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Evidence summaries

Hospital at Home Versus in-Patient Hospital Care

Hospital at home services appear not to provide outcomes that would differ from inpatient hospital care but home care appears to increase patient satisfaction. End of life home-care programmes increase the number of patients who will die at home. Level of evidence: "B"

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).

    References

    • Shepperd S, Doll H, Broad J, Gladman J, Iliffe S, Langhorne P, Richards S, Martin F, Harris R. Early discharge hospital at home. Cochrane Database Syst Rev 2009;(1):CD000356.[PubMed]
    • 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;(4):CD007491 [Assessed as up-to-date: 2 March 2016]. [PubMed]
    • Shepperd S, Gonçalves-Bradley DC, Straus SE et al. Hospital at home: home-based end-of-life care. Cochrane Database Syst Rev 2021;(3):CD009231. [PubMed]

Primary/Secondary Keywords