Hospital at Home Versus in-Patient Hospital Care

The quality of evidence is downgraded by imprecision (wide confidence intervals).

Hospital at home care, with the option of transfer to hospital, is recommended for patients in need of recurrent medical attention, but not round-the-clock in-hospital care.

The recommendation is strong because potential benefits of the intervention exceed plausible harms (being admitted to institutional care).

A Cochrane review [Abstract] 1 included 32 studies with a total of 4746 patients. When compared to in-hospital care, early discharge hospital at home services made no difference to patient health outcomes or being readmitted to hospital, and decreased hospital length of stay. Patients who received care at home were more satisfied and less likely to be admitted to institutional care. There was little evidence of cost savings to the healthcare system.

• For patients recovering from stroke, early discharge hospital at home made no difference to mortality at 3-6 months (RR 0.92, 95% CI 0.57 to 1.48, n=1114, 11 trials, moderate-certainty evidence) or to the risk of hospital readmission (RR 1.09, 95% CI 0.71 to 1.66, n=345, 5 trials, low-certainty evidence). Hospital at home seemed to lower the risk of living in institutional setting at 6 months follow-up (RR 0.63, 96% CI 0.40 to 0.98; n=574, 4 trials, low-certainty evidence) and improved patient satisfaction slightly (n=795, low-certainty evidence). Patient assigned to hospital at home were discharged from the intervention 6.68 days earlier than patients receiving inpatient care (95% CI 10.19 to 3.17 days earlier, n=528, 4 trials, moderate-certainty evidence).
• For patients with a mix of medical conditions, early discharge hospital at home made no difference to mortality (RR 1.07, 95% CI 0.76 to 1.49; n=1247, 8 trials, moderate-certainty evidence). The intervention seemed to increase the risk of hospital readmission at 3 months follow-up (RR 1.25, 95% CI 0.98 to 1.58, n=1276, 9 trials, moderate-certainty evidence). Hospital at home lowered the risk of living in an institutional setting at 1-year follow-up (RR 0.69, 0.48 to 0.99; n=484, 3 trials, low-certainty evidence). The intervention improved patient satisfaction slightly (n=900, low-certainty evidence). The effect of early discharge hospital at home on hospital length of stay for older patients with a mix of conditions ranged from a reduction of 20 days to less than half a day (n=767, moderate-certainty evidence).
• For patients undergoing elective (mainly orthopedic) surgery, 3 studies did not report higher rates of mortality with hospital at home compared with inpatient care (n=856, low-certainty evidence). Hospital at home lead to no difference in readmission to hospital for people who were mainly recovering from orthopaedic surgery (n=1229, low-certainty evidence). The intervention improved patient satisfaction slightly (n=1229, low-certainty evidence). Patients recovering from surgery allocated to early discharge hospital at home were discharged from the intervention 4.44 days earlier than patients allocated to usual inpatient care (95% CI 6.37 to 2.51 days earlier, n=411, 4 trials, moderate-certainty evidence).

Another Cochrane review [Abstract] 2 included 20 RCTs with a total of 3100 subjects (4 trials with COPD; 2 trials recovering from a stroke; 7 trials with an acute medical condition; and the remaining trials with a mix of conditions). Most of the trials recruited older patients with an average age that ranged from 70 to over 80 years.

• Admission avoidance hospital at home made no difference on mortality at 6 months' follow-up (RR 0.88, 95% CI 0.68 to 1.13; 5 trials, n=1502, moderate-certainty evidence); no difference on the likelihood of being readmitted to hospital within 3 to 12 months' follow-up (RR 1.14, 95% CI 0.97 to 1.34; 8 trials, n=1757, moderate-certainty evidence); and reduced the likelihood of living in residential care at 6 months' follow-up (RR 0.53, 95% CI 0.41 to 0.69; 4 trials, n=1271, moderate-certainty evidence). Hospital at home resulted in no difference in patient's self-reported health status (n=2006, moderate-certainty evidence). Satisfaction with health care received was improved with hospital at home (n=1812, low-certainty evidence). Hospital at home reduced the initial average hospital length of stay (n=2036, 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. Admission avoidance hospital at home seemed to reduce costs to the health service compared with hospital admission (n=2148, moderate-certainty evidence).

A third Cochrane review[Abstract] 3 included 4 trials with a total of 1128 patients assessing home-based end-of-life care. The mean age of participants ranged from 63 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, high-certainty evidence). Admission to hospital while receiving home-based end of life care varied between studies. 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, low-certainty evidence). The effect on caregivers, staff, and health service costs was uncertain.

References

• Gonçalves-Bradley DC, Iliffe S, Doll HA, ym. Early discharge hospital at home. Cochrane Database Syst Rev 2017;6(6):CD000356 [PubMed]
• Edgar K, Iliffe S, Doll HA, ym. Admission avoidance hospital at home. Cochrane Database Syst Rev 2024;3(3):CD007491 [PubMed]
• Shepperd S, Gonçalves-Bradley DC, Straus SE, ym. Hospital at home: home-based end-of-life care. Cochrane Database Syst Rev 2021;3(3):CD009231 [PubMed]