Supported Discharge Teams for older people in hospital acute care: a randomised controlled trial

The Effect of Hospital-to-Home Discharge Interventions on Reducing Unplanned Hospital Readmissions: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

Unplanned hospital readmissions (UHRs) constitute a persistent health concern worldwide. A high level of UHRs imposes a burden on individuals, their families, and health care system budgets. This systematic review and meta-analysis aimed to evaluate the effectiveness of discharge interventions in the transition from hospital to home in the context of reducing UHRs.

METHODS

The study design was a meta-analysis of randomized and nonrandomized controlled trials. Eight databases were searched. The effect on UHR rates (odds ratio [OR]) of discharge interventions in the transition from hospital to home was calculated at a 95% confidence interval (95% CI) based on meta-regression and meta-analysis of random-effects models.

RESULTS

Results showed that discharge interventions were effective in reducing rehospitalizations (effectiveness/OR =1.39; 95% CI, 1.24-1.55). It was furthermore determined that the studies showed heterogeneous characteristics (P ≤ .001, Q = 50.083, I2 = 44.093; df = 28). According to Duval and Tweedie's trim and fill results, there was no publication bias. Interventions in which telephone communications and hospital visits (OR = 1.64; 95% CI, 1.25-2.16; P < .001) were applied together were effective among patients with cardiovascular diseases (OR = 1.54; 95% CI, 1.28-2.09; P < .001), and it was found that UHRs were reduced within a period of 90 days (OR = 1.68; 95% CI, 1.16-2.42; P < .001). It was also found that discharge interventions applied to transitions from hospital to home had a diminishing effect on UHRs as the publication dates of the reviewed studies advanced from the past to the present (OR = 0.015; 95% CI, 0.002-0.003; P < .001).

CONCLUSION

Supporting and facilitating cooperation between health care professionals and families should be a key focus of discharge interventions.

Exploring Goal-Setting and Achievement Within Reablement: A Comparative Case Study of Three Countries

Purpose

Over the last two decades, reablement programs have been studied and implemented internationally. Goal-setting and multidisciplinary collaboration are central elements of reablement. Unfortunately, limited intervention descriptions leave questions on how they are applied in practice and how goals set by the user are achieved. As a consequence, healthcare providers and organizations often lack knowledge to implement and align reablement to their national and local context. This study aimed to collect data on goal-setting and achievement, and multidisciplinary collaboration within reablement services to provide insight into how these processes inform reablement practice as well as to explore the experiences of healthcare professionals in Norway, New Zealand, and the Netherlands.

Material and Methods

A qualitative exploratory design was used comprising three focus group interviews with 20 healthcare professionals (nursing and allied health) involved in reablement programs from the three countries. Purposive sampling was employed considering a mix of gender, age and educational level.

Results

Findings reflected healthcare professionals' experiences and reablement processes in three main themes: (1) Goal-setting processes; clearly demonstrating goal-setting as an essential part of reablement and contributing to better understanding of users' motives; (2) Impact of goal-setting on multidisciplinary collaboration; promoting a sense of community, learning climate, job satisfaction and task-shifting; and (3) Behavior change techniques used to reach users' goals, promoting self-reflection and changing users' perspectives.

Conclusion

This study offers valuable insights from three countries. Goal-setting serves a crucial role enabling effective reablement implementation across diverse contexts. More specifically, to facilitate tailoring of reablement programs to the user's needs as well as establish more effective multidisciplinary collaboration by promoting trust, shared vision, and utilizing each other's expertise. However, despite the acknowledgement of the significance of reablement, it was reported by all that a cultural shift is necessary for users, informal caregivers as well as healthcare professionals.

Length of stay in the clinical wards in a hospital after introducing a multiprofessional discharge team: An effectiveness improvement report

INTRODUCTION

Emergency overcrowding is a problem in hospitals worldwide. The expansion of wards has limitations. Hospital administrative leaders are constantly looking for opportunities to improve the efficiency of resource use.

METHODS

This is a care improvement study with a quasi-experimental design. We created a hospital discharge team (HDT) to solve the issues of prolonged hospital stays. The main interventions were active search and resolution of prolongation of stay and multi-disciplinary huddles. We developed strategies with different hospital units to expedite the processing of patients near discharge. Length of stay (LOS), morning hospital discharges, readmission rates, and bed usage were compared before (2018) and after (2019) HDT implementation.

RESULTS

There was a reduction in the mean LOS of 1.8 days (95% confidence interval [CI] -0.9 to -2.6; p < .001). The rate of hospital discharges before noon increased by 7.0% (95% CI 4%-11%; p < .001). The readmission rate was similar between 2018 and 2019 (+0.7%; 95% CI -0.1% to 1.9%; p = .358). We observed higher bed turnover, with 0.5 more hospitalizations per bed per month (95% CI 0.1-0.7; p = .01; mean of 3.7 ± 0.3 in 2018 and 4.1 ± 0.3 in 2019).

CONCLUSION

HDT brought benefits to our hospital, reducing the length of stay and increasing bed turnover. However, there is a need for a team focused on the project and support from managers to overcome resistance and integrate units until they are fully operational.

Higher levels of multimorbidity are associated with increased risk of readmission for older people during post-acute transitional care

PURPOSE

Older patients are at high risk for poor outcomes after an acute hospital admission. The Transitional Aged Care Programme (TACP) was established by the Australian government to provide a short-term care service aiming to optimise functional independence following hospital discharge. We aim to investigate the association between multimorbidity and readmission amongst patients on TACP.

METHODS

Retrospective cohort study of all TACP patients over 12 months. Multimorbidity was defined using the Charlson Comorbidity Index (CCI), and prolonged TACP (pTACP) as TACP ≥ 8 weeks.

RESULTS

Amongst 227 TACP patients, the mean age was 83.3 ± 8.0 years, and 142 (62.6%) were females. The median length-of-stay on TACP was 8 weeks (IQR 5-9.67), and median CCI 7 (IQR 6-8). 21.6% were readmitted to hospital. Amongst the remainder, 26.9% remained at home independently, 49.3% remained home with supports; < 1% were transferred to a residential facility (0.9%) or died (0.9%). Hospital readmission rates increased with multimorbidity (OR 1.37 per unit increase in CCI, 95% CI 1.18-1.60, p < 0.001). On multivariable logistic regression analysis, including polypharmacy, CCI, and living alone, CCI remained independently associated with 30-day readmission (aOR 1.43, 95% CI 1.22-1.68, p < 0.001).

CONCLUSIONS

CCI is independently associated with a 30-day hospital readmission in TACP cohort. Identifying vulnerability to readmission, such as multimorbidity, may allow future exploration of targeted interventions.

A qualitative evidence synthesis exploring people after stroke, family members, carers and healthcare professionals' experiences of early supported discharge (ESD) after stroke

OBJECTIVE

Early supported discharge (ESD) after stroke has been shown to generate significant cost savings and reduce both hospital length of stay, and long-term dependency. This study aimed to systematically review and synthesise qualitative studies of the experiences and views of ESD from the perspective of people after stroke, their family members, carers and healthcare professionals.

METHOD

A systematic search of eleven databases; CINAHL, PubMed Central, Embase, MEDLINE, PsycINFO, Sage, Academic Search Complete, Directory of Open Access Journal, The Cochrane Library, PsycARTICLES and SCOPUS, was conducted from 1995 to January 2022. Qualitative or mixed methods studies that included qualitative findings on the perspectives or experiences of people after stroke, family members, carers and healthcare professionals of an ESD service were included. The protocol was registered with the Prospero database (Registration: CRD42020135197). The methodological quality of studies was assessed using the 10-item CASP checklist for qualitative studies. Results were synthesised using Thomas and Harden's three step approach for thematic synthesis.

RESULTS

Fourteen studies were included and five key themes were identified (1) ESD eases the transition home, but not to community services, (2) the home environment enhances rehabilitation, (3) organisational, and interprofessional factors are critical to the success of ESD, (4) ESD is experienced as a goal-focused and collaborative process, and (5) unmet needs persisted despite ESD.

CONCLUSION

The findings of this qualitative evidence synthesis highlight that experiences of ESD were largely very positive. The transition from ESD to community services was deemed to be problematic and other unmet needs such as information needs, and carer support require further investigation.

Using machine learning to model older adult inpatient trajectories from electronic health records data

Electronic Health Records (EHR) data can provide novel insights into inpatient trajectories. Blood tests and vital signs from de-identified patients' hospital admission episodes (AE) were represented as multivariate time-series (MVTS) to train unsupervised Hidden Markov Models (HMM) and represent each AE day as one of 17 states. All HMM states were clinically interpreted based on their patterns of MVTS variables and relationships with clinical information. Visualization differentiated patients progressing toward stable 'discharge-like' states versus those remaining at risk of inpatient mortality (IM). Chi-square tests confirmed these relationships (two states associated with IM; 12 states with ≥1 diagnosis). Logistic Regression and Random Forest (RF) models trained with MVTS data rather than states had higher prediction performances of IM, but results were comparable (best RF model AUC-ROC: MVTS data = 0.85; HMM states = 0.79). ML models extracted clinically interpretable signals from hospital data. The potential of ML to develop decision-support tools for EHR systems warrants investigation.

Effectiveness of integrating primary healthcare in aftercare for older patients after discharge from tertiary hospitals-a systematic review and meta-analysis

Background

Quality of aftercare can crucially impact health status of older patients and reduce the extra burden of unplanned healthcare resource utilisation. However, evidence of effectiveness of primary healthcare in supporting aftercare, especially for older patients after discharge are limited.

Methods

We searched for English articles of randomised controlled trials published between January 2000 and March 2022. All-cause hospital readmission rate and length of hospital stay were pooled using a random-effects model. Subgroup analyses were conducted to identify the relationship between intervention characteristics and the effectiveness on all-cause hospital readmission rate.

Results

A total of 30 studies with 11,693 older patients were included in the review. Compared with patients in the control group, patients in the intervention group had 32% less risk of hospital readmission within 30 days (RR = 0.68, P < 0.001, 95%CI: 0.56–0.84), and 17% within 6 months (RR = 0.83, P < 0.001, 95%CI: 0.75–0.92). According to the subgroup analysis, continuity of involvement of primary healthcare in aftercare had significant effect with hospital readmission rates (P < 0.001). Economic evaluations from included studies suggested that aftercare intervention was cost-effective due to the reduction in hospital readmission rate and risk of further complications.

Conclusion

Integrating primary healthcare into aftercare was designed not only to improve the immediate transition that older patients faced but also to provide them with knowledge and skills to manage future health problems. There is a pressing need to introduce interventions at the primary healthcare level to support long-term care.

Early supported discharge for older adults admitted to hospital with medical complaints: a systematic review and meta-analysis

INTRODUCTION

Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home and continue to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. The concept has shown reduced length of stay and improved functional outcomes in stroke patients. This systematic review aims to explore the totality of evidence for the use of early supported discharge in older adults hospitalised with medical complaints.

METHODS

A literature search of CINAHL in EBSCO, Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL), EMBASE and MEDLINE in EBSCO was carried out. Randomised controlled trials or quasi-randomised controlled trials were included. The Cochrane Risk of Bias Tool 2.0 was used for quality assessment. The primary outcome measure was hospital length of stay. Secondary outcomes included mortality, function, health related quality of life, hospital readmissions, long-term care admissions and cognition. A pooled meta-analysis was conducted using RevMan software 5.4.1.

RESULTS

Five studies met the inclusion criteria. All studies were of some concern in terms of their risk of bias. Statistically significant effects favouring ESD interventions were only seen in terms of length of stay (REM, MD = -6.04, 95% CI -9.76 to -2.32, I2 = 90%, P = 0.001). No statistically significant effects favouring ESD interventions were established in secondary outcomes.

CONCLUSION

ESD interventions can have a statistically significant impact on the length of stay of older adults admitted to hospital for medical reasons. There is a need for further higher quality research in the area, with standardised interventions and outcome measures used.

[Implementation of discharge management in the surgical department of a university hospital: exploratory analysis of costs, length of stay, and patient satisfaction]

BACKGROUND

Discharge management has been mandatory by law in Germany since October 2017, and hospitals are required to finance and implement this. Currently there are no data available on the costs and effects of discharge management on the length of hospital stay.

AIMS

Determination of the costs of discharge management in the Department of Surgery at the University Hospital rechts der Isar of the Technical University of Munich, Germany, assessment of the length of stay in comparison with and without discharge management, and evaluation of patients' satisfaction to create first precedents for future negotiations about adequate financing.

METHODS

Cost analysis of discharge management in the Department of Surgery at the School of Medicine at the Technical University of Munich, retrospective analysis of the mean length of hospital stays before and after implementation of discharge management, and patient surveys on the quality of the structured transition process and their satisfaction.

RESULTS

The cost analysis revealed lump costs of € 43 per patient and € 391 for patients with a need for complex management. No statistically significant shorter length of hospital stay after the implementation of discharge management was found by analyzing three patient subgroups. The overall rate of patients returning to the hospital due to complications associated with the surgical procedure was 3.4%.

DISCUSSION

Discharge management in the Department of Surgery at the hospital is an effective and potentially quality-enhancing but at the same time cost-driving measure, which, in the medium term, will enter G‑DRG rates and may thus increase costs. A possible solution to meet various stakeholders' needs could be a case-specific financial remuneration of discharge management that is adapted to the transition qualities of the various medical departments.

Urgent care for older people

Geriatric medicine is the clinical specialty that focuses upon the care of older people-especially those with frailty (a state of increased vulnerability). In hospital, older people living with frailty are at high risk of developing a range of unpleasant outcomes such as delirium, falls, fractures, pressure sores and death. Comprehensive geriatric assessment is a form of holistic care that incorporates a specific set of clinical competencies that are able to reduce these adverse outcomes. Over the years, geriatric medicine has moved from being more of a community-based service towards a more acute specialty-encroaching now upon emergency department care. The challenge now is to work out how best to deliver geriatric care across the whole hospital (older people with frailty are not just cared for in geriatric wards!). The themed collection published on the Age & Ageing journal website outlines key articles that are attempting to develop solutions to this challenging conundrum. We hope that you enjoy reading them.

Early supported discharge for older adults admitted to hospital with medical complaints: a protocol for a systematic review

INTRODUCTION

Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home and continue to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. The concept has been researched extensively in the stroke population, showing reduced length of stay for patients and improved functional outcomes. This systematic review aims to explore the totality of evidence for the use of ESD in an older adult population who have been hospitalised with medical complaints.

METHODS

A systematic review of randomised controlled trials and quasi randomised controlled trials will be carried out in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies will be included if they provide an ESD intervention to older adults admitted to hospital for medical complaints compared with continuing inpatient care. MEDLINE, CINAHL, CENTRAL and EMBASE databases will be searched. The primary outcome measure will be length of hospital stay, secondary outcomes will include functional abilities, falls, quality of life, carer and patient satisfaction, unplanned emergency department re-presentation, unscheduled hospital readmission, nursing home admission or mortality. Titles and abstracts of studies will be screened independently by two authors. The Cochrane Risk of Bias Tool will be used independently by two reviewers to assess the methodological quality of the included studies. GRADE will be used to assess the quality of the body of evidence. A pooled meta-analysis will be conducted using RevMan software V.5.4.1, depending on the uniformity of the data.

ETHICS AND DISSEMINATION

The authors will present the findings of the review to a patient and public involvement stakeholder panel of older people that has been established at the Ageing Research Centre in the University of Limerick. Formal ethical approval is not required for the review as all data collected will be secondary data and will be analysed anonymously.

PROSPERO REGISTRATION NUMBER

CRD42021223112.

Integration of Physical Activity in Reablement for Community Dwelling Older Adults: A Systematic Scoping Review

BACKGROUND

Reablement is a rehabilitative intervention provided to homecare receivers with the aim of improving function and independence. There is limited evidence of the effectiveness of reablement, and the content of these interventions is variable. Physical activity (PA) is known to be important for improving and maintaining function among older adults, but it is unclear how PA is integrated in reablement.

PURPOSE

To map existing evidence of how PA strategies are integrated and explored in studies of reablement for community dwelling older adults and to identify knowledge gaps.

METHODS

An a priori protocol was published. Studies of time-limited, interdisciplinary reablement for community-dwelling older adults were considered for inclusion. Eight databases were searched for studies published between 1996 and June 2020, in addition to reference and citation searches. Study selection and data extraction were made independently by two reviewers.

RESULTS

Fifty-one studies were included. Exercise strategies and practice of daily activities were included in the majority of intervention studies, but, in most cases, little information was provided about the intensity of PA. Interventions aiming to increase general PA levels or reduce sedentary behavior were rarely described. None of the studies explored older adults', healthcare providers' or family members' experiences with PA in a reablement setting, but some of the studies touched upon themes related to PA experiences. Some studies reported outcomes of physical fitness, including mobility, strength, and balance, but there was insufficient evidence for any synthesis of these results. None of the studies reported PA levels among older adults receiving reablement.

CONCLUSION

There is limited evidence of how PA is integrated and targeted to older adults' individual needs and preferences in a reablement setting. The feasibility and effectiveness of PA interventions, as well as experiences or barriers related to PA in a reablement setting, should be further investigated.

The effect of delegation of therapy to allied health assistants on patient and organisational outcomes: a systematic review and meta-analysis

Background

Allied health assistants (AHAs) are support staff who complete clinical and non-clinical tasks under the supervision and delegation of an allied health professional. The effect of allied health professional delegation of clinical tasks to AHAs on patient and healthcare organisational outcomes is unknown. The purpose of this systematic review was to investigate the effect of allied health professional delegation of therapy to AHAs on patient and organisational outcomes.

Methods

A systematic review and meta-analysis was conducted. Databases MEDLINE (Ovid), Embase (Ovid), Informit (all databases), Emcare (Ovid), PsycINFO (Ovid), Cumulative Index to Nursing and Allied Health Literature [CINAHL] (EbscoHost) and the Cochrane Database of Systematic Reviews were searched from earliest date available. Additional studies were identified by searching reference lists and citation tracking. Two reviewers independently applied inclusion and exclusion criteria. The quality of the study was rated using internal validity items from the Downs and Black checklist. Risk ratios (RR) and mean differences (MD) were calculated for patient and organisational outcomes. Meta-analyses were conducted using the inverse variance method and random-effects model.

Results

Twenty-two studies met the inclusion criteria. Results of meta-analysis provided low quality evidence that AHA supervised exercise in addition to usual care improved the likelihood of patients discharging home (RR 1.28, 95%CI 1.03 to 1.59, I² = 60%) and reduced length of stay (MD 0.28 days, 95%CI 0.03 to 0.54, I² = 0%) in an acute hospital setting. There was preliminary evidence from one high quality randomised controlled trial that AHA provision of nutritional supplements and assistance with feeding reduced the risk of patient mortality after hip fracture (RR 0.41, 95%CI 0.16 to 1.00). In a small number of studies (n = 6) there was no significant difference in patient and organisational outcomes when AHA therapy was substituted for therapy delivered by an allied health professional.

Conclusion

We found preliminary evidence to suggest that the use of AHAs to provide additional therapy may be effective for improving some patient and organisational outcomes.

Review registration

CRD42019127449.

Post-Acute Care for Older People Following Injury: A Randomized Controlled Trial

OBJECTIVES

The study sought to determine whether older people, on discharge from hospital and on referral to a supported discharge team (SDT), will have: (1) reduced length of stay in hospital; (2) reduced risk of hospital readmission; and (3) reduced healthcare costs.

DESIGN/INTERVENTION

Randomized controlled trial with follow-up at 4 and 12 months of post-acute home-based rehabilitation team (SDT). Programs were delivered by trained healthcare assistants, up to 4 times a day, 7 days a week, under the guidance of registered nurses, allied health, and geriatricians for up to 6 weeks.

PARTICIPANTS/SETTING

A total of 303 older women and 100 older men (mean age 81) in hospital because of injury, were randomized to either SDT (n = 201) or usual care (n = 202). The intervention was operated from Waikato hospital, a regional hospital in New Zealand.

METHODS

Days spent in hospital in the year following randomization and healthcare costs were collected from hospital datasets, and functional status assessed using the interRAI Contact Assessment was gathered by health professional research associates.

RESULTS

Participants randomized to the SDT spent less time in hospital in the period immediately prior to discharge (mean 20.9 days) in comparison to usual care (mean 26.6 days) and spent less time in hospital in the 12 months following discharge home. Healthcare costs were lower in the SDT group in the 12 months following randomization.

CONCLUSIONS/IMPLICATIONS

SDT can provide an important role in reducing hospital length of stay and readmissions of older people following an injury. Almost a million older people (65+ years of age) a year in the US are hospitalized as a consequence of falls-related injuries, most often fractured hip. Hospitals are not always the best location to provide care for older people. SDTs can help with the transition from hospital to home, while reducing hospital length-of-stay.

Post-discharge adjustment of medication in geriatric patients : A prospective cohort study

BACKGROUND

Little is known to what extent general practitioners (GP) change hospital discharge medications in older patients.

OBJECTIVE

This prospective cohort study aimed to analyze medication changes at the interface between hospital and community in terms of quality, quantity and type of drugs.

METHODS

A total of 121 out of 248 consecutively enrolled patients admitted to an acute geriatric hospital unit participated in the study. Medication regimens were recorded at admission and discharge and 4 weeks after hospital discharge the general practitioners in charge were contacted to provide the current medication charts. Changes in the extent of polypharmacy, in the type of drugs using anatomical therapeutic chemical classification (ATC) codes and potentially inappropriate medications (PIM) were analyzed.

RESULTS

Medication charts could be obtained for 98 participants in primary care. Only 21% of these patients remained on the original discharge medication. Overall, the average number of medications rose from hospital admission (6.58 SD ± 3.45) to discharge (6.96 SD ± 3.49) and again post-discharge in general practice (7.22 SD ± 3.68). The rates of patients on excessive polypharmacy (≥10 drugs) and on PIM were only temporarily reduced during hospital stay. The GPs stopped anti-infective drugs (ATC-J) and prescribed more antirheumatic drugs (ATC-M). Although no significant net changes occurred in other ATC groups, a substantial number of drugs were interchanged regarding the subgroups.

CONCLUSION

The study found that GPs extensively adjusted geriatric discharge medications. Whereas some changes may be necessary due to alterations in patients' state of health, a thorough communication between hospital doctors and GPs may level off different prescribing cultures and contribute to consistency in medication across sectors.

Early discharge hospital at home

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 METHODS

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 strokeEarly 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 conditionsEarly 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 surgeryThree 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).

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.