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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