‘Hospital at home’ schemes are as safe as inpatient care for people with exacerbated chronic obstructive pulmonary disease (COPD)

ARTICLE IN PRESS Evidence-Based Healthcare & Public Health (2005) 9, 46–47

www.elsevier.com/locate/ebhph

EVIDENCE-BASED HEALTHCARE MANAGEMENT

‘Hospital at home’ schemes are as safe as inpatient care for people with exacerbated chronic obstructive pulmonary disease (COPD)$

KEYWORDS Chronic obstructive pulmonary disease; Home care; Hospital admission; Hospital at home; Treatment outcome; Mortality; Systematic review

Question: Are ‘hospital at home’ schemes as safe as inpatient care for people with acutely exacerbated chronic obstructive pulmonary disease (COPD)? Study design: Systematic review with meta-analysis. Main results: Seven RCTs met inclusion criteria (n ¼ 754). At 3 months, there was no significant difference between hospital at home schemes and inpatient care for either readmissions (28% v 31%, RR 0.89, 95% CI 0.72 to 1.12) or mortality rate (5% v 9%, RR 0.61, 95% CI 0.36 to 1.05). Three RCTs reported reduced costs (£533 per individual for hospital at home v £649 for inpatient care) and two reported higher subsequent hospital bed availability (201 bed days per year). Authors’ conclusions: Hospital at home schemes are as safe as inpatient treatment and can be used for selected people with acute exacerbations of COPD. Further trials of cost, other relevant outcomes and models of care are needed. & 2005 Published by Elsevier Ltd.

Further details Search strategy MEDLINE, EMBASE, Science Citation Index, UK National Research Register, Web of Science, Cochrane controlled trials register, individual respiratory journal websites, and proceedings of the European Respiratory Society, American Thoracic Society, British Thoracic Society, and Thoracic Society of Australia and New Zealand, searched up to May 2003 plus contact with experts. Authors of selected papers were contacted for unpublished data and non-English publications were translated. Trials were independently selected by two reviewers based on quality.

$ Abstracted from: Ram FSF, Wedzicha JA, Wright J et al. Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: systematic review of evidence. BMJ 2004; 329: 315–318.

1744-2249/$ - see front matter & 2005 Published by Elsevier Ltd. doi:10.1016/j.ehbc.2004.11.004

ARTICLE IN PRESS EVIDENCE-BASED HEALTHCARE MANAGEMENT

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Inclusion/exclusion criteria Studies involving individuals presenting to an emergency department with an acute exacerbation of COPD, categorised into hospital at home or inpatient care after initial assessment. Randomisation had to occur within 3 days of admission. People randomised to home care were cared for by a specialist respiratory nurse guided by the hospital team; people in hospital groups were treated as usual. Individuals were not included in the original trials if they were obligatory admissions (as defined by the British Thoracic Society Guidelines) or if they presented with other medical complications or social reasons.

Data analysis RCT data were abstracted onto standard forms and trial quality assessed. Continuous variables were pooled using fixed effect weighted mean differences and 95% CI determined; fixed effect risk and 95% CI were calculated for dichotomous variables. Heterogeneity was tested using the DerSimonian and Laird method.

Main outcomes Mortality, readmission into hospital (2 to 3 months after initial admission).

Notes From the combined data, 744 of 2786 (26.7%) people who had been admitted to hospital for acute exacerbations of COPD were eligible for home care. Authors note that trials did not include weekend care in their analysis, perhaps underestimating cost implications. Sources of funding: Netherlands Asthma Foundation. Abstract provided by Bazian Ltd, London