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

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

The objective of this review was to establish the costs and effects of such services compared with conventional services.

SEARCH STRATEGY

The Stroke Group Specialist Register of Controlled Trials was searched and supplemented by discussion with colleagues and trialists. This was last updated in March 1999.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Two independent reviewers 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.

REVIEWER'S 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.

Conceptual and practical difficulties with the economic evaluation of health services developments

Five recent economic evaluations comparing hospital at home schemes with acute hospital care faced remarkably similar problems. This paper outlines these problems and considers what strategies can be derived from these experiences, which will be relevant to economic evaluations of other aspects of the organisation of care, particularly those crossing the interfaces between primary and secondary health care or the interface between health and social services. The difficulties experienced can be divided into conceptual and practical problems. Conceptual problems were primarily associated with issues of context and related to the choice of comparator, capacity constraints and size of schemes, and the choice between a short or a long run perspective. Practical problems were connected with the time at which schemes were evaluated, the type of clinical study alongside which studies were conducted and the types of data available for use in the analysis. Strategies which can be pursued in conducting economic evaluations of organisational change include giving greater attention to conceptual and hence contextual problems as well as reporting these contextual issues in detail, accepting the need for repeated economic evaluations as organisational changes become more widespread and considering carefully the clinical study design where economic evaluations of organisational change are conducted alongside. These strategies are of importance not just to those conducting economic evaluations but also to those funding appraisals of changes in the organisation of care. Use of different strategies such as those suggested here should be evaluated.

Cost effectiveness of quinolones in hospitals and the community

In hospitals, oral quinolone therapy has lower daily associated costs (acquisition and administration) than most intravenous regimens. In addition, oral switch therapy shortens the duration of hospital stay for most patients. However, randomised trials are required to measure the economic impact of the switch to oral therapy in terms of hospital care costs and the burden imposed on community health services, on relatives or carers and on the patient. Evidence about the reliability of absorption of quinolones in hospitalised patients is more likely to be obtained from large population kinetic studies than randomised effectiveness trials. The existing literature on cost effectiveness of quinolones in the community is disappointing. The principal problems are poor definition of diagnostic criteria, inclusion of irrelevant comparator drugs and a failure to include infections caused by bacteria that are resistant to the comparator. Consequently, there is little evidence to support the use of economic models to determine the consequences of antibiotic resistance in the community.

Economic evaluation of hospital at home versus hospital care: cost minimisation analysis of data from randomised controlled trial

OBJECTIVES

To compare the costs of admission to a hospital at home scheme with those of acute hospital admission.

DESIGN

Cost minimisation analysis within a pragmatic randomised controlled trial.

SETTING

Hospital at home scheme in Leicester and the city's three acute hospitals.

PARTICIPANTS

199 consecutive patients assessed as being suitable for admission to hospital at home for acute care during the 18 month trial period (median age 84 years).

INTERVENTION

Hospital at home or hospital inpatient care.

MAIN OUTCOME MEASURES

Costs to NHS, social services, patients, and families during the initial episode of treatment and the three months after admission.

RESULTS

Mean (median) costs per episode (including any transfer from hospital at home to hospital) were similar when analysed by intention to treat-hospital at home 2569 pounds sterling (1655 pounds sterling), hospital ward 2881 pounds sterling (2031 pounds sterling), bootstrap mean difference -305 (95% confidence interval -1112 to 448). When analysis was restricted to those who accepted their allocated place of care, hospital at home was significantly cheaper-hospital at home 2557 pounds sterling(1710 pounds sterling), hospital ward 3660 pounds sterling (2903 pounds sterling), bootstrap mean difference -1071 (-1843 to -246). At three months the cost differences were sustained. Costs with all cases included were hospital at home 3671 pounds sterling (2491 pounds sterling), hospital ward 3877 pounds sterling (3405 pounds sterling), bootstrap mean difference -210 (-1025 to 635). When only those accepting allocated care were included the costs were hospital at home 3698 pounds sterling (2493 pounds sterling), hospital ward 4761 pounds sterling (3940 pounds sterling), bootstrap mean difference -1063 (-2044 to -163); P=0.009. About 25% of the costs for episodes of hospital at home were incurred through transfer to hospital. Costs per day of care were higher in the hospital at home arm (mean 207 pounds sterling v 134 pounds sterling in the hospital arm, excluding refusers, P<0.001).

CONCLUSIONS

Hospital at home can deliver care at similar or lower cost than an equivalent admission to an acute hospital.

The influence of case mix, site selection, and methods biases on costs of hospitalization for acute exacerbations of chronic obstructive airways disease and lower respiratory tract infections

OBJECTIVE

To compare costs of hospitalization for lower respiratory tract infection (LRTI) in patients who received antibiotics before admission to those who did not, and in patients with and without underlying chronic obstructive airways disease (COAD) or diabetes mellitus.

METHODS

All hospitalizations in a population of 366,849 residents in Tayside Scotland from 1993 to 1994 were analyzed. Three groups of patients were identified by primary discharge diagnosis in 1993/94 and previous admissions from 1980 to 1992: 1) acute exacerbation of COAD; 2) LRTI plus a secondary diagnosis of COAD or previous admission with COAD; 3) LRTI but no secondary COAD or previous admission with COAD. Setting specific costs were applied (e.g., general medicine, intensive care, geriatrics). Dispensed antibiotic prescribing in the 28 days before admission was identified from all community pharmacies. Nonparametric statistical tests were used.

RESULTS

Patients with COAD were more likely to have received antibiotics before admission: COAD (n = 893) 49%; COAD + LRTI (n = 316) 43%; LRTI only (n = 822) 33%. Patients who received antibiotics before admission had lower hospital costs than patients who did not. Mean total costs per admission: COAD pound1604 versus pound1625 (p = .5); COAD + LRTI pound2281 versus pound2297 (p = .5); LRTI only pound2365 versus pound3233; (p = .009). Increasing age and diabetes mellitus were associated with higher hospital costs in all three groups.

CONCLUSION

Economic models of the value of preventing hospital admissions for COAD or LRTI will be subject to case mix bias unless they adjust for age, community antibiotic use, and comorbidity.

The health and cost effects of substituting home care for inpatient acute care: a review of the evidence

BACKGROUND

There is much interest in reducing hospital stays by providing some health care services in patients' homes. The authors review the evidence regarding the effects of this acute care at home (acute home care) on the health of patients and caregivers and on the social costs (public and private costs) of managing the patients' health conditions.

METHODS

MEDLINE and HEALTHSTAR databases were searched for articles using the key term "home care." Bibliographies of articles read were checked for additional references. Fourteen studies met the selection criteria (publication between 1975 and early 1998, evaluation of an acute home care program for adults, and use of a control group to evaluate the program). Of the 14, only 4 also satisfied 6 internal validity criteria (patients were eligible for home care, comparable patients in home care group and hospital care group, adequate patient sample size, appropriate analytical techniques, appropriate health measures and appropriate costing methods).

RESULTS

The 4 studies with internal validity evaluated home care for 5 specific health conditions (hip fracture, hip replacement, chronic obstructive pulmonary disease [COPD], hysterectomy and knee replacement); 2 of the studies also evaluated home care for various medical and surgical conditions combined. Compared with hospital care, home care had no notable effects on patients' or caregivers' health. Social costs were not reported for hip fracture. They were unaffected for hip and knee replacement, and higher for COPD and hysterectomy; in the 2 studies of various conditions combined, social costs were higher in one and lower in the other. Effects on health system costs were mixed, with overall cost savings for hip fracture and higher costs for hip and knee replacement.

INTERPRETATION

The limited existing evidence indicates that, compared with hospital care, acute home care produces no notable difference in health outcomes. The effects on social and health system costs appear to vary with condition. More well-designed evaluations are needed to determine the appropriate use of acute home care.

Shifting care: GP opinions of hospital at home

Hospital at home (HaH) has become an increasingly popular model of care over the past few years. However, there is little evidence to suggest that this is a superior form of care when compared with standard inpatient care in terms of cost, satisfaction, or clinical outcomes. Despite concerns that these schemes increase general practitioner (GP) workload, there is also no published evidence on the effect of HaH on GPs. As part of a broader study, a survey was undertaken of all GPs in an inner London health authority for their views of HaH. Overall, GPs felt that such schemes increased their workload, but GPs who had used HaH were more strongly in favour of these schemes for a range of conditions.

Randomised controlled trial comparing hospital at home care with inpatient hospital care. I: three month follow up of health outcomes

OBJECTIVES

To compare hospital at home care with inpatient hospital care in terms of patient outcomes.

DESIGN

Randomised controlled trial with three month follow up.

SETTING

District general hospital and catchment area of neighbouring community trust.

SUBJECTS

Patients recovering from hip replacement (n=86), knee replacement (n=86), and hysterectomy (n=238); elderly medical patients (n=96); and patients with chronic obstructive airways disease (n=32).

INTERVENTIONS

Hospital at home care or inpatient hospital care.

MAIN OUTCOME MEASURES

Dartmouth COOP chart to measure patients' general health status; SF-36 to measure possible limitations in physical functioning of patients with hysterectomy; disease specific measures-chronic respiratory disease questionnaire, Barthel index for elderly medical patients, Oxford hip score, and Bristol knee score; hospital readmission and mortality data; carer strain index to measure burden on carers; patients' and carers' preferred form of care.

RESULTS

At follow up, there were no major differences in outcome between hospital at home care and hospital care for any of the patient groups except that those recovering from hip replacement reported a significantly greater improvement in quality of life with hospital at home care (difference in change from baseline value 0.50, 95% confidence interval 0.13 to 0.88). Hospital at home did not seem suitable for patients recovering from a knee replacement, as 14 (30%) of patients allocated to hospital at home remained in hospital. Patients in all groups preferred hospital at home care except those with chronic obstructive airways disease. No differences were detected for carer burden. Carers of patients recovering from knee replacement preferred hospital at home care, while carers of patients recovering from a hysterectomy preferred hospital care.

CONCLUSIONS

Few differences in outcome were detected. Thus, the cost of hospital at home compared with hospital care becomes a primary concern.