Services for patients discharged home early

What is the aim of this review?

To find out if providing early discharge hospital at home improves patient health outcomes and reduces costs to the health service, compared with in-hospital care.

Key messages

Compared with in-hospital care, early discharge hospital at home probably makes little or no difference to patient health outcomes or being readmitted to hospital, and probably reduces hospital length of stay and the chance of being admitted to an institution such as a care home. Patients who receive care at home might be more satisfied with the care received. The effect on health service costs is uncertain.

What was studied in this review?

One way to deal with the demand for hospital beds is to reduce hospital length of stay by discharging people early to receive health care at home. We systematically reviewed the literature on the effect of providing early discharge hospital at home services. These services are usually provided by a team of healthcare professionals, such as doctors, nurses and physiotherapists. The team visits the homes of people who have been discharged early to provide them with acute hospital care in their homes. We were interested in assessing the impact of early discharge hospital at home had on patient health outcomes and health service costs. This is an update of a Cochrane Review.

What are the main results of this review?
The review authors found 32 studies, six of which are new for this update. In total, 4746 people from twelve countries participated in those studies. The intervention was mainly delivered by hospital outreach services and community-based services. Most of the studies were well designed and conducted. The studies looked at the effect of these services in patients with different types of conditions: patients who had a stroke, older patients with different types of medical conditions and patients who had surgery. These studies show that, when compared to in-hospital care, early discharge hospital at home services probably make little or no difference to patient health outcomes or being readmitted to hospital, yet probably decreases hospital length of stay. Patients who receive care at home might be more satisfied and less likely to be admitted to institutional care. There is little evidence of cost savings to the healthcare system of discharging patients home early to hospital at home care.

How up to date is the review?

The review authors searched for studies that had been published up to 9 January 2017.

Authors' conclusions: 

Despite increasing interest in the potential of early discharge hospital at home services as a less expensive alternative to inpatient care, this review provides insufficient evidence of economic benefit (through a reduction in hospital length of stay) or improved health outcomes.

Read the full abstract...
Background: 

Early discharge hospital at home is a service that provides active treatment by healthcare professionals in the patient's home for a condition that otherwise would require acute hospital inpatient care. This is an update of a Cochrane review.

Objectives: 

To determine the effectiveness and cost of managing patients with early discharge hospital at home compared with inpatient hospital care.

Search strategy: 

We searched the following databases to 9 January 2017: the Cochrane Effective Practice and Organisation of Care Group (EPOC) register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and EconLit. We searched clinical trials registries.

Selection criteria: 

Randomised trials comparing early discharge hospital at home with acute hospital inpatient care for adults. We excluded obstetric, paediatric and mental health hospital at home schemes.  

Data collection and analysis: 

We followed the standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes.

Main results: 

We included 32 trials (N = 4746), six of them new for this update, mainly conducted in high-income countries. We judged most of the studies to have a low or unclear risk of bias. The intervention was delivered by hospital outreach services (17 trials), community-based services (11 trials), and was co-ordinated by a hospital-based stroke team or physician in conjunction with community-based services in four trials.

Studies recruiting people recovering from stroke

Early discharge hospital at home probably makes little or no difference to mortality at three to six months (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.57 to 1.48, N = 1114, 11 trials, moderate-certainty evidence) and may make little or no difference to the risk of hospital readmission (RR 1.09, 95% CI 0.71 to 1.66, N = 345, 5 trials, low-certainty evidence). Hospital at home may lower the risk of living in institutional setting at six months (RR 0.63, 96% CI 0.40 to 0.98; N = 574, 4 trials, low-certainty evidence) and might slightly improve patient satisfaction (N = 795, low-certainty evidence). Hospital at home probably reduces hospital length of stay, as moderate-certainty evidence found that people assigned to hospital at home are discharged from the intervention about seven days earlier than people receiving inpatient care (95% CI 10.19 to 3.17 days earlier, N = 528, 4 trials). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).

Studies recruiting people with a mix of medical conditions

Early discharge hospital at home probably makes little or no difference to mortality (RR 1.07, 95% CI 0.76 to 1.49; N = 1247, 8 trials, moderate-certainty evidence). In people with chronic obstructive pulmonary disease (COPD) there was insufficient information to determine the effect of these two approaches on mortality (RR 0.53, 95% CI 0.25 to 1.12, N = 496, 5 trials, low-certainty evidence). The intervention probably increases the risk of hospital readmission in a mix of medical conditions, although the results are also compatible with no difference and a relatively large increase in the risk of readmission (RR 1.25, 95% CI 0.98 to 1.58, N = 1276, 9 trials, moderate-certainty evidence). Early discharge hospital at home may decrease the risk of readmission for people with COPD (RR 0.86, 95% CI 0.66 to 1.13, N = 496, 5 trials low-certainty evidence). Hospital at home may lower the risk of living in an institutional setting (RR 0.69, 0.48 to 0.99; N = 484, 3 trials, low-certainty evidence). The intervention might slightly improve patient satisfaction (N = 900, low-certainty evidence). The effect of early discharge hospital at home on hospital length of stay for older patients with a mix of conditions ranged from a reduction of 20 days to a reduction of less than half a day (moderate-certainty evidence, N = 767). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).

Studies recruiting people undergoing elective surgery

Three studies did not report higher rates of mortality with hospital at home compared with inpatient care (data not pooled, N = 856, low-certainty evidence; mainly orthopaedic surgery). Hospital at home may lead to little or no difference in readmission to hospital for people who were mainly recovering from orthopaedic surgery (N = 1229, low-certainty evidence). We could not establish the effects of hospital at home on the risk of living in institutional care, due to a lack of data. The intervention might slightly improve patient satisfaction (N = 1229, low-certainty evidence). People recovering from orthopaedic surgery allocated to early discharge hospital at home were discharged from the intervention on average four days earlier than people allocated to usual inpatient care (4.44 days earlier, 95% CI 6.37 to 2.51 days earlier, , N = 411, 4 trials, moderate-certainty evidence). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).

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