Randomised controlled trial comparing hospital at home care with inpatient hospital care. II: cost minimisation analysis

Cost-effectiveness of home care compared to hospital care in patients with chronic obstructive pulmonary disease (COPD): a systematic review

Background

To compare, through a systematic literature review, the cost-effectiveness ratio of home care compared to hospital care for following up patients with chronic obstructive pulmonary disease (COPD).

Methods

This review was registered in PROSPERO, and the bibliographic search was performed in six primary databases [MedLine (via PubMed), Scopus, LILACS, SciELO, Web of Science, and Embase], two dedicated databases for economic studies (NHS Economic Evaluation Database (NHS EED) and Cost-Effectiveness Analysis (CEA) Registry), and two databases for partially searching the "gray literature" (DansEasy and ProQuest). This review only included studies that compared home and hospital care for patients diagnosed with COPD, regardless of publication year or language. Two reviewers selected the studies, extracted the data, and assessed the risk of bias independently. A JBI tool was used for risk of bias assessment.

Results and discussion

7,279 studies were found, of which 14 met the eligibility criteria. Only one study adequately met all items of the risk of bias assessment. Thirteen studies found lower costs and higher effectiveness for home care. Home care showed a better cost-effectiveness ratio than hospital care for COPD patients. Regarding effectiveness, there is no possibility of choosing a more effective care for COPD patients, given the incipience of the data presented on eligible studies. However, considering the analyzed data refer only to high-income countries, caution is required when extrapolating this conclusion to low- and low-middle-income countries.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022319488.

Inpatient-level care at home delivered by virtual wards and hospital at home: a systematic review and meta-analysis of complex interventions and their components

BACKGROUND

Technology-enabled inpatient-level care at home services, such as virtual wards and hospital at home, are being rapidly implemented. This is the first systematic review to link the components of these service delivery innovations to evidence of effectiveness to explore implications for practice and research.

METHODS

For this review (registered here https://osf.io/je39y ), we searched Cochrane-recommended multiple databases up to 30 November 2022 and additional resources for randomised and non-randomised studies that compared technology-enabled inpatient-level care at home with hospital-based inpatient care. We classified interventions into care model groups using three key components: clinical activities, workforce, and technology. We synthesised evidence by these groups quantitatively or narratively for mortality, hospital readmissions, cost-effectiveness and length of stay.

RESULTS

We include 69 studies: 38 randomised studies (6413 participants; largely judged as low or unclear risk of bias) and 31 non-randomised studies (31,950 participants; largely judged at serious or critical risk of bias). The 69 studies described 63 interventions which formed eight model groups. Most models, regardless of using low- or high-intensity technology, may have similar or reduced hospital readmission risk compared with hospital-based inpatient care (low-certainty evidence from randomised trials). For mortality, most models had uncertain or unavailable evidence. Two exceptions were low technology-enabled models that involve hospital- and community-based professionals, they may have similar mortality risk compared with hospital-based inpatient care (low- or moderate-certainty evidence from randomised trials). Cost-effectiveness evidence is unavailable for high technology-enabled models, but sparse evidence suggests the low technology-enabled multidisciplinary care delivered by hospital-based teams appears more cost-effective than hospital-based care for those with chronic obstructive pulmonary disease (COPD) exacerbations.

CONCLUSIONS

Low-certainty evidence suggests that none of technology-enabled care at home models we explored put people at higher risk of readmission compared with hospital-based care. Where limited evidence on mortality is available, there appears to be no additional risk of mortality due to use of technology-enabled at home models. It is unclear whether inpatient-level care at home using higher levels of technology confers additional benefits. Further research should focus on clearly defined interventions in high-priority populations and include comparative cost-effectiveness evaluation.

TRIAL REGISTRATION

https://osf.io/je39y .

The Cost-Effectiveness of Homecare Services for Adults and Older Adults: A Systematic Review

This study provides an overview of the literature on the cost-effectiveness of homecare services compared to in-hospital care for adults and older adults. A systematic review was performed using Medline, Embase, Scopus, Web of Science, CINAHL and CENTRAL databases from inception to April 2022. The inclusion criteria were as follows: (i) (older) adults; (ii) homecare as an intervention; (iii) hospital care as a comparison; (iv) a full economic evaluation examining both costs and consequences; and (v) economic evaluations arising from randomized controlled trials (RCTs). Two independent reviewers selected the studies, extracted data and assessed study quality. Of the 14 studies identified, homecare, when compared to hospital care, was cost-saving in seven studies, cost-effective in two and more effective in one. The evidence suggests that homecare interventions are likely to be cost-saving and as effective as hospital. However, the included studies differ regarding the methods used, the types of costs and the patient populations of interest. In addition, methodological limitations were identified in some studies. Definitive conclusions are limited and highlight the need for better standardization of economic evaluations in this area. Further economic evaluations arising from well-designed RCTs would allow healthcare decision-makers to feel more confident in considering homecare interventions.

The risk of overestimating cost savings from hospital-at-home schemes: A literature review

BACKGROUND

The concept of hospital-at-home means that home treatment is provided to patients who would otherwise have been treated in the hospital. This may lead to lower costs, but estimates of savings may be overstated if inpatient hospital costs are priced incorrectly.

OBJECTIVE

The objective of this study was to evaluate the quality of cost analyses of hospital-at-home studies for acute conditions published from 1996 through 2019 and to present an overview of evidence.

DESIGN

Literature review DATA SOURCES: The PubMed and NHS EED databases were searched.

REVIEW METHODS

The overall quality of studies was evaluated based on Quality of Health Economic Studies (QHES) score, design, sample size, alignment of cost calculation with study perspective, time horizon, use of tariffs or real resource use and clarity of calculations. Furthermore, we systematically assessed whether cost savings were likely to be overestimated, based on criteria about the costing of inpatient hospital days, informal care costs and bias.

RESULTS

We identified 48 studies. The average QHES score was 60 out of a maximum of 100 points. Almost all studies violated one or more criteria for the risk of overestimation of cost savings. The most frequent problems were the use of average unit prices per inpatient day (not taking into account the decreasing intensity of care) and biased designs. Most studies found cost differences in favour of hospital-at-home; the range varied from savings of €8773 to a cost increase of €2316 per patient.

CONCLUSION

Overall quality of studies was not good, with some exceptions. Many cost savings were probably overestimated.

Place of Death and Use of Health Services in the Last Year of Life

Aim

To investigate whether health service input in the last year of life differs between cancer patients who die at home versus those dying in inpatient care.

Methods

Post hoc exploratory case-control study of 127 home deaths and 200 inpatient deaths. Retrospective electronic record linkage of patients’ community and inpatient care during the last year of life.

Results

Patients who died at home began their home nursing care closer to death than those who died as inpatients. Their first contact with inpatient hospice care began further from death. Before their final month, home death patients also had more specialist and district nursing than patients who died in inpatient care.

Conclusions

Patients who began their home nursing early were less likely to die at home than those who began such care late. This suggests that it may be difficult to sustain end-of-life care at home for an extended period. Further research incorporating assessment of informal care input and disease trajectory is required to investigate this issue.

Cost analysis of improving emergency care for aged care residents under a Hospital in the Nursing Home program in Australia

Background

This study aims to examine the costs associated with a Hospital in the Nursing Home (HiNH) program in Queensland Australia directed at patients from residential aged care facilities (RACFs) with emergency care needs.

Methods

A cost analysis was undertaken comparing the costs under the HiNH program and the current practice, in parallel with a pre-post controlled study design. The study was conducted in two Queensland public hospitals: the Royal Brisbane and Women’s Hospital (intervention hospital) and the Logan Hospital (control hospital). Main outcome measures were the associated incremental costs or savings concerning the HiNH program provision and the acute hospital care utilisation over one year after intervention.

Results

The initial deterministic analysis calculated the total induced mean costs associated with providing the HiNH program over one year as AU$488,116, and the total induced savings relating to acute hospital care service utilisation of AU$8,659,788. The total net costs to the health service providers were thus calculated at -AU$8,171,671 per annum. Results from the probabilistic sensitivity analysis (based on 10,000 simulations) showed the mean and median annual net costs associated with the HiNH program implementation were -AU$8,444,512 and–AU$8,202,676, and a standard deviation of 2,955,346. There was 95% certainty that the values of net costs would fall within the range from -AU$15,018,055 to -AU$3,358,820.

Conclusions

The costs relating to implementing the HiNH program appear to be much less than the savings in terms of associated decreases in acute hospital service utilisation. The HiNH service model is likely to have the cost-saving potential while improving the emergency care provision for RACF residents.

Home-Based Compared with Hospital-Based Rehabilitation Program for Patients Undergoing Total Knee Arthroplasty for Osteoarthritis: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

The aim of this study was to compare the effects of home-based with those of hospital-based rehabilitation on patients undergoing total knee arthroplasty (TKA).

DESIGN

PubMed, Web of Science, EMBASE, and Cochrane Library were systematically searched for randomized controlled trials; the studies were assessed with the modified Jadad scale. Ten trials involving 1240 patients were eligible for meta-analysis.

RESULTS

The results revealed that home-based rehabilitation is not inferior to hospital-based rehabilitation according to the total Western Ontario and McMaster Universities Osteoarthritis index score, physical function, stiffness, walk test, and Oxford Knee Score at 12 or 52 weeks after TKA (P > 0.05). Neither pain nor knee flexion range of motion differed between the groups in the first 12 weeks. Unexpectedly, the pain score in the hospital-based group was better than that in the home-based group (P < 0.05), whereas the knee flexion range of motion in the home-based group was superior to that in the hospital-based group (P < 0.05) at 52 weeks. The meta-analysis revealed that the 2 rehabilitation programs have similar costs (P > 0.05).

CONCLUSION

Home-based rehabilitation after primary TKA was comparable to hospital-based rehabilitation and thus is a significant alternative for patients.

Early supported discharge services for people with acute stroke

BACKGROUND

People with stroke conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed that offer people in hospital an early discharge with rehabilitation at home (early supported discharge: ESD).

OBJECTIVES

To establish if, in comparison with conventional care, services that offer people in hospital with stroke a policy of early discharge with rehabilitation provided in the community (ESD) can: 1) accelerate return home, 2) provide equivalent or better patient and carer outcomes, 3) be acceptable satisfactory to patients and carers, and 4) have justifiable resource implications use.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (January 2017), Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1) in the Cochrane Library (searched January 2017), MEDLINE in Ovid (searched January 2017), Embase in Ovid (searched January 2017), CINAHL in EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to December 2016), and Web of Science (to January 2017). In an effort to identify further published, unpublished, and ongoing trials we searched six trial registries (March 2017). We also performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists.

SELECTION CRITERIA

Randomised controlled trials (RCTs) recruiting stroke patients in hospital to receive either conventional care or any service intervention that has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care.

DATA COLLECTION AND ANALYSIS

The primary patient outcome was the composite end-point of death or long-term dependency recorded at the end of scheduled follow-up. Two review authors scrutinised trials, categorised them on their eligibility and extracted data. Where possible we sought standardised data from the primary trialists. We analysed the results for all trials and for subgroups of patients and services, in particular whether the intervention was provided by a co-ordinated multidisciplinary team (co-ordinated ESD team) or not. We assessed risk of bias for the included trials and used GRADE to assess the quality of the body of evidence.

MAIN RESULTS

We included 17 trials, recruiting 2422 participants, for which outcome data are currently available. Participants tended to be a selected elderly group of stroke survivors with moderate disability. The ESD group showed reductions in the length of hospital stay equivalent to approximately six days (mean difference (MD) -5.5; 95% confidence interval (CI) -3 to -8 days; P < 0.0001; moderate-grade evidence). The primary outcome was available for 16 trials (2359 participants). Overall, the odds ratios (OR) for the outcome of death or dependency at the end of scheduled follow-up (median 6 months; range 3 to 12) was OR 0.80 (95% CI 0.67 to 0.95, P = 0.01, moderate-grade evidence) which equates to five fewer adverse outcomes per 100 patients receiving ESD. The results for death (16 trials; 2116 participants) and death or requiring institutional care (12 trials; 1664 participants) were OR 1.04 (95% CI 0.77 to 1.40, P = 0.81, moderate-grade evidence) and OR 0.75 (95% CI 0.59 to 0.96, P = 0.02, moderate-grade evidence), respectively. Small improvements were also seen in participants' extended activities of daily living scores (standardised mean difference (SMD) 0.14, 95% CI 0.03 to 0.25, P = 0.01, low-grade evidence) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, P = 0.02, low-grade evidence). We saw no clear differences in participants' activities of daily living scores, patients subjective health status or mood, or the subjective health status, mood or satisfaction with services of carers. We found low-quality evidence that the risk of readmission to hospital was similar in the ESD and conventional care group (OR 1.09, 95% CI 0.79 to 1.51, P = 0.59, low-grade evidence). The evidence for the apparent benefits were weaker at one- and five-year follow-up. Estimated costs from six individual trials ranged from 23% lower to 15% greater for the ESD group in comparison to usual care.In a series of pre-planned analyses, the greatest reductions in death or dependency were seen in the trials evaluating a co-ordinated ESD team with a suggestion of poorer results in those services without a co-ordinated team (subgroup interaction at P = 0.06). Stroke patients with mild to moderate disability at baseline showed greater reductions in death or dependency than those with more severe stroke (subgroup interaction at P = 0.04).

AUTHORS' CONCLUSIONS

Appropriately resourced ESD services with co-ordinated multidisciplinary team input provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as reducing the length of hospital stay. Results are inconclusive for services without co-ordinated multidisciplinary team input. We observed no adverse impact on the mood or subjective health status of patients or carers, nor on readmission to hospital.

Early discharge hospital at home

BACKGROUND

Early discharge hospital at home is a service that provides active treatment by healthcare professionals in the patient's home for a condition that otherwise would require acute hospital inpatient care. This is an update of a Cochrane review.

OBJECTIVES

To determine the effectiveness and cost of managing patients with early discharge hospital at home compared with inpatient hospital care.

SEARCH METHODS

We searched the following databases to 9 January 2017: the Cochrane Effective Practice and Organisation of Care Group (EPOC) register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and EconLit. We searched clinical trials registries.

SELECTION CRITERIA

Randomised trials comparing early discharge hospital at home with acute hospital inpatient care for adults. We excluded obstetric, paediatric and mental health hospital at home schemes.   DATA COLLECTION AND ANALYSIS: We followed the standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes.

MAIN RESULTS

We included 32 trials (N = 4746), six of them new for this update, mainly conducted in high-income countries. We judged most of the studies to have a low or unclear risk of bias. The intervention was delivered by hospital outreach services (17 trials), community-based services (11 trials), and was co-ordinated by a hospital-based stroke team or physician in conjunction with community-based services in four trials.Studies recruiting people recovering from strokeEarly discharge hospital at home probably makes little or no difference to mortality at three to six months (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.57 to 1.48, N = 1114, 11 trials, moderate-certainty evidence) and may make little or no difference to the risk of hospital readmission (RR 1.09, 95% CI 0.71 to 1.66, N = 345, 5 trials, low-certainty evidence). Hospital at home may lower the risk of living in institutional setting at six months (RR 0.63, 96% CI 0.40 to 0.98; N = 574, 4 trials, low-certainty evidence) and might slightly improve patient satisfaction (N = 795, low-certainty evidence). Hospital at home probably reduces hospital length of stay, as moderate-certainty evidence found that people assigned to hospital at home are discharged from the intervention about seven days earlier than people receiving inpatient care (95% CI 10.19 to 3.17 days earlier, N = 528, 4 trials). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).Studies recruiting people with a mix of medical conditionsEarly discharge hospital at home probably makes little or no difference to mortality (RR 1.07, 95% CI 0.76 to 1.49; N = 1247, 8 trials, moderate-certainty evidence). In people with chronic obstructive pulmonary disease (COPD) there was insufficient information to determine the effect of these two approaches on mortality (RR 0.53, 95% CI 0.25 to 1.12, N = 496, 5 trials, low-certainty evidence). The intervention probably increases the risk of hospital readmission in a mix of medical conditions, although the results are also compatible with no difference and a relatively large increase in the risk of readmission (RR 1.25, 95% CI 0.98 to 1.58, N = 1276, 9 trials, moderate-certainty evidence). Early discharge hospital at home may decrease the risk of readmission for people with COPD (RR 0.86, 95% CI 0.66 to 1.13, N = 496, 5 trials low-certainty evidence). Hospital at home may lower the risk of living in an institutional setting (RR 0.69, 0.48 to 0.99; N = 484, 3 trials, low-certainty evidence). The intervention might slightly improve patient satisfaction (N = 900, low-certainty evidence). The effect of early discharge hospital at home on hospital length of stay for older patients with a mix of conditions ranged from a reduction of 20 days to a reduction of less than half a day (moderate-certainty evidence, N = 767). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).Studies recruiting people undergoing elective surgeryThree studies did not report higher rates of mortality with hospital at home compared with inpatient care (data not pooled, N = 856, low-certainty evidence; mainly orthopaedic surgery). Hospital at home may lead to little or no difference in readmission to hospital for people who were mainly recovering from orthopaedic surgery (N = 1229, low-certainty evidence). We could not establish the effects of hospital at home on the risk of living in institutional care, due to a lack of data. The intervention might slightly improve patient satisfaction (N = 1229, low-certainty evidence). People recovering from orthopaedic surgery allocated to early discharge hospital at home were discharged from the intervention on average four days earlier than people allocated to usual inpatient care (4.44 days earlier, 95% CI 6.37 to 2.51 days earlier, , N = 411, 4 trials, moderate-certainty evidence). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).

AUTHORS' CONCLUSIONS

Despite increasing interest in the potential of early discharge hospital at home services as a less expensive alternative to inpatient care, this review provides insufficient evidence of economic benefit (through a reduction in hospital length of stay) or improved health outcomes.

The development of an evaluation framework for a Hospital at Home service

Purpose

– The purpose of this paper is to share good practice with interested professionals, commissioners and health service managers regarding the development of an evidence-based approach to evaluation of an integrated care service providing acute level care for patients in their own homes in South London called the Guys and St Thomas’ @home service.

Design/methodology/approach

– A literature review related to Hospital at Home (HH) schemes was carried out with an aim of scoping approaches used during previous evaluations of HH type interventions to inform the development of an evaluation strategy for @home. The results of the review were then applied to the Donabedian conceptual model: Structure; Process; and Outcome and contextualised to the population being served by the scheme to ensure a robust, practical and comprehensive approach to evaluation.

Findings

– Due to the heterogeneity of the studies it was not possible to conduct a systematic review or meta-analysis. In total, 28 studies were identified that met the inclusion criteria and included both HH to facilitate early discharge and admission prevention across a wide range of conditions. The key finding was there is a dearth of literature evaluating staff preparation to work on HH, models of delivery, specifically integrated care and trans-disciplinary working and few studies included the experiences of family carers.

Originality/value

– This paper will be of value to those involved in the commissioning and delivery of HH and other models of integrated care services type services and will help to inform evaluation strategies that are practical, evidence based and include all stakeholder perspectives.

Home Health Care (HHC) Managers Perceptions About Challenges and Obstacles that Hinder HHC Services in Jordan

Home care aims at supporting people with various degrees of dependency to remain at home rather than use residential, long-term, or institutional-based nursing care. Demographic, epidemiological, social, and cultural trends in Jordan as in other countries are changing the traditional patterns of care with growing emphasis on home care. The purpose of this study is to highlight the most common challenges related to home health care (HHC) services in Jordan as perceived by the managers of HHC agencies.

METHODS

A descriptive qualitative design that depends on focus group discussions has been used to collect data from a sample of 18 managers who met the selection criteria and who are willing to participate, the study found that, the main challenges of HHC services as perceived by managers were: shortage of female staff, lack of governance and regulation, poor management, unethical practices, lack of referral systems, and low accessibility of the poor and less privileged as HHC services are not included in health insurance schemes, it concludes also that the home health care industry in Jordan is facing many challenges and problems that may have negative effects on the effectiveness, efficiency, equity and quality of services and should be addressed by health policy makers.

Incremental analysis of the reengineering of an outpatient billing process: an empirical study in a public hospital

BACKGROUND

A smartcard is an integrated circuit card that provides identification, authentication, data storage, and application processing. Among other functions, smartcards can serve as credit and ATM cards and can be used to pay various invoices using a 'reader'. This study looks at the unit cost and activity time of both a traditional cash billing service and a newly introduced smartcard billing service in an outpatient department in a hospital in Taipei, Taiwan.

METHODS

The activity time required in using the cash billing service was determined via a time and motion study. A cost analysis was used to compare the unit costs of the two services. A sensitivity analysis was also performed to determine the effect of smartcard use and number of cashier windows on incremental cost and waiting time.

RESULTS

Overall, the smartcard system had a higher unit cost because of the additional service fees and business tax, but it reduced patient waiting time by at least 8 minutes. Thus, it is a convenient service for patients. In addition, if half of all outpatients used smartcards to pay their invoices, along with four cashier windows for cash payments, then the waiting time of cash service users could be reduced by approximately 3 minutes and the incremental cost would be close to breaking even (even though it has a higher overall unit cost that the traditional service).

CONCLUSIONS

Traditional cash billing services are time consuming and require patients to carry large sums of money. Smartcard services enable patients to pay their bill immediately in the outpatient clinic and offer greater security and convenience. The idle time of nurses could also be reduced as they help to process smartcard payments. A reduction in idle time reduces hospital costs. However, the cost of the smartcard service is higher than the cash service and, as such, hospital administrators must weigh the costs and benefits of introducing a smartcard service. In addition to the obvious benefits of the smartcard service, there is also scope to extend its use in a hospital setting to include the notification of patient arrival and use in other departments.

Cost-effectiveness of early assisted discharge for COPD exacerbations in The Netherlands

OBJECTIVES

Hospital admissions for exacerbations of chronic obstructive pulmonary disease are the main cost drivers of the disease. An alternative is to treat suitable patients at home instead of in the hospital. This article reports on the cost-effectiveness and cost-utility of early assisted discharge in The Netherlands.

METHODS

In the multicenter randomized controlled Assessment of GOing Home under Early Assisted Discharge trial (n = 139), one group received 7 days of inpatient hospital treatment (HOSP) and one group was discharged after 3 days and treated at home by community nurses for 4 days. Health care resource use, productivity losses, and informal care were recorded in cost questionnaires. Microcosting was performed for inpatient day costs.

RESULTS

Seven days after admission, mean change from baseline Clinical Chronic Obstructive Pulmonary Disease Questionnaire score was better for HOSP, but not statistically significantly: 0.29 (95% confidence interval [CI]-0.04 to 0.61). The difference in the probability of having a clinically relevant improvement was significant in favor of HOSP: 19.0%-point (95% CI 0.5%-36.3%). After 3 months of follow-up, differences in effectiveness had almost disappeared. The difference in quality-adjusted life-years was 0.0054 (95% CI-0.021 to 0.0095). From a health care perspective, early assisted discharge was cost saving:-€244 (treatment phase, 95% CI-€315 to-€168) and-€168 (3 months, 95% CI-€1253 to €922). Societal perspective:-€65 (treatment phase, 95% CI-€152 to €25) and €908 (3 months, 95% CI-€553 to €2296). The savings per quality-adjusted life-year lost were €31,111 from a health care perspective. From a societal perspective, HOSP was dominant.

CONCLUSIONS

No clear evidence was found to conclude that either treatment was more effective or less costly.

Patient evaluation of early discharge after hip arthroplasty: development of a measure and comparison of three centres with differing durations of stay

OBJECTIVE

We compared patients' evaluation of care between a surgical unit with a rapid discharge policy and two comparison units to test the hypothesis that the centre with rapid discharge has outcomes that are not inferior to those of the comparison sites.

DESIGN

Cross-sectional cohort study.

SUBJECTS

Consecutive consenting patients undergoing primary hip arthroplasty during 12 months in: a unit that had reduced postoperative stay to median three days; a specialised orthopaedic surgery treatment centre with median stay of five days; a traditional unit with median stay of six days (N = 316, 125, 119, respectively).

METHODS

Six weeks postoperatively, patients completed a specially developed questionnaire measuring their evaluation of care and recovery, together with measures of function and quality of life for validation purposes.

RESULTS

Factor analysis of questionnaire responses identified two independent components of patients' evaluation: problems in staff care and problems in physical recovery. Neither component was impaired in the unit with rapid discharge: similar proportions of patients reported recovery problems in each site (odds radios (ORs) for the two comparators versus unit with rapid discharge: 0.96, 1.18); and more patients reported care problems in the two comparator sites (ORs 2.97, 2.16).

CONCLUSION

Duration of stay after primary hip arthroplasty can be reduced to three days without intensive pre- or postoperative care, without detriment to patient evaluation.

Services for reducing duration of hospital care for acute stroke patients

BACKGROUND

Stroke patients conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed which offer patients in hospital an early discharge with rehabilitation at home (early supported discharge (ESD)).

OBJECTIVES

To establish the effects and costs of ESD services compared with conventional services.

SEARCH METHODS

We searched the trials registers of the Cochrane Stroke Group (January 2012) and the Cochrane Effective Practice and Organisation of Care (EPOC) Group, MEDLINE (2008 to 7 February 2012), EMBASE (2008 to 7 February 2012) and CINAHL (1982 to 7 February 2012). In an effort to identify further published, unpublished and ongoing trials we searched 17 trial registers (February 2012), performed citation tracking of included studies, checked reference lists of relevant articles and contacted trialists.

SELECTION CRITERIA

Randomised controlled trials recruiting stroke patients in hospital to receive either conventional care or any service intervention which has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care.

DATA COLLECTION AND ANALYSIS

The primary patient outcome was the composite end-point of death or long-term dependency recorded at the end of scheduled follow-up. Two review authors scrutinised trials and categorised them on their eligibility. We then sought standardised individual patient data from the primary trialists. We analysed the results for all trials and for subgroups of patients and services, in particular whether the intervention was provided by a co-ordinated multidisciplinary team (co-ordinated ESD team) or not.

MAIN RESULTS

Outcome data are currently available for 14 trials (1957 patients). Patients tended to be a selected elderly group with moderate disability. The ESD group showed significant reductions (P < 0.0001) in the length of hospital stay equivalent to approximately seven days. Overall, the odds ratios (OR) (95% confidence interval (CI)) for death, death or institutionalisation, death or dependency at the end of scheduled follow-up were OR 0.91 (95% CI 0.67 to 1.25, P = 0.58), OR 0.78 (95% CI 0.61 to 1.00, P = 0.05) and OR 0.80 (95% CI 0.67 to 0.97, P = 0.02) respectively. The greatest benefits were seen in the trials evaluating a co-ordinated ESD team and in stroke patients with mild to moderate disability. Improvements were also seen in patients' extended activities of daily living scores (standardised mean difference 0.12, 95% CI 0.00 to 0.25, P = 0.05) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, P = 0.02) but no statistically significant differences were seen in carers' subjective health status, mood or satisfaction with services. The apparent benefits were no longer statistically significant at five-year follow-up.

AUTHORS' CONCLUSIONS

Appropriately resourced ESD services provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as reducing the length of hospital stay. We observed no adverse impact on the mood or subjective health status of patients or carers.

Hospital at home for acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Hospital at home schemes are a recently adopted method of service delivery for the management of acute exacerbations of chronic obstructive pulmonary disease (COPD) aimed at reducing demand for acute hospital inpatient beds and promoting a patient-centred approach through admission avoidance. However, evidence in support of such a service is contradictory.

OBJECTIVES

To evaluate the efficacy of hospital at home compared to hospital inpatient care in acute exacerbations of COPD.

SEARCH METHODS

Trials were identified from searches of electronic databases, including CENTRAL, MEDLINE, EMBASE, and the Cochrane Airways Group Register (CAGR). The review authors checked the reference lists of included trials. The CAGR was searched up to February 2012. The additional databases were searched up to October 2010.

SELECTION CRITERIA

We considered randomised controlled trials where patients presented to the emergency department with an exacerbation of their COPD. Studies must not have recruited patients for whom treatment at home is usually not viewed as an responsible option (e.g. patients with an impaired level of consciousness, acute confusion, acute changes on the radiograph or electrocardiogram, arterial pH less than 7.35, concomitant medical conditions).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected articles for inclusion, assessed the risk of bias and extracted data for each of the included trials.

MAIN RESULTS

Eight trials with 870 patients were included in the review and showed a significant reduction in readmission rates for hospital at home compared with hospital inpatient care of acute exacerbations of COPD (risk ratio (RR)0.76; 95% confidence interval (CI) from 0.59 to 0.99; P=0.04). Moreover, we observed a trend towards lower mortality in the hospital at home group, but the pooled effect estimate did not reach statistical significance (RR 0.65, 95% CI 0.40 to 1.04, P = 0.07). For health-related quality of life, lung function (FEV1) and direct costs, the quality of the available evidence is in general too weak to make firm conclusions.

AUTHORS' CONCLUSIONS

Selected patients presenting to hospital emergency departments with acute exacerbations of COPD can be safely and successfully treated at home with support from respiratory nurses. We found evidence of moderate quality that hospital at home may be advantageous with respect to readmission rates in these patients. Treatment of acute exacerbation of COPD in hospital at home also show a trend towards reduced mortality rate when compared with conventional inpatient treatment, but these results did not reach statistical significance (moderate quality evidence). For other outcomes than readmission and mortality rate, we assessed the evidence to be of low or very low quality.

Hospital-at-home programs for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD): an evidence-based analysis

In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions. After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses. The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html. Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework. Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Long-term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Home Telehealth for Patients with Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Cost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy Model. Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature. For more information on the qualitative review, please contact Mita Giacomini at: http://fhs.mcmaster.ca/ceb/faculty_member_giacomini.htm. For more information on the economic analysis, please visit the PATH website: http://www.path-hta.ca/About-Us/Contact-Us.aspx. The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: http://theta.utoronto.ca/static/contact. OBJECTIVE: The objective of this analysis was to compare hospital-at-home care with inpatient hospital care for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) who present to the emergency department (ED). CLINICAL NEED: CONDITION AND TARGET POPULATION: ACUTE EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE: Chronic obstructive pulmonary disease is a disease state characterized by airflow limitation that is not fully reversible. This airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. The natural history of COPD involves periods of acute-onset worsening of symptoms, particularly increased breathlessness, cough, and/or sputum, that go beyond normal day-to-day variations; these are known as acute exacerbations. Two-thirds of COPD exacerbations are caused by an infection of the tracheobronchial tree or by air pollution; the cause in the remaining cases is unknown. On average, patients with moderate to severe COPD experience 2 or 3 exacerbations each year. Exacerbations have an important impact on patients and on the health care system. For the patient, exacerbations result in decreased quality of life, potentially permanent losses of lung function, and an increased risk of mortality. For the health care system, exacerbations of COPD are a leading cause of ED visits and hospitalizations, particularly in winter. TECHNOLOGY: Hospital-at-home programs offer an alternative for patients who present to the ED with an exacerbation of COPD and require hospital admission for their treatment. Hospital-at-home programs provide patients with visits in their home by medical professionals (typically specialist nurses) who monitor the patients, alter patients’ treatment plans if needed, and in some programs, provide additional care such as pulmonary rehabilitation, patient and caregiver education, and smoking cessation counselling. There are 2 types of hospital-at-home programs: admission avoidance and early discharge hospital-at-home. In the former, admission avoidance hospital-at-home, after patients are assessed in the ED, they are prescribed the necessary medications and additional care needed (e.g., oxygen therapy) and then sent home where they receive regular visits from a medical professional. In early discharge hospital-at-home, after being assessed in the ED, patients are admitted to the hospital where they receive the initial phase of their treatment. These patients are discharged into a hospital-at-home program before the exacerbation has resolved. In both cases, once the exacerbation has resolved, the patient is discharged from the hospital-at-home program and no longer receives visits in his/her home. In the models that exist to date, hospital-at-home programs differ from other home care programs because they deal with higher acuity patients who require higher acuity care, and because hospitals retain the medical and legal responsibility for patients. Furthermore, patients requiring home care services may require such services for long periods of time or indefinitely, whereas patients in hospital-at-home programs require and receive the services for a short period of time only. Hospital-at-home care is not appropriate for all patients with acute exacerbations of COPD. Ineligible patients include: those with mild exacerbations that can be managed without admission to hospital; those who require admission to hospital; and those who cannot be safely treated in a hospital-at-home program either for medical reasons and/or because of a lack of, or poor, social support at home. The proposed possible benefits of hospital-at-home for treatment of exacerbations of COPD include: decreased utilization of health care resources by avoiding hospital admission and/or reducing length of stay in hospital; decreased costs; increased health-related quality of life for patients and caregivers when treated at home; and reduced risk of hospital-acquired infections in this susceptible patient population. ONTARIO CONTEXT: No hospital-at-home programs for the treatment of acute exacerbations of COPD were identified in Ontario. Patients requiring acute care for their exacerbations are treated in hospitals. RESEARCH QUESTION: What is the effectiveness, cost-effectiveness, and safety of hospital-at-home care compared with inpatient hospital care of acute exacerbations of COPD? RESEARCH METHODS: LITERATURE SEARCH: SEARCH STRATEGY: A literature search was performed on August 5, 2010, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database for studies published from January 1, 1990, to August 5, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists and health technology assessment websites were also examined for any additional relevant studies not identified through the systematic search. INCLUSION CRITERIA: English language full-text reports; health technology assessments, systematic reviews, meta-analyses, and randomized controlled trials (RCTs); studies performed exclusively in patients with a diagnosis of COPD or studies including patients with COPD as well as patients with other conditions, if results are reported for COPD patients separately; studies performed in patients with acute exacerbations of COPD who present to the ED; studies published between January 1, 1990, and August 5, 2010; studies comparing hospital-at-home and inpatient hospital care for patients with acute exacerbations of COPD; studies that include at least 1 of the outcomes of interest (listed below). Cochrane Collaboration reviews have defined hospital-at-home programs as those that provide patients with active treatment for their acute exacerbation in their home by medical professionals for a limited period of time (in this case, until the resolution of the exacerbation). If a hospital-at-home program had not been available, these patients would have been admitted to hospital for their treatment. EXCLUSION CRITERIA: < 18 years of age; animal studies; duplicate publications; grey literature. OUTCOMES OF INTEREST: PATIENT/CLINICAL OUTCOMES: mortality; lung function (forced expiratory volume in 1 second); health-related quality of life; patient or caregiver preference; patient or caregiver satisfaction with care; complications. HEALTH SYSTEM OUTCOMES: hospital readmissions; length of stay in hospital and hospital-at-home. ED visits; transfer to long-term care; days to readmission; eligibility for hospital-at-home. STATISTICAL METHODS: When possible, results were pooled using Review Manager 5 Version 5.1; otherwise, results were summarized descriptively. Data from RCTs were analyzed using intention-to-treat protocols. In addition, a sensitivity analysis was done assigning all missing data/withdrawals to the event. P values less than 0.05 were considered significant. A priori subgroup analyses were planned for the acuity of hospital-at-home program, type of hospital-at-home program (early discharge or admission avoidance), and severity of the patients’ COPD. Additional subgroup analyses were conducted as needed based on the identified literature. Post hoc sample size calculations were performed using STATA 10.1. QUALITY OF EVIDENCE: The quality of each included study was assessed, taking into consideration allocation concealment, randomization, blinding, power/sample size, withdrawals/dropouts, and intention-to-treat analyses. The quality of the body of evidence was assessed as high, moderate, low, or very low according to the GRADE Working Group criteria. The following definitions of quality were used in grading the quality of the evidence: [Table: see text] SUMMARY OF FINDINGS: Fourteen studies met the inclusion criteria and were included in this review: 1 health technology assessment, 5 systematic reviews, and 7 RCTs. The following conclusions are based on low to very low quality of evidence. The reviewed evidence was based on RCTs that were inadequately powered to observe differences between hospital-at-home and inpatient hospital care for most outcomes, so there is a strong possibility of type II error. Given the low to very low quality of evidence, these conclusions must be considered with caution. Approximately 21% to 37% of patients with acute exacerbations of COPD who present to the ED may be eligible for hospital-at-home care. Of the patients who are eligible for care, some may refuse to participate in hospital-at-home care. Eligibility for hospital-at-home care may be increased depending on the design of the hospital-at-home program, such as the size of the geographical service area for hospital-at-home and the hours of operation for patient assessment and entry into hospital-at-home. Hospital-at-home care for acute exacerbations of COPD was associated with a nonsignificant reduction in the risk of mortality and hospital readmissions compared with inpatient hospital care during 2- to 6-month follow-up. Limited, very low quality evidence suggests that hospital readmissions are delayed in patients who received hospital-at-home care compared with those who received inpatient hospital care (mean additional days before readmission comparing hospital-at-home to inpatient hospital care ranged from 4 to 38 days). There is insufficient evidence to determine whether hospital-at-home care, compared with inpatient hospital care, is associated with improved lung function. The majority of studies did not find significant differences between hospital-at-home and inpatient hospital care for a variety of health-related quality of life measures at follow-up. However, follow-up may have been too late to observe an impact of hospital-at-home care on quality of life. A conclusion about the impact of hospital-at-home care on length of stay for the initial exacerbation (defined as days in hospital or days in hospital plus hospital-at-home care for inpatient hospital and hospital-at-home, respectively) could not be determined because of limited and inconsistent evidence. Patient and caregiver satisfaction with care is high for both hospital-at-home and inpatient hospital care.

WITHDRAWN: Services for helping acute stroke patients avoid hospital admission

BACKGROUND

Stroke patients are usually admitted to hospital for their acute care and rehabilitation. Services to help acute stroke patients avoid admission to hospital ('hospital-at-home') have now been developed.

OBJECTIVES

To establish the costs and effects of such services compared with conventional services.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register in March 1999 and supplemented this through discussion with colleagues and trialists.

SELECTION CRITERIA

Controlled clinical trials recruiting stroke patients who have not been admitted to hospital and compare (1) services which provided support with an aim of helping prevent admission to hospital with (20 conventional services (which could include hospital admission).

DATA COLLECTION AND ANALYSIS

Two independent review authors determined the eligibility and methodological quality of trials. Trialists were then contacted to obtain standardised descriptive and outcome data.

MAIN RESULTS

Four trials are included in the review, of which three currently have outcome data available (921 patients; 857 from one controlled trial, 64 from two randomised trials). There were no statistically significant differences between the patient and carer outcomes of the intervention and control groups either within individual trials or in pooled analyses. There was a trend toward greater hospital bed use and increased costs in the intervention groups.

AUTHORS' CONCLUSIONS

There is currently no evidence from clinical trials to support a radical shift in the care of acute stroke patients from hospital-based care.

Management of liver cirrhosis between primary care and specialists

This article discusses a practical, evidence-based approach to the diagnosis and management of liver cirrhosis by focusing on etiology, severity, presence of complications, and potential home-managed treatments. Relevant literature from 1985 to 2010 (PubMed) was reviewed. The search criteria were peer-reviewed full papers published in English using the following MESH headings alone or in combination: "ascites", "liver fibrosis", "cirrhosis", "chronic hepatitis", "chronic liver disease", "decompensated cirrhosis", "hepatic encephalopathy", "hypertransaminasemia", "liver transplantation" and "portal hypertension". Forty-nine papers were selected based on the highest quality of evidence for each section and type (original, randomized controlled trial, guideline, and review article), with respect to specialist setting (Gastroenterology, Hepatology, and Internal Medicine) and primary care. Liver cirrhosis from any cause represents an emerging health issue due to the increasing prevalence of the disease and its complications worldwide. Primary care physicians play a key role in early identification of risk factors, in the management of patients for improving quality and length of life, and for preventing complications. Specialists, by contrast, should guide specific treatments, especially in the case of complications and for selecting patient candidates for liver transplantation. An integrated approach between specialists and primary care physicians is essential for providing better outcomes and appropriate home care for patients with liver cirrhosis.

Effectiveness and cost-effectiveness of early assisted discharge for chronic obstructive pulmonary disease exacerbations: the design of a randomised controlled trial

BACKGROUND

Exacerbations of chronic obstructive pulmonary disease (COPD) are the main cause for hospitalisation. These hospitalisations result in a high pressure on hospital beds and high health care costs. Because of the increasing prevalence of COPD this will only become worse. Hospital at home is one of the alternatives that has been proved to be a safe alternative for hospitalisation in COPD. Most schemes are early assisted discharge schemes with specialised respiratory nurses providing care at home. Whether this type of service is cost-effective depends on the setting in which it is delivered and the way in which it is organised.

METHODS/DESIGN

GO AHEAD (Assessment Of Going Home under Early Assisted Discharge) is a 3-months, randomised controlled, multi-centre clinical trial. Patients admitted to hospital for a COPD exacerbation are either discharged on the fourth day of admission and further treated at home, or receive usual inpatient hospital care. Home treatment is supervised by general nurses. Primary outcome is the effectiveness and cost effectiveness of an early assisted discharge intervention in comparison with usual inpatient hospital care for patients hospitalised with a COPD exacerbation. Secondary outcomes include effects on quality of life, primary informal caregiver burden and patient and primary caregiver satisfaction. Additionally, a discrete choice experiment is performed to provide insight in patient and informal caregiver preferences for different treatment characteristics. Measurements are performed on the first day of admission and 3 days, 7 days, 1 month and 3 months thereafter. Ethical approval has been obtained and the study has been registered.

DISCUSSION

This article describes the study protocol of the GO AHEAD study. Early assisted discharge could be an effective and cost-effective method to reduce length of hospital stay in the Netherlands which is beneficial for patients and society. If effectiveness and cost-effectiveness can be proven, implementation in the Dutch health care system should be considered.

TRIAL REGISTRATION

Netherlands Trial Register NTR1129.

The consequences of early discharge after hip arthroplasty for patient outcomes and health care costs: comparison of three centres with differing durations of stay

OBJECTIVE

To compare outcomes from hip arthroplasty between a surgical unit with a rapid discharge policy and two comparison units to test the hypothesis that the centre with rapid discharge has outcomes that are not inferior to the comparison sites.

DESIGN

Prospective cohort study.

SUBJECTS

Consecutive consenting patients receiving primary hip arthroplasty during 12 months beginning July 2006 in three UK National Health Service surgical units. One has shortened postoperative stay to median three days; one was a new treatment centre with median stay of five days; the third was a traditional unit with median stay of six days (N = 316, 119, 87, respectively).

METHODS

Patients were assessed preoperatively and six weeks postoperatively. The primary indicator of function was the Oxford Hip Score. Additional secondary measures included further self-report indicators of function and quality of life and health service costs.

RESULTS

Patient outcome in the unit with rapid discharge was not impaired by comparison with the other sites on any measure: Oxford Hip Score decreased from 49 to 27 in the short-stay unit, from 40 to 30 in the treatment centre and from 43 to 32 in the traditional unit. Cost of arthroplasty was least in the short-stay unit, although there was potential for cost savings in each.

CONCLUSION

Short postoperative stay after hip arthroplasty can be achieved without intensive patient preparation or post-discharge care and without compromising short-term patient outcome or increasing health care costs. Longer term follow-up is needed.

Providing comprehensive smoking cessation care to surgical patients: the case for computers

INTRODUCTION AND AIMS

The provision of smoking cessation care to surgical patients before admission can reduce post-operative complications and encourage long-term smoking cessation. Our aim was to show how a comprehensive computer-based smoking cessation intervention, developed to enhance smoking cessation care to surgical patients, addresses barriers to care provision.

DESIGN AND METHODS

Consultations with preoperative clinic staff and reviews of the scientific literature were conducted and identified the following barriers to the provision of effective smoking cessation care: a lack of organisational support, perceived patient objection, a lack of systems to identify smokers, a lack of staff time and skill, perceived inability to change care practices, a perceived lack of efficacy of cessation care and the cost of providing care. Based on positive findings of a pilot trial, a comprehensive computer-based smoking cessation intervention was implemented in a preoperative clinic. Data from previous evaluations of the intervention were used to assess the extent to which the intervention addressed clinician barriers to care.

RESULTS

The computer-based intervention was found to provide a means to accurately and systematically identify smokers; it required little clinical staff time or skill; it was considered an acceptable form of care by staff and patients; it was effective in encouraging patient cessation and it was inexpensive to deliver relative to other surgical costs. Furthermore, the computer-based intervention continues to operate in the preoperative clinic in the absence of ongoing research support.

DISCUSSION AND CONCLUSIONS

The implementation of such a model of care should be considered by clinical services interested in reducing the smoking related morbidity and mortality of patients.

Targeted early rehabilitation at home after total hip and knee joint replacement: Does it work?

PURPOSE

This study evaluates the benefits of targeted early rehabilitation at home after total hip or knee replacement surgery and analyses the cost effectiveness of such a scheme.

METHOD

Patients recovering from Total hip replacement (THR, n = 220) and Total knee replacement (TKR, n = 174) were assessed in a NHS District General Hospital setting. Suitability of patients for early rehabilitation at home scheme (RAHS) was assessed at the pre-operative clinic by rehabilitation team. Length of in-patient stay (LOSH), duration on the scheme, number of bed days saved, cost appraisal, readmission rates and complications were recorded.

RESULTS

Targeted early rehabilitation resulted in reduced hospital stay (from 14-8.17 days for THR and from 12-8.21 days for TKR), without any increase in complication rates. Significance testing revealed no statistical difference between the patient groups with regards to age, residence status, mobility and transfer ability on their length of stay in hospital or on the rehabilitation scheme. The patients who underwent total knee replacement required significantly more number of visits by the rehabilitation team than those who underwent total hip replacement (p value < 0.05). This resulted in an overall saving of pound 301,124 for the trust over the study period.

CONCLUSIONS

Targeted early rehabilitation resulted in reducing the length of hospital stay without an increase in complication rates. The use of such a scheme brought significant savings to the trust without an increase in readmission rates.

Early discharge hospital at home

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 STRATEGY

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.

Leaders, leadership and future primary care clinical research

BACKGROUND

A strong and self confident primary care workforce can deliver the highest quality care and outcomes equitably and cost effectively. To meet the increasing demands being made of it, primary care needs its own thriving research culture and knowledge base.

METHODS

Review of recent developments supporting primary care clinical research.

RESULTS

Primary care research has benefited from a small group of passionate leaders and significant investment in recent decades in some countries. Emerging from this has been innovation in research design and focus, although less is known of the effect on research output.

CONCLUSION

Primary care research is now well placed to lead a broad re-vitalisation of academic medicine, answering questions of relevance to practitioners, patients, communities and Government. Key areas for future primary care research leaders to focus on include exposing undergraduates early to primary care research, integrating this early exposure with doctoral and postdoctoral research career support, further expanding cross disciplinary approaches, and developing useful measures of output for future primary care research investment.

Inpatient compared with home-based rehabilitation following primary unilateral total hip or knee replacement: a randomized controlled trial

BACKGROUND

Home-based rehabilitation is increasingly utilized to reduce health-care costs; however, with a shorter hospital stay, the possibility arises for an increase in adverse clinical outcomes. We evaluated the effectiveness and cost of care of home-based compared with inpatient rehabilitation following primary total hip or knee joint replacement.

METHODS

We randomized 234 patients, using block randomization techniques, to either home-based or inpatient rehabilitation following total joint replacement. All patients followed standardized care pathways and were evaluated, with use of validated outcome measures (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], Short Form-36, and patient satisfaction), prior to surgery and at three and twelve months following surgery. The primary outcome was the WOMAC function score at three months after surgery.

RESULTS

The mean length of stay (and standard deviation) in the acute care hospital was 6.3 +/- 2.5 days for the group designated for inpatient rehabilitation prior to transfer to that facility compared with 7.0 +/- 3.0 days for the home-based rehabilitation group prior to discharge home (p = 0.06). The mean length of stay in inpatient rehabilitation was 17.7 +/- 8.6 days. The mean number of postoperative home-based rehabilitation visits was eight. The prevalence of postoperative complications up to twelve months postoperatively was similar in both groups, which each had a 2% rate of dislocation and a 3% rate of clinically important deep venous thrombosis. The prevalence of infection was 0% in the home-based group and 2% in the inpatient group. None of these differences was clinically important. Both groups showed substantial improvements at three and twelve months, with no significant differences between the groups with respect to WOMAC, Short Form-36, or patient satisfaction scores (p > 0.05). The total episode-of-care costs (in Canadian dollars) for the inpatient rehabilitation and home-based rehabilitation arms were $14,532 and $11,082, respectively (p < 0.01).

CONCLUSIONS

Despite concerns about early hospital discharge, there was no difference in pain, functional outcomes, or patient satisfaction between the group that received home-based rehabilitation and the group that had inpatient rehabilitation. On the basis of our findings, we recommend the use of a home-based rehabilitation protocol following elective primary total hip or knee replacement as it is the more cost-effective strategy.

Early discharge and home intervention reduces unit costs after total hip replacement: results of a cost analysis in a randomized study

Total hip replacement (THR) is a common and costly procedure. The number of THR is expected to increase over the coming years. Two pathways of postoperative treatment were compared in a randomized study. Fifty patients from two hospitals were randomized into a study group (SG) of 27 patients receiving preoperative and postoperative education programs, as well as home visits from an outpatient team. A control group (CG) of 23 patients received "conventional" rehabilitation augmented by a stay at a rehabilitation center if needed. All costs for the two groups both in hospitals and after discharge were collected and analyzed. On average total costs for the SG were $8,550 and $11,952 for the CG, a 28% cost reduction. Total inpatient costs were $5,225 for the SG and $6,515 for the CG. In a regression analysis the group difference is statistically significant. Adjusting for changes in the Oxford Hip Score gives effective costs (C/E). The ratio of the SGs C/E to the CGs is 0.60. That is a cost-effectiveness gain of 40%. A shorter hospital stay augmented with better preoperative education and home treatment appears to be more effective and costs less than the traditional in hospital pathway of treatment.

Valuing care recipient and family caregiver time: a comparison of methods

OBJECTIVES

The purpose of this study is to compare the approaches used for valuing family caregiver and care recipient time devoted to providing and receiving care.

METHODS

Valuation approaches were operationalized within a cohort of cystic fibrosis care recipients (n = 110). Base-case analyses, grounded in human capital theory, applied earnings estimates to caregiving time to impute the market value of time lost from labor. Unpaid labor and leisure time was valued with a replacement cost (homemaker's wage rate). Total time costs were computed and sensitivity analyses were conducted to describe the effects of alternative valuation methods on total costs.

RESULTS

The mean time cost per care recipient-caregiver dyad over 28 days was $2,026CAD. The majority (76 percent) of time costs were due to losses from unpaid labor and leisure time. Varying the valuation of paid labor time did not result in significantly different total time costs (p = .0877). However, varying the method of valuing unpaid labor and leisure time did significantly affect total costs (p < .0001).

CONCLUSIONS

Care recipients and caregivers primarily lost time from unpaid labor and leisure in the treatment of cystic fibrosis. Moreover, when the above losses were aggregated, the method of valuation greatly influenced overall results. The findings clearly indicate that omitting caregiver and unpaid labor and leisure costs may result in an inaccurate assessment of ambulatory and home-based healthcare programs.

Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy

BACKGROUND

Joint replacements are common procedures and treatment of choice for those with intractable joint pain and disability arising from arthropathy of the hip or knee. Multidisciplinary rehabilitation is considered integral to the outcome of joint replacement.

OBJECTIVES

To assess the evidence for effectiveness of multidisciplinary rehabilitation on activity and participation in adults following hip or knee joint replacement for chronic arthropathy.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL up to September 2006.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared organised multidisciplinary rehabilitation with routine services following hip or knee replacement, and included outcome measures of activity and participation in accordance with the International Classification of Functioning, Health and Disability (ICF).

DATA COLLECTION AND ANALYSIS

Four authors independently extracted data and assessed methodological quality of included trials.

MAIN RESULTS

Five trials (619 participants) met the inclusion criteria; two addressed inpatient rehabilitation (261 participants) and three (358 participants) home-based settings. There were no trials addressing outpatient centre-based programmes. Pooling of data was not possible due to differences in study design and outcomes used. Methodological assessment showed all trials were of low quality. For inpatient settings early commencement of rehabilitation and clinical pathways led to more rapid attainment of functional milestones (disability) (Functional Independence Measure (FIM) transfer WMD 0.5, 95% CI 0.15, 0.85, number needed to treat to benefit (NNTB) = 6, FIM ambulation WMD 1.55 (95%CI 0.96, 2.14), NNTB = 3), shorter hospital stay, fewer post-operative complications and reduced costs in the first three to four months. Home-based multidisciplinary care improved functional gain (Oxford Hip Score (OHS) WMD at 6 months -7.00 (95%CI -10.36, -3.64), NNT = 2 and quality of life (QoL) and reduced hospital stay in the medium term (six months). No trials addressed longer-term outcomes following hip replacement only.

AUTHORS' CONCLUSIONS

Based on the heterogeneity and the low quality of the included trials that precluded pooled meta-analysis, there is silver level evidence that following hip or knee joint replacement, early multidisciplinary rehabilitation can improve outcomes at the level of activity and participation. The optimal intensity, frequency and effects of rehabilitation over a longer period and associated social costs need further study. Future research should focus on improving methodological and scientific rigour of clinical trials, and use of standardised outcome measures, so that results can be pooled for statistical analysis.

Costs and determinants of privately financed home-based health care in Ontario, Canada

The Canadian context in which home-based healthcare services are delivered is characterised by limited resources and escalating healthcare costs. As a result, a financing shift has occurred, whereby care recipients receive a mixture of publicly and privately financed home-based services. Although ensuring that care recipients receive efficient and equitable care is crucial, a limited understanding of the economic outcomes and determinants of privately financed services exists. The purposes of this study were (i) to determine costs incurred by families and the healthcare system; (ii) to assess the determinants of privately financed home-based care; and (iii) to identify whether public and private expenditures are complements or substitutes. Two hundred and fifty-eight short-term clients (<90 days of service utilisation) and 256 continuing care clients (>90 days of utilisation) were recruited from six regions across the province of Ontario, Canada, from November 2003 to August 2004. Participants were interviewed by telephone once a week for 4 weeks and asked to provide information about time and monetary costs of care, activities of daily living (ADL), and chronic conditions. The mean total cost of care for a 4-week period was $7670.67 (in 2004 Canadian dollars), with the overwhelming majority of these costs (75%) associated with private expenditures. Higher age, ADL impairment, being female, and a having four or more chronic conditions predicted higher private expenditures. While private and public expenditures were complementary, private expenditures were somewhat inelastic to changes in public expenditures. A 10% increase in public expenditures was associated with a 6% increase in private expenditures. A greater appreciation of the financing of home-based care is necessary for practitioners, health managers and policy decision-makers to ensure that critical issues such as inequalities in access to care and financial burden on care recipients and families are addressed.

Design and analysis of health products and services: An example at a specialized COPD unit

Health care demands have increased dramatically in recent decades. With the introduction of major changes in the management of health problems, health care costs have spiralled. Today, in the interests of cost control, medicine is geared towards outpatient care whenever possible.

In this process, the medical community has been obliged to adapt its traditional criteria to the dictates of national economies. Today the criteria for the organization and evaluation of the health services are based on the concepts of efficacy, effectiveness and efficiency. This has led to the emergence of a new discipline for the design and evaluation of medical service production, known as servuction, an amalgam of “service” and “production”. The organigram of a new health product should include the problems the program faces and the steps proposed to overcome these problems.

The concept of evaluation can be divided into two categories: administrative evaluation, and evaluative research. Avedis Donabedian was one of the founders of evaluative research, based on an easy-to-remember triad: structure-process-results. In the final evaluation of a new health care model, the innovations it provides must be considered.

In this article we describe the stages involved in the design of a new health product and correlate them with the types of evaluation that should be applied at each point in the process. Our discussion addresses general aspects of servuction, but also focuses on the design of a particular service, created to care for patients with severe COPD.

Immediate and early discharge for patients with exacerbations of chronic obstructive pulmonary disease: is there a role in "real life"?

An exacerbation of chronic obstructive pulmonary disease (COPD) is the most common respiratory condition necessitating admission to hospital. Many of these are relatively mild in nature and as a consequence, there is increasing interest in immediate and early discharge of patients with nonsevere exacerbations. Following initial assessment, “hospital at home” or “assisted discharge” schemes enable suitable patients with COPD to be discharged into the community earlier than normally anticipated. The putative implication is that substantial financial savings can be made in addition to increasing the availability of in-patient beds, without compromising patient care or satisfaction. We highlight the current literature which has evaluated the role of hospital at home and assisted discharge schemes and discuss our own “real life” service operating in a large teaching hospital in Scotland.

Home-based intermediate care program vs hospitalization: Cost comparison study

OBJECTIVE

To explore whether a home-based intermediate care program in a large Canadian city lowers the cost of care and to look at whether such home-based programs could be a solution to the increasing demands on Canadian hospitals.

DESIGN

Single-arm study with historical controls.

SETTING

Department of Family Medicine at the Ottawa Hospital (Civic campus) in Ontario.

PARTICIPANTS

Patients requiring hospitalization for acute care. Participants were matched with historical controls based on case-mix, most responsible diagnosis, and level of complexity.

INTERVENTIONS

Placement in the home-based intermediate care program. Daily home visits from the nurse practitioner and 24-hour access to care by telephone.

MAIN OUTCOME MEASURES

Multivariate regression models were used to estimate the effect of the program on 5 outcomes: length of stay in hospital, cost of care substituted for hospitalization (Canadian dollars), readmission for a related diagnosis, readmission for any diagnosis, and costs incurred by community home-care services for patients following discharge from hospital.

RESULTS

The outcomes of 43 hospital admissions were matched with those of 363 controls. Patients enrolled in the program stayed longer in hospital (coefficient 3.3 days, P < .001), used more community care services following discharge (coefficient $729, P = .007), and were more likely to be readmitted to hospital within 3 months of discharge (coefficient 17%, P = .012) than patients treated in hospital. Total substituted costs of home-based care were not significantly different from the costs of hospitalization (coefficient -$501, P = .11).

CONCLUSION

While estimated cost savings were not statistically significant, the limitations of our study suggest that we underestimated these savings. In particular, the economic inefficiencies of a small immature program and the inability to control for certain factors when selecting historical controls affected our results. Further research is needed to determine the economic effect of mature home-based programs.

The impact of home hospitalization on healthcare costs of exacerbations in COPD patients

Home-hospitalization (HH) improves clinical outcomes in selected patients with chronic obstructive pulmonary disease (COPD) admitted at the emergency room due to an exacerbation, but its effects on healthcare costs are poorly known. The current analysis examines the impact of HH on direct healthcare costs, compared to conventional hospitalizations (CH). A randomized controlled trial was performed in two tertiary hospitals in Barcelona (Spain). A total of 180 exacerbated COPD patients (HH 103 and CH 77) admitted at the emergency room were studied. In the HH group, a specialized respiratory nurse delivered integrated care at home. The average direct cost per patient was significantly lower for HH than for CH, with a difference of euro 810 (95% CI, euro 418-1,169) in the mean cost per patient. The magnitude of monetary savings attributed to HH increased with the severity of the patients considered eligible for the intervention.

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary

Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.

Patient, informal caregiver and care provider acceptance of a hospital in the home program in Ontario, Canada

BACKGROUND

Hospital in the home programs have been implemented in several countries and have been shown to be safe substitutions (alternatives) to in-patient hospitalization. These programs may offer a solution to the increasing demands made on tertiary care facilities and to surge capacity. We investigated the acceptance of this type of care provision with nurse practitioners as the designated principal home care providers in a family medicine program in a large Canadian urban setting.

METHODS

Patients requiring hospitalization to the family medicine service ward, for any diagnosis, who met selection criteria, were invited to enter the hospital in the home program as an alternative to admission. Participants in the hospital in the home program, their caregivers, and the physicians responsible for their care were surveyed about their perceptions of the program. Nurse practitioners, who provided care, were surveyed and interviewed.

RESULTS

Ten percent (104) of admissions to the ward were screened, and 37 patients participated in 44 home hospital admissions. Twenty nine patient, 17 caregiver and 38 provider surveys were completed. Most patients (88%-100%) and caregivers (92%-100%) reported high satisfaction levels with various aspects of health service delivery. However, a significant proportion in both groups stated that they would select to be treated in-hospital should the need arise again. This was usually due to fears about the safety of the program. Physicians (98%-100%) and nurse practitioners also rated the program highly. The program had virtually no negative impact on the physician workload. However nurse practitioners felt that the program did not utilize their full expertise.

CONCLUSION

Provision of hospital level care in the home is well received by patients, their caregivers and health care providers. As a new program, investment in patient education about program safety may be necessary to ensure its long term success. A small proportion of hospital admissions were screened for this program. Appropriate dissemination of program information to family physicians should help buy-in and participation. Nurse practitioners' skills may not be optimally utilized in this setting.

The impact of intermediate care services on job satisfaction, skills and career development opportunities

AIM

The purpose of this study was to examine, in depth, the impact of intermediate care services on staff job satisfaction, skills development and career development opportunities.

BACKGROUND

Recruitment and retention difficulties present a major barrier to the effective delivery of intermediate care services in the UK. The limited existing literature is contradictory, but points to the possibility of staff deskilling and suggests that intermediate care is poorly understood and may be seen by other practitioners as being of lower status than hospital work. These factors have the potential to reduce staff morale and limit the possibilities of recruiting staff.

DESIGN

The research is based on interviews with 26 staff from case studies of two intermediate care services in South Yorkshire.

RESULTS

Participants reported high levels of job satisfaction, which was because of the enabling philosophy of care, increased autonomy, the setting of care and the actual teams within which the workers were employed. For most disciplines, intermediate care facilitated the application of existing skills in a different way; enhancing some skills, while restricting the use of others. Barriers to career development opportunities were attributed to the relative recency of intermediate care services, small size of the services and lack of clear career structures.

CONCLUSIONS

Career development opportunities in intermediate care could be improved through staff rotations through acute, community and intermediate care to increase their awareness of the roles of intermediate care staff. The non-hierarchical management structures limits management career development opportunities, instead, there is a need to enhance professional growth opportunities through the use of consultant posts and specialization within intermediate care.

RELEVANCE TO CLINICAL PRACTICE

This study provides insight into the impact of an increasingly popular model of care on the roles and job satisfaction of workers and highlights the importance of this learning for recruitment and retention of staff.

Musculoskeletal rehabilitation: current understandings and future directions

This work examines the current state of knowledge regarding the efficacy of rehabilitation for patients with major lower-extremity joint replacements, hip fractures, and amputations. Of particular focus is the use of inpatient rehabilitation strategies for functional restoration. These areas of rehabilitation involve common conditions in the elderly population. Cost-containment pressures have highlighted the focus on the efficacy of inpatient rehabilitation for persons with joint replacements in particular. Medicare's "75% rule" specifically limits persons with elective joint replacements from entering rehabilitation units after their surgeries. This article highlights research relevant to these issues and was written to examine the state of knowledge about these topics with the goal of highlighting areas that need more research attention.

Specialist nurse supported discharge in gynaecology: A randomised comparison and economic evaluation

AIM

To determine the effect on quality of life and cost effectiveness of specialist nurse early supported discharge for women undergoing major abdominal and/or pelvic surgery for benign gynaecological disease compared with routine care.

STUDY DESIGN

Randomised controlled trial comparing specialist nurse supported discharge with routine hospital care in gynaecology. The SF-36, a generic health status questionnaire, was used to measure women's evaluation of their health state before surgery and at 6 weeks after surgery. A further questionnaire scoring patient symptoms, milestones of recovery, information given and satisfaction, was administered prior to discharge from hospital and at 6 weeks thereafter.

SETTING

Gynaecology service at the Western Infirmary Glasgow, part of North Glasgow University, NHS Trust.

PARTICIPANTS

One hundred and eleven women scheduled for major abdominal or pelvic surgery for benign gynaecological disease.

MAIN OUTCOME MEASURES

SF-36 health survey questionnaire baseline scores were reported before surgery and at 6 weeks follow-up. Complications, length of hospital stay, readmission, information on discharge support and satisfaction of women were recorded at discharge from hospital and at 6 weeks follow-up. A cost consequence analysis was conducted based on the perspective of the NHS.

RESULTS

The addition of a specialist nurse to routine hospital care in gynaecology significantly reduced the post-operative length of hospital stay p = 0.001, improved information delivery and satisfaction of women. The specialist nurse supported discharge group was associated with significantly lower total costs to the NHS than routine care resulting principally from the difference in the cost of the post-operative length of stay.

CONCLUSIONS

Women undergoing major abdominal and pelvic surgery were discharged home earlier with provision of support from a specialist gynaecology nurse. The results of this study suggest that duration of hospital stay can be shortened by the introduction of a specialist nurse without introducing any adverse physical and psychological effects. This process of care is associated with receipt of information on health and lifestyle issues and maintenance of high levels of patient satisfaction and demonstrates the effectiveness of the specialist nurse role in the provision of health information for women. Earlier hospital discharge at 48 h after major abdominal and pelvic surgery is an acceptable, cost effective alternative to current routine practice in the absence of further randomised evidence.

Closure of a home hospital program: impact on hospitalization rates

Home hospitalization (HH), as a substitute to in-patient care, is an area of growing interest, particularly amongst the elderly. Debate nonetheless exists concerning its economic justification. This study describes a natural experiment that arose following spending cuts and closure of the 400 patient Jerusalem HH program. It examines the hypothesis that HH closure would cause increasing geriatric and general medical hospital utilization amongst the 45,000 beneficiaries of the Jerusalem Clalit Health Fund (HMO) aged 65 years and over. Hospitalization rates were measured prior to and following HH closure, and analysis of variance confirmed the significance of the differences in both geriatric (p<0.0001) and general medical hospitalization rates (p=0.02) over the study period. Linear regression analyses of the hospitalization rates prior to HH closure were performed to determine the expected trajectory of hospitalization rates following HH closure. The observed hospital utilization in the year following HH closure cost 6.2 million US dollars in excess of predicted expenditure; closure of the HH resulted in the saving of 1.3 million USdollars. The ratio of direct increased costs to savings was 5:1 thus confirming the hypothesis that HH closure would result in increased hospital utilization rates among the local elderly population.

Hospital at home for acute respiratory patients

BACKGROUND

The issue of "hospital at home" (HAH) for acute respiratory patients is one that is still being debated, partly because economic, cultural and health service differences between locations imply that HAH schemes need to be tailored to local situations. The aim of the present study was to analyze the feasibility and effectiveness of HAH for patients with acute respiratory disease at our institution.

METHODS

Of all the patients admitted to our institution via the emergency department during a 34-day subject enrollment period, 25 with diagnoses of respiratory infection, pneumonia, pulmonary insufficiency or exacerbated chronic obstructive pulmonary disease who were living within 25 km of our center and who were willing to receive HAH care were assigned to HAH. Fifty sex-matched controls with the same diagnoses were given conventional hospital care (CHC) as inpatients. The dependent variables evaluated included time to discharge, readmissions within 3 months and deaths within 3 months.

RESULTS

There were no significant differences between the HAH and CHC groups with regard to age, diagnoses, physical and analytical findings, or co-morbidity, or with regard to deaths (HAH 16%, CHC 10%) or readmissions (HAH 17%, CHC 24%). Time to final discharge was significantly shorter for HAH patients (7 days) than for CHC patients (12 days). Some 95% of the HAH patients were satisfied and would choose HAH again.

CONCLUSIONS

HAH seems feasible for appropriately selected acute respiratory disease patients presenting in our emergency department. It frees hospital beds for other patients, its readmission and mortality rates are no higher than for conventional hospitalization, and, in general, it is favorably evaluated by patients.