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Edgar K, Iliffe S, Doll HA, Clarke MJ, Gonçalves-Bradley DC, Wong E, Shepperd S. Admission avoidance hospital at home. Cochrane Database Syst Rev 2024; 3:CD007491. [PMID: 38438116 PMCID: PMC10911897 DOI: 10.1002/14651858.cd007491.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
BACKGROUND Admission avoidance hospital at home provides active treatment by healthcare professionals in the patient's home for a condition that would otherwise require acute hospital inpatient care, and always for a limited time period. This is the fourth update of this review. OBJECTIVES To determine the effectiveness and cost of managing patients with admission avoidance hospital at home compared with inpatient hospital care. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL on 24 February 2022, and checked the reference lists of eligible articles. We sought ongoing and unpublished studies by searching ClinicalTrials.gov and WHO ICTRP, and by contacting providers and researchers involved in the field. SELECTION CRITERIA Randomised controlled trials recruiting participants aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital inpatient care. DATA COLLECTION AND ANALYSIS We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. We performed meta-analysis for trials that compared similar interventions, reported comparable outcomes with sufficient data, and used individual patient data when available. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes. MAIN RESULTS We included 20 randomised controlled trials with a total of 3100 participants; four trials recruited participants with chronic obstructive pulmonary disease; two trials recruited participants recovering from a stroke; seven trials recruited participants with an acute medical condition who were mainly older; and the remaining trials recruited participants with a mix of conditions. We assessed the majority of the included studies as at low risk of selection, detection, and attrition bias, and unclear for selective reporting and performance bias. For an older population, admission avoidance hospital at home probably makes little or no difference on mortality at six months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.68 to 1.13; P = 0.30; I2 = 0%; 5 trials, 1502 participants; moderate-certainty evidence); little or no difference on the likelihood of being readmitted to hospital after discharge from hospital at home or inpatient care within 3 to 12 months' follow-up (RR 1.14, 95% CI 0.97 to 1.34; P = 0.11; I2 = 41%; 8 trials, 1757 participants; moderate-certainty evidence); and probably reduces the likelihood of living in residential care at six months' follow-up (RR 0.53, 95% CI 0.41 to 0.69; P < 0.001; I2 = 67%; 4 trials, 1271 participants; moderate-certainty evidence). Hospital at home probably results in little to no difference in patient's self-reported health status (2006 patients; moderate-certainty evidence). Satisfaction with health care received may be improved with admission avoidance hospital at home (1812 participants; low-certainty evidence); few studies reported the effect on caregivers. Hospital at home reduced the initial average hospital length of stay (2036 participants; low-certainty evidence), which ranged from 4.1 to 18.5 days in the hospital group and 1.2 to 5.1 days in the hospital at home group. Hospital at home length of stay ranged from an average of 3 to 20.7 days (hospital at home group only). Admission avoidance hospital at home probably reduces costs to the health service compared with hospital admission (2148 participants; moderate-certainty evidence), though by a range of different amounts and using different methods to cost resource use, and there is some evidence that it decreases overall societal costs to six months' follow-up. AUTHORS' CONCLUSIONS Admission avoidance hospital at home, with the option of transfer to hospital, may provide an effective alternative to inpatient care for a select group of older people who have been referred for hospital admission. The intervention probably makes little or no difference to patient health outcomes; may improve satisfaction; probably reduces the likelihood of relocating to residential care; and probably decreases costs.
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Affiliation(s)
- Kate Edgar
- Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Steve Iliffe
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Helen A Doll
- Clinical Outcomes Assessments, ICON Commercialisation and Outcomes, Dublin, Ireland
| | - Mike J Clarke
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | | | - Eric Wong
- St. Michael's Hospital and Unity Health Toronto, University of Toronto, Toronto, Canada
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Shannon B, Bowles KA, Williams C, Ravipati T, Deighton E, Andrew N. Does a Community Care programme reach a high health need population and high users of acute care hospital services in Melbourne, Australia? An observational cohort study. BMJ Open 2023; 13:e077195. [PMID: 37751947 PMCID: PMC10533720 DOI: 10.1136/bmjopen-2023-077195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/05/2023] [Indexed: 09/30/2023] Open
Abstract
OBJECTIVE The Community Care programme is an initiative aimed at reducing hospitalisations and emergency department (ED) presentations among patients with complex needs. We aimed to describe the characteristics of the programme participants and identify factors associated with enrolment into the programme. DESIGN This observational cohort study was conducted using routinely collected data from the National Centre for Healthy Ageing data platform. SETTING The study was carried out at Peninsula Health, a health service provider serving a population in Melbourne, Victoria, Australia. PARTICIPANTS We included all adults with unplanned ED presentation or hospital admission to Peninsula Health between 1 November 2016 and 31 October 2017, the programme's first operational year. OUTCOME MEASURES Community Care programme enrolment was the primary outcome. Participants' demographics, health factors and enrolment influences were analysed using a staged multivariable logistic regression. RESULTS We included 47 148 adults, of these, 914 were enrolled in the Community Care programme. Participants were older (median 66 vs 51 years), less likely to have a partner (34% vs 57%) and had more frequent hospitalisations and ED visits. In the multivariable analysis, factors most strongly associated with enrolment included not having a partner (adjusted OR (aOR) 1.83, 95% CI 1.57 to 2.12), increasing age (aOR 1.01, 95% CI 1.01 to 1.02), frequent hospitalisations (aOR 7.32, 95% CI 5.78 to 9.24), frequent ED visits (aOR 2.0, 95% CI 1.37 to 2.85) and having chronic diseases, such as chronic pulmonary disease (aOR 2.48, 95% CI 2.06 to 2.98), obesity (aOR 2.06, 95% CI 1.39 to 2.99) and diabetes mellitus (complicated) (aOR 1.75, 95% CI 1.44 to 2.13). Residing in aged care home and having high socioeconomic status) independently associated with reduced odds of enrolment. CONCLUSIONS The Community Care programme targets patients with high-readmission risks under-representation of individuals residing in residential aged care homes warrants further investigation. This study aids service planning and offers valuable feedback to clinicians about programme beneficiaries.
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Affiliation(s)
- Brendan Shannon
- Department of Paramedicine, Monash University, Franskton, Victoria, Australia
| | - Kelly-Ann Bowles
- Department of Paramedicine, Monash University, Franskton, Victoria, Australia
| | - Cylie Williams
- School of Primary and Allied Health Care, Monash University, Frankston, Victoria, Australia
| | - Tanya Ravipati
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
- National Centre for Healthy Ageing, Monash University and Peninsula Health, Frankston, Victoria, Australia
| | - Elise Deighton
- Community Care, Peninsula Health, Frankston, Victoria, Australia
| | - Nadine Andrew
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
- National Centre for Healthy Ageing, Monash University and Peninsula Health, Frankston, Victoria, Australia
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3
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Saenger PM, Ornstein KA, Garrido MM, Lubetsky S, Bollens-Lund E, DeCherrie LV, Leff B, Siu AL, Federman AD. Cost of home hospitalization versus inpatient hospitalization inclusive of a 30-day post-acute period. J Am Geriatr Soc 2022; 70:1374-1383. [PMID: 35212391 DOI: 10.1111/jgs.17706] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/20/2021] [Accepted: 01/16/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Previous studies have demonstrated that hospital at home (HaH) care is associated with lower costs than traditional hospital care. Most prior studies were small, not U.S.-focused, or did not include post-acute costs in their analyses. Our objective was to determine if combined acute and 30-day post-acute costs of care were lower for HaH patients compared to inpatient comparisons in a Center for Medicare and Medicaid Innovation Center demonstration of HaH. METHODS A single-center New York City retrospective observational cohort study of patients admitted to either HaH or inpatient care from September 1, 2014 through August 31, 2017. Eligible patients were 18 years or older, required inpatient admission, lived in Manhattan, and met home safety requirements. Comparison individuals met the same criteria and were included if they refused HaH care or were admitted when HaH was not available. HaH care was substitutive hospital-level care and 30-days of post-acute transitional care. Main outcomes were costs of care of the acute and post-acute 30-day episodes. We matched subjects on age, sex, and insurance and conducted regression analyses using an unadjusted model and one adjusted for several patient characteristics. RESULTS Of 523 Medicare admission episodes, data were available for 201 episodes in the HaH arm and 101 episodes of usual care. HaH patients were older (81.6 [SD = 12.3] years vs. 74.6 [SD = 14.0], p < 0.0001) and more likely to have activities of daily living (ADL) impairments (75.4% vs. 46.5%, p < 0.0001). Unadjusted mean costs were $5054 lower for HaH episodes compared to inpatient episodes. Regression analysis with matching showed HaH costs were $5116 (95% CI -$10,262 to $30, p = 0.05) lower, and when adjusted for age, sex, insurance, diagnosis, and ADL impairments, $5977 (95% CI -$10,758 to -$1196, p = 0.01) lower. CONCLUSIONS HaH combined with 30-day post-acute transition care was less costly than inpatient care.
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Affiliation(s)
- Pamela M Saenger
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Melissa M Garrido
- Department of Health Law, Policy and Management, Boston University School of Public Health and Partnered Evidence-based Policy Resource Center (PEPReC), Boston VA Healthcare System, Boston, Massachusetts, USA
| | - Sara Lubetsky
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Evan Bollens-Lund
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Linda V DeCherrie
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bruce Leff
- Division of Geriatric Medicine, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Albert L Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education, and Clinical Center, James J Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Alex D Federman
- Department of Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Bourbeau J, Echevarria C. Models of care across the continuum of exacerbations for patients with chronic obstructive pulmonary disease. Chron Respir Dis 2021; 17:1479973119895457. [PMID: 31970998 PMCID: PMC6978821 DOI: 10.1177/1479973119895457] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with
significant morbidity and mortality, and treatments require a multidisciplinary
approach to address patient needs. This review considers different models of
care across the continuum of exacerbations (1) chronic care and self-management
interventions with the action plan, (2) domiciliary care for severe exacerbation
and the impact on readmission prevention and (3) the discharge care bundle for
management beyond the acute exacerbation episode. Self-management strategies
include written action plans and coaching with patient and family support.
Self-management interventions facilitate the delivery of good care, can reduce
exacerbations associated with admission, be cost-effective and improve quality
of life. Hospitalization as a complication of exacerbation is not always
unavoidable. Domiciliary care has been proposed as a solution to replace part,
and perhaps even all, of the patient’s in-hospital stay, and to reduce hospital
bed days, readmission rates and costs; low-risk patients can be identified using
risk stratification tools. A COPD discharge bundle is another potentially
important approach that can be considered to improve the management of COPD
exacerbations complicated by hospital admission; it comprised treatments that
have demonstrated efficacy, such as smoking cessation, personalized
pharmacotherapy and non-pharmacotherapy such as pulmonary rehabilitation. COPD
bundles may also improve the transition of care from the hospital to the
community following exacerbation and may reduce readmission rates. Future models
of care should be personalized – providing patient education aiming at behaviour
changes, identifying and treating co-morbidities, and including outcomes that
measure quality of care rather than focusing only on readmission quantity within
30 days.
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Affiliation(s)
- Jean Bourbeau
- Respiratory Epidemiology and Clinical Research Unit, Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Carlos Echevarria
- Respiratory Department, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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5
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Shi G, Chen C. Home-based versus outpatient pulmonary rehabilitation program for patients with chronic obstructive pulmonary disease: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e26099. [PMID: 34032747 PMCID: PMC8154446 DOI: 10.1097/md.0000000000026099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Although home-based pulmonary rehabilitation programs have been shown in some studies to be an alternative and effective model, there is a lack of consensus in the medical literature due to different study designs and lack of standardization among procedures. Therefore, the purpose of this study was to compare the efficacy of a home-based versus outpatient pulmonary rehabilitation program for patients with chronic obstructive pulmonary disease (COPD). METHODS Five electronic databases including Embase, PubMed, Scopus, Science Direct, and Cochrane Library will be searched in May 2021 by 2 independent reviewers. The reference lists of the included studies will be also checked for additional studies that are not identified with the database search. There is no restriction on the dates of publication or language in the search. The randomized controlled trials focusing on comparing home-based and outpatient pulmonary rehabilitation for COPD patients will be included in our meta-analysis. The following outcomes should have been measured: functional exercise capacity, disease-specific health-related quality of life, and cost-effectiveness measures. Risk ratio with a 95% confidence interval or standardized mean difference with 95% CI is assessed for dichotomous outcomes or continuous outcomes, respectively. RESULTS It was hypothesized that these 2 methods would provide similar therapeutic benefits. REGISTRATION NUMBER 10.17605/OSF.IO/5CV48.
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Affiliation(s)
| | - Chuanjun Chen
- Department of Oncology, Xinchang County People's Hospital, Zhejiang 312500, China
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7
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Goossens LMA, Vemer P, Rutten-van Mölken MPMH. The risk of overestimating cost savings from hospital-at-home schemes: A literature review. Int J Nurs Stud 2020; 109:103652. [PMID: 32569827 DOI: 10.1016/j.ijnurstu.2020.103652] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Lucas M A Goossens
- Erasmus School for Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam 3000, the Netherlands.
| | - Pepijn Vemer
- Erasmus School for Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam 3000, the Netherlands; Department of Pharmacotherapy, Epidemiology & Economics, University of Groningen, P.O. Box 196, 9700 AD, Groningen, the Netherlands
| | - Maureen P M H Rutten-van Mölken
- Erasmus School for Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam 3000, the Netherlands
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8
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Elliott MJ, Love S, Donald M, Manns B, Donald T, Premji Z, Hemmelgarn BR, Grinman M, Lang E, Ronksley PE. Outpatient Interventions for Managing Acute Complications of Chronic Diseases: A Scoping Review and Implications for Patients With CKD. Am J Kidney Dis 2020; 76:794-805. [PMID: 32479925 DOI: 10.1053/j.ajkd.2020.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 04/02/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Patients with chronic kidney disease (CKD) have high rates of emergency department (ED) use and hospitalization. Outpatient care may provide an alternative to ED and inpatient care in this population. We aimed to explore the scope of outpatient interventions used to manage acute complications of chronic diseases and highlight opportunities to adapt and test interventions in the CKD population. STUDY DESIGN Scoping review of quantitative and qualitative studies. SETTING & POPULATION Outpatient interventions for adults experiencing acute complications related to 1 of 5 eligible chronic diseases (ie, CKD, chronic respiratory disease, cardiovascular disease, cancer, and diabetes). SELECTION CRITERIA FOR STUDIES MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, grey literature, and conference abstracts were searched to December 2019. DATA EXTRACTION Intervention and study characteristics were extracted using standardized tools. ANALYTICAL APPROACH Quantitative data were summarized descriptively; qualitative data were summarized thematically. Our approach observed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews. RESULTS 77 studies (25 randomized controlled trials, 29 observational, 12 uncontrolled before-after, 5 quasi-experimental, 4 qualitative, and 2 mixed method) describing 57 unique interventions were included. Of identified intervention types (hospital at home [n = 16], observation unit [n = 9], ED-based specialist service [n = 4], ambulatory program [n = 18], and telemonitoring [n = 10]), most were studied in chronic respiratory and cardiovascular disease populations. None targeted the CKD population. Interventions were delivered in the home, ED, hospital, and ambulatory setting by a variety of health care providers. Cost savings were demonstrated for most interventions, although improvements in other outcome domains were not consistently observed. LIMITATIONS Heterogeneity of included studies; lack of data for outpatient interventions for acute complications related to CKD. CONCLUSIONS Several interventions for outpatient management of acute complications of chronic disease were identified. Although none was specific to the CKD population, features could be adapted and tested to address the complex acute-care needs of patients with CKD.
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Affiliation(s)
- Meghan J Elliott
- Department of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Shannan Love
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Maoliosa Donald
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bryn Manns
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Teagan Donald
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Zahra Premji
- Department of Libraries and Cultural Resources, University of Calgary, Calgary, AB, Canada
| | - Brenda R Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Michelle Grinman
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Echevarria C, Gray J, Hartley T, Steer J, Miller J, Simpson AJ, Gibson GJ, Bourke SC. Home treatment of COPD exacerbation selected by DECAF score: a non-inferiority, randomised controlled trial and economic evaluation. Thorax 2018; 73:713-722. [PMID: 29680821 PMCID: PMC6204956 DOI: 10.1136/thoraxjnl-2017-211197] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 02/27/2018] [Accepted: 03/19/2018] [Indexed: 11/15/2022]
Abstract
Background Previous models of Hospital at Home (HAH) for COPD exacerbation (ECOPD) were limited by the lack of a reliable prognostic score to guide patient selection. Approximately 50% of hospitalised patients have a low mortality risk by DECAF, thus are potentially suitable. Methods In a non-inferiority randomised controlled trial, 118 patients admitted with a low-risk ECOPD (DECAF 0 or 1) were recruited to HAH or usual care (UC). The primary outcome was health and social costs at 90 days. Results Mean 90-day costs were £1016 lower in HAH, but the one-sided 95% CI crossed the non-inferiority limit of £150 (CI −2343 to 312). Savings were primarily due to reduced hospital bed days: HAH=1 (IQR 1–7), UC=5 (IQR 2–12) (P=0.001). Length of stay during the index admission in UC was only 3 days, which was 2 days shorter than expected. Based on quality-adjusted life years, the probability of HAH being cost-effective was 90%. There was one death within 90 days in each arm, readmission rates were similar and 90% of patients preferred HAH for subsequent ECOPD. Conclusion HAH selected by low-risk DECAF score was safe, clinically effective, cost-effective, and preferred by most patients. Compared with earlier models, selection is simpler and approximately twice as many patients are eligible. The introduction of DECAF was associated with a fall in UC length of stay without adverse outcome, supporting use of DECAF to direct early discharge. Trial registration number Registered prospectively ISRCTN29082260.
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Affiliation(s)
- Carlos Echevarria
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK.,ICM, Newcastle University, Newcastle Upon Tyne, UK
| | - Joanne Gray
- Nursing, Midwifery and Health Department, Northumbria University, Newcastle Upon Tyne, UK
| | - Tom Hartley
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK.,ICM, Newcastle University, Newcastle Upon Tyne, UK
| | - John Steer
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK.,ICM, Newcastle University, Newcastle Upon Tyne, UK
| | - Jonathan Miller
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | | | | | - Stephen C Bourke
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK.,ICM, Newcastle University, Newcastle Upon Tyne, UK
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10
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Dres M. [Criteria for hospital discharge after COPD exacerbation]. Rev Mal Respir 2017; 34:487-489. [PMID: 28522148 DOI: 10.1016/j.rmr.2017.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- M Dres
- Unité de réanimation médicale et surveillance continue, service de pneumologie et réanimation médicale, groupe hospitalier Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
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11
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Wedzicha JA, Miravitlles M, Hurst JR, Calverley PMA, Albert RK, Anzueto A, Criner GJ, Papi A, Rabe KF, Rigau D, Sliwinski P, Tonia T, Vestbo J, Wilson KC, Krishnan JA. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J 2017; 49:49/3/1600791. [PMID: 28298398 DOI: 10.1183/13993003.00791-2016] [Citation(s) in RCA: 314] [Impact Index Per Article: 44.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 11/15/2016] [Indexed: 01/20/2023]
Abstract
This document provides clinical recommendations for treatment of chronic obstructive pulmonary disease (COPD) exacerbations.Comprehensive evidence syntheses, including meta-analyses, were performed to summarise all available evidence relevant to the Task Force's questions. The evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation approach and the results were summarised in evidence profiles. The evidence syntheses were discussed and recommendations formulated by a multidisciplinary Task Force of COPD experts.After considering the balance of desirable and undesirable consequences, quality of evidence, feasibility, and acceptability of various interventions, the Task Force made: 1) a strong recommendation for noninvasive mechanical ventilation of patients with acute or acute-on-chronic respiratory failure; 2) conditional recommendations for oral corticosteroids in outpatients, oral rather than intravenous corticosteroids in hospitalised patients, antibiotic therapy, home-based management, and the initiation of pulmonary rehabilitation within 3 weeks after hospital discharge; and 3) a conditional recommendation against the initiation of pulmonary rehabilitation during hospitalisation.The Task Force provided recommendations related to corticosteroid therapy, antibiotic therapy, noninvasive mechanical ventilation, home-based management, and early pulmonary rehabilitation in patients having a COPD exacerbation. These recommendations should be reconsidered as new evidence becomes available.
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Affiliation(s)
- Jadwiga A Wedzicha
- Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, UK
| | - Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Peter M A Calverley
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Richard K Albert
- Dept of Medicine, University of Colorado, Denver, Aurora, CO, USA
| | - Antonio Anzueto
- University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Gerard J Criner
- Dept of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Alberto Papi
- Respiratory Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Klaus F Rabe
- Dept of Internal Medicine, Christian-Albrechts University, Kiel and LungenClinic Grosshansdorf, Airway Research Centre North, German Centre for Lung Research, Grosshansdorf, Germany
| | - David Rigau
- Iberoamerican Cochrane Center, Barcelona, Spain
| | - Pawel Sliwinski
- 2nd Dept of Respiratory Medicine, Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Kevin C Wilson
- Dept of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jerry A Krishnan
- University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
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Shepperd S, Iliffe S, Doll HA, Clarke MJ, Kalra L, Wilson AD, Gonçalves‐Bradley DC. Admission avoidance hospital at home. Cochrane Database Syst Rev 2016; 9:CD007491. [PMID: 27583824 PMCID: PMC6457791 DOI: 10.1002/14651858.cd007491.pub2] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Admission avoidance hospital at home provides active treatment by healthcare professionals in the patient's home for a condition that otherwise would require acute hospital inpatient care, and always for a limited time period. This is the third update of the original review. OBJECTIVES To determine the effectiveness and cost of managing patients with admission avoidance hospital at home compared with inpatient hospital care. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, two other databases, and two trials registers on 2 March 2016. We checked the reference lists of eligible articles. We sought unpublished studies by contacting providers and researchers who were known to be involved in the field. SELECTION CRITERIA Randomised controlled trials recruiting participants aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital inpatient care. DATA COLLECTION AND ANALYSIS We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. We performed meta-analysis for trials that compared similar interventions and reported comparable outcomes with sufficient data, requested individual patient data from trialists, and relied on published data when this was not available. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes. MAIN RESULTS We included 16 randomised controlled trials with a total of 1814 participants; three trials recruited participants with chronic obstructive pulmonary disease, two trials recruited participants recovering from a stroke, six trials recruited participants with an acute medical condition who were mainly elderly, and the remaining trials recruited participants with a mix of conditions. We assessed the majority of the included studies as at low risk of selection, detection, and attrition bias, and unclear for selective reporting and performance bias. Admission avoidance hospital at home probably makes little or no difference on mortality at six months' follow-up (risk ratio (RR) 0.77, 95% confidence interval (CI) 0.60 to 0.99; P = 0.04; I2 = 0%; 912 participants; moderate-certainty evidence), little or no difference on the likelihood of being transferred (or readmitted) to hospital (RR 0.98, 95% CI 0.77 to 1.23; P = 0.84; I2 = 28%; 834 participants; moderate-certainty evidence), and may reduce the likelihood of living in residential care at six months' follow-up (RR 0.35, 95% CI 0.22 to 0.57; P < 0.0001; I2 = 78%; 727 participants; low-certainty evidence). Satisfaction with healthcare received may be improved with admission avoidance hospital at home (646 participants, low-certainty evidence); few studies reported the effect on caregivers. When the costs of informal care were excluded, admission avoidance hospital at home may be less expensive than admission to an acute hospital ward (287 participants, low-certainty evidence); there was variation in the reduction of hospital length of stay, estimates ranged from a mean difference of -8.09 days (95% CI -14.34 to -1.85) in a trial recruiting older people with varied health problems, to a mean increase of 15.90 days (95% CI 8.10 to 23.70) in a study that recruited patients recovering from a stroke. AUTHORS' CONCLUSIONS Admission avoidance hospital at home, with the option of transfer to hospital, may provide an effective alternative to inpatient care for a select group of elderly patients requiring hospital admission. However, the evidence is limited by the small randomised controlled trials included in the review, which adds a degree of imprecision to the results for the main outcomes.
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Affiliation(s)
- Sasha Shepperd
- University of OxfordNuffield Department of Population HealthRosemary Rue Building, Old Road CampusHeadingtonOxfordOxfordshireUKOX3 7LF
| | - Steve Iliffe
- University College LondonResearch Department of Primary Care and Population HealthLondonUK
| | - Helen A Doll
- ICON Commercialisation and OutcomesClinical Outcomes AssessmentsDublinIreland
| | - Mike J Clarke
- Queen's University BelfastCentre for Public HealthInstitute of Clinical Sciences, Block B, Royal Victoria HospitalGrosvenor RoadBelfastNorthern IrelandUKBT12 6BJ
| | - Lalit Kalra
- Guy's, King's & St Thomas' School of MedicineDepartment of MedicineKing's Denmark Hill CampusBessemer RoadLondonUKSE5 9PJ
| | - Andrew D Wilson
- University of LeicesterDepartment of Health SciencesLeicesterLeicestershireUKLE1 7RH
| | - Daniela C. Gonçalves‐Bradley
- University of OxfordNuffield Department of Population HealthRosemary Rue Building, Old Road CampusHeadingtonOxfordOxfordshireUKOX3 7LF
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Echevarria C, Brewin K, Horobin H, Bryant A, Corbett S, Steer J, Bourke SC. Early Supported Discharge/Hospital At Home For Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Review and Meta-Analysis. COPD 2016; 13:523-33. [PMID: 26854816 DOI: 10.3109/15412555.2015.1067885] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A systematic review and meta-analysis was performed to assess the safety, efficacy and cost of Early Supported Discharge (ESD) and Hospital at Home (HAH) compared to Usual Care (UC) for patients with acute exacerbation of COPD (AECOPD). The structure of ESD/HAH schemes was reviewed, and analyses performed assuming return to hospital during the acute period (prior to discharge from home treatment) was, and was not, considered a readmission. The pre-defined search strategy completed in November 2014 included electronic databases (Medline, Embase, Amed, BNI, Cinahl and HMIC), libraries, current trials registers, national organisations, key respiratory journals, key author contact and grey literature. Randomised controlled trials (RCTs) comparing ESD/HAH to UC in patients admitted with AECOPD, or attending the emergency department and triaged for admission, were included. Outcome measures were mortality, all-cause readmissions to 6 months and cost. Eight RCTs were identified; seven reported mortality and readmissions. The structure of ESD/HAH schemes, particularly selection criteria applied and level of support provided, varied considerably. Compared to UC, ESD/HAH showed a trend towards lower mortality (RRMH = 0.66; 95% CI 0.40-1.09, p = 0.10). If return to hospital during the acute period was not considered a readmission, ESD/HAH was associated with fewer readmissions (RRMH = 0.74, 95% CI: 0.60-0.90, p = 0.003), but if considered a readmission, the benefit was lost (RRMH = 0.84; 95% CI 0.69-1.01, p = 0.07). Costs were lower for ESD/HAH than UC. ESD/HAH is safe in selected patients with an AECOPD. Further research is required to define optimal criteria to guide patient selection and models of care.
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Affiliation(s)
- Carlos Echevarria
- a Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital , Newcastle Upon Tyne , United Kingdom
| | - Karen Brewin
- b Critical Care and Respiratory Medicine Physiotherapy, Northumbria Healthcare NHS Foundation Trust, Wansbeck General Hospital , Northumberland , United Kingdom
| | - Hazel Horobin
- c Sheffield Hallam University , Sheffield , United Kingdom
| | - Andrew Bryant
- d Institute of Health and Society, Newcastle University , Newcastle Upon Tyne , United Kingdom
| | - Sally Corbett
- e Research and Development Department, Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital , Newcastle Upon Tyne , United Kingdom
| | - John Steer
- a Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital , Newcastle Upon Tyne , United Kingdom
| | - Stephen C Bourke
- a Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital , Newcastle Upon Tyne , United Kingdom
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Jester R, Titchener K, Doyle-Blunden J, Caldwell C. The development of an evaluation framework for a Hospital at Home service. JOURNAL OF INTEGRATED CARE 2015. [DOI: 10.1108/jica-09-2015-0038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Efficacy of hospital in the home services providing care for patients admitted from emergency departments. INT J EVID-BASED HEA 2014; 12:128-41. [DOI: 10.1097/xeb.0000000000000011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Collins AM, Eneje OJ, Hancock CA, Wootton DG, Gordon SB. Feasibility study for early supported discharge in adults with respiratory infection in the UK. BMC Pulm Med 2014; 14:25. [PMID: 24571705 PMCID: PMC3943804 DOI: 10.1186/1471-2466-14-25] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 02/17/2014] [Indexed: 11/29/2022] Open
Abstract
Background Many patients with pneumonia and lower respiratory tract infection that could be treated as outpatients according to their clinical severity score, are in fact admitted to hospital. We investigated whether, with medical and social input, these patients could be discharged early and treated at home. Objectives: (1) To assess the feasibility of providing an early supported discharge scheme for patients with pneumonia and lower respiratory tract infection (2) To assess the patient acceptability of a study comprising of randomisation to standard hospital care or early supported discharge scheme. Methods Design: Randomised controlled trial. Setting: Liverpool, UK. Two University Teaching hospitals; one city-centre, 1 suburban in Liverpool, a city with high deprivation scores and unemployment rates. Participants: 200 patients screened: 14 community-dwelling patients requiring an acute hospital stay for pneumonia or lower respiratory tract infection were recruited. Intervention: Early supported discharge scheme to provide specialist respiratory care in a patient’s own home as a substitute to acute hospital care. Main outcome measures: Primary - patient acceptability. Secondary – safety/mortality, length of hospital stay, readmission, patient/carer (or next of kin) satisfaction, functional status and symptom improvement. Results 42 of the 200 patients screened were eligible for early supported discharge; 10 were only identified at the point of discharge, 18 declined participation and 14 were randomised to either early supported discharge or standard hospital care. The total hospital length of hospital stay was 8.33 (1–31) days in standard hospital care and 3.4 (1–7) days in the early supported discharge scheme arm. In the early supported discharge scheme arm patient carers reported higher satisfaction with care and there were less readmissions and hospital-acquired infections. Limitations: A small study in a single city. This was a feasibility study and therefore not intended to compare outcome data. Conclusions An early supported discharge scheme for patients with pneumonia and lower respiratory tract infection was feasible. Larger numbers of patients would be eligible if future work included patients with dementia and those residing in care homes. Trial registration ISRCTN25542492.
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Affiliation(s)
- Andrea M Collins
- Biomedical Research Centre (BRC) in Microbial Diseases, Respiratory Infection Group, Royal Liverpool and Broadgreen University Hospital Trust, Prescot Street, L7 8XP Liverpool, UK.
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Utens CMA, Goossens LMA, van Schayck OCP, Rutten-Vanmölken MPHM, Braken MW, van Eijsden LMGA, Smeenk FWJM. Evaluation of health care providers' role transition and satisfaction in hospital-at-home for chronic obstructive pulmonary disease exacerbations: a survey study. BMC Health Serv Res 2013; 13:363. [PMID: 24074294 PMCID: PMC3849519 DOI: 10.1186/1472-6963-13-363] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 09/25/2013] [Indexed: 11/10/2022] Open
Abstract
Background Hospital-at-home is an accepted alternative for usual hospital treatment for patients with a Chronic Obstructive Pulmonary Disease (COPD) exacerbation. The introduction of hospital-at-home may lead to changes in health care providers’ roles and responsibilities. To date, the impact on providers’ roles is unknown and in addition, little is known about the satisfaction and acceptance of care providers involved in hospital-at-home. Methods Objective of this survey study was to investigate the role differentiation, role transitions and satisfaction of professional care providers (i.e. pulmonologists, residents, hospital respiratory nurses, generic and specialised community nurses and general practitioners) from 3 hospitals and 2 home care organisations, involved in a community-based hospital-at-home scheme. A combined multiple-choice and open-end questionnaire was administered in study participants. Results Response rate was 10/17 in pulmonologists, 10/23 in residents, 9/12 in hospital respiratory nurses, 15/60 in generic community nurses, 6/10 in specialised community nurses and 25/47 in general practitioners. For between 66% and 100% of respondents the role in early discharge was clear and between 57% and 78% of respondents was satisfied with their role in early discharge. For nurses the role in early discharge was different compared to their role in usual care. 67% of generic community nurses felt they had sufficient knowledge and skills to monitor patients at home, compared to 100% of specialised community nurses. Specialised community nurses felt they should monitor patients. 60% of generic community nurses responded they should monitor patients at home. 78% of pulmonologists, 12% of general practitioners, 55% of hospital respiratory nurses and 48 of community nurses was satisfied with early discharge in general. For coordination of care 29% of community nurses had an unsatisfied response. For continuity of care this was 12% and 10% for hospital respiratory nurses and community nurses, respectively. Conclusion A community-based early assisted discharge for COPD exacerbations is possible and well accepted from the perspective of health care providers’ involved. Satisfaction with the different aspects is good and the transfer of patients in the community while supervised by generic community nurses is possible. Attention should be paid to coordination and continuity of care, especially information transfer between providers.
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Affiliation(s)
- Cecile M A Utens
- Department of Respiratory Medicine, Catharina Hospital, Eindhoven, the Netherlands.
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18
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Goossens LMA, Utens CMA, Smeenk FWJM, van Schayck OCP, van Vliet M, van Litsenburg W, Braken MW, Rutten-van Mölken MPMH. Cost-effectiveness of early assisted discharge for COPD exacerbations in The Netherlands. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2013; 16:517-528. [PMID: 23796285 DOI: 10.1016/j.jval.2013.01.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 01/28/2013] [Accepted: 01/29/2013] [Indexed: 06/02/2023]
Abstract
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.
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Affiliation(s)
- Lucas M A Goossens
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands.
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Pericás JM, Aibar J, Soler N, López-Soto A, Sanclemente-Ansó C, Bosch X. Should alternatives to conventional hospitalisation be promoted in an era of financial constraint? Eur J Clin Invest 2013; 43:602-15. [PMID: 23590593 DOI: 10.1111/eci.12087] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 03/10/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Because the current economic crisis has led to austerity in health policies, with severe restrictions on public health care, avoiding unnecessary admissions and shortening hospital stays is rapidly becoming an urgent priority. Alternatives to hospitalisation replace or shorten hospital processes, including diagnosis, monitoring, treatment and follow-up. This review aims to present the available evidence on alternatives to conventional hospitalisation for medical disorders; options for surgery, psychiatry and palliative care are largely excluded. MATERIALS AND METHODS Narrative review. RESULTS The main alternatives to conventional hospitalisation include day centres (DC), quick diagnosis units (QDU), hospital at home (HaH) and, in some circumstances, telemonitoring. DC increase patient comfort, reduce costs and can improve efficiency. In generally healthy patients with suspected severe disease, QDU may be a good alternative to hospitalisation for diagnostic procedures. However, their cost-effectiveness remains to be clearly proven. Randomised controlled trials have shown that hospital-at-home (HaH) can lead to earlier hospital discharges, improve outcomes and reduce costs in patients with prevalent chronic diseases. Although telemonitoring seems to be promising and its use is increasing, methodologically sounder studies with a higher level of evidence are needed to assess its clinical effectiveness. CONCLUSIONS Factors such as ageing, the need for an earlier diagnosis of suspected severe disease, the increasing complexity of medical care and the increasing costs of hospitalisation mean that, whenever possible, giving priority to less expensive alternatives to hospital admission, such as QDU, DC, HaH and telemedicine, is an urgent task in the current economic crisis.
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Affiliation(s)
- Juan M Pericás
- Department of Internal Medicine, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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Caplan GA, Sulaiman NS, Mangin DA, Aimonino Ricauda N, Wilson AD, Barclay L. A meta-analysis of "hospital in the home". Med J Aust 2013; 197:512-9. [PMID: 23121588 DOI: 10.5694/mja12.10480] [Citation(s) in RCA: 191] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the effect of "hospital in the home" (HITH) services that significantly substitute for inhospital time on mortality, readmission rates, patient and carer satisfaction, and costs. DATA SOURCES MEDLINE, Embase, Social Sciences Citation Index, CINAHL, EconLit, PsycINFO and the Cochrane Database of Systematic Reviews, from the earliest date in each database to 1 February 2012. STUDY SELECTION Randomised controlled trials (RCTs) comparing HITH care with inhospital treatment for patients aged > 16 years. DATA EXTRACTION Potentially relevant studies were reviewed independently by two assessors, and data were extracted using a collection template and checklist. DATA SYNTHESIS 61 RCTs met the inclusion criteria. HITH care led to reduced mortality (odds ratio [OR], 0.81; 95% CI, 0.69 to 0.95; P = 0.008; 42 RCTs with 6992 patients), readmission rates (OR, 0.75; 95% CI, 0.59 to 0.95; P = 0.02; 41 RCTs with 5372 patients) and cost (mean difference, -1567.11; 95% CI, -2069.53 to -1064.69; P < 0.001; 11 RCTs with 1215 patients). The number needed to treat at home to prevent one death was 50. No heterogeneity was observed for mortality data, but heterogeneity was observed for data relating to readmission rates and cost. Patient satisfaction was higher in HITH in 21 of 22 studies, and carer satisfaction was higher in and six of eight studies; carer burden was lower in eight of 11 studies, although not significantly (mean difference, 0.00; 95% CI, -0.19 to 0.19). CONCLUSION HITH is associated with reductions in mortality, readmission rates and cost, and increases in patient and carer satisfaction, but no change in carer burden.
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Affiliation(s)
- Gideon A Caplan
- Post Acute Care Services, Prince of Wales Hospital, Sydney, NSW.
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Ohnuma T, Makizako H, Abe T, Miura H, Shimada H. [Predictors of interruptions to living at home in elderly people enrolled in a home visit rehabilitation service]. Nihon Ronen Igakkai Zasshi 2012; 49:214-21. [PMID: 23268871 DOI: 10.3143/geriatrics.49.214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM The purpose of this study was to determine the predictors of interruption to living at home as a result of death, hospitalization, or admission to a long-term care facility in frail elderly people enrolled in a home visit rehabilitation service. METHODS A total of 311 patients entered a home visit rehabilitation service within a study period of 1 September, 2005 to 31 March, 2010, 146 of whom met the criteria to be enrolled in this study and gave consent. Of these, 73 received a continuous home visit rehabilitation service (continuous group) of over 2 years and 73 experienced interruption to this service due to death, hospitalization, or admission to a long-term care facility (interruption group). The following physical, social, and medical factors were recorded and analyzed: age, sex, care level, disease diagnoses, gait disability, cognitive impairment, living with another person and cause of the interruption to the home-visit rehabilitation service. We compared each item between the interruption and continuous groups. Logistic regression analysis was used to identify the significant predictors of interruptions to living at home. RESULTS Patients in the interruption group demonstrated significantly lower functioning in activities of daily living (ADL), gait ability and lower cognitive status, and higher rates of respiratory diseases and cancer compared with the continuous group. On logistic regression analysis, ADL score (odds ratio [OR]=0.97, p<0.01), and the presence of respiratory diseases (OR=4.35, p=0.04) and cancer (OR=13.46, p<0.01) were significantly associated with interruptions to living at home. CONCLUSIONS Lower ADL functioning, respiratory diseases and cancer were significant predictors of interruption to living at home in frail elderly adults.
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Wang Y, Haugen T, Steihaug S, Werner A. Patients with acute exacerbation of chronic obstructive pulmonary disease feel safe when treated at home: a qualitative study. BMC Pulm Med 2012; 12:45. [PMID: 22920051 PMCID: PMC3517315 DOI: 10.1186/1471-2466-12-45] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 08/21/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The design of new interventions to improve health care for patients with chronic obstructive pulmonary disease (COPD) requires knowledge about what patients with an acute exacerbation experience as important and useful. The objective of the study was to explore patients' experiences of an early discharge hospital at home (HaH) treatment programme for exacerbations in COPD. METHODS Six exacerbated COPD patients that were randomised to receiving HaH care and three patients randomised to receiving traditional hospital care were interviewed in semi-structured in-depth interviews. Four spouses were present during the respective patients' interviews. The interviews were audio-taped, transcribed and analysed by a four-step method for systematic text condensing. RESULTS Despite limited assistance from the health care service, the patients and their spouses experienced the HaH treatment as safe. They expressed that information that was adapted to specific situations in their daily lives and given in a familiar environment had positive impact on their self-management of COPD. CONCLUSION The results contribute to increased knowledge and awareness about what the patients experienced as important aspects of a HaH treatment programme. How adapted input from health services can make patients with exacerbation of COPD feel safe and better able to manage their disease, is important knowledge for developing new and effective health services for patients with chronic disease.
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Affiliation(s)
- Ying Wang
- HØKH, Research Centre, Akershus University Hospital, P.O. Box 95, N-1478, Lørenskog, Norway
- Faculty Division Akershus University Hospital, University of Oslo, Oslo, Norway
| | - Torbjørn Haugen
- HØKH, Research Centre, Akershus University Hospital, P.O. Box 95, N-1478, Lørenskog, Norway
- Clinic for Allergy and Airway Diseases, Oslo, Norway
| | - Sissel Steihaug
- HØKH, Research Centre, Akershus University Hospital, P.O. Box 95, N-1478, Lørenskog, Norway
- SINTEF Technology and Society, Health Research, P.O. Box 124, Blindern, N-0314, Norway
| | - Anne Werner
- HØKH, Research Centre, Akershus University Hospital, P.O. Box 95, N-1478, Lørenskog, Norway
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Jeppesen E, Brurberg KG, Vist GE, Wedzicha JA, Wright JJ, Greenstone M, Walters JAE. Hospital at home for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2012:CD003573. [PMID: 22592692 DOI: 10.1002/14651858.cd003573.pub2] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
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.
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Utens CMA, Goossens LMA, Smeenk FWJM, Rutten-van Mölken MPMH, van Vliet M, Braken MW, van Eijsden LMGA, van Schayck OCP. Early assisted discharge with generic community nursing for chronic obstructive pulmonary disease exacerbations: results of a randomised controlled trial. BMJ Open 2012; 2:bmjopen-2012-001684. [PMID: 23075570 PMCID: PMC3488726 DOI: 10.1136/bmjopen-2012-001684] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To determine the effectiveness of early assisted discharge for chronic obstructive pulmonary disease (COPD) exacerbations, with home care provided by generic community nurses, compared with usual hospital care. DESIGN Prospective, randomised controlled and multicentre trial with 3-month follow-up. SETTING Five hospitals and three home care organisations in the Netherlands. PARTICIPANTS Patients admitted to the hospital with an exacerbation of COPD. Patients with no or limited improvement of respiratory symptoms and patients with severe unstable comorbidities, social problems or those unable to visit the toilet independently were excluded. INTERVENTION Early discharge from hospital after 3 days inpatient treatment. Home visits by generic community nurses. Primary outcome measure was change in health status measured by the Clinical COPD Questionnaire (CCQ). Treatment failures, readmissions, mortality and change in generic health-related quality of life (HRQL) were secondary outcome measures. RESULTS 139 patients were randomised. No difference between groups was found in change in CCQ score at day 7 (difference in mean change 0.29 (95% CI -0.03 to 0.61)) or at 3 months (difference in mean change 0.04 (95% CI -0.40 to 0.49)). No difference was found in secondary outcomes. At day 7 there was a significant difference in change in generic HRQL, favouring usual hospital care. CONCLUSIONS While patients' disease-specific health status after 7-day treatment tended to be somewhat better in the usual hospital care group, the difference was small and not clinically relevant or statistically significant. After 3 months, the difference had disappeared. A significant difference in generic HRQL at the end of the treatment had disappeared after 3 months and there was no difference in treatment failures, readmissions or mortality. Early assisted discharge with community nursing is feasible and an alternative to usual hospital care for selected patients with an acute COPD exacerbation. TRIAL REGISTRATION NetherlandsTrialRegister NTR 1129.
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Affiliation(s)
- Cecile M A Utens
- Department of Respiratory Medicine, Catharina-hospital Eindhoven, Eindhoven, The Netherlands
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Utens CMA, Goossens LMA, Smeenk FWJM, van Schayck OCP, van Litsenburg W, Janssen A, van Vliet M, Seezink W, Demunck DRAJ, van de Pas B, de Bruijn PJ, van der Pouw A, Retera JMAM, de Laat-Bierings P, van Eijsden L, Braken M, Eijsermans R, Rutten-van Mölken MPMH. Effectiveness and cost-effectiveness of early assisted discharge for chronic obstructive pulmonary disease exacerbations: the design of a randomised controlled trial. BMC Public Health 2010; 10:618. [PMID: 20955582 PMCID: PMC2965725 DOI: 10.1186/1471-2458-10-618] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 10/18/2010] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Cecile MA Utens
- Department of Respiratory Medicine, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Lucas MA Goossens
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, the Netherlands
| | - Frank WJM Smeenk
- Department of Respiratory Medicine, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Onno CP van Schayck
- Department of General Practice, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Walter van Litsenburg
- Department of Respiratory Medicine, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Annet Janssen
- Department of Respiratory Medicine, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Monique van Vliet
- Department of Respiratory Medicine, Atrium Medical Centre, Heerlen, the Netherlands
| | - Wiel Seezink
- Department of Respiratory Medicine, Atrium Medical Centre, Heerlen, the Netherlands
| | - Dirk RAJ Demunck
- Department of Respiratory Medicine, Máxima Medical Centre, Veldhoven/Eindhoven, the Netherlands
| | - Brigitte van de Pas
- Department of Respiratory Medicine, Máxima Medical Centre, Veldhoven/Eindhoven, the Netherlands
| | - Peter J de Bruijn
- Department of Respiratory Medicine, Alysis zorggroep Rijnstate Arnhem, Arnhem, the Netherlands
| | - Anouschka van der Pouw
- Department of Respiratory Medicine, Alysis zorggroep Rijnstate Arnhem, Arnhem, the Netherlands
| | - Jeroen MAM Retera
- Department of Respiratory Medicine, TweeSteden Hospital, Tilburg, the Netherlands
| | | | - Loes van Eijsden
- Department of Health Care Policy, Meander Group Zuid-Limburg, Heerlen, the Netherlands
| | - Maria Braken
- Department of Staff Nurses Nursing and Care, ZuidZorg, Veldhoven, the Netherlands
| | - Riet Eijsermans
- Department of Transmural Care, Thebe, Tilburg, the Netherlands
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Caress AL, Luker KA, Chalmers KI, Salmon MP. A review of the information and support needs of family carers of patients with chronic obstructive pulmonary disease. J Clin Nurs 2009; 18:479-91. [PMID: 19191997 DOI: 10.1111/j.1365-2702.2008.02556.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIMS AND OBJECTIVES The objectives of this narrative review were to identify: (1) The information and support needs of carers of family members with chronic obstructive pulmonary disease; (2) appropriate interventions to support carers in their caregiving role; (3) information on carers' needs as reported in studies of patients living with COPD in the community. BACKGROUND Chronic obstructive pulmonary disease is a major health problem in the UK resulting in significant burden for patients, families and the health service. Current National Health Service policies emphasise, where medically appropriate, early discharge for acute exacerbations, hospital-at-home care and other models of community care to prevent or reduce re-hospitalisations of people with chronic conditions. Understanding carers' needs is important if health care professionals are to support carers in their caregiving role. DESIGN A narrative literature review. METHODS Thirty five papers were reviewed after searching electronic databases. RESULTS Few studies were identified which addressed, even peripherally, carers' needs for information and support, and no studies were found which described and evaluated interventions designed to enhance caregiving capacity. Several studies of hospital-at-home/early discharge, self care and home management programmes were identified which included some information on patients' living arrangements or marital status. However, there was little or no detail reported on the needs of, and in many cases, even the presence of a family carer. CONCLUSIONS This review highlights the dearth of information on the needs of carers of chronic obstructive pulmonary disease patients and the need for future research. RELEVANCE TO CLINICAL PRACTICE There is little research based knowledge of the needs of carers of chronic obstructive pulmonary disease patients and interventions to assist them in providing care. This knowledge is critical to ensure that carers receive the information they need to carry out this role while maintaining their own physical and emotional health.
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Affiliation(s)
- Ann-Louise Caress
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
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Shepperd S, Doll H, Angus RM, Clarke MJ, Iliffe S, Kalra L, Ricauda NA, Tibaldi V, Wilson AD. Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data. CMAJ 2009; 180:175-82. [PMID: 19153394 DOI: 10.1503/cmaj.081491] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Avoidance of admission through provision of hospital care at home is a scheme whereby health care professionals provide active treatment in the patient's home for a condition that would otherwise require inpatient treatment in an acute care hospital. We sought to compare the effectiveness of this method of caring for patients with that type of in-hospital care. METHODS We searched the MEDLINE, EMBASE, CINAHL and EconLit databases and the Cochrane Effective Practice and Organisation of Care Group register from the earliest date in each database until January 2008. We included randomized controlled trials that evaluated a service providing an alternative to admission to an acute care hospital. We excluded trials in which the program did not offer a substitute for inpatient care. We performed meta-analyses for trials for which the study populations had similar characteristics and for which common outcomes had been measured. RESULTS We included 10 randomized trials (with a total of 1327 patients) in our systematic review. Seven of these trials (with a total of 969 patients) were deemed eligible for meta-analysis of individual patient data, but we were able to obtain data for only 5 of these trials (with a total of 844 patients [87%]). There was no significant difference in mortality at 3 months for patients who received hospital care at home (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.54-1.09, p = 0.15). However, at 6 months, mortality was significantly lower for these patients (adjusted HR 0.62, 95% CI 0.45-0.87, p = 0.005). Admissions to hospital were greater, but not significantly so, for patients receiving hospital care at home (adjusted HR 1.49, 95% CI 0.96-2.33, p = 0.08). Patients receiving hospital care at home reported greater satisfaction than those receiving inpatient care. These programs were less expensive than admission to an acute care hospital ward when the analysis was restricted to treatment actually received and when the costs of informal care were excluded. INTERPRETATION For selected patients, avoiding admission through provision of hospital care at home yielded similar outcomes to inpatient care, at a similar or lower cost.
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Affiliation(s)
- Sasha Shepperd
- Department of Public Health, University of Oxford, Old Road Campus, Headington, Oxford, United Kingdom.
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Shepperd S, Doll H, Angus RM, Clarke MJ, Iliffe S, Kalra L, Ricauda NA, Wilson AD. Admission avoidance hospital at home. Cochrane Database Syst Rev 2008:CD007491. [PMID: 18843751 PMCID: PMC4033791 DOI: 10.1002/14651858.cd007491] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Admission avoidance hospital at home is a service that provides active treatment by health care professionals in the patient's home for a condition that otherwise would require acute hospital in-patient care, and always for a limited time period. In particular, hospital at home has to offer a specific service to patients in their home requiring health care professionals to take an active part in the patients' care. If hospital at home were not available then the patient would be admitted to an acute hospital ward. Many countries are adopting this type of care in an attempt to reduce the demand for acute hospital admission. OBJECTIVES To determine, in the context of a systematic review and meta analysis, the effectiveness and cost of managing patients with admission avoidance hospital at home compared with in-patient hospital care. SEARCH STRATEGY The following databases were searched through to January 2008: MEDLINE, EMBASE, CINAHL, EconLit and the Cochrane Effective Practice and Organisation of Care Group (EPOC) register. We checked the reference lists of articles identified electronically for evaluations of hospital at home and obtained potentially relevant articles. Unpublished studies were sought by contacting providers and researchers who were known to be involved in this field. SELECTION CRITERIA Randomised controlled trials recruiting patients aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital in-patient care. The admission avoidance hospital at home interventions may admit patients directly from the community thereby avoiding physical contact with the hospital, or may admit from the emergency room. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed study quality. Our statistical analyses sought to include all randomised patients and were done on an intention to treat basis. We requested individual patient data (IPD) from trialists, and relied on published data when we did not receive trial data sets or the IPD did not include the relevant outcomes. When combining outcome data was not possible because of differences in the reporting of outcomes we have presented the data in narrative summary tables.For the IPD meta-analysis, where at least one event was reported in both study groups in a trial, Cox regression models were used to calculate the log hazard ratio and its standard error for mortality and readmission separately for each data set (where both outcomes were available). We included randomisation group (admission avoidance hospital at home versus control), age (above or below the median), and gender in the models. The calculated log hazard ratios were combined using fixed effects inverse variance meta analysis. If there were no events in one group we used the Peto odds ratio method to calculate a log odds ratio from the sum of the log-rank test 'O-E' statistics from a Kaplan Meier survival analysis. Statistical significance throughout was taken at the two-sided 5% level (p<0.05) and data are presented as the estimated effect with 95% confidence intervals. For each comparison using published data for dichotomous outcomes we calculated risk ratios using a fixed effects model to combine data. MAIN RESULTS We included 10 RCTs (n=1333), 7 of which were eligible for the IPD. Five out of these seven trials contributed to the IPD meta-analysis (n=850/975; 87%). There was a non significant reduction in mortality at three months for the admission avoidance hospital at home group (adjusted HR 0.77, 95% CI 0.54 to 1.09; p=0.15), which reached significance at six months follow-up (adjusted HR 0.62, 95% CI 0.45 to 0.87; p=0.005). A non significant increase in admissions was observed for patients allocated to hospital at home (adjusted HR 1.49, 95% CI 0.96 to 2.33; p=0.08). Few differences were reported for functional ability, quality of life or cognitive ability. Patients reported increased satisfaction with admission avoidance hospital at home. Two trials conducted a full economic analysis, when the costs of informal care were excluded admission avoidance hospital at home was less expensive than admission to an acute hospital ward. AUTHORS' CONCLUSIONS We performed meta-analyses where there was sufficient similarity among the trials and where common outcomes had been measured. There is no evidence from the analysis to suggest that admission avoidance hospital at home leads to outcomes that differ from inpatient hospital care.
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Affiliation(s)
- Sasha Shepperd
- Department of Public Health, University of Oxford, Rosemary Rue Building, Headington, Oxford, Oxfordshire, UK, OX3 7LF.
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Chetty M, MacKenzie M, Douglas G, Currie GP. Immediate and early discharge for patients with exacerbations of chronic obstructive pulmonary disease: is there a role in "real life"? Int J Chron Obstruct Pulmon Dis 2008; 1:401-7. [PMID: 18044096 PMCID: PMC2707805 DOI: 10.2147/copd.2006.1.4.401] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Mahendran Chetty
- Respiratory Unit, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, Scotland, UK
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Aimonino Ricauda N, Tibaldi V, Leff B, Scarafiotti C, Marinello R, Zanocchi M, Molaschi M. Substitutive "hospital at home" versus inpatient care for elderly patients with exacerbations of chronic obstructive pulmonary disease: a prospective randomized, controlled trial. J Am Geriatr Soc 2008; 56:493-500. [PMID: 18179503 DOI: 10.1111/j.1532-5415.2007.01562.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate hospital readmission rates and mortality at 6-month follow-up in selected elderly patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). DESIGN Prospective randomized, controlled, single-blind trial with 6-month follow-up. SETTING San Giovanni Battista Hospital of Torino. PARTICIPANTS One hundred four elderly patients admitted to the hospital for acute exacerbation of COPD were randomly assigned to a general medical ward (GMW, n=52) or to a geriatric home hospitalization service (GHHS, n=52). MEASUREMENTS Measurements of baseline sociodemographic information; clinical data; functional, cognitive, and nutritional status; depression; and quality of life were obtained. RESULTS There was a lower incidence of hospital readmissions for GHHS patients than for GMW patients at 6-month follow-up (42% vs 87%, P<.001). Cumulative mortality at 6 months was 20.2% in the total sample, without significant differences between the two study groups. Patients managed in the GHHS had a longer mean length of stay than those cared for in the GMW (15.5+/-9.5 vs 11.0+/-7.9 days, P=.010). Only GHHS patients experienced improvements in depression and quality-of-life scores. On a cost per patient per day basis, GHHS costs were lower than costs in GMW ($101.4+/-61.3 vs $151.7+/-96.4, P=.002). CONCLUSION Physician-led substitutive hospital-at-home care as an alternative to inpatient care for elderly patients with acute exacerbations of COPD is associated with a substantial reduction in the risk of hospital readmission at 6 months, lower healthcare costs, and better quality of life.
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Affiliation(s)
- Nicoletta Aimonino Ricauda
- Department of Medical and Surgical Disciplines, Geriatric Section, S. Giovanni Battista Hospital, University of Torino, Torino, Italy
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Abstract
Hospital spending represents approximately one third of total national health spending, and the majority of hospital spending is by public payers. Elderly individuals with long-term care needs are at particular risk for hospitalization. While some hospitalizations are unavoidable, many are not, and there may be benefits to reducing hospitalizations in terms of health and cost. This article reviews the evidence from 55 peer-reviewed articles on interventions that potentially reduce hospitalizations from formal long-term care settings. The interventions showing the strongest potential are those that increase skilled staffing, especially through physician assistants and nurse practitioners; improve the hospital-to-home transition; substitute home health care for selected hospital admissions; and align reimbursement policies such that providers do not have a financial incentive to hospitalize. Much of the evidence is weak and could benefit from improved research design and methodology.
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Taylor R, Dawson S, Roberts N, Sridhar M, Partridge MR. Why do patients decline to take part in a research project involving pulmonary rehabilitation? Respir Med 2007; 101:1942-6. [PMID: 17540553 DOI: 10.1016/j.rmed.2007.04.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2007] [Revised: 04/03/2007] [Accepted: 04/13/2007] [Indexed: 11/21/2022]
Abstract
BACKGROUND It is important that those taking part in research trials are as representative as possible of those with the disease being studied. In a study of those with chronic obstructive pulmonary disease involving pulmonary rehabilitation, 120 of 297 suitable patients responded that they did not wish to take part in the trial. We were keen to know why these patients declined to take part in the study. METHODS A total of 120 patients who had responded that they did not wish to take part in the main trial were approached to ask if they would be willing to undertake a semi-structured face-to-face interview in their own home or by telephone. Those who were willing (n=39) underwent tape-recorded interviews and data analysis was performed using the framework method. RESULTS This was a qualitative study which revealed that several themes influenced patients' willingness or otherwise to take part in a research project involving pulmonary rehabilitation. Travelling to the hospital and location of the rehabilitation, along with competing commitments, and a variable perception of the benefits to the patient were clearly major factors and some had previous negative experiences of either the hospital, healthcare or research. While there was an element of negativity or impaired understanding regarding the research itself, the other factors appeared to be of greater importance. CONCLUSION Recruitment to pulmonary rehabilitation courses or recruitment to research involving pulmonary rehabilitation may be more successful if the location of the rehabilitation can be made as near to the patient's home as possible, and if the patient is given as much information as possible about what is involved.
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Affiliation(s)
- Renay Taylor
- NHLI Division, Faculty of Medicine, Imperial College London, Charing Cross Campus, London W6 8RP, UK
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Quantrill SJ, Lowe D, Hosker HSR, Anstey K, Pearson MG, Roberts CM. Survey of early discharge schemes from the 2003 UK National COPD Audit. Respir Med 2007; 101:1026-31. [PMID: 17000098 DOI: 10.1016/j.rmed.2006.08.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2006] [Revised: 08/21/2006] [Accepted: 08/22/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Early discharge for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) has been shown to be effective by clinical trials. To evaluate its implementation and efficacy in clinical practice, data concerning early discharge schemes (EDS) from the 2003 National COPD Audit were collected and analysed. METHODS All acute Trusts in the UK were surveyed in Autumn 2003 by two means: one a questionnaire relating to organisation of care and second an audit of 40 clinical cases admitted with AECOPD. RESULTS Data were available for both organisation of care and clinical activity for 233 units, of which 103 (44%) had EDS. Models of care included admission prevention in the accident and emergency department (5%), rapid discharge in <48h (27%), assisted discharge occurring 2 days or more after admission (24%) and combinations of these (12%). There was wide variation in organisation of care overall. 30% of patients in units with EDS were discharged early from hospital. Units with EDS had an average LOS 1-day shorter with no increase in readmission rate (32% vs. 32%) as for those without an EDS and no increase in mortality. CONCLUSIONS There is wide variation in the availability of EDS for AECOPD in the UK, with increasing implementation of schemes. Thirty percent of patients can effectively be put into EDS which is higher than the figure of 25% from randomised controlled trials (RCTs). Mortality and readmission rates are the same as for units where no EDS is available and similar to results reported in RCTs. EDS therefore appears to be effective in routine clinical practice.
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Affiliation(s)
- Simon J Quantrill
- Chest Clinic, Whipps Cross University Hospital, Leytonstone, London E11 1NR, UK.
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Intermediate care--Hospital-at-Home in chronic obstructive pulmonary disease: British Thoracic Society guideline. Thorax 2007; 62:200-10. [PMID: 17090570 PMCID: PMC2117156 DOI: 10.1136/thx.2006.064931] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2006] [Accepted: 08/23/2006] [Indexed: 01/16/2023]
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Davison AG, Monaghan M, Brown D, Eraut CD, O'Brien A, Paul K, Townsend J, Elston C, Ward L, Steeples S, Cubitt L. Hospital at home for chronic obstructive pulmonary disease: an integrated hospital and community based generic intermediate care service for prevention and early discharge. Chron Respir Dis 2007; 3:181-5. [PMID: 17190120 DOI: 10.1177/1479972306070074] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Recent randomized controlled studies have reported success for hospital at home for prevention and early discharge of chronic obstructive pulmonary disease (COPD) patients using hospital based respiratory nurse specialists. This observational study reports results using an integrated hospital and community based generic intermediate care service. The length of care, readmission within 60 days and death within 60 days in the early discharge (9.37 days, 21.1%, 7%) and the prevention of admission (five to six days, 34.1%, 3.8%) are similar to previous studies. We suggest that this generic community model of service may allow hospital at home services for COPD to be introduced in more areas.
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Affiliation(s)
- A G Davison
- Southend Associated University Hospital, Westcliff on Sea, Essex, UK.
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Abstract
A review of the most relevant evidence based therapeutic options currently available for the management of exacerbations of COPD.
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Affiliation(s)
- R Rodríguez-Roisin
- Servei de Pneumologia, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain.
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Abstract
BACKGROUND Hospital at home is defined as a service that provides active treatment by health care professionals, in the patient's home, of a condition that otherwise would require acute hospital in-patient care, always for a limited period. OBJECTIVES To assess the effects of hospital at home compared with in-patient hospital care. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register (November 2004), MEDLINE (1966 to 1996), EMBASE (1980 to 1995), Social Science Citation Index (1992 to 1995), Cinahl (1982 to 1996), EconLit (1969 to 1996), PsycLit (1987 to 1996), Sigle (1980 to 1995) and the Medical Care supplement on economic literature (1970 to 1990). SELECTION CRITERIA Randomised trials of hospital at home care compared with acute hospital in-patient care. The participants were patients aged 18 years and over. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data and assessed study quality. MAIN RESULTS Twenty two trials are included in this update of the review. Among trials evaluating early discharge hospital at home schemes we found an odds ratio (OR) for mortality of 1.79 95% CI 0.85 to 3.76 for elderly medical patients (age 65 years and over) (n = 3 trials); OR 0.58; 95% CI 0.29 to 1.17 for patients with chronic obstructive pulmonary disease (COPD) (n = 5 trials); and OR 0.78; 95%CI 0.52 to 1.19 for patients recovering from a stroke (n = 4 trials). Two trials evaluating the early discharge of patients recovering from surgery reported an OR 0.43 (95% CI 0.02 to 10.89) for patients recovering from a hip replacement and an OR 1.01 (95% CI 0.37 to 2.81) for patients with a mix of conditions at three months follow-up. For readmission to hospital we found an OR 1.76; 95% CI 0.78 to 3.99 at 3 months follow-up for elderly medical patients (n = 2 trials); OR 0.81; 95% CI 0.55 to 1.19 for patients with COPD (n = 5 trials); and OR 0.96; 95% CI 0.63 to 1.45 for patients recovering from a stroke (n = 3 trials). No significant heterogeneity was observed. One trial recruiting patients following surgery for hernia or varicose veins reported 0/117 versus 2/121 patients were re admitted (Ruckley 1978); another that 2/37 (5%) versus 1/49 (2%) (difference 3%, 95% CI -5% to 12%) of patients recovering from a hip replacement, 4/47 (9%) versus 1/39 (3%) (difference 6%, 95% CI -3% to 15%) of patients recovering from a knee replacement, and 7/114 (6%) versus 13/124 (10%) (difference -4% 95% CI -11% to 3%) of patients recovering from a hysterectomy were readmitted. A third trial analysing surgical and medical patients together reported that 42/159 versus 17/81 patients were readmitted at 3 months (OR 1.34 95% CI 0.66 to 2.20). Allocation to hospital at home resulted in a small reduction in hospital length of stay, but hospital at home increased overall length of care. Patients allocated to hospital at home expressed greater satisfaction with care than those in hospital, while the view of carers was mixed. AUTHORS' CONCLUSIONS Despite increasing interest in the potential of hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit. Early discharge schemes for patients recovering from elective surgery and elderly patients with a medical condition may have a place in reducing the pressure on acute hospital beds, providing the views of the carers are taken into account. For these clinical groups hospital length of stay is reduced, although this is offset by the provision of hospital at home. Future primary research should focus on rigorous evaluations of admission avoidance schemes and standards for original research should aim at assisting future meta-analyses of individual patient data from these and future trials.
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Affiliation(s)
- S Shepperd
- Continuing Professional Development Centre, Department of Continuing Education, University of Oxford, 16/17 St. Ebbes Street, Oxford, UK, OX1 1PT.
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38
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Ram FSF, Wedzicha JA, Wright J, Greenstone M. Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: systematic review of evidence. BMJ 2004; 329:315. [PMID: 15242868 PMCID: PMC506849 DOI: 10.1136/bmj.38159.650347.55] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2004] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To evaluate the efficacy of hospital at home schemes compared with inpatient care in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD). DESIGN A systematic review of randomised controlled trials. MAIN OUTCOME MEASURE Mortality and readmission to hospital. RESULTS Seven trials with 754 patients were included in the review. Hospital readmission and mortality were not significantly different when hospital at home schemes were compared with inpatient care (relative risk 0.89, 95% confidence interval 0.72 to 1.12, and 0.61, 0.36 to 1.05, respectively). However, compared with inpatient care, hospital at home schemes were associated with substantial cost savings as well as freeing up hospital inpatient beds. CONCLUSIONS Hospital at home schemes can be safely used to care for patients with acute exacerbations of COPD who would otherwise be admitted to hospital. Clinicians should consider this form of management, especially as there is increasing pressure for inpatient beds in the United Kingdom.
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Affiliation(s)
- Felix S F Ram
- National Collaborating Centre for Women and Children's Health, London NW1 4RG.
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39
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Kim S, Emerman CL, Cydulka RK, Rowe BH, Clark S, Camargo CA. Prospective multicenter study of relapse following emergency department treatment of COPD exacerbation. Chest 2004; 125:473-81. [PMID: 14769727 DOI: 10.1378/chest.125.2.473] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To determine the incidence and risk factors of relapse after an emergency department (ED) visit for COPD exacerbation. DESIGN Prospective cohort study as part of the Multicenter Airway Research Collaboration. SETTING Twenty-nine North American EDs. PATIENTS ED patients with COPD exacerbations, age > or =55 years. For the present analysis of post-ED relapse, the cohort was restricted to COPD patients who had been discharged from the ED directly to home. MEASUREMENTS AND RESULTS Eligible patients underwent a structured interview to assess their demographic characteristics, COPD history, and details of the current COPD exacerbation. Data on ED medical management and disposition were obtained by chart review. Patients were contacted by telephone 2 weeks later regarding incident relapse events (ie, urgent clinic or ED visit for worsening COPD). The cohort consisted of 140 COPD patients. Over the next 2 weeks, patients demonstrated a consistent daily relapse rate that summed to 21% (95% confidence interval, 15 to 28%) at day 14. In a multivariate model, the significant risk factors for relapse were the number of urgent clinic or ED visits for COPD exacerbation in the past year (odds ratio [OR], 1.49 [per five visits]), self-reported activity limitation during the past 24 h (OR, 2.93 [per unit on scale of 1 [none] to 4 [severe]), and respiratory rate at ED presentation (OR, 1.76 [per 5 breaths/min]). CONCLUSIONS Among patients discharged to home after ED treatment of a COPD exacerbation, one in five patients will experience an urgent/emergent relapse event during the next 2 weeks. Both chronic factors (ie, a history of urgent clinic or ED visits) and acute factors (ie, activity limitations and initial respiratory rate) are associated with increased risk. Further research should focus on ways to decrease the relapse rate among these high-risk patients. The clinicians may wish to consider these historical factors when making ED decisions.
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Affiliation(s)
- Sunghye Kim
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Clinics Building 397, Boston, MA 02114, USA
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40
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A prospective cohort study of the effectiveness of clinical pathways for the in-patient management of acute exacerbation of chronic obstructive pulmonary disease (COPD). Collegian 2004. [DOI: 10.1016/s1322-7696(08)60438-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Ram FSF, Wedzicha JA, Wright J, Greenstone M. Hospital at home for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2003:CD003573. [PMID: 14583984 DOI: 10.1002/14651858.cd003573] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hospital at home schemes are a recently adopted method of service delivery for the management of acute exacerbations of chronic obstructive pulmonary disease aimed at reducing demand for acute hospital in-patient beds and promoting a patient centered 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 chronic obstructive pulmonary disease. SEARCH STRATEGY The Cochrane Central Register of Controlled Trials; electronically available databases e.g. MEDLINE (1966-current), EMBASE (1980-current), PubMed, ClincalTrials, Science Citation Index and on-line individual respiratory journals; bibliographies of included trials were all searched and contact with authors was made to obtain studies. The most recent searches were carried out in August 2003. SELECTION CRITERIA Only randomised controlled trials were considered where patients presented to the emergency department with an exacerbation of their chronic obstructive pulmonary disease. Studies must not have recruited patients that are usually deemed obligatory admissions. DATA COLLECTION AND ANALYSIS Two reviewers independently selected articles for inclusion, evaluated methodological quality of the studies and abstracted data. MAIN RESULTS Seven studies with 754 patients were included in the review. Studies provided data on hospital readmission and mortality both of which were not significantly different when the two study groups were compared (RR 0.89; 95%CI 0.72 to 1.12 & RR 0.61; 95%CI 0.36 to 1.05, respectively). Both the patients and the carers preferred hospital at home schemes to inpatient care (RR 1.53; 95%CI 1.23 to 1.90). Other reported outcomes included few studies. REVIEWER'S CONCLUSIONS This review has shown that one in four carefully selected patients presenting to hospital emergency departments with acute exacerbations of chronic obstructive pulmonary disease can be safely and successfully treated at home with support from respiratory nurses. This review found no evidence of significant differences between "hospital at home" patients and hospital inpatients for readmission rates and mortality at two to three months after the initial exacerbation. Both the patients and carers preferred "hospital at home" schemes to inpatient care.
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Affiliation(s)
- F S F Ram
- National Collaborating Centre for Women's and Children's Health, Royal College of Obstetricians and Gynaecologists, 27, Sussex Place, Regent's Park, London, UK, NW1 4RG
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