community thereby avoiding physical contact with the hospital, or may admit from the emergency room.
Data collection and analysis
Two authors independently extracted data and assessed study quality. Our statistical analyses sought to include all randomised patients and 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. When combining outcome data was not possible because of differences in the reporting of outcomes we have presented the data in narrative summary tables.
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 (where both outcomes were available). We included randomisation group (admission avoidance hospital at home versus control), age (above or below the median), and gender in the models. The calculated log hazard ratios were combined using fixed effects inverse variance meta analysis. If there were no events in one group we used the Peto odds ratio method to calculate a log odds ratio from the sum of the log‐rank test 'O‐E' statistics from a Kaplan Meier survival analysis. Statistical significance throughout was taken at the two‐sided 5% level (p<0.05) and data are presented as the estimated effect with 95% confidence intervals. For each comparison using published data for dichotomous outcomes we calculated risk ratios using a fixed effects model to combine data.
Main results
We included 10 RCTs (n=1333), seven of which were eligible for the IPD. Five out of these seven trials contributed to the IPD meta‐analysis (n=850/975; 87%). There was a non significant reduction in mortality at three months for the admission avoidance hospital at home group (adjusted HR 0.77, 95% CI 0.54 to 1.09; p=0.15), which reached significance at six months follow‐up (adjusted HR 0.62, 95% CI 0.45 to 0.87; p=0.005). A non significant increase in admissions was observed for patients allocated to hospital at home (adjusted HR 1.49, 95% CI 0.96 to 2.33; p=0.08). Few differences were reported for functional ability, quality of life or cognitive ability. Patients reported increased satisfaction with admission avoidance hospital at home. Two trials conducted a full economic analysis, when the costs of informal care were excluded admission avoidance hospital at home was less expensive than admission to an acute hospital ward.
Authors' conclusions
We performed meta‐analyses where there was sufficient similarity among the trials and where common outcomes had been measured. There is no evidence from the analysis to suggest that admission avoidance hospital at home leads to outcomes that differ from inpatient hospital care.
PICOs
Plain language summary
'Hospital at home' services to avoid admission to hospital
There continues to be, in some countries, more demand for acute care hospital beds than there are beds. One way to decrease or avoid admissions to hospital is to provide people with acute care treatment at home.
Special services have been developed which provide people with hospital care in their homes. Typically, these people would require treatment in an acute care hospital for a period of time. Instead, a team of health care professionals, such as doctors, nurses and physiotherapists, provide them with their treatment while they are at home. Many times, if the service is available, people can avoid the hospital altogether and be referred by their family doctor to receive the service, or be referred after visiting the emergency room. The key is that if the hospital at home service was not available, then the patient would need to be admitted to an acute hospital ward.
A review of the effect of hospital at home services to avoid admission was conducted. After searching for all relevant studies, 10 studies were found. The evidence shows that when compared to in‐hospital care, hospital at home services may reduce the chances of dying. However, later on, admissions to hospital may increase. Admission avoidance hospital at home may not reduce or improve quality of life, function, or cognitive abilities (such as mental alertness and thinking) more than in hospital care. And while it may improve satisfaction in people at home, it is not known how it affects the carers of the people at home. With respect to costs, hospital at home services may be less expensive than in hospital care.
From this review however, it is not known which people would most benefit from hospital at home services. Although in these studies, most people were on average 70 to 80 years old. It is also not clear how the current state of the health system in a country would modify the effect of a hospital at home service.
