What is the aim of this review?
The aim of this Cochrane Review was to find out if providing health care in an admission avoidance hospital at home setting improves patient health outcomes and reduces health service costs.
Key messages
Admission avoidance hospital at home probably makes little or no difference to risk of death; probably increases the chances of living at home at six months' follow-up; and may be slightly less expensive.
What was studied in this review?
There continues to be more demand for acute hospital beds than there are beds available. One way to reduce reliance on hospital beds is to provide people with acute health care at home, sometimes called 'admission avoidance hospital at home'. In contrast, 'early discharge hospital at home' refers to patients being discharged early from hospital to be treated at home; this topic has been reviewed separately.
What did we want to find out?
We wanted to find out if hospital at home makes a difference to patient health outcomes and to living independently at home. We also wanted to find out if it was less expensive than hospital care, and if it affects length of stay in treatment and patient satisfaction.
What did we do?
We searched for studies that compared hospital at home treatment for an acute health event with inpatient hospital care. We compared and summarised the results of the studies, and rated our confidence in the evidence based on factors such as study methods and sizes.
What did we find?
We found 20 studies, of which four were identified for this update, with a total of 3100 patients with a range of acute conditions. Four studies recruited participants with chronic obstructive (lung) disease; two studies recruited participants recovering from a stroke; seven studies recruited participants with a (sudden or short-term) medical condition who were mainly older; and the remaining studies recruited participants with a mix of conditions.
When compared to in-hospital care, admission avoidance hospital at home services for a select group of patients probably make little or no difference to risk of death or to the likelihood of being taken to hospital in the next 3 to 12 months, and probably increase the chances of living at home at six months' follow-up. Patients who receive care at home may have increased satisfaction compared to those in hospital; however, the effects of this type of care on the caregivers who support them are unclear. Hospital at home probably results in little to no difference in patients' health status. Hospital at home decreases the amount of time patients spend in hospital, while length of stay in hospital at home tended to be longer than a typical hospital stay. Admission avoidance hospital at home probably decreases treatment costs, though by a range of different amounts.
What are the limitations of the evidence?
Due to the small size of most of the studies, we are moderately confident that admission avoidance hospital at home does not make a difference to the number of people who died when compared to in-hospital care. Our confidence in the evidence for readmission and living in residential care was reduced to moderate because the lengths of follow-up differed among studies. We are moderately confident in the evidence for patient-reported health status, as participants were aware of which treatment they were getting, which could have influenced the results. We have little confidence in the evidence on patient satisfaction because not many studies reported this outcome, and on length of stay because length of stay varied across studies. We are moderately confident in the evidence for cost because only three trials looked at this fully.
How up-to-date is the review?
We searched for studies published up to February 2022.
Admission avoidance hospital at home, with the option of transfer to hospital, may provide an effective alternative to inpatient care for a select group of older people who have been referred for hospital admission. The intervention probably makes little or no difference to patient health outcomes; may improve satisfaction; probably reduces the likelihood of relocating to residential care; and probably decreases costs.
Admission avoidance hospital at home provides 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. This is the fourth update of this review.
To determine the effectiveness and cost of managing patients with admission avoidance hospital at home compared with inpatient hospital care.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL on 24 February 2022, and checked the reference lists of eligible articles. We sought ongoing and unpublished studies by searching ClinicalTrials.gov and WHO ICTRP, and by contacting providers and researchers involved in the field.
Randomised controlled trials recruiting participants aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital inpatient care.
We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. We performed meta-analysis for trials that compared similar interventions, reported comparable outcomes with sufficient data, and used individual patient data when available. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes.
We included 20 randomised controlled trials with a total of 3100 participants; four trials recruited participants with chronic obstructive pulmonary disease; two trials recruited participants recovering from a stroke; seven trials recruited participants with an acute medical condition who were mainly older; and the remaining trials recruited participants with a mix of conditions. We assessed the majority of the included studies as at low risk of selection, detection, and attrition bias, and unclear for selective reporting and performance bias.
For an older population, admission avoidance hospital at home probably makes little or no difference on mortality at six months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.68 to 1.13; P = 0.30; I2 = 0%; 5 trials, 1502 participants; moderate-certainty evidence); little or no difference on the likelihood of being readmitted to hospital after discharge from hospital at home or inpatient care within 3 to 12 months' follow-up (RR 1.14, 95% CI 0.97 to 1.34; P = 0.11; I2 = 41%; 8 trials, 1757 participants; moderate-certainty evidence); and probably reduces the likelihood of living in residential care at six months' follow-up (RR 0.53, 95% CI 0.41 to 0.69; P < 0.001; I2 = 67%; 4 trials, 1271 participants; moderate-certainty evidence).
Hospital at home probably results in little to no difference in patient's self-reported health status (2006 patients; moderate-certainty evidence). Satisfaction with health care received may be improved with admission avoidance hospital at home (1812 participants; low-certainty evidence); few studies reported the effect on caregivers. Hospital at home reduced the initial average hospital length of stay (2036 participants; low-certainty evidence), which ranged from 4.1 to 18.5 days in the hospital group and 1.2 to 5.1 days in the hospital at home group. Hospital at home length of stay ranged from an average of 3 to 20.7 days (hospital at home group only). Admission avoidance hospital at home probably reduces costs to the health service compared with hospital admission (2148 participants; moderate-certainty evidence), though by a range of different amounts and using different methods to cost resource use, and there is some evidence that it decreases overall societal costs to six months' follow-up.