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Systematic reviews

A meta-analysis of “hospital in the home”

Gideon A Caplan, Nur S Sulaiman, Dee A Mangin, Nicoletta Aimonino Ricauda, Andrew D Wilson and Louise Barclay
Med J Aust 2012; 197 (9): 512-519.
doi:
10.5694/mja12.10480
Abstract

Objective: To assess the effect of “hospital in the home” (HITH) services that significantly substitute for inhospital time on mortality, readmission rates, patient and carer satisfaction, and costs.

Data sources: MEDLINE, Embase, Social Sciences Citation Index, CINAHL, EconLit, PsycINFO and the Cochrane Database of Systematic Reviews, from the earliest date in each database to 1 February 2012.

Study selection: Randomised controlled trials (RCTs) comparing HITH care with inhospital treatment for patients aged > 16 years.

Data extraction: Potentially relevant studies were reviewed independently by two assessors, and data were extracted using a collection template and checklist.

Data synthesis: 61 RCTs met the inclusion criteria. HITH care led to reduced mortality (odds ratio [OR], 0.81; 95% CI, 0.69 to 0.95; P = 0.008; 42 RCTs with 6992 patients), readmission rates (OR, 0.75; 95% CI, 0.59 to 0.95; P = 0.02; 41 RCTs with 5372 patients) and cost (mean difference, 1567.11; 95% CI, 2069.53 to 1064.69; P < 0.001; 11 RCTs with 1215 patients). The number needed to treat at home to prevent one death was 50. No heterogeneity was observed for mortality data, but heterogeneity was observed for data relating to readmission rates and cost. Patient satisfaction was higher in HITH in 21 of 22 studies, and carer satisfaction was higher in and six of eight studies; carer burden was lower in eight of 11 studies, although not significantly (mean difference, 0.00; 95% CI, 0.19 to 0.19).

Conclusion: HITH is associated with reductions in mortality, readmission rates and cost, and increases in patient and carer satisfaction, but no change in carer burden.

“Hospital in the home” (HITH) provides acute or subacute treatment in a patient’s residence for a condition that would normally require admission to hospital.1 It is also known as “hospital at home”, “home hospitalisation” and “early supported discharge”,2-6 and it has been speculated that HITH improves outcomes. The key is substituting for inhospital care. HITH includes admission avoidance (ie, full substitution for hospitalisation) and early discharge followed by care at home (ie, shortened hospitalisation).7,8

Most HITH services are nurse based, but they may include doctors and allied health professionals.9,10 Some focus on specialties (eg, surgical specialties,11-20 medical specialties,21-33 rehabilitation medicine,34,35 geriatrics,36,37 psychiatry,38-42 infectious diseases,43,44 respiratory diseases45-55 or orthopaedics56), diagnostic groups (eg, hip fracture57,58 or stroke59-70) or a mixture.71 The literature is confusing because many studies on HITH do not use the term HITH (or any similar terms) and some studies use the term HITH but do not involve substitution for inhospital care.

HITH has increased in popularity because of concerns about safety, availability and cost of inhospital care. Although hospitalisation is associated with mortality, adverse events and deteriorating cognitive and physical function, one cannot assume that a change of location will alter such outcomes. However, hospital-based clinicians have expressed concern that HITH care is lower quality than inhospital care and reduces access to technologies and resources that deliver urgent, life-saving treatment.72

Disease-specific reviews have not shown consistent benefit.5,6 Location of care at home may be crucial to different outcomes, rather than particular diseases, subspecialties or the amount of hospital care that is replaced by HITH care, as long as some clinically significant substitution occurs.1

Reviews that did not look at specific diseases have similarly concluded no benefit,2,7,8 but these have been criticised for problems with inclusion and exclusion criteria and lack of an overall meta-analysis.73 Difficulties relating to definitions of HITH (which did not stipulate significant substitution) may have reduced the effect attributable to substitution,2,74 although some benefit (eg, reduced mortality at 6 months) was seen.7

We conducted a review restricted to HITH services that significantly substitute for inhospital time, to determine (a) whether the hazards of hospitalisation are due to illness or time in hospital and (b) whether a change in location might reduce these. We hypothesised that replacing inhospital care with home-based care for ≥ 7 days or for ≥ 25% of the duration of the control hospital admissions would produce different clinical outcomes — relating to mortality, readmission rates, and patient and carer satisfaction — and result in different costs of care. We considered specialties and diagnostic groups to be of secondary importance, so all types of HITH service that substitute for inhospital care were included, and HITH services that do not substitute for inhospital care were excluded.

Methods

We report this meta-analysis according to the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)75 and the recommendations of the Cochrane Effective Practice and Organisation of Care (EPOC) Group.76

We searched MEDLINE, Embase, Social Sciences Citation Index, CINAHL, EconLit, PsycINFO and the Cochrane Database of Systematic Reviews, from the earliest date in each database to 1 February 2012. We used the search strategy reported in the initial Cochrane protocol,2 which combined acute and subacute studies (Appendix 1, PDF). Additional records were identified through other sources (backward searching through references of published articles, forward searching through citations, and articles known to us).

We included randomised controlled trials (RCTs) that compared HITH care with inhospital care for patients aged > 16 years. Significant substitution for inhospital care was defined as the intervention group spending significantly less time in hospital — the duration of out-of-hospital care being either ≥ 7 days or ≥ 25% of the average length of stay (ALOS) for control hospital admissions.

We included studies from the community,21-24 emergency departments (EDs),28-33,36-42,44-48,55,59,70 hospitalisations in departments other than EDs,11-20,25-27,34,35,43,48-54,56-58,60-69,71 and hospital-based outreach teams and community-based teams.11,13-15,21,44,48,69 We excluded long-term care, outpatient care without any care provided at home, elaborate home care services in which patients in the control group were also at home, paediatric care and obstetric care.

Study selection

The initial search for potentially relevant studies was performed by a research assistant. Two of us (G A C and N S S) independently read the abstracts of potentially relevant studies (excluding articles that clearly did not meet the inclusion criteria and selecting articles for detailed analysis), independently read the remaining studies in full to assess them for eligibility, and extracted data using a collection template and checklist (which were developed by the Cochrane Collaboration and modified for this review). Disagreements were resolved by discussion or referral to external assessors. Quality of eligible studies was assessed by Cochrane criteria. Four of us (D A M, N A R, A D W and L B) checked the selected studies to ensure that they met the inclusion criteria.

Outcomes of interest were mortality, readmission rates, patient and carer satisfaction, and cost. We collected data on these outcomes at longest available follow-up. We assessed each study for bias using EPOC criteria. This included concealment of allocation, blinded assessment of outcomes, measurement of baseline data, use of reliable outcome measures (objective measures or measures known to be reliable and valid) and protection against contamination. One criterion, follow-up by professionals, was not applicable and was therefore excluded.

We analysed mortality data using fixed-effects Peto odds ratios (ORs) with 95% confidence intervals, and readmissions and cost data using random-effects Peto ORs with 95% confidence intervals. Continuous data (such as data on cost and carer burden) were also analysed by calculation of differences in means. Categorical data (patient and carer satisfaction, and subsidiary information about cost and carer burden) were reported as counts. Statistical heterogeneity was measured by χ2 and I2 tests.

We analysed intention-to-treat data wherever available. A 2-sided P value of 0.05 or lower was considered significant. Meta-analyses were conducted using RevMan 5.1.6 (Nordic Cochrane Centre). Studies were also analysed by specialty, age of participants, and date of publication.

In cases where different validated instruments were used for the same outcomes, attempts were made to collapse scores into dichotomous outcomes. If this was not rational, the results of the different outcomes were counted. A direct cost comparison was attempted, taking into account inflation, by using proportional differences in costs, rather than absolute values.

Publication bias was assessed using a funnel plot, and reporting bias was assessed by comparing the number of studies included in our study with the numbers included in other meta-analyses.

Sensitivity analyses were conducted on data relating to mortality, readmission rates and cost to determine how many studies could be omitted without affecting the results, starting with the strongest results.

Results

Of 1582 potentially relevant studies, 61 met the inclusion criteria (Box 1). For brevity, we only cite the principal publications. For eight studies,19,31,37,44,55,56,68,70 additional information was obtained from authors. Almost all studies were not blinded. However, many studies used blinded initial assessments before randomisation. Some outcome assessment was blinded.

The effect sizes for data relating to mortality are shown in Box 2. There was a clinically significant reduction in mortality (OR, 0.81; 95% CI, 0.69 to 0.95; P = 0.008) in favour of HITH, giving a 19% relative reduction and 2.01% absolute reduction in mortality; the number needed to treat at home to prevent one death was 50. No significant heterogeneity was observed in the mortality data (P > 0.99), and there were similar reductions in mortality in medical (OR, 0.79; 95% CI, 0.65 to 0.97; P = 0.02), surgical (OR, 0.78; 95% CI, 0.29 to 2.10; P = 0.62) and rehabilitation studies (OR, 0.83; 95% CI, 0.63 to 1.08; P = 0.17), with no significant heterogeneity in these subgroups. Analysis by degree of substitution, age of patients and year of publication did not reveal marked shifts (Box 3), although there was a significant reduction in mortality in the middle age group (OR, 0.70; 95% CI, 0.51 to 0.95; P = 0.02).

The effect sizes for data relating to readmission rates are shown in Box 4. The reduction in readmission rates (OR, 0.75; 95% CI, 0.59 to 0.95; P = 0.02) in favour of HITH was associated with significant heterogeneity by one test (χ2 = 73.27; P = 0.001) but not the other (I2 = 45%) owing to larger reductions in readmissions in psychiatric (OR, 0.29; 95% CI, 0.05 to 1.65; P = 0.16) compared with medical (OR, 0.76; 95% CI, 0.60 to 0.97; P = 0.02), surgical (OR, 0.66; 95% CI, 0.36 to 1.22; P = 0.18) and rehabilitation studies (OR, 0.96; 95% CI, 0.70 to 1.31; P = 0.79). The absolute reduction in readmissions was 2.09%.

The effect sizes for data relating to cost are shown in Box 5. There was strong evidence for reduced cost (mean difference, 1567.11; 95% CI, 2069.53 to 1064.69; P < 0.001) albeit with heterogeneity (χ2 = 237.45; P < 0.001; I2 = 96%), although all 11 studies favoured HITH. The heterogeneity was due to inflation, different currencies and different cost structures for brief surgical stays compared with much longer rehabilitation stays, causing a nearly 20-fold difference in raw numbers. Reduced costs were seen in all subgroups.

Of the 34 studies in which any cost data were presented, 32 concluded that HITH care was cheaper.12-16,23,24,27-29,33-36,40-43,46,48,49,51,53,55,59-64,69,70 The other two studies concluded that hospital care was cheaper.40,71 Overall, the cost for HITH care was 73.5% of the average for the control groups.

It was not possible to perform a meta-analysis on patient or carer satisfaction data because the studies that met our inclusion criteria used different validated and non-validated measurements. Data from 21 of 22 studies favoured HITH for patient satisfaction,14,15,19,23,27,35,36,41,42,44,47,48,51,52,55,57,60,62,63,66,69 and data from the other showed equal patient satisfaction for hospital- and home-based care.46

Carer satisfaction in HITH was higher in six of eight studies,15,35,36,57,63,66 one study showed no difference,60 and one showed higher carer satisfaction in the control group.27 Similarly, eight of 11 studies showed lower carer burden in HITH,19,27,39,57,59,64,69,71 one found no difference,63 and two favoured the control groups.60,68 For carer burden, a meta-analysis of seven studies yielded no difference (mean difference, 0.00; 95% CI, 0.19 to 0.19).

A funnel plot for mortality (Appendix 2, PDF) was generally symmetrical, indicating that publication bias was unlikely. Compared with similar meta-analyses, the larger number of trials that we found indicates a low risk of reporting biases.

The sensitivity analyses for mortality, readmission rates and cost showed that after removing nine, five and nine studies, respectively, the meta-analyses became non-significant. Also, a meta-analysis of mortality data that included four additional studies (which had been excluded because they did not meet the 25% or 7-day criterion) did not produce markedly different results (OR, 0.84; 95% CI, 0.72 to 0.99; P = 0.03; no heterogeneity). In addition, a meta-analysis of 14 admission-substitution studies showed a similar, although not statistically significant, effect on mortality (OR, 0.81; 95% CI, 0.62 to 1.05; P = 0.11).

Discussion

Our study shows that HITH reduces mortality, readmission rates and cost compared with inhospital care, in a statistically and clinically significant way. Similar reductions in mortality were found for all age groups. The results also suggest that HITH increases patient and carer satisfaction but does not affect carer burden. These outcomes are likely to be generalisable as our study covered a broad range of clinical conditions and 61 RCTs from five continents.

Our study adds to the findings of four Cochrane reviews of HITH. The first of these reviews combined early discharge of older medical patients (acute and subacute), early discharge of elective surgical patients, admission avoidance for a mix of medical conditions, and care of terminally ill patients (which did not directly involve substitution for inhospital care).2 A second iteration of this review was divided into three reviews, covering admission substitution,7 early discharge (acute and subacute)8 and palliative care.76 A strength of our study is the quantified definition of HITH. The 25% or 7-day criterion was appropriate because ALOS is 4–5 days in many countries, so a 25% decrease represents > 1 day out of hospital. In addition, in countries with an ALOS of several weeks, a 7-day reduction is still clinically significant. This meant that our study included HITH models regardless of temporal-, team- and disease-specific frameworks. Our HITH definition increased the number of included studies compared with recent Cochrane reviews, and provided findings that were similar in direction but with more statistical power due to the larger dataset. We clarified the definition of HITH used in the Cochrane reviews by including replacement of both acute and subacute hospitalisation. Studies of HITH replacing subacute hospitalisation35,56,57,60-64,66-69 have actually been included in the Cochrane reviews, although the reviews state that they only included replacement of acute hospitalisation.2,8

We omitted two studies that were included in the first and last of the four Cochrane reviews of HITH.2,77 These did not meet our HITH definition because they compared different intensities of home-based care.78,79 The Cochrane reviews excluded studies of surgical early discharge followed up by specialist hospital outreach16,17 but included studies of community-based follow-up.14,15

We included 14 admission-substitution studies, and their OR for mortality was 0.81. The Cochrane review on admission substitution included five studies and showed that mortality decreased by 38% with HITH; it also showed improved functional outcomes, greater patient satisfaction, lower costs and less chance of ending up in institutional care, but concluded that both groups had “similar outcomes”.7 This review included studies of patients with stroke, patients with acute exacerbations of chronic obstructive pulmonary disease (COPD), and older patients with a mix of conditions; however, to reduce heterogeneity, it excluded studies of patients with pneumonia, patients with cellulitis, and frail elderly people with dementia.80 The Cochrane review on early discharge included 26 trials, but the largest meta-analysis calculation included only six trials, despite eight being included in a earlier single-diagnosis early-discharge meta-analysis.5,8 None of these Cochrane reviews included a meta-analysis calculation on all studies that met the inclusion criteria.

The results of two meta-analyses of HITH care for patients with stroke differed — one showed no benefit, but the second showed reduced death or dependency.5,81 A systematic review of HITH for patients with COPD showed no differences.6 In practice, patients move between diagnostic groups, older people have comorbidities, and HITH services treat many diagnostic groups across subspecialties.

The mechanisms by which changing location of care reduces mortality are likely to be multifactorial. A recent review demonstrated that HITH reduces delirium,1 but it may also reduce iatrogenic infections, falls and adverse events.10,30,82

The reduction in cost shown in our study may be an underestimate of the true savings that result from HITH. Because HITH costings done during trials usually represent the period during which HITH is introduced, they are generally based on services that are not at full capacity, and are therefore operating at reduced efficiency. Also, the savings associated with reduced readmission rates were not taken into account in our study.

Our study also raises concern regarding inhospital care, particularly where HITH care is an option, and supports further investigation of differences between the two care models so that the quality of inpatient care can be improved.

A limitation of our study is that the wide range of HITH services included makes it difficult to determine which elements of care affected the outcomes. The HITH services varied from full multidisciplinary team care23,24,34-37,39-42,46,60,61,63-65,68,70,71 and care by partial teams13,15,20,27,38,47,48,52,54,55,57-59,62,66,69 to services with a single health worker, most often a nurse with doctor supervision.11,12,14,16-18,19,21,22,25,26,43-45,49-53,67 Some services included outpatient care12,18,38,46 and some involved parenteral self-administration of medications (such as antibiotics49 or heparin25,26,31,32), but all involved health practitioners visiting the home and the control group being in hospital.

The central criterion that we used — for HITH care to significantly replace inhospital time — resulted in four studies being excluded, but including them made no difference to the outcome of mortality. This criterion is not likely to introduce a bias favouring positive findings, as admission to hospital is expected to reduce mortality, and early discharge is associated with higher readmission rates. Therefore any bias due to the central criterion should be negative.

Our data support greater use of HITH to improve patient outcomes, as measured by mortality, readmission rates and patient and carer satisfaction. Where suitable care can be provided at home as an alternative to hospitalisation, we believe that it should be recommended.

1 Flow of information

2 Effects of hospital in the home (HITH) on mortality

3 Effect sizes of hospital in the home (HITH) on mortality in different subgroups

No. of studies

No. of patients treated in HITH

Odds ratio (95% CI)

P


Degree of admission substitution (n = 42)

Full substitution

14

1249

0.81 (0.62–1.05)

0.11

> 50% substitution*

11

1055

0.72 (0.49–1.07)

0.11

< 50% substitution

17

1251

0.84 (0.67–1.06)

0.15

Average age of patients in HITH group (n = 42)

Youngest group, average age < 70 years

15

1560

0.79 (0.59–1.05)

0.10

Middle group, average age 70–73 years

13

1012

0.70 (0.51–0.95)

0.02

Oldest group, average age ≥ 74 years

14

983

0.89 (0.71–1.13)

0.35

Year of publication (n = 42)

First third, 1964–1998

12

1452

0.80 (0.63–1.01)

0.06

Middle third, 1998–2002

16

1212

0.82 (0.63–1.06)

0.13

Last third, 2003–2011

14

854

0.83 (0.57–1.21)

0.32


* This category excludes full substitution. Eight studies were published in 1998; five are in the first third and three are in the middle third.

4 Effects of hospital in the home (HITH) on readmission rates

5 Effects of hospital in the home (HITH) on cost

Received 
12 Mar 2012
accepted 
23 Jul 2012
Gideon A Caplan, MB BS, MD, FRACP, Director,1 and Conjoint Associate Professor2
Nur S Sulaiman, MB BS, Registrar3
Dee A Mangin, MB ChB, Director, General Practice Research Group4
Nicoletta Aimonino Ricauda, MD, Director, Hospital in the Home5
Andrew D Wilson, MD, FRCGP, Professor of General Practice6
Louise Barclay, BN, Nurse Manager1
1 Post Acute Care Services, Prince of Wales Hospital, Sydney, NSW.
2 Prince of Wales Clinical School, University of New South Wales, Sydney, NSW.
3 Queen Elizabeth Hospital, Adelaide, SA.
4 School of Public Health and General Practice, Christchurch School of Medicine, Christchurch, New Zealand.
5 Department of Medical and Surgical Disciplines, San Giovanni Battista Hospital, University of Torino, Torino, Italy.
6 Department of Health Sciences, University of Leicester, Leicester, UK.
Correspondence: 
Acknowledgements: 

This study was supported by an unrestricted grant from the Julianna Lowy Foundation, which had no role in the study design, data analysis or writing of this article.

Competing Interests: 

Gideon Caplan and Nicoletta Aimonino Ricauda work in a hospital and a HITH unit. Louise Barclay works in a HITH unit.

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