A Cochrane review [Abstract] 1 included 26 studies with a total of 3967 subjets; 21 were eligible for the individual patient data (IPD) meta-analysis and 13 of the 21 trials contributed data. For patients recovering from a stroke and elderly patients with a mix of conditions there was insufficient evidence of a difference in mortality between groups (adjusted HR 0.79, 95% CI 0.32 to 1.91; N = 494; and adjusted HR 1.06, 95% CI 0.69 to 1.61; N = 978). Readmission rates were significantly increased for elderly patients with a mix of conditions allocated to hospital at home (adjusted HR 1.57, 95% CI 1.10 to 2.24; N = 705). For patients recovering from a stroke and elderly patients with a mix of conditions respectively, significantly fewer people allocated to hospital at home were in residential care at follow up (RR 0.63, 95% CI 0.40 to 0.98; N = 4 trials; RR 0.69, 95% CI 0.48 to 0.99; N =3 trials). Patients reported increased satisfaction with early discharge hospital at home. There was insufficient evidence of a difference for readmission between groups in trials recruiting patients recovering from surgery. Evidence on cost savings was mixed.
Another Cochrane review [Abstract] 2 included 16 studies with a total of 1 814 subjects. Five of these RCTs were included in the individual patient data (IPD) meta-analysis (n=850). There was little or no difference in mortality at 6 months for the admission avoidance hospital at home group (RR 0.77, 95% CI 0.60 to 0.99; 6 trials, n=912, I²=0%. Admission avoidance hospital at home showed little or no difference in admissions to hospital at home (RR 0.98, 95% CI 0.77 to 1.23; 7 trials, n=834, I²=28%) but reduced the likelihood of living in residential care at 6 months' follow-up (RR 0.35, 95% CI 0.22 to 0.57; 5 trials, n=787, 0.0001; I²=78%). Patients reported increased satisfaction with admission avoidance hospital at home.
A third Cochrane review[Abstract] 3 included 4 trials with a total of 1128 patients. The mean age of participants ranged from 63 years to 74 years. The diagnosis of trial participants varied, the most common was cancer. The intervention in 3 trials was multidisciplinary care, in one trial it was on nursing care, which was only available for the last two weeks of life. Those receiving home-based end of life care were statistically significantly more likely to die at home compared with those receiving usual care (RR 1.31, 95% CI 1.12 to 1.52; 2 studies, n=539). Admission to hospital while receiving home-based end of life care varied between studies. The effect on patient outcomes and control of symptoms was uncertain. Home-based end-of-life care slightly improved patient satisfaction at 1-month follow-up, with little or no difference at 6-month follow-up (2 studies). The effect on caregivers, staff, and health service costs was uncertain.
Comment: The quality of evidence is downgraded by inconsistency (heterogeneity in interventions and outcomes).
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