Hospital at home early discharge

  • Review
  • Intervention

Authors


Abstract

Background

'Early discharge hospital at home' is a service that provides active treatment by health care professionals in the patient's home for a condition that otherwise would require acute hospital in-patient care. If hospital at home were not available then the patient would remain in an acute hospital ward.

Objectives

To determine, in the context of a systematic review and meta-analysis, the effectiveness and cost of managing patients with early discharge hospital at home compared with in-patient hospital care.

Search methods

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register , MEDLINE (1950 to 2008), EMBASE (1980 to 2008), CINAHL (1982 to 2008) and EconLit through to January 2008. We checked the reference lists of articles identified for potentially relevant articles.

Selection criteria

Randomised controlled trials recruiting patients aged 18 years and over. Studies comparing early discharge hospital at home with acute hospital in-patient care. Evaluations of obstetric, paediatric and mental health hospital at home schemes are excluded from this review.  

Data collection and analysis

Two authors independently extracted data and assessed study quality. Our statistical analyses were done on an intention-to-treat basis. We requested individual patient data (IPD) from trialists, and relied on published data when we did not receive trial data sets or the IPD did not include the relevant outcomes. For the IPD meta-analysis, where at least one event was reported in both study groups in a trial, Cox regression models were used to calculate the log hazard ratio and its standard error for mortality and readmission separately for each data set. The calculated log hazard ratios were combined using fixed-effect inverse variance meta-analysis.

Main results

Twenty-six trials were included in this review [n = 3967]; 21 were eligible for the IPD meta-analysis and 13 of the 21 trials contributed data [1899/2872; 66%]. 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.

Authors' conclusions

Despite increasing interest in the potential of early discharge hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit or improved health outcomes.

摘要

背景

提早出院的居家照護

“提早出院的居家照護”是一種健康照護專家以病患住家為條件提供主動治療的服務,否則病患將需要急性醫院的住院照護。如果病患無法居家醫療,則將繼續入住急性病房。

目標

經由系統性回顧及統合分析確定早期出院居家照護相對於住院照護之病患管理的效果及成本。

搜尋策略

我們檢索Cochrane Effective Practice and Organisation of Care (EPOC) Group Register,MEDLINE (1950至2008年),EMBASE (1980至2008年),CINAHL (1982至2008年)及EconLit至2008年1月。

選擇標準

納入18歲以上病患的隨機對照試驗。比較提早出院的居家照護與急性醫院住院照護的研究。這篇回顧排除評估產科,小兒科及精神衛生醫院的居家方案。

資料收集與分析

兩名作者分別摘錄資料並評估研究品質。以意圖治療為基礎完成統計分析。我們向試驗人員要求個別的病患資料(individual patient data (IPD)),且當我們無法獲得試驗資料或個別病患資料中不包括相關結果時,則依據已發表的資料。關於IPD的統合分析,一篇試驗中兩個研究群體至少要報告一個結果事件,每一組資料使用Cox regression models分別計算死亡率及再住院的log hazard ratio及其standard error。採用變異數倒數固定效果的統合分析來合併log hazard ratios。

主要結論

這篇回顧納入26篇試驗[n = 3967];合格的有21篇可進行IPD的統合分析,且其中13篇有提供資料[1899/2872;66%]。對於中風康復的病患及有混合症狀的老年病患,沒有足夠的證據顯示兩群體間其死亡率有差異(adjusted HR為0.79,95% CI為0.32至1.91;N = 494;且adjusted HR為1.06,95% CI為0.69至1.61;N = 978)。分配到居家醫療之混合症狀的老年病患其再住院率顯著增加(adjusted HR為1.57;95% CI為1.10至2.24;N = 705)。分別針對中風康復及混合症狀的老年病患,追蹤時顯示分配到居家醫療者顯著地較少人入住住宅式照護(RR為0.63;95% CI為0.40至0.98;N = 4篇試驗;RR為0.69,95% CI為0.48至0.99;N = 3篇試驗)。病患報告對於提早出院的居家照護滿意度增加。缺乏納入手術恢復病患其再住院率差異的足夠證據。節省成本的證據是複雜的。

作者結論

儘管一般對提早出院的居家照護的興趣與日俱增,其被認為是住院病患照護較省錢的替代方案,但這篇回顧未充分提供經濟效益或改善健康結果的客觀證據。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

某些國家一直以來對於急性照護醫院病床的需求比有病床的需求更多。空出病床以騰出空間供其他人住院的一種方法就是讓病人早日出院回家。但出院的病患仍需要急性照護。所以,發展出特殊的居家服務。通常由健康照護專家團隊,如醫師,護士及物理治療師提供這些服務。團隊訪視那些提早出院的民眾以在其家中提供急性照護。回顧提早出院之居家服務的影響。在所有相關研究的檢索後,確定了26篇研究。研究觀察這些服務對於不同狀況下患者的影響:中風病患,手術病患,及有混合狀況的老年病患。沒有足夠的證據顯示提供提早出院的民眾接受居家服務也許會增加死亡風險或再住院;或負面的生活品質或完成日常活動(如穿衣或每天的家務)。中風病患或老年病患如果提早出院接受居家醫療服務也許其入住住宅式照護的風險較低。病患也許對他們的居家照護有較高的滿意度,且大部分的案例中他們的照護者報告沒有額外的負擔。然而,幾乎沒有關於病患提早出院接受居家醫療服務對於健康照護系統節省成本的證據。

Plain language summary

Services for patients discharged home early

There continues to be, in some countries, more demand for acute care hospital beds than there are beds. One way to free up beds to make room for other people being admitted is to discharge patients home early. But the patients who are discharged still need acute care. Therefore, special home services have been developed. These services are usually provided by a team of health care professionals, such as doctors, nurses and physiotherapists. The team visits the home of people who have been discharged early to provide them with acute hospital care in their homes. 

A review of the effect of services for patients discharged home early was conducted. After searching for all relevant studies, 26 studies were identified. The studies looked at the effect of these services in patients with different types of conditions: patients who had a stroke, patients who had surgery, and elderly patients who had different types of conditions. 

There was insufficient evidence that providing services to people at home after being discharged home early may increase the risk of death or readmission; or adversely effect quality of life or the completion of daily activities (such as dressing or daily chores).  Patients who had a stroke or elderly patients may have less risk of being admitted to residential care if they are discharged home early with hospital at home services. 

Patients may also be more satisfied with their care at home, and at the same time their carers, in most cases, did not report additional burden. However, there is little evidence of cost savings to the health care system of discharging patients home early to hospital at home care.

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