Hospitalización domiciliaria para evitar el ingreso en hospital
Resumen
Antecedentes
La hospitalización domiciliaria de evitación del ingreso es un servicio que proporciona tratamiento activo por parte de profesionales sanitarios en el domicilio del paciente para una afección que, de otro modo, requeriría una atención hospitalaria para enfermedades agudas y siempre por un período de tiempo limitado. Esta es la cuarta actualización de esta revisión.
Objetivos
Determinar la efectividad y el coste de la gestión de los pacientes con hospitalización domiciliaria de evitación del ingreso en comparación con la atención hospitalaria.
Métodos de búsqueda
Se hicieron búsquedas en el Registro Cochrane central de ensayos controlados (Cochrane Central Register of Controlled Trials; CENTRAL), MEDLINE, Embase y CINAHL el 24 de febrero de 2022 y se comprobaron las listas de referencias de los artículos elegibles. Para detectar estudios no publicados o en curso se buscó en clinicalTrials.gov y en la ICTRP de la OMS y se estableció contacto con sanitarios e investigadores de este campo.
Criterios de selección
Ensayos controlados aleatorizados que reclutaron participantes de 18 años o más. Estudios que compararon la hospitalización domiciliaria de evitación de ingresos con la atención hospitalaria de agudos.
Obtención y análisis de los datos
Se siguieron los procedimientos metodológicos estándar previstos por Cochrane y el Grupo Cochrane para una Práctica y organización sanitaria efectivas (Effective Practice and Organisation of Care Group; EPOC). Se realizó el metanálisis de los ensayos que compararon intervenciones similares, informaron sobre desenlaces comparables con datos suficientes y utilizaron datos individuales de pacientes cuando fue posible. Se utilizó el sistema GRADE para evaluar la certeza del conjunto de evidencia para los desenlaces más importantes.
Resultados principales
Se incluyeron 20 ensayos controlados aleatorizados con un total de 3100 participantes; cuatro ensayos reclutaron a participantes con enfermedad pulmonar obstructiva crónica, dos ensayos reclutaron a participantes que se recuperaban de un accidente cerebrovascular, siete ensayos reclutaron a participantes con una afección médica aguda que eran principalmente personas mayores, y los ensayos restantes reclutaron a participantes con una combinación de afecciones. Se evaluó la mayoría de los estudios incluidos como de bajo riesgo de sesgo de selección, detección y desgaste, y riesgo incierto en cuanto al informe selectivo y el sesgo de realización.
En personas mayores, la hospitalización domiciliaria de evitación del ingreso probablemente suponga poca o ninguna diferencia en la mortalidad a los seis meses de seguimiento (razón de riesgos [RR] 0,88; intervalo de confianza [IC] del 95%: 0,68 a 1,13; p = 0,30; I 2 = 0%; cinco ensayos, 1502 participantes; evidencia de certeza moderada), poca o ninguna diferencia en la probabilidad de reingreso en el hospital tras el alta de la hospitalización domiciliaria o atención hospitalaria en los 3 a 12 meses de seguimiento (RR 1,14; IC del 95%: 0,97 a 1,34; p = 0,11; I 2 = 41%; ocho ensayos, 1757 participantes; evidencia de certeza moderada) y probablemente reduzca la posibilidad de vivir en una residencia a los seis meses de seguimiento (RR 0,53; IC del 95%: 0,41 a 0,69; p < 0,001; I 2 = 67%; cuatro ensayos, 1271 participantes; evidencia de certeza moderada).
Es probable que la hospitalización domiciliaria dé lugar a poca o ninguna diferencia en el estado de salud autoinformado del paciente (2006 pacientes; evidencia de certeza moderada). La satisfacción con la atención sanitaria recibida podría mejorar con la hospitalización domiciliaria de evitación de ingresos (1812 participantes, evidencia de certeza baja); pocos estudios informaron sobre el efecto en los cuidadores. La hospitalización domiciliaria redujo la duración media inicial de la estancia hospitalaria (2036 participantes; evidencia de certeza baja), que varió de 4,1 a 18,5 días en el grupo del hospital y de 1,2 a 5,1 días en el grupo de hospitalización domiciliaria. La duración de la hospitalización domiciliaria varió en una media de 3 a 20,7 días (grupo de hospitalización domiciliaria solo). Es probable que la hospitalización domiciliaria de evitación del ingreso reduzca los costes del servicio sanitario en comparación con el ingreso hospitalario (2148 participantes; evidencia de certeza moderada), aunque en cantidades variables y mediante distintos métodos para calcular el coste del uso de recursos y existe evidencia de que reduce los costes sociales generales en el seguimiento a los seis meses.
Conclusiones de los autores
La hospitalización domiciliaria de evitación del ingreso hospitalario, con la opción de traslado al hospital, podría constituir una alternativa eficaz al ingreso hospitalario para un grupo determinado de personas de edad avanzada que requieren ingresar en el hospital. Es probable que la intervención suponga poca o ninguna diferencia en los desenlaces de salud del paciente, podría mejorar la satisfacción, probablemente reduzca la posibilidad de internamiento en una residencia y probablemente reduzca los costes.
PICOs
Resumen en términos sencillos
Servicios de «hospitalización a domicilio» para evitar el ingreso en el hospital
¿Cuál es el objetivo de esta revisión?
El objetivo de esta revisión Cochrane fue averiguar si la prestación de asistencia sanitaria en un contexto de hospitalización domiciliaria para evitar el ingreso en el hospital mejora los desenlaces de salud de los pacientes y reduce el coste del servicio de salud.
Mensajes clave
La hospitalización domiciliaria de evitación del ingreso probablemente apenas influya en el riesgo de muerte; probablemente aumente las posibilidades de vivir en casa a los seis meses de seguimiento y podría ser ligeramente más económica.
¿Qué se estudió en esta revisión?
La demanda de camas de hospital para enfermedades agudas sigue superando la cantidad de camas disponibles. Una forma de reducir la dependencia de las camas de hospital es proporcionar a las personas asistencia sanitaria aguda en casa, a veces llamada «hospitalización domiciliaria de evitación del ingreso». Por contra, la «hospitalización domiciliaria de alta temprana» hace referencia a los pacientes que son dados de alta del hospital de forma anticipada para ser tratados en casa; este tema se ha analizado en otra revisión.
¿Qué se quiso averiguar?
Se quiso saber si la hospitalización domiciliaria afecta a los desenlaces de salud del paciente y a su vida independiente en su domicilio. También se quiso averiguar si era más económica que la atención hospitalaria y si afectaba a la duración del tratamiento y a la satisfacción del paciente.
¿Qué se hizo?
Se buscaron estudios que compararan el tratamiento con hospitalización domiciliaria para un episodio agudo con la atención con ingreso en el hospital. Los resultados de estos estudios se compararon y resumieron, y la confianza en la evidencia se calificó según factores como la metodología y el tamaño de los estudios.
¿Qué se encontró?
Se encontraron 20 estudios, de los cuales cuatro se identificaron en esta actualización, con un total de 3100 pacientes con un abanico de afecciones agudas. Cuatro estudios incluyeron a participantes con enfermedad pulmonar obstructiva crónica; dos incluyeron a participantes que se recuperaban de un ictus; siete incluyeron a participantes con una afección médica (repentina o a corto plazo) que eran principalmente personas mayores, y los estudios restantes incluyeron a participantes con una mezcla de enfermedades.
En comparación con la atención en el hospital, los servicios de hospitalización domiciliaria de evitación del ingreso probablemente apenas supongan una diferencia en el riesgo de muerte o en la probabilidad de ser llevados al hospital en los 3 a 12 meses siguientes, y probablemente aumenten las posibilidades de continuar viviendo en el domicilio a los seis meses de seguimiento. Los pacientes que reciben atención domiciliaria podrían tener mayor satisfacción en comparación con quienes están ingresados en el hospital; los efectos de este tipo de atención sobre sus cuidadores no están claros. Es probable que la hospitalización domiciliaria dé lugar a poca o ninguna diferencia en el estado de salud del paciente. La hospitalización domiciliaria reduce el tiempo que pasan los pacientes en el hospital, aunque la duración de la hospitalización domiciliaria tendió a ser más larga que la estancia hospitalaria habitual. Es probable que la hospitalización domiciliaria de evitación del ingreso reduzca los costes del tratamiento, aunque en unas cantidades variables.
¿Cuáles son las limitaciones de la evidencia?
Debido al pequeño tamaño de la mayoría de estudios, se tiene una confianza moderada en que la hospitalización domiciliaria de evitación del ingreso no supone una diferencia en la cifra de personas que fallecen al compararla con la atención en el hospital. La confianza en la evidencia para el reingreso hospitalario y el internamiento en residencias se redujo a moderada debido a que las duraciones del seguimiento difirieron de un estudio a otro. Se tiene una confianza moderada en la evidencia para los estados de salud comunicados por el paciente, ya que los participantes eran conocedores del tratamiento que estaban recibiendo, lo cual podría haber influido en los resultados. Se tiene poca confianza en la evidencia acerca de la satisfacción del paciente, ya que hubo pocos estudios que informaran acerca de este desenlace, y acerca de la duración de la estancia, ya que esta varió de un estudio a otro. Se tiene una confianza moderada en la evidencia acerca del coste, debido a que solo tres ensayos lo analizaron en profundidad.
¿Cuál es el grado de actualización de la revisión?
Se buscaron estudios publicados hasta febrero de 2022.
Authors' conclusions
Summary of findings
| Admission avoidance hospital at home compared with inpatient admission for older people requiring admission to hospital | |||||
| Patient or population: older people requiring hospital admission Settings: home Intervention: admission avoidance hospital at home Comparison: inpatient care | |||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Certainty of the evidence | |
|---|---|---|---|---|---|
| Assumed risk | Corresponding risk | ||||
| Inpatient care | Admission avoidance hospital at home | ||||
| Mortality (6 months' follow‐up) (using data from trialists and published data) | Study population | RR 0.88 (0.68 to 1.13) | 1502 | ⊕⊕⊕⊝a | |
| 208 per 1000 | 183 per 1000 | ||||
| Admission to hospital (3 to 12 months' follow‐up) (using individual patient data and published data) | Study population | RR 1.14 (0.97 to 1.34 | 1757 | ⊕⊕⊕⊝b | |
| 407 per 1000 | 464 per 1000 | ||||
| Living in residential care at follow‐up (6 months' follow‐up) | Study population | RR 0.53 (0.41 to 0.69) | 1271 | ⊕⊕⊕⊝b Moderate | |
| 124 per 1000 | 66 per 1000 | ||||
| Patient self‐reported health status | Patient‐reported health status was largely the same for participants treated in hospital at home and hospital, with some reporting higher quality of life or better health status in hospital at home.D | ‐ | 2006 (9 studies) | ⊕⊕⊕⊝c Moderate | |
| Patient satisfaction | Patients allocated to hospital at home reported higher levels of satisfaction on average; a small proportion preferred hospital, or satisfaction was equal between groups.E | ‐ | 1812 (8 studies) | ⊕⊕⊝⊝d Low | |
| Length of stay in hospital and hospital at home | Hospital at home reduced average length of stay in hospital, which ranged from an average of 4.1 to 18.5 days in the hospital group to 1.2 to 5.1 days in the hospital at home group.F Hospital at home length of stay ranged from an average of 3 to 20.7 days (hospital at home group only).G Length of stay for the acute episode ranged from a mean increase of 0.7 to 9.1 daysF for the hospital at home group compared to the hospital group. | ‐ | 2036 (11 studies) | ⊕⊕⊝⊝e Low | |
| Cost and resource use | Hospital at home was generally less costly than hospital care, with a range of estimates for the mean reduction per episode with different levels of certainty, from USD −215 (P = 0.38) to GBP −1981 (95% CI −2551 to −1411).H Estimates for the difference in total health and social care costs for a variety of follow‐up durations also varied, ranging from GBP −1015.7 (95% CI −2735.5 to 644.8) to GBP −2265 (95% CI −4279 to −252).I | ‐ | 2148 (12 studies) | ⊕⊕⊕⊝f Moderate | |
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||||
| GRADE Working Group grades of evidence | |||||
| aWe downgraded the certainty of the evidence by one level to moderate due to imprecision of the estimate. ACaplan 1999; Ricauda 2008; Shepperd 2021; Tibaldi 2009; Wilson 1999. | |||||
Background
In the last 20 years, efforts to manage the steady increase in hospital admissions have included expanding out‐of‐hospital services. Examples include hospital at home services, which are designed to avoid a hospital admission or to provide early supported discharge from hospital (Leong 2021; Oliver 2021). Possible benefits of these services include releasing hospital beds; reducing the risk of adverse events associated with time in hospital (Rafter 2015); loss of independence associated with prolonged hospitalisations (Loyd 2020); receiving rehabilitation within the home environment (Kimmel 2020); and improved patient satisfaction and communication (Leff 2006).
Recent developments in remote monitoring technology, as well as pressures on health systems caused by the COVID‐19 pandemic, have motivated more countries to prioritise hospital at home services. Examples include Queensland Australia Hospital in the Home (Mackay 2023; Queensland Government 2022), Spain (Nogues 2021), and the UK, where NHS England has committed to funding the set‐up of virtual wards (otherwise known as 'hospital at home'), and Integrated Care Systems have been asked to deliver capacity equivalent to 40 to 50 virtual ward 'beds' per 100,000 population (NHS England 2021). In Scotland, health boards are required to provide hospital at home services, and some of these services have been running for many years (British Geriatrics Society 2022). In Spain, hospital at home units became popular in the 1990s, and gradually progressed to most of the country (de Sousa Vale 2020). In Australia, 'hospital in the home' activity is also growing, accounting for 3.7% of admissions from 2011 to 2017, and there are calls for more systematic monitoring and oversight (Montalto 2020).
The type of patient treated in hospital at home services varies, as does the use of technology, similar to the variation in hospitals. Some services are designed to care for specific conditions, such as chronic obstructive pulmonary disease, or to provide specific skills such as parenteral nutrition (Kumpf 2019). These services usually have close ties with acute hospitals and may be encouraged by the different structure of incentives in insurance‐based systems of health care by providing the type of service that is reimbursed.
Description of the condition
The demographic shift of a rising number of older people has increased the demand for hospital‐level care. For example, in the UK more than 40% of people admitted to hospital are over 65 years of age (NHS Digital 2019; WHO 2021 to 2030), and between 2006 and 2018 there was a 59% increase in the number of people aged over 85 who required emergency hospital admission (Steventon 2018). Healthcare decision‐makers in a number of countries are attempting to reconfigure services to deal with a year‐on‐year increase in hospital admissions, often with an inadequate evidence base (Nolte 2008; Steventon 2018). These changes have raised concerns that the pressure of delivering health care to greater numbers may be at odds with the provision of person‐centred, high‐quality care (RCP 2017). In addition to ageing, other factors such as remote monitoring are driving the adoption of hospital at home services.
Description of the intervention
The majority of admission avoidance hospital at home services provide co‐ordinated, multidisciplinary health care in the home for people who would otherwise be admitted to hospital (Arsenault‐Lapierre 2021; Leff 2009). Similar to hospitals, services are adapted to suit the patient population. People are admitted to admission avoidance hospital at home after assessment in the community by their primary care physician or in the emergency department or a medical admissions unit. Hospital at home may also provide hospital‐level care following early discharge from hospital (we have conducted a parallel systematic review of early discharge hospital at home, recently updated with no new studies identified (Gonçalves‐Bradley 2017), and a review of home‐based end‐of‐life care (Shepperd 2016b).
In single‐payer systems, hospital at home is commonly integrated with existing services, for example using telehealth that is routinely available, or existing emergency services or out‐of‐hours stand‐by services to provide publicly funded 24‐hour cover for patients if they deteriorate. This is the case in the UK, Spain, and Canada.
How the intervention might work
As well as reducing the demand for acute hospital beds, receiving hospital at home may lower the risk of functional decline from the limited mobility that can occur during an admission to hospital. This may be particularly beneficial for older people living with frailty, by providing co‐ordinated health care in the less restrictive home environment and thereby providing patients with the opportunity for continued involvement in activities of daily living (Covinsky 2003).
Why it is important to do this review
With the current policy emphasis on care closer to home (WHO 2021 to 2030), and concern about the steadily increasing demand for hospital bed‐based care (Monitor 2015; Virtual Wards 2022), we are updating this review to incorporate new randomised evidence. Along with more widespread use of admission avoidance hospital at home services, concerns have been raised about standards of care, lack of data, oversight systems, and the role of financial incentives in insurance‐based health systems that motivate providers to establish these services (Batt 2023). An up‐to‐date systematic review of the global evidence is needed to establish whether hospital at home is effective and cost‐effective when compared with bed‐based hospital care, or if there is a risk that it reduces the quality of care (Batt 2023). This is the fourth update of this review (Shepperd 2016a).
Objectives
To determine the effectiveness and cost of managing patients with admission avoidance hospital at home compared with inpatient hospital care.
Methods
Criteria for considering studies for this review
Types of studies
Randomised controlled trials.
Types of participants
This review included evaluations of admission avoidance hospital at home schemes involving people aged 18 years and over. We did not include people with long‐term care needs unless they required admission to hospital for an acute episode of care. We excluded evaluations of obstetric, paediatric, and mental health hospital at home schemes from the review as our preliminary literature searches suggested that separate reviews would be justified for each of these groups. For the purposes of this review, we defined older patients as those aged 65 years and older.
Types of interventions
Studies comparing admission avoidance hospital at home with acute hospital inpatient care. The admission avoidance hospital at home studies may have admitted patients directly from the community, thereby avoiding physical contact with the hospital, or may have admitted from the emergency room or an acute assessment unit. We used the following definition to determine whether studies should be included in the review: hospital at home is a service that can avoid the need for hospital admission by providing active treatment by healthcare professionals (including doctors) in the patient's home for a condition that would otherwise require acute hospital inpatient care, and always for a limited time period. In particular, hospital at home has to offer a specific service to patients in their home requiring healthcare professionals to take an active part in the patient's care. If hospital at home were not available, then the patient would be admitted to an acute hospital ward. We have therefore excluded the following services from this review:
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services providing long‐term care;
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services provided in outpatient settings or postdischarge from hospital; and
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self‐care by the patient in their home such as self‐administration of an intravenous infusion.
Types of outcome measures
Primary outcomes
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Mortality.
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Admission to hospital.
Secondary outcomes
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Living in residential care at follow‐up.
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Patient self‐reported health status: quality of life, functional status, psychological health.
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Satisfaction: patient, caregiver, health professionals.
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Length of stay in hospital and hospital at home.
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Cost and resource use.
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Clinical outcomes.
Search methods for identification of studies
Electronic searches
For this update we searched the following databases on 24 February 2022 for references published since 2 March 2016, the last version of this review:
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Cochrane Central Register of Controlled Trials (CENTRAL; 2022, Issue 2);
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MEDLINE (Ovid) (MEDALL);
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Embase (Ovid);
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CINAHL (Cumulative Index to Nursing and Allied Health Literature) (EBSCOhost).
We sought ongoing and unpublished studies by searching ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and by contacting providers and researchers involved in the field.
Search strategies are comprised of natural language and controlled vocabulary terms. Search terms for this update were revised based on terminology used in studies included in previous versions of the review. We applied no limits on language. We ran searches from 2015 onwards, the date of publication of the previous version of the review. In databases where it was possible and appropriate, study design filters for randomised trials were used; in MEDLINE we used a modified version of the Cochrane Highly Sensitive Search Strategy for identifying randomised trials in MEDLINE: sensitivity‐ and precision‐maximising version (2008 revision) (Lefebvre 2021). Limits were used in Embase to remove MEDLINE records in order to avoid duplication in downloaded results. Remaining results were deduplicated in EndNote against each other and against results from searches conducted for previous versions of the review. All search strategies used in this version of the review are provided in Appendix 1. Search strategies and search methods used in previous versions of the review are published within those prior publications.
Searching other resources
We searched the following trial registries on 14 November 2022 (Appendix 1):
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WHO ICTRP (trialsearch.who.int);
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US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (clinicaltrials.gov).
We checked the reference lists of articles identified electronically for evaluations of hospital at home and obtained potentially relevant articles. We checked relevant systematic reviews for other relevant studies.
Data collection and analysis
For a previous version of this review we contacted the investigators of 10 of the included trials that recruited similar populations, inviting them to contribute individual patient data (IPD) to the hospital at home admission avoidance collaborative review (Shepperd 2005), and had access to IPD for one new study for this update (Shepperd 2021).
Selection of studies
Three review authors (KE, SS, DGB) read all the abstracts in the records retrieved by the electronic searches to identify potentially eligible publications. We retrieved the full‐text papers for these publications, and two review authors (KE, SS, SI or DGB) independently assessed their eligibility. We selected studies for the review according to the prespecified inclusion criteria and resolved any disagreements by discussion. As an author of one of the studies (Shepperd 2021), SS was not involved in assessing their own study for inclusion, risk of bias, or data extraction.
Data extraction and management
Four review authors (SS, SI, DGB, KE) independently completed data extraction using a good‐practice extraction form developed by Cochrane that was modified and amended for the purposes of this review (EPOC 2015a).
Assessment of risk of bias in included studies
Four review authors (SS, SI, DGB, KE) independently assessed risk of bias in the included studies using the suggested risk of bias criteria for Cochrane Effective Practice and Organisation of Care (EPOC) reviews (EPOC 2015b):
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random sequence generation;
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allocation concealment;
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baseline outcome measurement;
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baseline characteristics;
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blinding of participants and personnel;
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blinding of outcome assessment;
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incomplete outcome data;
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selective reporting of outcomes.
Measures of treatment effect
We used IPD data and published data to conduct meta‐analyses on the outcomes of mortality, admission to hospital after discharge from hospital at home or inpatient care, and place of residence (living in residential care). We used a two‐stage approach: first we obtained or calculated the study treatment effects and their standard errors, and then subsequently combined them.
For mortality at three months, treatment effects adjusted for age and sex were estimated in a previous version of the review, based on IPD received from three trialists (Davies 2000; Harris 2005; Wilson 1999). These risk ratios were then combined using fixed‐effect inverse variance meta‐analysis (Deeks 2001). The pooled effect is expressed as the risk ratio for hospital at home compared with usual hospital care, with 95% confidence interval.
For mortality at six months, we extracted numbers of dead and alive in each group from published data from three studies, Caplan 1999; Ricauda 2008; Tibaldi 2009, and from IPD from two studies (Shepperd 2021; Wilson 1999), and combined this information as unadjusted risk ratios using a fixed‐effect model with inverse variance weights. Though studies published some adjusted risk ratios, they varied in the covariates they adjusted for, and therefore it was most straightforward to use only unadjusted estimates.
We analysed the effect of admission avoidance hospital at home on admission to hospital after discharge from hospital at home or inpatient care using IPD received from five trialists (Davies 2000; Harris 2005; Mendoza 2009; Shepperd 2021; Wilson 1999), and published data from three studies (Caplan 1999; Ricauda 2008; Tibaldi 2009), again combined using a fixed‐effect model and inverse variance weights. This outcome describes subsequent admission to inpatient hospital care after discharge (from either hospital at home or hospital) for a range of follow‐up times (3 to 12 months). We also extracted and presented data for transfer to hospital during the hospital at home episode, but as this only applies to the intervention group, we did not meta‐analyse these data.
There were insufficient IPD for living in residential care, therefore for this outcome we used available published data from three studies, Ricauda 2008; Tibaldi 2004; Tibaldi 2009, combined with the unadjusted risk ratio obtained from (Shepperd 2021), using a fixed‐effect model with inverse variance weights. The analyses in this review were carried out in Stata 16.1.
Our statistical analyses sought to include all randomised participants, using the intention‐to‐treat principle. We relied on published data when the IPD did not include the relevant outcomes.
Unit of analysis issues
The unit of allocation was the participant in all trials.
Dealing with missing data
In one data set contributing to the IPD meta‐analysis (Davies 2000), some dates were missing for known events, and so we gave the missing event a time at the midpoint between randomisation and last follow‐up, or as the midpoint between follow‐up times if these were known. For one trial where follow‐up was 90 days, we set the time to event as 45 days for three cases in the admission avoidance hospital at home arm and for one case in the control group where we knew death had occurred but we did not have a date (Davies 2000).
Assessment of heterogeneity
We quantified heterogeneity by Cochran's Q and the I2 statistic (Cochran 1954), the latter quantifying the percentage of the total variation across studies that is due to heterogeneity rather than chance (Higgins 2003); smaller percentages suggest less observed heterogeneity.
Assessment of reporting biases
If we identified an adequate number of studies (more than 10) and included these in a meta‐analysis, we explored publicaion bias using a funnel plot to visually assess funnel plot asymmetry (Higgins 2019).
Data synthesis
We used IPD when this information was available for studies that recruited similar populations (Davies 2000; Harris 2005; Mendoza 2009; Shepperd 2021; Wilson 1999). The pooled effect is expressed as the risk ratio for hospital at home compared with usual hospital care. Throughout the analyses, we took statistical significance at the two‐sided 5% level (P < 0.05), presenting data as the estimated effect with 95% confidence intervals. For this update, we conducted the analysis using Review Manager 5 (Review Manager 2020).
When combining outcome data was not possible because of differences in the measurement or reporting of outcomes, or in the case of outcomes that only applied to the intervention group, we presented data from individual studies in tables. Although planned, we did not attempt a direct comparison of costs because the trials collected data on different resources and used different methods to calculate costs.
Subgroup analysis and investigation of heterogeneity
We grouped studies by study population to reduce the amount of variation in the analysis.
Sensitivity analysis
We did not conduct a sensitivity analysis.
Summary of findings and assessment of the certainty of the evidence
We assessed our confidence in the evidence by creating a summary of findings table using the approach recommended by the GRADE Working Group, in Guyatt 2008, and specific guidance developed by EPOC (EPOC 2017), employing GRADEpro GDT software (GRADEpro GDT 2022). We included the main outcomes of mortality and admission to hospital, as well as living in residential care at follow‐up, patient satisfaction, length of stay, patient self‐reported health status, and cost and resource use. We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and risk of bias) to assess the certainty of the evidence as it relates to the main outcomes (Guyatt 2008). We used the methods and recommendations described in Chapter 14 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2019).
Results
Description of studies
We identified 20 trials that randomised individual participants (N = 3100), of which four were located in this update (Echevarria 2018; Levine 2018 (a pilot study); Levine 2020; Shepperd 2021) (Characteristics of included studies).
Results of the search
The updated search retrieved 2982 records from the electronic databases. We found 10 additional records from other sources, for a total of 2992 records after duplicates were removed, of which 2973 were ineligible. We obtained the full texts for the remaining 19 records, four of which fulfilled the inclusion criteria (four trials, five records), bringing the total number of trials included in the review to 20 (Figure 1). We excluded 12 studies with reasons provided (Excluded studies). We also identified two ongoing trials (NCT03156686; Pouw 2018; see Characteristics of ongoing studies).
PRISMA flow diagram.
Included studies
See Characteristics of included studies.
For a previous version of this review, we contacted the investigators of 10 of the included trials that recruited similar populations, inviting them to contribute IPD to the hospital at home admission avoidance collaborative review (Shepperd 2005). We used summaries of this information from the previous review for the three‐month mortality comparison using three studies (Davies 2000; Harris 2005; Wilson 1999), and had access to IPD for one new study (Shepperd 2021). We have summarised each study in Table 1, including details of the intervention and population in each study.
| N | Length of follow‐up | Population | Conditions | Intervention | Control | Location | Mean age (SD) | 24‐hour care provision | |
|---|---|---|---|---|---|---|---|---|---|
| 45 | 12 months | Patients with chronic heart failure that had deteriorated at a minimum of 1 week prior to recruitment | Chronic heart failure | Admission avoidance hospital at home; the first 48 hours of treatment was in the ED | Unknown | Romania | Unknown | Not reported | |
| T: 51 C: 49 | 6 months | Patients attended casualty | Range of acute conditions | Hospital community outreach team | Hospital care | Australia | T: 73 (median) C: 79 (median) | Not reported | |
| T: 98 C: 96 | 6 days | Patients attended emergency department | Cellulitis | Hospital at home admission avoidance from the ED by GP and community care nursing staff | Hospital care | New Zealand | T: 54.6 (20.6) C: 48.4 (19.0) | Not reported | |
| T: 100 C: 50 | 3 months | Patients attended A&E with chronic obstructive airways disease | COPD | Admission avoidance hospital at home by outreach specialist nurses and GP/community nurses | Hospital care | UK | Unknown | District nurses | |
| T: 62 C: 58 | 90 days | Patients over 35 years of age admitted to hospital with COPD | COPD | Once‐ or twice‐daily vists from respiratory specialist nurse under remote supervision from consultant | Hospital care | UK | T: 71.0 (9.6) C: 68.7 (10.5) | 24/7 contact with HAH team available | |
| T: 39 C: 37 | 90 days | Patients attended emergency department or acute assessment ward | Range of acute conditions | Hospital outreach programme; nurse‐led team provided care and rehab in patients' homes | Hospital care | New Zealand | 80.0 | 24‐hour on‐call geriatrician | |
| T: 153 C: 152 | 12 months | Patients within 72 hours of stroke onset | Moderately severe stroke | Hospital outreach admission avoidance multidisciplinary care | Hospital care, stroke unit care | UK | T: 77.7 C: 77.3 (medians) | Not reported | |
| T: 9 C: 11 | 30 days | Patients over 18 years of age attending emergency department | Infection, heart failure, COPD, asthma exacerbation | Hospital at home; at least 1 daily visit from general internist, 2 daily visits from nurse | Hospital care | USA | T: 65 (28) C: 60 (29) median (IQR) | Attending physician available 24/7 | |
| T: 43 C: 48 | 30 days | Patients over 18 years of age attending emergency department | Infection, heart failure, COPD, asthma exacerbation | Hospital at home; at least 1 daily visit from general internist, 2 daily visits from nurse | Hospital care | USA | T: 80 (19) C: 72 (23) median (IQR) | Attending physician available 24/7 | |
| T: 37 C: 34 | 1 year | Patients in A&E with acute decompensation of chronic heart failure | Heart failure | Admission avoidance hospital at home; hospital outreach model | Hospital care | Spain | 79 | Emergency services | |
| T: 13 C: 12 | Duration of treatment | Patients over 45 years of age with COPD referred by GP or emergency staff | COPD | Hospital at home | Hospital care | Australia | Unknown | 24‐hour telephone support by hospital staff | |
| T: 60 C: 60 | 6 months | Patients admitted to hospital within 24 hours of onset of stroke symptoms | Stroke | Hospital outreach admission avoidance | Hospital care | Italy | T: 82.5 (8.6) C: 79.5 (6.7) | Physician and nurse available 24 hours | |
| T: 52 C: 52 | 6 months | Patients admitted to hospital for acute exacerbation of COPD | COPD | Physician‐led admission avoidance hospital outreach service | Hospital care | Italy | T: 80.1 (3.2) C: 79.2 (3.1) | HAH staff available 24 hours | |
| T: 24 C: 25 | 6 weeks | Patients presented to emergency room with pneumonia | Community‐acquired pneumonia | Hospital at home: admission avoidance from emergency room | Hospital care | New Zealand | T: 50.1 C: 49.8 | 24‐hour emergency contact number | |
| T: 687 C: 345 | 12 months | Patients over 65 years of age referred to HAH | Range of acute conditions | Admission avoidance hospital at home; geriatrician‐led multidisciplinary team | Hospital care | UK | T: 83.3 (7.0) C: 83.3 (6.9) | NHS telephone out‐of‐hours service, plus site‐specific arrangements for overnight care | |
| T: 47 C: 66 | Duration of acute episode | Patients who had chemotherapy | Febrile neutropenia | Admission avoidance hospital at home; commercial home care provider | Hospital care | USA | 47 (median) 20 to 81 (range) | Not reported | |
| T: 56 C: 53 | Until discharge | Patients with advanced dementia | Range of acute conditions | Hospital at home; geriatric home hospitalisation service | Hospital care | Italy | T: 82.9 (7.9) C: 84.1 (7.5) | Not reported | |
| T: 48 C: 53 | 6 months | Patients presented to emergency department | Chronic heart failure | Admission avoidance hospital at home; hospital outreach | Hospital care | Italy | 81 | HAH staff available 24 hours | |
| T: 26 C: 27 | 3 months | Patients with neuromuscular disease | Acute respiratory tract infection | Hospital at home; portable ventilator, respiratory therapist daily visits | Hospital care | Italy | T: 44.6 (20.4) C: 46.7 (20.2) | Pulmonologist available by telephone | |
| T: 102 C: 97 | 3 months | Majority elderly, referred by GP to Bed Bureau | Range of acute conditions | Admission avoidance hospital at home | Hospital care | UK | 84 (median) | 24‐hour care available |
A&E: accident & emergency department
C: control
COPD: chronic obstructive pulmonary disease
ED: emergency department
GP: general practitioner
HAH: hospital at home
IQR: interquartile range
SD: standard deviation
T: treatment
Study populations
Four trials recruited participants with chronic obstructive pulmonary disease (COPD), with an average age range of 69.9 to 81 years (Davies 2000; Echevarria 2018; Nicholson 2001; Ricauda 2008). Two trials recruited participants recovering from a moderately severe stroke who were clinically stable, with an average age range of 77.5 to 81 years (Kalra 2000; Ricauda 2004). Seven trials recruited participants with an acute medical condition who were mainly elderly, with an average age range of 76 to 84 years (Andrei 2011; Caplan 1999; Harris 2005; Mendoza 2009; Shepperd 2021; Tibaldi 2009; Wilson 1999). Harris 2005 included two treatment groups and a control (hospital) group. One treatment group was an "admission prevention" group, and the other was an "early discharge" group. Harris provided IPD data for the admission prevention and control groups only. Two trials, one of which was the pilot for the main effectiveness trial, recruited adults attending the emergency department with a primary diagnosis of any infection, heart failure exacerbation, COPD exacerbation, or asthma exacerbation, with an average age of each 62.5 and 65 years respectively (Levine 2018; Levine 2020). There was one trial each for participants with cellulitis, average age 51.5 years (Corwin 2005), community‐acquired pneumonia, average age 50 (Richards 2005), fever and neutropenia, average age 47 (Talcott 2011), frail elderly participants with dementia, average age 83.5 (Tibaldi 2004), and neuromuscular disease, average age 45.7 years (Vianello 2013). The 20 trials were conducted in seven countries: Australia (two trials), Italy (five trials), New Zealand (three trials), Romania (one trial), Spain (one trial), the UK (five trials), and the USA (three trials).
Interventions
Details of the intervention components are described in Table 1 and Table 2. Participants were admitted to hospital at home from the emergency room (Andrei 2011; Caplan 1999; Corwin 2005; Davies 2000; Levine 2018; Levine 2020; Mendoza 2009; Nicholson 2001; Ricauda 2004; Ricauda 2008; Richards 2005; Tibaldi 2004; Tibaldi 2009; Vianello 2013), after a hospital assessment (within 24 hours) (Echevarria 2018), the community following referral by their primary care physician (Harris 2005; Kalra 2000; Wilson 1999), an outpatient department (Talcott 2011), and a hospital acute assessment unit or primary care (Shepperd 2021). For participants allocated to hospital at home, health care was provided by a hospital outreach team (Caplan 1999; Echevarria 2018; Harris 2005; Mendoza 2009; Ricauda 2004; Ricauda 2008; Talcott 2011; Tibaldi 2004; Tibaldi 2009), a mix of outreach and community staff (Davies 2000; Kalra 2000; Levine 2018; Levine 2020; Nicholson 2001; Shepperd 2021; Vianello 2013), or by the general practitioner (GP) and community nursing staff (Corwin 2005; Richards 2005; Wilson 1999). For one trial it was not clear who provided care (Andrei 2011). In two trials, the intervention was provided by Pegasus Health, an independent association of GPs (Corwin 2005; Richards 2005). One trial was a three‐group comparison of stroke unit care, inpatient stroke team, and hospital at home (Kalra 2000); we selected the inpatient stroke team as the comparison group, as this was most similar to the comparator in the other trials.
| Mode of referral | ||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Emergency room | X | X | X | X | X | X | X | X | X | X | X | X | X | X | ||||||
| Community (by primary care physician) | X | X | X | |||||||||||||||||
| Outpatient department | X | |||||||||||||||||||
| From admission < 24 hours | X | |||||||||||||||||||
| Acute assessment unit/home | X | |||||||||||||||||||
| Hospital at home provision | ||||||||||||||||||||
| Hospital outreach team | X | X | X | X | X | X | X | X | X | X | X | |||||||||
| Mix of outreach/community staff | X | X | X | X | X | |||||||||||||||
| GP/community nursing staff | X | X | X | |||||||||||||||||
| Unclear | X | |||||||||||||||||||
| Types of care | ||||||||||||||||||||
| Physiotherapy | X | X | X | X | X | X | X | X | X | |||||||||||
| Social worker | X | X | X | X | X | X | X | X | X | |||||||||||
| Occupational therapy | X | X | X | X | X | X | X | X | ||||||||||||
| Counsellor | X | |||||||||||||||||||
| Speech therapist | X | X | ||||||||||||||||||
| Cultural link worker | X | |||||||||||||||||||
| Portable ventilator | X | |||||||||||||||||||
GP: general practitioner
Physiotherapy care was described in 10 of the interventions (Harris 2005; Kalra 2000; Levine 2018; Levine 2020; Nicholson 2001; Ricauda 2004; Ricauda 2008; Shepperd 2021; Tibaldi 2004; Wilson 1999), and occupational therapist care in seven (Harris 2005; Kalra 2000; Levine 2018; Levine 2020; Nicholson 2001; Shepperd 2021; Wilson 1999). A social worker was part of the hospital at home team in 10 of the interventions (Davies 2000; Harris 2005; Kalra 2000; Levine 2018; Levine 2020; Ricauda 2004; Shepperd 2021; Talcott 2011; Tibaldi 2004; Wilson 1999), and a counsellor in one (Talcott 2011). Access to a speech therapist was described in three of the interventions (Kalra 2000; Ricauda 2004; Wilson 1999). In two trials, participants could access a home health aide and medical meals, if required (Levine 2018; Levine 2020). One trial described access to a cultural link worker (Wilson 1999). The intervention in one trial included the use of a portable ventilator; a respiratory therapist made daily visits for the first three days of home care, and district nurses and caregivers were trained in the application of the device and on assisting with coughing (Vianello 2013). District nurses visited daily until recovery from the respiratory tract infection; participants also had telephone access to pulmonary specialists (Vianello 2013).
Excluded studies
The main reason for exclusion was that the trial tested the feasibility of introducing technologies for ameliorating a condition at home (four trials), Duiverman 2019; Hazenberg 2014; Mascardi 2016; NCT02363413, and not hospital at home (see Characteristics of excluded studies).
Risk of bias in included studies
See Characteristics of included studies. Summaries of the risk of bias assessments for the included studies are presented in Figure 2 and Figure 3.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Allocation
In 15 studies concealment of allocation was adequate (Figure 2; Figure 3) (Caplan 1999; Corwin 2005; Davies 2000; Echevarria 2018; Harris 2005; Kalra 2000; Levine 2018; Levine 2020; Mendoza 2009; Ricauda 2008; Richards 2005; Shepperd 2021; Talcott 2011; Tibaldi 2009; Wilson 1999), and in 12 studies sequence generation was adequately described (Caplan 1999; Echevarria 2018; Harris 2005; Kalra 2000; Levine 2018; Levine 2020; Mendoza 2009; Ricauda 2004; Ricauda 2008; Richards 2005; Shepperd 2021; Talcott 2011).
Blinding
We assessed seven studies as having a low risk of performance bias (Davies 2000; Echevarria 2018; Harris 2005; Kalra 2000; Ricauda 2008; Shepperd 2021; Wilson 1999). Three studies were at unclear risk of bias for the measurement of objective outcomes, and nine studies were at low risk of bias for the measurement of subjective outcomes (Figure 3).
Incomplete outcome data
Most studies had a low risk of attrition bias, with seven studies having an unclear risk (Andrei 2011; Mendoza 2009; Nicholson 2001; Ricauda 2004; Richards 2005; Tibaldi 2004; Tibaldi 2009).
Selective reporting
Nine studies were at low risk of bias for selective reporting (Davies 2000; Echevarria 2018; Harris 2005; Kalra 2000; Levine 2020; Ricauda 2008; Shepperd 2021; Tibaldi 2009; Wilson 1999).
Other potential sources of bias
Other sources of bias were not assessed.
Effects of interventions
See summary of findings Table 1 for the main comparison admission avoidance hospital at home versus inpatient admission for older people requiring admission to hospital.
Mortality
We combined IPD for a subset of three studies (N = 420), adjusted for age and sex, for mortality at three months' follow‐up (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.55 to 1.45; P = 0.64; N = 420 participants; moderate‐certainty evidence) (Davies 2000; Harris 2005; Wilson 1999) (Analysis 1.1). We combined published data from three studies, Caplan 1999; Ricauda 2008; Tibaldi 2009, with data received from trialists of two studies, Shepperd 2021; Wilson 1999, for mortality at six months (RR 0.88, 95% CI 0.68 to 1.13; P = 0.30; N = 1502 participants; moderate‐certainty evidence) (Analysis 1.2). Results indicated that admission avoidance hospital at home probably makes little to no difference to mortality when compared with in‐hospital care.
Admission to hospital
We analysed the effect of admission avoidance hospital at home on hospital admission after discharge from hospital at home or inpatient care at 3 to 12 months' follow‐up using data received from five trialists, Davies 2000; Harris 2005; Mendoza 2009; Shepperd 2021; Wilson 1999, and published data from three studies, Caplan 1999; Ricauda 2008; Tibaldi 2009. Results indicated that admission avoidance hospital at home probably makes little to no difference to hospital admission (RR 1.14, 95% CI 0.97 to 1.34; P = 0.11; I2 = 41%; N = 1757 participants; moderate‐certainty evidence) (Analysis 1.3). Four trials reported transfer to hospital while receiving hospital at home (Analysis 1.4) (Corwin 2005; Ricauda 2008; Richards 2005; Talcott 2011).
Living in residential care at follow‐up
Admission avoidance probably reduces the likelihood of living in residential care, measured at discharge to six months' follow‐up (RR 0.53, 95% CI 0.41 to 0.69; P < 0.001; I2 = 67%; 4 trials; N = 1271 participants; moderate‐certainty evidence) (Analysis 1.5) (Ricauda 2008; Shepperd 2021; Tibaldi 2004; Tibaldi 2009).
Patient self‐reported health status
Quality of life
Nine trials assessed health status or quality of life using different measures, as described below (Analysis 1.6).
One trial that recruited people with cellulitis reported 36‐Item Short Form Health Survey (SF‐36) scores at six days' follow‐up. The difference in score from day 0 was compared between the treatment groups; each item is scored between 0 and 100, with a higher score indicating better health; a difference above 0 favours the treatment group (physical component scale mean difference (MD) −5.2, 95% CI −13.7 to 3.2; role physical scale MD 2.2, 95% CI −10.7 to 15.1; pain scale MD −3.8, 95% CI −10.6 to 3.0) (Corwin 2005).
A second trial measuring health status with the SF‐36 reported follow‐up data at one year for the physical component scale (treatment group (T): 3.6 (−0.5 to 7.7), control group (C): 2.2 (−1.9 to 6.4); P = 0.47) and the mental component scale (T: 4.0 (−0.9 to 8.9), C: 2.8 (−2.4 to 8.0); P = 0.38) (Mendoza 2009). One trial measured quality of life with the SF‐12 at six weeks' follow‐up and reported similar scores for each group on the physical component (T: 42.2, C: 45.8; P = 0.18) and mental component scale (T: 50.4, C: 51.0; P = 0.81) (Richards 2005).
Two trials assessed quality of life using the Nottingham Health Profile at six months' follow‐up. Yes/no answers are given for 38 items, which are then weighted to give a score between 0 and 100, with a higher score indicating better health. In these two trials, the change from baseline to six months was compared between treatment groups (T: +1.09 (standard deviation (SD) 2.57) N = 48, C: +0.18 (SD 1.94); P = 0.046) (Tibaldi 2009) and (T: 3.6 (SD 7.9), C: 0.8 (SD 4.5); P = 0.04) (Ricauda 2008).
One trial assessed change from baseline in quality of life when a participant had a health event using the EORTC QLQ‐C30, measuring the change before and after the episode (range 0 to 100, higher is better quality of life) (T: 0.58, C: 0.78, P = 0.05; emotional function hospital at home 3.27, hospital −6.94; P = 0.04) (Talcott 2011). One trial reported median values at three months' follow‐up for the Sickness Impact Profile (range 0 to 100, higher score is better health) (T: 24 (interquartile range (IQR) 20 to 31), C: 26 (IQR 20 to 31); MD −2, 95% CI −4 to 4; P = 0.73) and the EuroQol (utility score anchored at 0 for death and 1 for perfect health) (T: 0.64, n = 73, C: 0.63, n = 96; MD 0.01, 95% CI −0.12 to 0.09; P = 0.94) (Wilson 1999). Two trials reported mean changes for the EQ‐5D: Echevarria 2018 reported small changes from baseline to 14‐ and 90‐day follow‐up, and Shepperd 2021 reported that there was likely little or no difference between groups at six months' follow‐up.
Functional status
Ten trials reported measures of functional ability, for which higher scores indicate greater independence (see Analysis 1.7 for specific details on the scales used), described as follows.
Caplan 1999 reported scores for instrumental activities of daily living between admission and discharge (MD −0.23, P = 0.04) and the Barthel Index (high score = greater independence) (hospital at home (T): 0.37 (0.27), hospital (C): −0.04 (0.27)). A trial that recruited participants with dementia reported that fewer participants in the hospital at home group had problems with sleep (difference 34%, P < 0.001), agitation and aggression (difference 32.5%, P < 0.001), and feeding (difference 31%, P < 0.001) (Tibaldi 2004).
One trial recruiting participants who had had a stroke reported the number of participants with a favourable outcome measured by the Barthel Index (score of 15 to 20) at three months (T: 106/145 (73%), C: 106/151 (70%); RR 0.96, 95% CI 0.83 to 1.11; P = 0.58) (Kalra 2000). Ricauda 2004, which also recruited participants with a stroke, reported activities of daily living (scale 0 to 6) at six months (median (IQR), T: 4 (2 to 5), C: 4 (2 to 6); P = 0.57). Two trials recruiting participants with COPD reported follow‐up data: Ricauda 2008 reported change in activities of daily living at six months (score 0 to 6) (T: 0.12 (SD) 0.64, C: 0.08 (SD 0.73); P = 0.81), and Davies 2000 reported forced expiratory volume in 1 second (FEV1) at three months' follow‐up (T: 41.5%, 95% CI 8.2% to 74.8%; C: 41.9%, 95% CI 6.2% to 77.6%).
Two studies recruiting participants with heart failure reported little or no change in activities of daily living measured by the Barthel Index at baseline and six months' follow‐up (mean T: −1.95 (SD 9.61), C: −0.30 (SD 10.12)) (Tibaldi 2009); and at one year (T: 4.0, 95% CI −0.9 to 8.9; C: 4.7, 95% CI −2.2 to 11.5; P = 0.21), adjusted for baseline differences (Mendoza 2009). Wilson 1999, which recruited older people with a mix of conditions, assessed functional ability at three months using the Barthel Index (median (IQR) T: 16 (13 to 19), C: 16 (12 to 20)). Levine 2020 reported that patients who received their health care at home were less sedentary than those in hospital, and that reductions in functional status at 30 days after discharge were similar in both groups. Shepperd 2021 reported little or no difference between groups in activities of daily living measured by the Barthel Index at six months' follow‐up (Analysis 1.7).
Psychological health
Seven trials measured cognitive function and depression, detailed as follows (Analysis 1.8).
One trial that recruited participants recovering from a stroke reported that hospital at home may lead to lower scores on the Geriatric Depression Scale (GDS) (lower scores = fewer symptoms) (MD 7 points on a 0‐to‐30‐point scale, P < 0.001) (Ricauda 2004), and one trial reported a lower score at six months for participants who had COPD and were allocated to hospital at home (T: −3.1 (SD 4.7), C: 0.7 (SD 3.2); P < 0.001) (Ricauda 2008). One trial that recruited participants with acute chronic heart failure reported fewer depressive symptoms at six months follow‐up (measured by the GDS) for those allocated to admission avoidance hospital at home (mean change T: 1.48 (SD 1.86), C: 0.12 (SD 3.36); P = 0.02) (Tibaldi 2009). Wilson 1999 reported median (IQR) scores for the Philadelphia Geriatric Morale Scale at three months, finding little to no difference between groups (T: 37 (30 to 42), C: 37 (31 to 43); MD 0, 95% CI −4.1 to 4.1). Echevarria 2018 and Shepperd 2021, using the Hospital Anxiety and Depression Scale and the Montreal Cognitive Assessment (MoCA) questionnaire, respectively, reported little or no differences between groups.
Two trials used the Mini‐Mental State Examination (max score 30) to assess cognitive functioning at six months' follow‐up and reported little to no difference between groups (T: −0.4 (SD 4.0), C: −0.5 (SD 1.8); P = 0.88) (Ricauda 2004); and (T: 0.07 (SD 1.38), C: 0.08 (SD 1.36); P = 0.97) (Tibaldi 2009). One trial that recruited participants with a mix of conditions reported cognitive function scores: mean T: 0.43 (standard error of the mean (SEM) 0.12), C: 0.27 (SEM 0.12); and that fewer people receiving hospital at home care experienced short‐term confusion during an episode of care (MD −20.4%, 95% CI −32% to −9%) (Caplan 1999). One trial used the Confusion Assessment Method (CAM) to screen for delirium at baseline, three days, five days, and one month, and reported a difference at one month (T: 10/602 (1.7%), C: 13/297 (4.4%), RR 0.38 (0.19, 0.76); P = 0.006) (Shepperd 2021).
Satisfaction: patient, caregiver, and health professionals
Admission avoidance may increase patient satisfaction with the health care received. Participants allocated to hospital at home care reported higher levels of patient satisfaction across a range of different conditions (8 studies; 1812 participants; low‐certainty evidence). Twenty‐seven per cent (P < 0.001) more participants with cellulitis in the hospital at home group reported increased satisfaction with their location of care compared with those admitted to hospital (Corwin 2005), and 40% (P < 0.001) more participants with community‐acquired pneumonia allocated to hospital at home reported that they were happy with their care (Richards 2005). Two trials (recruiting mainly older participants with a mix of medical conditions) also reported increased levels of satisfaction for those allocated to hospital at home care (median difference of 3 on a 0‐to‐18‐point scale, P < 0.001 (Wilson 1999); and MD of 0.9 on a 4‐point scale, P < 0.001 (Caplan 1999)). However, in the latter trial, there was a low response rate for the control group: 40% compared with 78% in the hospital at home group (Caplan 1999).
Some participants (6/101; 6%) refused hospital at home care and were admitted to hospital, and a greater number of participants allocated to hospital care (23/97; 24%) were not admitted because of refusal by the participant, caregiver, or general practitioner (Wilson 1999). One trial recruiting participants with COPD reported the number of participants assessing satisfaction with care as very good or excellent (hospital at home 49/52 (94%), hospital 46/52 (88%); P = 0.83) (Analysis 1.9) (Ricauda 2008), and one trial reported that overall satisfaction scores favoured hospital at home (Shepperd 2021). Two trials (one pilot study, Levine 2018) found that patients in both groups had the same or similar median global satisfaction score, both indicating high satisfaction, though one point lower in the hospital group in Levine 2020.
One trial reported that caregivers in the hospital at home group had significantly higher levels of satisfaction compared with those in the hospital group (difference −0.8 on a 4‐point scale, P < 0.001) (Caplan 1999), although the response rate was 27% in the hospital group and 55% in the hospital at home group. A second trial assessed caregiver satisfaction through semi‐structured interviews; caregivers reported that although hospital would potentially relieve them from caring, the upheaval of visiting hospital and the accompanying anxiety was a less satisfactory option (Wilson 1999). One trial recruiting participants with COPD reported change in relatives' stress at six months (mean scores (SD) T: 4.6 (5.6), C: 2.6 (6.1); P = 0.16) (Analysis 1.10) (Ricauda 2008).
Health professionals' views
One trial evaluated general practitioners' satisfaction with the service (T: 1.17, C: 1.8, score of 1 to 4, high score = excellent, low score = poor); the response rate was poor: 63% in the hospital at home group and 37% in the control group (Analysis 1.11) (Caplan 1999).
Length of stay in hospital and hospital at home
Eleven trials reported the effect of admission avoidance hospital at home on length of hospital stay or hospital at home stay, or both, with differing results (Analysis 1.12). Four trials reported length of stay in hospital, for both the intervention and control groups (Davies 2000; Echevarria 2018; Shepperd 2021; Wilson 1999). Hospital length of stay ranged from an average of 4.1 days, Echevarria 2018, to 18.5 days, Wilson 1999, in the hospital group, and 1.2 days, Echevarria 2018, to 5.1 days, Wilson 1999, in the hospital at home group. Hospital at home length of stay ranged from an average of 3 to 20.7 days (hospital at home group only) (Harris 2005; Levine 2018; Levine 2020; Mendoza 2009; Ricauda 2008; Tibaldi 2009; Wilson 1999). One trial (Singh 2022 for Shepperd 2021) reported a reduction in hospital length of stay of just over a day at six months follow‐up for those allocated to hospital at home.
For the total length of stay in the acute episode, admission avoidance hospital at home increased the length of stay or made no difference. The increase ranged from 0.7 days, in Levine 2020, to 9.1 days, in Tibaldi 2009. In one study there was no difference in length of stay between treatment groups (Levine 2018).
Cost and resource use
Three trials reported a full evaluation of healthcare resources and costs (Echevarria 2018; Shepperd 2021; Wilson 1999); one of these trials included informal‐care costs (Shepperd 2021). Four trials reported the difference in mean cost per initial acute health episode (Caplan 1999; Nicholson 2001; Shepperd 2021; Wilson 1999); three trials reported the mean cost per patient (Ricauda 2004; Ricauda 2008; Richards 2005); and two trials reported the percentage reduction in median cost of episode and subsequent 30 days (Levine 2018; Levine 2020) (Analysis 1.13).
Admission avoidance hospital at home probably decreases healthcare costs (2148 participants, moderate‐certainty evidence) (Caplan 1999; Corwin 2005; Echevarria 2018; Levine 2018; Levine 2020; Mendoza 2009; Nicholson 2001; Ricauda 2004; Ricauda 2008; Richards 2005; Shepperd 2021; Wilson 1999), though by a range of different amounts, and there is some evidence that it decreases overall societal costs to six months' follow‐up (Shepperd 2021).
Older participants with a medical condition
One trial reported a cost minimisation analysis (Wilson 1999), finding an initial increase in the mean cost per day for hospital at home (difference GBP 99.71, P < 0.001) for all those randomised, and little or no difference in cost at three months' follow‐up (GBP −210.9, 95% CI GBP −1025 to GBP 635.47). When participants refusing their allocated place of care (T: 6/101, C: 23/97) were removed from the analysis, there was a reduction in costs for those receiving hospital at home for the initial episode of care (difference GBP −1070.53, 95% CI GBP −1843.2 to GBP −245.73) and at three months' follow‐up (difference GBP −1063.45, 95% CI GBP −2043 to GBP −162.7). The difference in mean cost per day between hospital at home and hospital care was reduced, although hospital at home care remained more costly per day (GBP 206.68 versus GBP 133.7, MD GBP 72.98, P < 0.001).
Another trial, recruiting mainly older participants with a mix of conditions, examined health service costs using average costs (Board 2000 secondary publication to Caplan 1999), and reported reduced health service costs for the intervention group (T: AUD 1764 (SD AUD 1253), C: AUD 3775 (SD AUD 2496) for an episode of care, MD per episode AUD −2011) and cost per day (T: AUD 191 (SD AUD 58), C: AUD 484 (SD AUD 67.23); MD AUD 293). The costs of the nurse co‐ordinator and hospital doctor involved were excluded from this analysis (see Analysis 1.13.1). Mendoza 2009 reported the mean (SD) cost at one‐year follow‐up (T: EUR 2541 (1334), C: EUR 4502 (2153); difference EUR 1961, P < 0.001).
Singh 2022 for Shepperd 2021 compared total health and social care costs, and total societal costs (includes the productivity loss of informal carers costed by the hour). They reported reduced health and social care costs for the intervention group from baseline to six months' follow‐up (T: GBP 15,124, C: GBP 17,390; difference GBP −2265, 95% CI GBP −4279 to GBP −252), adjusting for gender, cognitive decline, utilities, pre‐randomisation costs, and site. Total adjusted societal costs were also reduced for the intervention group at six months' follow‐up (T: GBP 19,067, C: GBP 21,907; difference GBP −2840, 95% CI GBP −5495 to GBP −185).
Participants recovering from a stroke
A trial recruiting participants recovering from a stroke compared stroke unit care, inpatient stroke team care, and hospital at home. Regarding immediate care, hospital at home care was less costly than inpatient stroke team care (MD GBP −2096, 95% CI GBP −3272 to GBP −920). The inclusion of costs of informal care, based on the minimum wage, resulted in an MD of GBP −2216 (95% CI GBP −4771 to GBP 339) (Analysis 1.13) (Patel 2004 for Kalra 2000). In another trial recruiting participants with a stroke, a small reduction in mean cost per patient was reported for those allocated to hospital at home (USD 6413.5 versus USD 6504.8) (Ricauda 2004), which translated to a lower cost per day for hospital at home of USD 112.00 (USD 163.0, SD 20.5 versus USD 275.6, SD 27.7; P < 0.001).
COPD and community‐acquired pneumonia
One trial recruiting participants with COPD reported a lower mean health service cost for participants allocated to hospital at home; hospital costs were based on an average DRG (a diagnostic‐related group categorised by resource use) cost per bed day (cost per episode MD GBP −1798, P < 0.01) (Nicholson 2001). Another trial recruiting participants with community‐acquired pneumonia, again using DRG costs for the control and actual resource use for costing the intervention, reported a reduced cost for those allocated to hospital at home (mean cost per patient T: NZD 1157.9, C: NZD 1556.28) (Richards 2005). Ricauda 2008 reported the total mean cost per patient (T: USD 1175.9, C: USD 1390.9, P = 0.38) and the total mean cost per day (T: USD 101.4 (SD 61.3), C: USD 151.7 (SD 96.4)).
Use of other health services and informal care
Davies 2000 reported an increase in referrals for social support for participants with COPD who were allocated to hospital at home. This occurred during the time they were receiving hospital at home or when the control group had been discharged from hospital (24% versus 6%, difference 18%, 95% CI 7.3% to 28.6%) (Analysis 1.13). One trial recruiting participants recovering from a stroke reported that 71% (100/140) of those allocated to hospital at home received informal care, compared with 67% (98/147) receiving care from the inpatient stroke team (Patel 2004). This translated into 979 hours (SD 1749) versus 846 hours (SD 1549) of care over a 12‐month period (Analysis 1.13). Singh 2022 for Shepperd 2021 found no significant difference in the total hours of informal care between the treatment groups up to six months' follow‐up (mean (SD) T: 594.89 (1093.63), C: 657.64 (1170.87); difference −62.76, 95% CI −224.61 to 99.09).
Clinical outcomes
One trial measured clinical complications, with fewer participants allocated to hospital at home reporting bowel complications (difference −22.5%, 95% CI −34% to −10.8%) or urinary complications (difference −14.4%, 95% CI −25.4% to −3.3%) (Caplan 1999). In a trial recruiting participants with dementia, fewer participants in the hospital at home group were prescribed antipsychotic drugs at discharge (difference −14%, 95% CI −28% to 0.3%) (Tibaldi 2004). One trial that recruited people with cellulitis reported risk of advancement of cellulitis (hazard ratio 0.98, 95% CI 0.73 to 1.32) (Corwin 2005), and one trial recruiting participants with COPD reported that more participants allocated to hospital at home were prescribed an antibiotic (difference 18%, 95% CI 1.4% to 34.6%) (Davies 2000). Talcott 2011 reported the difference in major complications during the episode of care (difference 1%, 95% CI −10% to 13%) (Analysis 1.14).
Discussion
Summary of main results
Admission avoidance hospital at home probably makes little or no difference to risk of death at six months' follow‐up and to readmission to hospital after discharge from hospital at home or inpatient care within 3 to 12 months (range of follow‐up times from the included studies), and probably reduces the likelihood of relocating from home to residential care at six months. Admission avoidance hospital at home probably results in little to no difference in patient‐reported health status, and the evidence suggests that it may increase patient satisfaction and reduce hospital length of stay; that total length of stay for hospital at home may be greater than for those allocated to hospital; and that hospital at home can be less costly than in‐hospital care (summary of findings Table 1).
Patients valued the quality of communication and personal care received in a hospital at home setting (Shepperd 2021; Wilson 1999). However, the increased satisfaction reported by patients must be balanced against the potential burden on caregivers; for example, interviews with caregivers showed that their contributions might be required to facilitate an episode of hospital at home (Makela 2020), and that this can place an additional burden on families. Comparing cost data from the different studies was limited by the different methods used to cost resources, and follow‐up times that ranged from 1 to 12 months. Three trials conducted a full economic evaluation (Jones 1999 for Wilson 1999; Singh 2022 for Shepperd 2021; and Patel 2004 for Kalra 2000), reporting that hospital at home may lead to a small reduction in health service cost, a reduction in societal costs, and can be a cost‐effective alternative to hospital admission for select groups of patients.
There was some variation in the way the admission avoidance hospital at home services operated that reflected different health systems, existing services available, and financing. Services admitted patients directly from the community (Harris 2005; Kalra 2000; Vianello 2013; Wilson 1999), outpatients (Talcott 2011), and from an accident and emergency department or medical assessment unit (Andrei 2011; Caplan 1999; Corwin 2005; Davies 2000; Echevarria 2018; Levine 2018; Levine 2020; Mendoza 2009; Nicholson 2001; Ricauda 2004; Ricauda 2008; Richards 2005; Shepperd 2021; Tibaldi 2004; Tibaldi 2009). Six trials evaluated interventions where the patient could be living alone, and five trials required a caregiver to be either living with the patient or nearby. This variation reflects the nature of complex interventions (i.e. similar to stroke units, case management, telemedicine), and we did not combine data from studies with a high level of clinical heterogeneity. There were some important common features across the different hospital at home services; these included access to a doctor, co‐ordinated care provided by a multidisciplinary team, the provision of 24‐hour cover if required, and a safe home environment being a requirement for the provision of hospital at home. Inevitably, hospital at home does not function as an isolated intervention, with the organisation of services reflecting local health systems, workforce, and available social care services. For some countries, integrating hospital at home into existing services is the most efficient way to deliver these services.
Overall completeness and applicability of evidence
The evidence indicates that admission avoidance hospital at home may provide an effective alternative to inpatient care for a select group of patients requiring hospital admission. The majority of the included trials recruited participants who were older, with an average age that ranged from 70 to over 80 years, and who had experienced a medical event that required admission to hospital. All trials but one, Andrei 2011, were conducted in high‐income countries. Eight trials excluded patients who did not have continuous family support (Caplan 1999; Mendoza 2009; Ricauda 2004; Ricauda 2008; Richards 2005; Tibaldi 2004; Tibaldi 2009; Vianello 2013). Four trials reported the number of participants recruited from ethnic minority groups; this ranged from 14% to 20% of all recruited participants (Corwin 2005; Levine 2020; Richards 2005; Talcott 2011). In one trial, hospital at home included remote monitoring for heart rate, respiratory rate, telemetry, movement, falls, and sleep via a small skin patch; cost was the primary outcome (Levine 2020), and the study was stopped early by the funder (who was also the service provider) due to the cost benefit of the intervention.
The 20 trials included in this review were conducted in Australia, Italy, New Zealand, Romania, Spain, the UK, and the USA. There is growing interest from other health systems in testing the delivery of hospital‐level care in the home. For example, in Singapore a large study that seeks to recruit 2000 participants is under way (Chong 2022; NCT04330378), and a large hospital in Pune, India expects to increase its capacity by 40% to 60% using remote patient monitoring (Mernin 2021). A large hospital in Bangkok, Thailand has also set up an @Home service, suitable for patients after surgery or acute illness, patients with chronic conditions who need regular follow‐up, and the dependent elderly (Bumrungrad 2023). Such services were also set up in the Philippines during COVID‐19 (CNN Philippines 2021). Additional large, high‐quality randomised trials will improve the certainty of the evidence and generalisability of these findings, and be a valuable guide to the development of out‐of‐hospital services to increase the capacity of health systems.
We defined admission avoidance hospital at home as: a service that can avoid the need for hospital admission by providing active treatment by healthcare professionals in the patient's home for a condition that would otherwise require acute hospital inpatient care, and always for a limited time period. All of the included studies met these criteria, and the evidence applies to services that also meet these criteria and do not provide long‐term care, outpatient care, or self‐administration of treatment. The studies varied in the amount of time that patients were in the emergency department before being admitted to hospital at home or a hospital bed; this was due to the type of illness and severity (and was not often analysed) and the ongoing demands on the health system in question. We did not apply a time threshold in the emergency room for the study to qualify as admission avoidance. If we had, it would likely have resulted in the exclusion of patients in the most pressured health systems, where evidence is arguably most needed, and have risked imposing an artificial time limit that isn't experienced on the ground, and thus limited the applicability of the evidence.
Hospital at home services inevitably place demands on those who live with the person receiving care, and family and friends who live elsewhere. Safety in the home, cultural considerations, and health problems experienced by the main carer pose further challenges (Simon 2022). An additional concern is inequality in the resources available to unpaid carers across different populations, which might increase the potential burden of receiving hospital at home (Vlachantoni 2012). A Cochrane qualitative evidence synthesis of factors that influence the implementation of hospital at home reports in detail on the barriers that limit implementation, as well as factors that support the implementation of sustainable hospital at home services (Wallis 2024). A limitation of the trials included in this review is that few reported if deaths occurred during the hospital at home admission, and if they were unexpected and related to the hospital at home intervention. The reason for this is likely the small sample size of many of the studies, and early death being a rare event. Mortality occurring during an episode of hospital at home or hospital (control group) admission might not be related to hospital at home or hospital care, and the cause would have to be assessed case by case. The cause of such adverse events was not always clearly reported in the included studies; further investigation would provide clarity on the causes of death and any links with the intervention.
Certainty of the evidence
While we assessed the overall risk of bias as low, most of the included studies were small. Shepperd 2021 was the largest trial, recruiting 1032 participants who contributed to the analysis. The meta‐analysis for the main outcome included a subgroup of five trials recruiting participants with similar conditions (older patients with a mix of medical conditions, excluding stroke) to limit heterogeneity. We downgraded the certainty of the evidence for mortality due to imprecision of the estimate: the result could be consistent with hospital at home being associated with both higher or lower risk of mortality. We downgraded for readmission to hospital and relocating to residential care, because the studies evaluated these outcomes at different lengths of follow‐up, therefore the comparison was indirect. We downgraded for patient satisfaction because only 35% of the studies evaluated this outcome, and patients/researchers were not blinded. We downgraded for patient self‐reported health status due to non‐blinding, and for length of stay because the time frame for measuring this outcome differed among studies, and the estimates covered a wide range. We downgraded for cost because only three trials did a full cost analysis (Kalra 2000; Shepperd 2021; Wilson 1999).
Potential biases in the review process
We limited publication bias by conducting an extensive search that included different databases of published articles and sources of unpublished literature; this was facilitated by a long‐established international network of people working in the field who alert us to new randomised controlled trials. Three review authors screened the search results of potentially eligible studies to reduce the risk of missing any eligible studies. To check that inclusion criteria had been applied consistently, eligibility of studies was discussed with the review team. As an author of one of the included studies (Shepperd 2021), review author SS was not involved in assessing their own study for inclusion, risk of bias assessment, or data extraction.
Agreements and disagreements with other studies or reviews
Other reviews have looked at the effect of hospital at home schemes for end‐of‐life care (Shepperd 2021), and hospital at home for early discharge (Gonçalves‐Bradley 2017). A review of a few studies of end‐of‐life care at home found that such programmes increase the chance of dying at home rather than in hospital, and patient satisfaction may be higher at one‐month follow‐up (Shepperd 2021). A review of early discharge hospital at home services found insufficient evidence for economic benefit, or improved health outcomes (Gonçalves‐Bradley 2017). The search for this review was updated in March 2020 and identified no new studies.
Systematic reviews of hospital at home services for patients with specific conditions, such as COPD and heart failure, have been published (Jeppesen 2012; Qaddoura 2015). For patients with COPD, it was reported that hospital at home reduced the number of readmissions when compared with hospital care, with uncertain evidence for mortality, health‐related quality of life, cost, and clinical outcomes (Jeppesen 2012). A review of a few studies that specifically recruited patients with heart failure found a slight increase in time to readmission, improved health‐related quality of life, and reduced index costs, with limited evidence for mortality for those allocated to hospital at home. The authors judged these studies to be of modest quality (Qaddoura 2015). A systematic review of studies of hospital at home for chronic disease identified nine studies: five trials of COPD, two of heart failure, one of stroke, and one of neuromuscular disease (Arsenault‐Lapierre 2021). We included all studies included in the Arsenault‐Lapierre 2021 review in the current review update except for Hernandez 2003, which did not compare admission avoidance hospital at home with inpatient care. In Hernandez 2003, patients who required immediate hospitalisation were excluded, and the control group was evaluated by a physician who decided on inpatient admission or discharge. The review found no significant difference in mortality for a range of follow‐up times, and a lower risk of readmission in the hospital at home group, using the longest follow‐up time for each study. In addition, similar to the current review, Arsenault‐Lapierre 2021 reported that length of treatment was longer in the hospital at home group, and relocation to residential care was less likely in the hospital at home group than in the in‐hospital group; study authors did not analyse mortality occurring during the hospital or hospital at home admission.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Comparison 1: Admission avoidance hospital at home versus inpatient care, Outcome 1: Mortality at 3 months using IPD
Comparison 1: Admission avoidance hospital at home versus inpatient care, Outcome 2: Mortality at 6 months' follow‐up (using published data, and IPD from Wilson and Shepperd)
Comparison 1: Admission avoidance hospital at home versus inpatient care, Outcome 3: Readmission to hospital after discharge from hospital at home or inpatient care (3 to 12 months' follow‐up)
| Transfer to hospital while receiving hospital at home | ||
| Study | Outcomes | Results |
|---|---|---|
| Corwin 2005 | Transfer to hospital | T= 11/98 |
| Ricauda 2008 | Transfer to acute hospital | T= 3/52 |
| Richards 2005 | Transfer to hospital | T= 2/24 |
| Talcott 2011 | Readmission to hospital while receiving hospital at home | T= 4/47 |
Comparison 1: Admission avoidance hospital at home versus inpatient care, Outcome 4: Transfer to hospital while receiving hospital at home
Comparison 1: Admission avoidance hospital at home versus inpatient care, Outcome 5: Living in residential care at follow‐up
| Quality of life/health status | |||
| Study | Outcomes | Results | Notes |
|---|---|---|---|
| Admission avoidance quality of life | |||
| Corwin 2005 | SF 36 | SF 36 | Differences calculated on absolute differences between day 0 & day 3, or day 0 & day 6. (high score=better health) |
| Echevarria 2018 | EQ‐5D‐5L utility 14 day EQ‐5D‐5L utility 90 day | EQ‐5D‐5L utility (SD), mean 14 day unit change from baseline T = 0.091 (0.249) C = 0.055 (0.316) EQ‐5D‐5L utility (SD), mean 90 day unit change from baseline T = 0.003 (0.287) C = 0.007 (0.338) | |
| Mendoza 2009 | SF 36 Physical component Mental component | Physical component T= 3.6 (‐0.5 to 7.7), C= 2.2 (‐1.9 to 6.4), P = 0.47 Mental component T= 4.0 (‐0.9 to 8.9), C= 2.8 (‐2.4 to 8.0), P = 0.38 | Score at 1 year (adjusted for baseline differences) |
| Ricauda 2008 | Nottingham Health Profile | 6 months, mean (SD) T= 3.6 (7.9), C= 0.8 (4.5), P = 0.04 | Changes at 6 months |
| Richards 2005 | SF‐12 Mean physical and mental component score | Physical component At 2 weeks | higher score=better health |
| Shepperd 2021 | Health status EQ‐5D‐5L utility Barthel Index | Mean EQ‐5D‐5L utility 6 months (SD) T = 0.451 (0.324) C = 0.457 (0.340) Difference in means (95% CI) ‐0.006 (‐0.053, 0.041) Mean (SD) Barthel Index at 6 months T = 15.8 (4.4) C = 15.6 (4.9) Adjusted mean difference (95% CI) 0.24 (‐0.33, 0.80) P=0.41 | |
| Talcott 2011 | Quality of life EORTC QLQ C‐30 | Role Function T= 0.58, C= 0.78, P = 0.05 Emotional Function T= 3.27, C= ‐6.94, P = 0.04 | Quality of life data were collected at the time of consent to join the study, as soon as possible after the resolution of the episode. Data were collected for the first study episode. Change score |
| Tibaldi 2009 | Nottingham Health Profile | 6 months, mean (SD) T= +1.09 (2.57), C= +0.18 (1.94), P = 0.046 | |
| Wilson 1999 | Sickness Impact Profile (SIP) | SIP, median (IQR) | At 3 months follow‐up |
Comparison 1: Admission avoidance hospital at home versus inpatient care, Outcome 6: Quality of life/health status
| Functional status | ||
| Study | Functional ability | Results |
|---|---|---|
| Admission avoidance patients with a medical condition ‐ functional ability | ||
| Caplan 1999 | Change in Barthel score from admission to discharge (high score=greater independence) | Mean (SEM) |
| Davies 2000 | St Georges' respiratory questionnaire (to a random sub‐group of 90 participants). High score indicates poorer health related quality of life. A minimum change in score of 4 units is clinically relevant. | Baseline scores Forced expiratory volume in 1 second (FEV1) |
| Levine 2018 | Activities of daily living Instrumental activities of daily living | ADLs worse at discharge T = 9 (0%) C = 11 (9%) IADLs worse at discharge T = 9 (0%) C = 11 (18%) |
| Levine 2020 | Instrumental activities of daily living Activities of daily living | IADLs worse: admission to discharge (%) T = 11 (26) N=42 C = 14 (31) N=45 IADLs worse: admission to 30d after discharge (%) T = 14 (37) N=42 C = 13 (34) N=38 ADLs worse: admission to discharge (%) T = 6 (14) N=42 C = 6 (13) N=45 ADLs worse: admission to 30d after discharge (%) T = 4 (11) N=42 C = 6 (16) N=38 |
| Mendoza 2009 | Activities of daily living | Mean score Barthel Index at 1 year (adjusted for baseline differences) T= 4.0 (‐0.9 to 8.9) C= 4.7 (‐2.2 to 11.5) P = 0.21 |
| Ricauda 2008 | Change in ADL (score 0 to 6) | At 6 months, mean (SD) T= 0.12 (0.64), C= 0.08 (0.73), P = 0.81 |
| Shepperd 2021 | Activities of daily living | Mean score Barthel Index at 6 months (SD) T = 15.8 (4.4) C = 15.6 (4.9) Adjusted mean difference (95% CI) 0.24 (‐0.33, 0.80) P=0.41 |
| Tibaldi 2004 | Behavioural disturbances | Sleeping disorders |
| Tibaldi 2009 | Activities of daily living Barthel Index | ADL at 6 months mean change T= ‐1.95 (9.61) N=48, C= ‐0.30 (10.12) N=53, |
| Wilson 1999 | Barthel Index | Barthel Index At 3 months (Median (IQR)) T= 16 (13‐19), C= 16 (12‐20) Barthel Index ‐ number (%) not assessed: T= 21 (28%), C= 18 (28%) Sickness Impact Profile: At 3 months (Median (IQR)) T= 24 (20‐31), C= 26 (20‐31) Sickness Impact Profile ‐ no (%) not assessed T= 31 (41%), C= 30 (46%) |
Comparison 1: Admission avoidance hospital at home versus inpatient care, Outcome 7: Functional status
| Psychological health | ||
| Study | Outcomes | Results |
|---|---|---|
| admission avoidance ‐ cognitive function/well being | ||
| Caplan 1999 | Mental status questionnaire score from admission to discharge (maximum score 10); | Mean (SEM) |
| Echevarria 2018 | Hospital Anxiety and Depression Scale score (HADS) | Number analysed: T=60; C=58 HADS ‐ Anxiety, 14 day (IQR), median unit change from baseline T = ‐1.0 (‐3 to 1.75) C = 0.5 (‐3 to 2) HADS ‐ Anxiety, 90 day (IQR), median unit change from baseline T = 0 (‐2 to 3) C = 0 (‐3 to 2) HADS ‐ Depression, 14 day (IQR), median unit change from baseline T = ‐1.0 (‐3 to 1) C = 0 (‐2 to 3) HADS ‐ Depression, 90 day (IQR), median unit change from baseline T = ‐0.5 (‐3 to 1.25) C = 0 (‐2 to 3) |
| Ricauda 2004 | Change in geriatric Depression Scale score (range 0‐30) | At 6 months, median IQR T=10 (5 to 15), C=17 (13 to 20) p<0.001 |
| Ricauda 2008 | Change in geriatric Depression Scale score (range 0‐30) | At 6 months, mean (SD) T= ‐3.1 (4.7), C=0.7 (3.2), P < 0.001 |
| Shepperd 2021 | Montreal Cognitive Assessment (MoCA) score (range 0‐30) Confusion Assessment Method (CAM) (Y/N for delirium) | At 6 months (%) T: Abnormal (score of <26): 273/407 (67.1) Normal (score of >=26): 134/183 (32.9) C: Abnormal: 115 (62.8) Normal: 68 (37.2) Adjusted RR (95% CI): 1.06 (0.93, 1.21) P = 0.36 CAM (presence/absence of delirium) (%) 3 days T = 25/645 (3.9) C = 11/312 (3.5) RR: 1.12 (0.54, 2.29) P=0.76 5 days T = 17/638 (2.7) C = 9/308 (3.0) RR: 0.93 (0.34, 2.47) P=0.87 1 month T = 10/602 (1.7) C = 13/297 (4.4) Relative risk: 0.38 (0.19, 0.76) P=0.006 |
| Tibaldi 2009 | Mini Mental State Exam (MMSE) Geriatric Depression Scale | At 6 months, mean change (SD) T= +0.07 (1.38), C= +0.08 (1.36), P = 0.97 At 6 months, mean change (SD) T= +1.48 (1.86), C= +0.12 (3.36), P = 0.02 |
| Wilson 1999 | Philadelphia Geriatric Morale Scale | At 3 months, median (IQR) |
Comparison 1: Admission avoidance hospital at home versus inpatient care, Outcome 8: Psychological health
| Patient satisfaction | |||
| Study | Outcomes | Results | Notes |
|---|---|---|---|
| Caplan 1999 | Satisfaction rated on a 4 point scale: 1=excellent, 2=good, 3=fair, 4=poor. | Mean score | Response rates were 78% for the treatment group, and 40% for the control. |
| Corwin 2005 | Patient satisfaction questionnaire (not described) | Overall P < 0.0001 | Numbers for control group vary between 88 and 91 due to missing data Proportion of participants satisfied or very satisfied |
| Levine 2018 | Global satisfaction score; | Median global satisfaction score (IQR) T = 10 (1) C = 10 (2) P=0.67 | |
| Levine 2020 | Global satisfaction score; range of scores from 0 to 10, high scores equal high satisfaction | Median global satisfaction score (IQR) T = 10 (1) N=42 C = 9 (1) N=38 | |
| Ricauda 2008 | Patient satisfaction questionnaire (not described) | T= 49/52 (94%), C= 46/52 (88%), P = 0.83 | Proportion of participants rating satisfaction as very good/excellent at discharge |
| Richards 2005 | Outcome not described | T= 24/24 (100%), C= 14/24 (60%), P = 0.001 | Proportion of patients very happy with care |
| Shepperd 2021 | Patient‐reported experience questionnaire at 1 month, developed by the Picker Institute Europe (Oxford, UK) | Patient satisfaction in favour of CGA HAH | |
| Wilson 1999 | Patient satisfaction, scale 0 to 18 | Median (IQR) | At 2 weeks, or discharge Reported in ⛔ Wilson 2002 |
Comparison 1: Admission avoidance hospital at home versus inpatient care, Outcome 9: Patient satisfaction
| Caregiver satisfaction | |||
| Study | Outcomes | Results | Notes |
|---|---|---|---|
| Care giver satisfaction | |||
| Caplan 1999 | Carer satisfaction | Mean score | Satisfaction rated on a 4 point scale: 1=excellent, 2=good, 3=fair, 4=poor |
| Ricauda 2008 | Change in Relative’s Stress Scale Score | At 6 months, mean (SD) T= 4.6 (5.6), C= 2.6 (6.1), P = 0.16 | |
Comparison 1: Admission avoidance hospital at home versus inpatient care, Outcome 10: Caregiver satisfaction
| Health professional satisfaction | |||
| Study | Outcomes | Results | Notes |
|---|---|---|---|
| Caplan 1999 | GP satisfaction | Mean score (95% CI) | Higher scores indicate higher satisfaction Response rate: T: 63%, C: 37% |
Comparison 1: Admission avoidance hospital at home versus inpatient care, Outcome 11: Health professional satisfaction
| Length of stay | |||
| Study | Results | Outcomes | Notes |
|---|---|---|---|
| Hospital and hospital at home length of stay | |||
| Davies 2000 | Hospital length of stay | Median (IQR) 5 days (4 to 7) N=100 6.72 days (4.3) N=100 | Data for the control group only |
| Echevarria 2018 | Length of hospital stay at 90 days Length of hospital stay (index admission) Length of stay within HAH | Mean length of hospital stay (index admission) T = 1.2 (2.1) C = 4.1 (4.6) Mean length of hospital stay at 90 days (SD) T = 6.1 (9.7) C = 10.3 (15.8) Median length of stay within HAH (IQR) T = 4 (2‐5) C = NA | |
| Harris 2005 | Average length of stay for the index episode until discharge from hospital or hospital at home (days) | T= 11.33 days (SD 11.14) N=39 C= 7.83 days (7.35) N=37 Mean difference 3.5 95% CI ‐0.80 to 7.80 | IPD |
| Levine 2018 | Length of stay during acute care episode | Median length of stay during acute care episode (IQR) T = 3 (1) C = 3 (3) P=0.79 | |
| Levine 2020 | Length of stay during acute care episode | Mean length of stay (95% CI) (days) T = 4.5 (3.9, 5.0) C = 3.8 (3.3, 4.4) | |
| Mendoza 2009 | Average length of stay for the index episode (days) | T= 10.9 (SD 5.9) N=37 C= 7.9 (SD 3.0), P = 0.01 N=34 | |
| Ricauda 2008 | Hospital at home and hospital length of stay (days) Total length of stay to include hospital transfers for the hospital at home group | Total days of care (hospital plus hospital at home), mean (SD) T= 15.5 (SD 9.5) N=52 C= 52 (SD 7.9) Difference 4.50, 95% CI 1.14, 7.86 | |
| Richards 2005 | Median number of days to discharge | T=4 (range 1‐14) N=24 C= 2 (range 0‐10) N=25 | |
| Shepperd 2021 | Average length of hospital stay | Mean length of initial stay (SD) (complete cases) T = 1.43 (4.84) N=563 C = 4.92 (7.64) N=274 Mean length of hospital length of stay at six months follow‐up T=9.47 (18.41) N=563 C=10.58 (19.49) N=274 | |
| Tibaldi 2009 | Time in the emergency department (hours) Length of stay (days) | Time in ED, mean (SD) T= 14.6 (3.4), C= 16.3 (3.0) Length of treatment, mean (SD) T= 20.7 (6.9) N=48, C= 11.6 (10.7) N=53, P = 0.001 | |
| Wilson 1999 | Length of stay | Treatment N=102 Control N=97 Length of hospital stay in days, median | |
Comparison 1: Admission avoidance hospital at home versus inpatient care, Outcome 12: Length of stay
| Cost and resource use | |||
| Study | Outcomes | Results | Notes |
|---|---|---|---|
| Health service resources and costs | |||
| Caplan 1999 | Cost | Average cost per episode, mean (SD) Mean difference per day ‐$293 | Cost data financial year 1995/1996 |
| Corwin 2005 | Days on oral antibiotics | HR 1.09 (0.82 to 1.45), P = 0.56 | |
| Echevarria 2018 | Health and formal social care costs | Mean health and formal social care costs (SD) T = 3857.8 (3199.6) C = 4873.5 (5631.1) Bootstrapped mean difference (95% CI) ‐1015.7 (‐2735.5, 644.8) | |
| Levine 2018 | Relative cost reduction of acute care episode Relative cost reduction of acute care episode and 30 days after acute care episode | Relative cost reduction of acute care episode, % 52% (IQR, 28%; p = 0.05) Relative cost reduction of acute care episode and 30 days after, % 67% (IQR, 77%; p<0.01) | % lower than for control patients Change in median cost |
| Levine 2020 | Relative cost reduction of acute care episode (including physician cost, Appendix Table 7 (Levine 2020) Relative cost reduction of acute care episode and 30 days after acute care episode | With physician labour Adjusted relative reduction in cost of acute care episode, % (95% CI) 19 (4, 31) P=0.017 Adjusted relative reduction in cost of acute care episode and 30 days after, % (95% CI) 25 (10,38) P<0.001 | Positive means home group costs less Relative reduction in mean cost (%) |
| Mendoza 2009 | Cost | Mean (SD) T= €2,541 (1,334), C= €4,502 (2,153) Difference €1,961 P < 0.0001 | Difference attributed to fewer investigations. Costs include health service costs used during follow‐up period of 1 year, excludes informal care. |
| Nicholson 2001 | Costs | Cost per episode, mean (95% C) T= $745 ($595 to $895),C= $2543 ($1766 to $3321) Total costs=$2182 per patient episode of care | Costs based on financial year 99/00; Used average DRG costs (Australian $), patient data for ED costs, and modelled costs for OPD clinic visits. |
| Ricauda 2004 | Mean total cost (EUR converted to US$ 1 Euro=$1.3) | T= $6 413.5 per patient, C= $6 504.8 per patient | |
| Ricauda 2008 | Hospital at home resources Total costs | Nursing visits (range) T= 14.1 (3 to 38) Physician visits T= 9.9 (2 to 28) Visits to hospital for diagnosis T= 11 Total mean cost per patient T=$1,175.9, C= $1,390.9, P = 0.38 Total mean cost per day (SD) T= $101.4 (61.3), C= 151.7 (96.4) | |
| Richards 2005 | Cost based on DRGs for control and actual cost for intervention | Mean cost per patient NZ$ | |
| Shepperd 2021 | Health and social care costs | Mean cost of initial admission (SD) T = 1742 (3234) C = 3723 (5095) Mean difference: ‐1981 (‐2551, ‐1411) Mean Health and Social care cost (adjusted), baseline to 6 months follow up T = 15,124 C = 17,390 Mean difference: ‐2265 (‐4279, ‐252) Mean Societal costs (adjusted), baseline to 6 month follow up T = 19,067 C = 21,907 Mean difference: ‐2,840 (‐5,495, ‐185) | |
| Wilson 1999 | Cost | Cost of initial episode (95% CI) | Cost data financial year 1995/1996 |
| Use of other social services | |||
| Davies 2000 | While receiving hospital at home care, or on discharge from hospital | Referred for increased social support T= 24/100 (24%), C= 3/50 (6%) Difference 18%, 95% CI 7.3% to 28.6% | |
| Echevarria 2018 | Patients with a social care package post discharge | Patients with a social care package post discharge (%) T = 7 (11.7) C = 5 (8.6) | |
| Informal care inputs | |||
| Kalra 2000 | Informal care inputs | Received informal care: | |
| Shepperd 2021 | Informal care | Mean total number of hours of unpaid help over the last 6 months (SD) T = 594.89 (1093.63) C = 657.64 (1170.87) Difference in means (95% CI): ‐62.76 (‐224.61, 99.09) | |
Comparison 1: Admission avoidance hospital at home versus inpatient care, Outcome 13: Cost and resource use
| Clinical outcomes | ||
| Study | Outcomes | Results |
|---|---|---|
| Clinical outcomes | ||
| Corwin 2005 | No advancement of cellulitis (indelible line drawn around peripheral margin of the cellulitis and dated) | Mean (SD) days |
| Davies 2000 | Proportion of patients prescribed an antibiotic at 3 months | T= 56/100 (56%), C= 19/50 (38%), Difference 18%, 95% CI 1.4 to 34.6% |
| Echevarria 2018 | COPD Assessment Tool (CAT) at 14 and 90 days | CAT, 14‐day (IQR) T = ‐4.0 (‐9.5, 0) C = ‐3.0 (‐7, 1) CAT, 90 day (IQR) T = ‐3.0 (‐8, 1) C = ‐1.0 (‐6, 1) |
| Levine 2020 | Any safety event Median pain score Inappropriate medication use Urinary catheter use Restraint use | Any safety event (%) T = 4 (9) C = 7 (15) Median pain score (IQR) T = 0 (1) C = 0 (3) Inappropriate medication use T = 0 (0) C = 5 (10) Urinary catheter use T = 0 (0) C = 2 (4) Restraint use T = 0 (0) C = 0 (0) |
| Shepperd 2021 | Charlson Comorbidity Index score | Mean at 6 months (SD) T = 6.17 (1.94) C = 6.00 (1.93) Adjusted mean difference (95% CI): 0.0002 (‐0.1452 to 0.1455) |
| Talcott 2011 | Major medical complications during care in hospital at home or hospital | T= 4/47 (9%), C= 5/66 (8%), Difference 1%, 95% CI ‐10 to13% |
| Tibaldi 2004 | Use of antipsychotic drugs | On admission |
Comparison 1: Admission avoidance hospital at home versus inpatient care, Outcome 14: Clinical outcomes
| Admission avoidance hospital at home compared with inpatient admission for older people requiring admission to hospital | |||||
| Patient or population: older people requiring hospital admission Settings: home Intervention: admission avoidance hospital at home Comparison: inpatient care | |||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | Number of participants | Certainty of the evidence | |
|---|---|---|---|---|---|
| Assumed risk | Corresponding risk | ||||
| Inpatient care | Admission avoidance hospital at home | ||||
| Mortality (6 months' follow‐up) (using data from trialists and published data) | Study population | RR 0.88 (0.68 to 1.13) | 1502 | ⊕⊕⊕⊝a | |
| 208 per 1000 | 183 per 1000 | ||||
| Admission to hospital (3 to 12 months' follow‐up) (using individual patient data and published data) | Study population | RR 1.14 (0.97 to 1.34 | 1757 | ⊕⊕⊕⊝b | |
| 407 per 1000 | 464 per 1000 | ||||
| Living in residential care at follow‐up (6 months' follow‐up) | Study population | RR 0.53 (0.41 to 0.69) | 1271 | ⊕⊕⊕⊝b Moderate | |
| 124 per 1000 | 66 per 1000 | ||||
| Patient self‐reported health status | Patient‐reported health status was largely the same for participants treated in hospital at home and hospital, with some reporting higher quality of life or better health status in hospital at home.D | ‐ | 2006 (9 studies) | ⊕⊕⊕⊝c Moderate | |
| Patient satisfaction | Patients allocated to hospital at home reported higher levels of satisfaction on average; a small proportion preferred hospital, or satisfaction was equal between groups.E | ‐ | 1812 (8 studies) | ⊕⊕⊝⊝d Low | |
| Length of stay in hospital and hospital at home | Hospital at home reduced average length of stay in hospital, which ranged from an average of 4.1 to 18.5 days in the hospital group to 1.2 to 5.1 days in the hospital at home group.F Hospital at home length of stay ranged from an average of 3 to 20.7 days (hospital at home group only).G Length of stay for the acute episode ranged from a mean increase of 0.7 to 9.1 daysF for the hospital at home group compared to the hospital group. | ‐ | 2036 (11 studies) | ⊕⊕⊝⊝e Low | |
| Cost and resource use | Hospital at home was generally less costly than hospital care, with a range of estimates for the mean reduction per episode with different levels of certainty, from USD −215 (P = 0.38) to GBP −1981 (95% CI −2551 to −1411).H Estimates for the difference in total health and social care costs for a variety of follow‐up durations also varied, ranging from GBP −1015.7 (95% CI −2735.5 to 644.8) to GBP −2265 (95% CI −4279 to −252).I | ‐ | 2148 (12 studies) | ⊕⊕⊕⊝f Moderate | |
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||||
| GRADE Working Group grades of evidence | |||||
| aWe downgraded the certainty of the evidence by one level to moderate due to imprecision of the estimate. ACaplan 1999; Ricauda 2008; Shepperd 2021; Tibaldi 2009; Wilson 1999. | |||||
| N | Length of follow‐up | Population | Conditions | Intervention | Control | Location | Mean age (SD) | 24‐hour care provision | |
|---|---|---|---|---|---|---|---|---|---|
| 45 | 12 months | Patients with chronic heart failure that had deteriorated at a minimum of 1 week prior to recruitment | Chronic heart failure | Admission avoidance hospital at home; the first 48 hours of treatment was in the ED | Unknown | Romania | Unknown | Not reported | |
| T: 51 C: 49 | 6 months | Patients attended casualty | Range of acute conditions | Hospital community outreach team | Hospital care | Australia | T: 73 (median) C: 79 (median) | Not reported | |
| T: 98 C: 96 | 6 days | Patients attended emergency department | Cellulitis | Hospital at home admission avoidance from the ED by GP and community care nursing staff | Hospital care | New Zealand | T: 54.6 (20.6) C: 48.4 (19.0) | Not reported | |
| T: 100 C: 50 | 3 months | Patients attended A&E with chronic obstructive airways disease | COPD | Admission avoidance hospital at home by outreach specialist nurses and GP/community nurses | Hospital care | UK | Unknown | District nurses | |
| T: 62 C: 58 | 90 days | Patients over 35 years of age admitted to hospital with COPD | COPD | Once‐ or twice‐daily vists from respiratory specialist nurse under remote supervision from consultant | Hospital care | UK | T: 71.0 (9.6) C: 68.7 (10.5) | 24/7 contact with HAH team available | |
| T: 39 C: 37 | 90 days | Patients attended emergency department or acute assessment ward | Range of acute conditions | Hospital outreach programme; nurse‐led team provided care and rehab in patients' homes | Hospital care | New Zealand | 80.0 | 24‐hour on‐call geriatrician | |
| T: 153 C: 152 | 12 months | Patients within 72 hours of stroke onset | Moderately severe stroke | Hospital outreach admission avoidance multidisciplinary care | Hospital care, stroke unit care | UK | T: 77.7 C: 77.3 (medians) | Not reported | |
| T: 9 C: 11 | 30 days | Patients over 18 years of age attending emergency department | Infection, heart failure, COPD, asthma exacerbation | Hospital at home; at least 1 daily visit from general internist, 2 daily visits from nurse | Hospital care | USA | T: 65 (28) C: 60 (29) median (IQR) | Attending physician available 24/7 | |
| T: 43 C: 48 | 30 days | Patients over 18 years of age attending emergency department | Infection, heart failure, COPD, asthma exacerbation | Hospital at home; at least 1 daily visit from general internist, 2 daily visits from nurse | Hospital care | USA | T: 80 (19) C: 72 (23) median (IQR) | Attending physician available 24/7 | |
| T: 37 C: 34 | 1 year | Patients in A&E with acute decompensation of chronic heart failure | Heart failure | Admission avoidance hospital at home; hospital outreach model | Hospital care | Spain | 79 | Emergency services | |
| T: 13 C: 12 | Duration of treatment | Patients over 45 years of age with COPD referred by GP or emergency staff | COPD | Hospital at home | Hospital care | Australia | Unknown | 24‐hour telephone support by hospital staff | |
| T: 60 C: 60 | 6 months | Patients admitted to hospital within 24 hours of onset of stroke symptoms | Stroke | Hospital outreach admission avoidance | Hospital care | Italy | T: 82.5 (8.6) C: 79.5 (6.7) | Physician and nurse available 24 hours | |
| T: 52 C: 52 | 6 months | Patients admitted to hospital for acute exacerbation of COPD | COPD | Physician‐led admission avoidance hospital outreach service | Hospital care | Italy | T: 80.1 (3.2) C: 79.2 (3.1) | HAH staff available 24 hours | |
| T: 24 C: 25 | 6 weeks | Patients presented to emergency room with pneumonia | Community‐acquired pneumonia | Hospital at home: admission avoidance from emergency room | Hospital care | New Zealand | T: 50.1 C: 49.8 | 24‐hour emergency contact number | |
| T: 687 C: 345 | 12 months | Patients over 65 years of age referred to HAH | Range of acute conditions | Admission avoidance hospital at home; geriatrician‐led multidisciplinary team | Hospital care | UK | T: 83.3 (7.0) C: 83.3 (6.9) | NHS telephone out‐of‐hours service, plus site‐specific arrangements for overnight care | |
| T: 47 C: 66 | Duration of acute episode | Patients who had chemotherapy | Febrile neutropenia | Admission avoidance hospital at home; commercial home care provider | Hospital care | USA | 47 (median) 20 to 81 (range) | Not reported | |
| T: 56 C: 53 | Until discharge | Patients with advanced dementia | Range of acute conditions | Hospital at home; geriatric home hospitalisation service | Hospital care | Italy | T: 82.9 (7.9) C: 84.1 (7.5) | Not reported | |
| T: 48 C: 53 | 6 months | Patients presented to emergency department | Chronic heart failure | Admission avoidance hospital at home; hospital outreach | Hospital care | Italy | 81 | HAH staff available 24 hours | |
| T: 26 C: 27 | 3 months | Patients with neuromuscular disease | Acute respiratory tract infection | Hospital at home; portable ventilator, respiratory therapist daily visits | Hospital care | Italy | T: 44.6 (20.4) C: 46.7 (20.2) | Pulmonologist available by telephone | |
| T: 102 C: 97 | 3 months | Majority elderly, referred by GP to Bed Bureau | Range of acute conditions | Admission avoidance hospital at home | Hospital care | UK | 84 (median) | 24‐hour care available | |
| A&E: accident & emergency department | |||||||||
| Mode of referral | ||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Emergency room | X | X | X | X | X | X | X | X | X | X | X | X | X | X | ||||||
| Community (by primary care physician) | X | X | X | |||||||||||||||||
| Outpatient department | X | |||||||||||||||||||
| From admission < 24 hours | X | |||||||||||||||||||
| Acute assessment unit/home | X | |||||||||||||||||||
| Hospital at home provision | ||||||||||||||||||||
| Hospital outreach team | X | X | X | X | X | X | X | X | X | X | X | |||||||||
| Mix of outreach/community staff | X | X | X | X | X | |||||||||||||||
| GP/community nursing staff | X | X | X | |||||||||||||||||
| Unclear | X | |||||||||||||||||||
| Types of care | ||||||||||||||||||||
| Physiotherapy | X | X | X | X | X | X | X | X | X | |||||||||||
| Social worker | X | X | X | X | X | X | X | X | X | |||||||||||
| Occupational therapy | X | X | X | X | X | X | X | X | ||||||||||||
| Counsellor | X | |||||||||||||||||||
| Speech therapist | X | X | ||||||||||||||||||
| Cultural link worker | X | |||||||||||||||||||
| Portable ventilator | X | |||||||||||||||||||
| GP: general practitioner | ||||||||||||||||||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1.1 Mortality at 3 months using IPD Show forest plot | 3 | 420 | mortality (IV, Fixed, 95% CI) | 0.89 [0.55, 1.45] |
| 1.2 Mortality at 6 months' follow‐up (using published data, and IPD from Wilson and Shepperd) Show forest plot | 5 | 1502 | Risk Ratio (IV, Fixed, 95% CI) | 0.88 [0.68, 1.13] |
| 1.3 Readmission to hospital after discharge from hospital at home or inpatient care (3 to 12 months' follow‐up) Show forest plot | 8 | 1757 | Risk Ratio (IV, Fixed, 95% CI) | 1.14 [0.97, 1.34] |
| 1.3.1 Readmission for older patients with a medical condition using IPD and published data. N=1856 | 8 | 1757 | Risk Ratio (IV, Fixed, 95% CI) | 1.14 [0.97, 1.34] |
| 1.4 Transfer to hospital while receiving hospital at home Show forest plot | 0 | Other data | No numeric data | |
| 1.5 Living in residential care at follow‐up Show forest plot | 4 | 1271 | Risk Ratio (IV, Fixed, 95% CI) | 0.53 [0.41, 0.69] |
| 1.5.1 With a medical condition (6 months' follow‐up) | 4 | 1271 | Risk Ratio (IV, Fixed, 95% CI) | 0.53 [0.41, 0.69] |
| 1.6 Quality of life/health status Show forest plot | 9 | Other data | No numeric data | |
| 1.6.1 Admission avoidance quality of life | 9 | Other data | No numeric data | |
| 1.7 Functional status Show forest plot | 10 | Other data | No numeric data | |
| 1.7.2 Admission avoidance patients with a medical condition ‐ functional ability | 10 | Other data | No numeric data | |
| 1.8 Psychological health Show forest plot | 7 | Other data | No numeric data | |
| 1.8.1 admission avoidance ‐ cognitive function/well being | 7 | Other data | No numeric data | |
| 1.9 Patient satisfaction Show forest plot | 0 | Other data | No numeric data | |
| 1.10 Caregiver satisfaction Show forest plot | 2 | Other data | No numeric data | |
| 1.10.1 Care giver satisfaction | 2 | Other data | No numeric data | |
| 1.11 Health professional satisfaction Show forest plot | 0 | Other data | No numeric data | |
| 1.12 Length of stay Show forest plot | 11 | Other data | No numeric data | |
| 1.12.1 Hospital and hospital at home length of stay | 11 | Other data | No numeric data | |
| 1.13 Cost and resource use Show forest plot | 14 | Other data | No numeric data | |
| 1.13.1 Health service resources and costs | 12 | Other data | No numeric data | |
| 1.13.2 Use of other social services | 2 | Other data | No numeric data | |
| 1.13.3 Informal care inputs | 2 | Other data | No numeric data | |
| 1.14 Clinical outcomes Show forest plot | 7 | Other data | No numeric data | |
| 1.14.1 Clinical outcomes | 7 | Other data | No numeric data | |
