Thursday 21 June 2012

As well as or instead of beds (the evidence on hospitals at home)…


Shepperd S, Doll H, Broad J, Gladman J, Iliffe S, Langhorne P, Richards S, Martin F, Harris R. Hospital at home early discharge. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD000356. DOI: 10.1002/14651858.CD000356.pub3. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000313.pub3/full

Why read this?

Pressure on acute beds leads managers to look for alternatives.    Hospital at home schemes have developed rapidly in different parts of the country, providing care from clinical staff for a fixed period for people who would otherwise need to stay in hospital.   This particular study brings the robust Cochrane methods of systematic review to bear on the important service question – do hospital at home schemes for early discharge lead to better outcomes for patients?  And do they cost less than inpatient stays?   This study published in 2009 looked at 26 published randomised trials (mainly from the UK) comparing hospital at home schemes for early discharge with usual care in hospital for patients with stroke, those recovering from surgery and older people with a mix of conditions.   As well as the results from these individual trials, the researchers led by Sasha Shepperd carried out a meta-analysis, pooling the individual patient data from 13 of these trials to answer the common question – does it work?

This study is important because complex service interventions, like hospital at home schemes, have not always been subject to rigorous evaluation and scrutiny.   Many new ideas spread rapidly across the health service, many with inflated claims of cost savings and benefits – from virtual wards to rapid response teams.  This study is as good as it gets in terms of applying `gold-standard’ research methods to address important service questions.  But it also highlights the limitations of any such study – it is basically as good as the research that is out there.  The small number of robust studies to review and the heterogeneity of interventions, making it very difficult to compare like with like.   In some cases, these were hospital outreach services led by specialists, in other these were community-based services.  Not all provided 24 hour care and the input varied, from specialist or dedicated nurses to range of physiotherapy and occupational therapy staff.  Context is all-important in understanding complex services, but these were not always well described or indeed able to be adjusted for in this method of review.   But this is still a `go-to’ source document for managers reviewing options to relieve pressure on hospital beds.


What does the study say?


For older people and those with a stroke, there was no difference in outcome and quality of life for those in hospital at home schemes compared with usual care.  Patients seemed to prefer hospital at home initiatives and there was no reported increase in burden to carers.   However, the readmission rates to hospital were higher for older people and those with a stroke in hospital at home schemes.  At the same time, there was a lower chance of such people being in residential care at follow-up.  Comparing hospital at homes with inpatient activity, there was evidence of increased total length of stay for patients using hospital at home.    
Overall, there was no evidence that hospital at home schemes generated cost savings.  

The authors took care to discuss and interpret some of the complex messages in this piece of work.  There are no categorical answers – for instance, on the critical cost-effectiveness question, the picture looks much stronger for hospital at home schemes if restricted to patients with mild disability (or where the running costs of local hospitals is high).   There is an argument that numbers for hospital at home schemes are still so small (around 1-2% of hospital patients) that it would be difficult to realise cost savings at scale.   Where local schemes are in place for older people with COPD or stroke, the evidence is not strong enough to discontinue these, given the likely benefits.  But these should probably best be considered as an adjunct to hospital care.  From the evidence to date, the review suggests no compelling case for hospital at homes acting as a substitute for inpatient care.

Bite-size messages for managers


Hospital at home schemes unlikely to justify closing a hospital ward...yet.

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