A recent Cochrane review gathered evidence on whether admission-avoidance hospital-at-home schemes provide different standards of care to inpatient services
Hospital-at-home services are a popular response in many countries to the increasing demand for acute hospital beds.
While these schemes include both avoiding admission and enabling early discharge, recently the emphasis has been on avoiding admission. Cutting costs is the main goal – other benefits include reducing the risk of adverse events and rehabilitating patients in their home environment.
Staff in admission-avoidance hospital-at-home services provide active treatment in patients’ homes for conditions that would otherwise require acute inpatient care.
It is not known whether such services lead to better or the same health outcomes compared with inpatient care.
What evidence did the review find?
This Cochrane review looked at the effectiveness and cost of managing patients by admission-avoidance hospital-at-home services compared with inpatient care. Issues examined included health outcomes, patient satisfaction and costs.
The authors carried out a systematic review and meta-analysis. They requested individual patient data (IPD) and used published data when they did not have access to this. The reviewers included 10 randomised controlled trials (with a total of 1,333 participants).
The authors combined individual patient data for five trials recording the time to death at three months’ follow-up, and for three trials with six months’ follow-up, adjusted for age and sex.
There was a non-significant reduction in death at three months for the admission-avoidance hospital-at-home group. This reached significance at six months’ follow-up.
One trial compared inpatient stroke unit care, inpatient stroke team care and hospital-at-home care. A significant reduction in death at three months was reported for those receiving stroke unit care compared with hospital-at-home care, with a non-significant reduction at six months.
Patients allocated to hospital-at-home care reported significantly higher levels of satisfaction across a range of conditions.
Among patients with cellulitis, 27% more in the hospital-at-home group were satisfied with place of care than those in hospital. Of those with community-acquired pneumonia, 40% more in a hospital-at-home scheme reported they were happy with their care. Two trials with mainly older patients with a mix of conditions also found those receiving hospital-at-home care were more satisfied.
Four trials looked at different clinical outcomes. One measured adverse events and medical complications, finding that fewer patients allocated to hospital-at-home care reported bowel or urinary complications. In a trial looking at patients with dementia, fewer in the hospital-at-home group were prescribed antipsychotic drugs at discharge. No difference was reported in the advancement of cellulitis in another study. A trial that recruited patients with COPD reported that significantly more were prescribed an antibiotic if allocated to hospital-at-home care.
A non-significant increase in admissions was observed in hospital-at-home care. Few differences were reported for functional ability, quality of life or cognitive ability.
Two trials conducted a full economic analysis. In one of these, hospital-at-home care was less expensive using an on-treatment analysis, but became more expensive with an intention-to-treat analysis (based on the initial treatment intent, not on the treatment given). In the other trial, hospital-at-home care was cheaper than inpatient stroke team care if the costs of informal care were excluded.
What did the review conclude?
Patients allocated to hospital-at-home care had a significantly reduced risk of death at six months. This was not significant at three months, possibly reflecting the lower number of events by that point.
The authors stress that this should not be taken as evidence that hospital care is hazardous. They say that there is no evidence to suggest that admission-avoidance hospital-at-home care leads to different outcomes. They conclude that admission-avoidance hospital-at-home can provide an effective alternative for certain older patients.
Determining which groups are most likely to benefit and to which other groups the results apply is not simple, as the study has some limitations. The authors point out that the degree of patient selection may reflect the high levels of satisfaction, with those taking part preferring to be treated at home.
While admission-avoidance hospital-at-home care provides an alternative to inpatient care for some patients, the authors argue that some patients will still need hospital services. Hospital-at-home care could supplement existing services. Future primary research should continue to measure mortality and readmission, with particular attention to transfer of patients between hospital-at-home and inpatient care. Trials should also include a formal, planned economic analysis.
Shepperd, S. et al (2008) Admission avoidance hospital at home. Cochrane Database of Systematic Reviews; Issue 4. Art. No: CD007491. DOI:10.1002/14651858.CD007491.