Home Hospitalization Service for Acute Uncomplicated First Ischemic Stroke in Elderly Patients: A Randomized Trial

Remote Vital Sign Monitoring in Admission Avoidance Hospital at Home: A Systematic Review

OBJECTIVES

To examine randomized controlled trials (RCTs) of "hospital at home" (HAH) for admission avoidance in adults presenting with acute physical illness to identify the use of vital sign monitoring approaches and evidence for their effectiveness.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

This review compared strategies for vital sign monitoring in admission avoidance HAH for adults presenting with acute physical illness. Vital sign monitoring can support HAH acute multidisciplinary care by contributing to safety, determining requirement of further assessment, and guiding clinical decisions. There are a wide range of systems currently available, including reliable and automated continuous remote monitoring using wearable devices.

METHODS

Eligible studies were identified through updated database and trial registries searches (March 2, 2016, to February 15, 2023), and existing systematic reviews. Risk of bias was assessed using the Cochrane risk of bias 2 tool. Random effects meta-analyses were performed, and narrative summaries provided stratified by vital sign monitoring approach.

RESULTS

Twenty-one eligible RCTs (3459 participants) were identified. Two approaches to vital sign monitoring were characterized: manual and automated. Reporting was insufficient in the majority of studies for classification. For HAH compared to hospital care, 6-monthly mortality risk ratio (RR) was 0.94 (95% CI 0.78-1.12), 3-monthly readmission to hospital RR 1.02 (0.77-1.35), and length of stay mean difference 1.91 days (0.71-3.12). Readmission to hospital was reduced in the automated monitoring subgroup (RR 0.30 95% CI 0.11-0.86).

CONCLUSIONS AND IMPLICATIONS

This review highlights gaps in the reporting and evidence base informing remote vital sign monitoring in alternatives to admission for acute illness, despite expanding implementation in clinical practice. Although continuous vital sign monitoring using wearable devices may offer added benefit, its use in existing RCTs is limited. Recommendations for the implementation and evaluation of remote monitoring in future clinical trials are proposed.

Assessment of the Impact of Home-Based Hospitalization on Health Outcomes: An Observational Study

INTRODUCTION

In Portugal, evidence of clinical outcomes within home-based hospitalization programs remains limited. Despite the adoption of homebased hospitalization services, it is still unclear whether these services represent an effective way to manage patients compared with inpatient hospital care. Therefore, the aim of this study was to evaluate the outcomes of home-based hospitalization compared with conventional hospitalization in a group of patients with a primary diagnosis of infectious, cardiovascular, oncological, or 'other' diseases.

METHODS

An observational retrospective study using anonymized administrative data to investigate the outcomes of home-based hospitalization (n = 209) and conventional hospitalization (n = 192) for 401 Portuguese patients admitted to CUF hospitals (Tejo, Cascais, Sintra, Descobertas, and the Unidade de Hospitalização Domiciliária CUF Lisboa). Data on demographics and clinical outcomes, including Barthel index, Braden scale, Morse scale, mortality, and length of hospital stay, were collected. The statistical analysis included comparison tests and logistic regression.

RESULTS

The study found no statistically significant differences between patients' admission and discharge for the Barthel index, Braden scale, and Morse scale scores, for both conventional and home-based hospitalizations. In addition, no statistically significant differences were found in the length of stay between conventional and home-based hospitalization, although patients diagnosed with infectious diseases had a longer stay than patients with other conditions. Although the mortality rate was higher in home-based hospitalization compared to conventional hospitalization, the mortality risk index (higher in home-based hospitalization) assessed at admission was a more important predictor of death than the type of hospitalization.

CONCLUSION

The study found that there were no significant differences in outcomes between conventional and home-based hospitalization. Home-based hospitalization was found to be a valuable aspect of patient- and family-centered care. However, it is noteworthy that patients with infectious diseases experienced longer hospital stays.

Individual- and Community-Level Predictors of Hospital-at-Home Outcomes

Advanced Care at Home is a Mayo Clinic hospital-at-home (HaH) program that provides hospital-level care for patients. The study examines patient- and community-level factors that influence health outcomes. The authors performed a retrospective study using patient data from July 2020 to December 2022. The study includes 3 Mayo Clinic centers and community-level data from the Agency for Healthcare Research and Quality. The authors conducted binary logistic regression analyses to examine the relationship among the independent variables (patient- and community-level characteristics) and dependent variables (30-day readmission, mortality, and escalation of care back to the brick-and-mortar hospital). The study examined 1433 patients; 53% were men, 90.58% were White, and 68.2% were married. The mortality rate was 2.8%, 30-day readmission was 11.4%, and escalation back to brick-and-mortar hospitals was 8.7%. At the patient level, older age and male gender were significant predictors of 30-day mortality (P-value <0.05), older age was a significant predictor of 30-day readmission (P-value <0.05), and severity of illness was a significant predictor for readmission, mortality, and escalation back to the brick-and-mortar hospital (P-value <0.01). Patients with COVID-19 were less likely to experience readmission, mortality, or escalations (P-value <0.05). At the community level, the Gini Index and internet access were significant predictors of mortality (P-value <0.05). Race and ethnicity did not significantly predict adverse outcomes (P-value >0.05). This study showed promise in equitable treatment of diverse patient populations. The authors discuss and address health equity issues to approximate the vision of inclusive HaH delivery.

SupporTive Care At Home Research (STAHR) for patients with advanced cancer: Protocol for a cluster non-randomized controlled trial

Advancements in the treatment and management of patients with cancer have extended their survival period. To honor such patients' desire to live in their own homes, home-based supportive care programs have become an important medical practice. This study aims to investigate the effects of a multidimensional and integrated home-based supportive care program on patients with advanced cancer. SupporTive Care At Home Research is a cluster non-randomized controlled trial for patients with advanced cancer. This study tests the effects of the home-based supportive care program we developed versus standard oncology care. The home-based supportive care program is based on a specialized home-based medical team approach that includes (1) initial assessment and education for patients and their family caregivers, (2) home visits by nurses, (3) biweekly regular check-ups/evaluation and management, (4) telephone communication via a daytime access line, and (5) monthly multidisciplinary team meetings. The primary outcome measure is unplanned hospitalization within 6 months following enrollment. Healthcare service use; quality of life; pain and symptom control; emotional status; satisfaction with services; end-of-life care; advance planning; family caregivers' quality of life, care burden, and preparedness for caregiving; and medical expenses will be surveyed. We plan to recruit a total of 396 patients with advanced cancer from six institutions. Patients recruited from three institutions will constitute the intervention group, whereas those recruited from the other three institutions will comprise the control group.

Inpatient-level care at home delivered by virtual wards and hospital at home: a systematic review and meta-analysis of complex interventions and their components

BACKGROUND

Technology-enabled inpatient-level care at home services, such as virtual wards and hospital at home, are being rapidly implemented. This is the first systematic review to link the components of these service delivery innovations to evidence of effectiveness to explore implications for practice and research.

METHODS

For this review (registered here https://osf.io/je39y ), we searched Cochrane-recommended multiple databases up to 30 November 2022 and additional resources for randomised and non-randomised studies that compared technology-enabled inpatient-level care at home with hospital-based inpatient care. We classified interventions into care model groups using three key components: clinical activities, workforce, and technology. We synthesised evidence by these groups quantitatively or narratively for mortality, hospital readmissions, cost-effectiveness and length of stay.

RESULTS

We include 69 studies: 38 randomised studies (6413 participants; largely judged as low or unclear risk of bias) and 31 non-randomised studies (31,950 participants; largely judged at serious or critical risk of bias). The 69 studies described 63 interventions which formed eight model groups. Most models, regardless of using low- or high-intensity technology, may have similar or reduced hospital readmission risk compared with hospital-based inpatient care (low-certainty evidence from randomised trials). For mortality, most models had uncertain or unavailable evidence. Two exceptions were low technology-enabled models that involve hospital- and community-based professionals, they may have similar mortality risk compared with hospital-based inpatient care (low- or moderate-certainty evidence from randomised trials). Cost-effectiveness evidence is unavailable for high technology-enabled models, but sparse evidence suggests the low technology-enabled multidisciplinary care delivered by hospital-based teams appears more cost-effective than hospital-based care for those with chronic obstructive pulmonary disease (COPD) exacerbations.

CONCLUSIONS

Low-certainty evidence suggests that none of technology-enabled care at home models we explored put people at higher risk of readmission compared with hospital-based care. Where limited evidence on mortality is available, there appears to be no additional risk of mortality due to use of technology-enabled at home models. It is unclear whether inpatient-level care at home using higher levels of technology confers additional benefits. Further research should focus on clearly defined interventions in high-priority populations and include comparative cost-effectiveness evaluation.

TRIAL REGISTRATION

https://osf.io/je39y .

Admission avoidance hospital at home

BACKGROUND

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.

OBJECTIVES

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

SEARCH METHODS

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.

SELECTION CRITERIA

Randomised controlled trials recruiting participants aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital inpatient care.

DATA COLLECTION AND ANALYSIS

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.

MAIN RESULTS

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.

AUTHORS' CONCLUSIONS

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.

Developing new hospital-at-home models based on Comprehensive Geriatric Assessment: Implementation recommendations by the Working Group on Hospital-at-Home and Community Geriatrics of the Catalan Society of Geriatrics and Gerontology

Last decade, the Government of Catalonia have urged an integrated care strategy for planning the care model to older populations living with frailty, multimorbidity and advanced illnesses. Based on international evidence that was reviewed by a group of experts from the Catalan Society of Gerontology and Geriatrics, we summarised some recommendation to adapt hospital-at-home care to older populations in our system. We defined Comprehensive Geriatric Assessment (CGA) hospital-at-home (HaH) as a specialised home hospitalisation service formed by interdisciplinary teams, characterised by using the clinical methodology of CGA, and by adapting geriatric units' protocols for the provision of person-centred care at home. Main benefits of CGA-HaH in these populations are: response to heath crises according to individualised care plans based on the situational diagnosis carried out by Primary Care teams; provision of a comprehensive health and social approach tailored to the complexity of cases and situations; and adaptation of multipurpose hospitalisation, by working on different person-centred care, aspects, such as caregivers support on care provision, focusing on function or home adaptation.

A social network analysis to explore collaborative practice in home care: research protocol

Background

The conceptualization of the home as a care environment and maintaining a high standard of care requires different professionals to collaborate. This study will explore collaborative practice in home care, needs and expectations of the stakeholders involved, and identify their roles and tasks. Secondly, it will investigate possible strategies to improve home care management and, more particularly, optimize collaborative practice in home care.

Methods

The study will be conducted during three distinct consecutive phases, within a multiphase mixed-methods design. Phase 1 will use a quantitative approach in which a social network analysis will be conducted to have an overview of collaborative practice in home care in French-speaking Switzerland. Phases 2 and 3 will be qualitative and focus on three different situations involving different locations (rural and urban) and different home care functioning (home care provided by agencies and home care providing by independent caregivers). In each situation, semi-structured interviews will be conducted with home care recipients and their home caregivers. In phase 2, results of phase 1’s network analysis will be discussed, such as roles, needs, and expectations of all stakeholders involved in home care. In phase 3, phase 2’s findings will be discussed and strategies to improve home care and to optimize collaborative practice will be explored.

Discussion

Over the past years, home care has grown considerably. Therefore, more and more different caregivers are involved in the recipients' homes. Since optimal coordination between these different caregivers is a prerequisite for quality and safe care, it is essential to investigate the existing collaborative practice and how it is functioning. This study will provide knowledge on roles, needs and expectations of different caregivers involved in home care. It will also allow for strategies to optimize collaborative practice and thus ensure comprehensive care for recipients. Finally, it will serve as a basis for future studies that can be conducted to address identified needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08548-4.

Effect of home-based interventions on basic activities of daily living for patients who had a stroke: a systematic review with meta-analysis

OBJECTIVES

To investigate the effectiveness of home-based interventions in improving the ability to do basic activities of daily living in patients who had a stroke.

METHODS

Randomised controlled trials were searched through MEDLINE, Embase and CINAHL from their inception to 31 December 2021. We included studies involving home-based intervention prescribed by professionals and implemented at patients' homes. The characteristics of these studies were collected. Risk of bias of individual study was assessed by Physiotherapy Evidence Database scale. Meta-analyses were performed where studies reported comparable interventions and outcomes.

RESULTS

In total, 49 studies were included in the systematic review and 16 studies had sufficient data for meta-analyses. The short-term effect of home-based intervention showed no significant difference when compared with institution-based intervention (standardised mean difference (SMD)=0.24, 95% CI -0.15 to 0.62, I²=0%). No significant difference was found between home-based intervention and usual care for long-term effect (SMD=0.02; 95% CI -0.17 to 0.22; I²=0%). Home-based rehabilitation combined with usual care showed a significant short-term effect on the ability to do basic daily activities, compared with usual care alone (SMD=0.55; 95% CI 0.22 to 0.87; p=0.001; I²=3%).

CONCLUSION

Home-based rehabilitation with usual care, which varied from no therapy to inpatient or outpatient therapy, may have a short-term effect on the ability to do basic activities of daily living for patients who had a stroke compared with usual care alone. However, the evidence quality is low because of the limited number of studies and participants included in the meta-analysis and the possible publication bias. Future research is needed to investigate the effectiveness of home-based rehabilitation in groups with stratification by stroke severity and time since stroke onset, with elaboration of details of the home-based and the control interventions. Moreover, more high-quality studies are required to prove the cost-effectiveness of newly developed strategies like caregiver-mediated rehabilitation and telerehabilitation.

THE PRIMARY SOURCE OF FUNDING

The Medical Research Fund of Guangdong Province (No: A2021041).

Organization of rehabilitation services in randomized controlled trials - which factors influence functional outcome? A systematic review

Objective

To identify factors related to the organization of rehabilitation services that may influence patients’ functional outcome and make recommendations for categories to be used in the reporting of rehabilitation interventions.

Data Sources

A systematic review based on a search in MEDLINE indexed journals (MEDLINE [OVID], Cumulative Index of Nursing and Allied Health Literature, PsycINFO, Cochrane Central Register of Controlled Trials) until June 2019.

Study Selection

In total 8587 candidate randomized controlled trials reporting on organizational factors of multidisciplinary rehabilitation interventions and their associations with functional outcome. An additional 1534 trials were identified from June 2019 to March 2021. Data Extraction: Quality evaluation was conducted by 2 independent researchers. The organizational factors were classified according to the International Classification for Service Organization in Health-related Rehabilitation 2.0.

Data Synthesis

In total 80 articles fulfilled the inclusion criteria. There was a great heterogeneity in the terminology and reporting of service organization across all studies. Aspects of Settings including the Mode of Service Delivery was the most explicitly analyzed organizational category (44 studies). The importance of the integration of rehabilitation in the inpatient services was supported. Furthermore, several studies documented a lack of difference in outcome between outpatient vs inpatient service delivery. Patient Centeredness, Integration of Care, and Time and Intensity factors were also analyzed, but heterogeneity of interventions in these studies prohibited aggregation of results.

Conclusions

Settings and in particular the way the services were delivered to the users influenced functional outcome. Hence, it should be compulsory to include a standardized reporting of aspects of service delivery in clinical trials. We would also advise further standardization in the description of organizational factors in rehabilitation interventions to build knowledge of effective service organization.

Virtual Behavioral Medicine Program: A Novel Model of Care for Neuropsychiatric Symptoms in Dementia

BACKGROUND

Patients with severe neuropsychiatric symptoms (NPS) due to dementia are often uprooted from their familiar environments in long-term care or the community and transferred to emergency departments, acute care hospitals, or specialized behavioral units which can exacerbate NPS. To address this issue, we developed the Virtual Behavioral Medicine Program (VBM), an innovative model of virtual care designed to support management of patients with NPS in their own environment.

OBJECTIVE

To determine efficacy of VBM in reducing admission to a specialized inpatient neurobehavioral unit for management of NPS.

METHODS

We reviewed outcomes in the first consecutive 95 patients referred to VBM. Referrals were classified into two groups. In one group, patients were referred to VBM with a simultaneous application to an inpatient Behavioral Neurology Unit (BNU). The other group was referred only to VBM. The primary outcome was reduction in proportion of patients requiring admission to the BNU regardless of whether they were referred to the BNU or to VBM alone.

RESULTS

For patients referred to VBM plus the BNU, the proportion needing admission to the BNU was reduced by 60.42%. For patients referred to VBM alone, it was 68.75%.

CONCLUSION

VBM is a novel virtual neurobehavioral unit for treatment of NPS. Although the sample size was relatively small, especially for the VBM group, the data suggest that this program is a game changer that can reduce preventable emergency department visits and acute care hospital admissions. VBM is a scalable model of virtual care that can be adopted worldwide.

Health, social care and technological interventions to improve functional ability of older adults living at home: An evidence and gap map

Background

By 2030, the global population of people older than 60 years is expected to be higher than the number of children under 10 years, resulting in major health and social care system implications worldwide. Without a supportive environment, whether social or built, diminished functional ability may arise in older people. Functional ability comprises an individual's intrinsic capacity and people's interaction with their environment enabling them to be and do what they value.

Objectives

This evidence and gap map aims to identify primary studies and systematic reviews of health and social support services as well as assistive devices designed to support functional ability among older adults living at home or in other places of residence.

Search Methods

We systematically searched from inception to August 2018 in: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL, PsycINFO, AgeLine, Campbell Library, ASSIA, Social Science Citation Index and Social Policy & Practice. We conducted a focused search for grey literature and protocols of studies (e.g., ProQuest Theses and Dissertation Global, conference abstract databases, Help Age, PROSPERO, Cochrane and Campbell libraries and ClinicalTrials.gov).

Selection Criteria

Screening and data extraction were performed independently in duplicate according to our intervention and outcome framework. We included completed and on-going systematic reviews and randomized controlled trials of effectiveness on health and social support services provided at home, assistive products and technology for personal indoor and outdoor mobility and transportation as well as design, construction and building products and technology of buildings for private use such as wheelchairs, and ramps.

Data Collection and Analysis

We coded interventions and outcomes, and the number of studies that assessed health inequities across equity factors. We mapped outcomes based on the International Classification of Function, Disability and Health (ICF) adapted categories: intrinsic capacities (body function and structures) and functional abilities (activities). We assessed methodological quality of systematic reviews using the AMSTAR II checklist.

Main Results

After de-duplication, 10,783 records were screened. The map includes 548 studies (120 systematic reviews and 428 randomized controlled trials). Interventions and outcomes were classified using domains from the International Classification of Function, Disability and Health (ICF) framework. Most systematic reviews (n = 71, 59%) were rated low or critically low for methodological quality.The most common interventions were home-based rehabilitation for older adults (n = 276) and home-based health services for disease prevention (n = 233), mostly delivered by visiting healthcare professionals (n = 474). There was a relative paucity of studies on personal mobility, building adaptations, family support, personal support and befriending or friendly visits. The most measured intrinsic capacity domains were mental function (n = 269) and neuromusculoskeletal function (n = 164). The most measured outcomes for functional ability were basic needs (n = 277) and mobility (n = 160). There were few studies which evaluated outcome domains of social participation, financial security, ability to maintain relationships and communication.There was a lack of studies in low- and middle-income countries (LMICs) and a gap in the assessment of health equity issues.

Authors' Conclusions

There is substantial evidence for interventions to promote functional ability in older adults at home including mostly home-based rehabilitation for older adults and home-based health services for disease prevention. Remotely delivered home-based services are of greater importance to policy-makers and practitioners in the context of the COVID-19 pandemic. This map of studies published prior to the pandemic provides an initial resource to identify relevant home-based services which may be of interest for policy-makers and practitioners, such as home-based rehabilitation and social support, although these interventions would likely require further adaptation for online delivery during the COVID-19 pandemic. There is a need to strengthen assessment of social support and mobility interventions and outcomes related to making decisions, building relationships, financial security, and communication in future studies. More studies are needed to assess LMIC contexts and health equity issues.

Hospital-at-Home Interventions vs In-Hospital Stay for Patients With Chronic Disease Who Present to the Emergency Department: A Systematic Review and Meta-analysis

Importance

Hospitalizations are costly and may lead to adverse events; hospital-at-home interventions could be a substitute for in-hospital stays, particularly for patients with chronic diseases who use health services more than other patients. Despite showing promising results, heterogeneity in past systematic reviews remains high.

Objective

To systematically review and assess the association between patient outcomes and hospital-at-home interventions as a substitute for in-hospital stay for community-dwelling patients with a chronic disease who present to the emergency department and are offered at least 1 home visit from a nurse and/or physician.

Data Sources

Databases were searched from date of inception to March 4, 2019. The databases were Ovid MEDLINE, Ovid Embase, Ovid PsycINFO, CINAHL, Health Technology Assessment, the Cochrane Library, OVID Allied and Complementary Medicine Database, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov.

Study Selection

Randomized clinical trials in which the experimental group received hospital-at-home interventions and the control group received the usual in-hospital care. Patients were 18 years or older with a chronic disease who presented to the emergency department and received home visits from a nurse or physician.

Data Extraction and Synthesis

Risk of bias was assessed, and a meta-analysis was conducted for outcomes that were reported by at least 2 studies using comparable measures. Risk ratios (RRs) were reported for binary outcomes and mean differences for continuous outcomes. Narrative synthesis was performed for other outcomes.

Main Outcomes and Measures

Outcomes of interest were patient outcomes, which included mortality, long-term care admission, readmission, length of treatment, out-of-pocket costs, depression and anxiety, quality of life, patient satisfaction, caregiver stress, cognitive status, nutrition, morbidity due to hospitalization, functional status, and neurological deficits.

Results

Nine studies were included, providing data on 959 participants (median age, 71.0 years [interquartile range, 70.0-79.9 years]; 613 men [63.9%]; 346 women [36.1%]). Mortality did not differ between the hospital-at-home and the in-hospital care groups (RR, 0.84; 95% CI, 0.61-1.15; I2 = 0%). Risk of readmission was lower (RR, 0.74; 95% CI, 0.57-0.95; I2 = 31%) and length of treatment was longer in the hospital-at-home group than in the in-hospital group (mean difference, 5.45 days; 95% CI, 1.91-8.97 days; I2 = 87%). In addition, the hospital-at-home group had a lower risk of long-term care admission than the in-hospital care group (RR, 0.16; 95% CI, 0.03-0.74; I2 = 0%). Patients who received hospital-at-home interventions had lower depression and anxiety than those who remained in-hospital, but there was no difference in functional status. Other patient outcomes showed mixed results.

Conclusions and Relevance

The results of this systematic review and meta-analysis suggest that hospital-at-home interventions represent a viable substitute to an in-hospital stay for patients with chronic diseases who present to the emergency department and who have at least 1 visit from a nurse or physician. Although the heterogeneity of the findings remained high for some outcomes, particularly for length of treatment, the heterogeneity of this study was comparable to that of past reviews and further explored.

The unique role of the social worker within the Hospital at Home care delivery team

Hospital at Home (HaH) provides acute, hospital-level care at home and post-discharge follow-up. Through a review of 293 HaH admissions conducted by an urban, multidisciplinary HaH program from 2014 to 2017, we find that the social worker is involved in 71% of admissions and plays a crucial role in pre-emergency department discharge home care and safety screening, home intake, follow-up support, and transition of care to primary care providers and community-based services. We describe the social work activities involved in this model of care and present composite case studies for further illustration.

Comparison of Hospital-at-Home models: a systematic review of reviews

OBJECTIVES

To provide an overview of the safety and effectiveness of Hospital-at-Home (HaH) according to programme type (early-supported discharge (ESD) vs admission avoidance (AA)), and identify the model with higher evidence for addressing clinical, length of stay (LOS) and cost outcomes.

METHODS

A systematic review of reviews was conducted by performing a search on PubMed, EMBASE, Cochrane Database of Systematic Reviews, Web of Science and Scopus (January 2005 to June 2020) for English-language systematic reviews evaluating HaH. Data on primary outcomes (mortality, readmissions, costs, LOS), secondary outcomes (patient/caregiver outcomes) and process indicators were extracted. Quality of the reviews was assessed using Assessment of Multiple Systematic Reviews-2. There was no registered protocol.

RESULTS

Ten systematic reviews were identified (four high quality, five moderate quality and one low quality). The reviews were classified according to three use cases. ESD reviews generally revealed comparable mortality (RR 0.92-1.03) and readmissions (RR 1.09-1.25) to inpatient care, shorter hospital LOS (MD -6.76 to -4.44 days) and unclear findings for costs. AA reviews observed a trend towards lower mortality (RR 0.77, 95% CI 0.54 to 1.09) and costs, and comparable or lower readmissions (RR 0.68-0.98). Among reviews including both programme types (ESD/AA), chronic obstructive pulmonary disease reviews revealed lower mortality (RR 0.65-0.68) and post-HaH readmissions (RR 0.74-0.76) but unclear findings for resource use.

CONCLUSION

For suitable patients, HaH generally results in similar or improved clinical outcomes compared with inpatient treatment, and warrants greater attention in health systems facing capacity constraints and rising costs. Preliminary comparisons suggest prioritisation of AA models over ESD due to potential benefits in costs and clinical outcomes. Nonetheless, future research should clarify costs of HaH programmes given the current low-quality evidence, as well as address evidence gaps pertaining to caregiver outcomes and adverse events under HaH care.

What are physiotherapists and occupational therapists doing in services that replace acute hospital admission? A systematic review

BACKGROUND

Alternatives to acute hospital admission are required to accommodate the increasing pressures on health services. Since physiotherapists and occupational therapists are integral to inpatient teams, they may also be integral to admission replacement services, and thus their roles in these services merit investigation.

AIMS

Primarily to determine the presence and roles of physiotherapists and occupational therapists in services replacing acute hospital admission. The secondary outcome is to determine the impact of therapists in such services.

METHODS

Five electronic databases were searched, with keywords related to therapy, discharge, and admission replacement. Inclusion criteria were that studies explicitly described at least one therapist role within a service replacing acute hospital admissions. Two authors independently reviewed all potentially eligible studies. Two reviewers independently assessed data extracted from included studies into a standardized data extraction form.

RESULTS

Fifteen studies (3 Hospital at Home, 12 Early Supported Discharge) were included. Both clinical (eg, exercise prescription) and non-clinical (eg, organization and study outcome assessments) therapist roles were described in different admission substitution services. Some roles were only reported among teams, not individually ascribed to therapists.

CONCLUSIONS

The roles of therapists in services that replace hospital admission are rarely described in detail, with wide variation in reported roles, including across service types and patient populations. This review could not determine the impact of individual therapists on patient or service-level outcomes. Future studies need to more clearly define therapist roles and impact.

Organised inpatient (stroke unit) care for stroke: network meta-analysis

BACKGROUND

Organised inpatient (stroke unit) care is provided by multi-disciplinary teams that manage stroke patients. This can been provided in a ward dedicated to stroke patients (stroke ward), with a peripatetic stroke team (mobile stroke team), or within a generic disability service (mixed rehabilitation ward). Team members aim to provide co-ordinated multi-disciplinary care using standard approaches to manage common post-stroke problems.

OBJECTIVES

• To assess the effects of organised inpatient (stroke unit) care compared with an alternative service. • To use a network meta-analysis (NMA) approach to assess different types of organised inpatient (stroke unit) care for people admitted to hospital after a stroke (the standard comparator was care in a general ward). Originally, we conducted this systematic review to clarify: • The characteristic features of organised inpatient (stroke unit) care? • Whether organised inpatient (stroke unit) care provide better patient outcomes than alternative forms of care? • If benefits are apparent across a range of patient groups and across different approaches to delivering organised stroke unit care? Within the current version, we wished to establish whether previous conclusions were altered by the inclusion of new outcome data from recent trials and further analysis via NMA.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (2 April 2019); the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 4), in the Cochrane Library (searched 2 April 2019); MEDLINE Ovid (1946 to 1 April 2019); Embase Ovid (1974 to 1 April 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 2 April 2019). In an effort to identify further published, unpublished, and ongoing trials, we searched seven trial registries (2 April 2019). We also performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists.

SELECTION CRITERIA

Randomised controlled clinical trials comparing organised inpatient stroke unit care with an alternative service (typically contemporary conventional care), including comparing different types of organised inpatient (stroke unit) care for people with stroke who are admitted to hospital.

DATA COLLECTION AND ANALYSIS

Two review authors assessed eligibility and trial quality. We checked descriptive details and trial data with co-ordinators of the original trials, assessed risk of bias, and applied GRADE. The primary outcome was poor outcome (death or dependency (Rankin score 3 to 5) or requiring institutional care) at the end of scheduled follow-up. Secondary outcomes included death, institutional care, dependency, subjective health status, satisfaction, and length of stay. We used direct (pairwise) comparisons to compare organised inpatient (stroke unit) care with an alternative service. We used an NMA to confirm the relative effects of different approaches.

MAIN RESULTS

We included 29 trials (5902 participants) that compared organised inpatient (stroke unit) care with an alternative service: 20 trials (4127 participants) compared organised (stroke unit) care with a general ward, six trials (982 participants) compared different forms of organised (stroke unit) care, and three trials (793 participants) incorporated more than one comparison. Compared with the alternative service, organised inpatient (stroke unit) care was associated with improved outcomes at the end of scheduled follow-up (median one year): poor outcome (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.69 to 0.87; moderate-quality evidence), death (OR 0.76, 95% CI 0.66 to 0.88; moderate-quality evidence), death or institutional care (OR 0.76, 95% CI 0.67 to 0.85; moderate-quality evidence), and death or dependency (OR 0.75, 95% CI 0.66 to 0.85; moderate-quality evidence). Evidence was of very low quality for subjective health status and was not available for patient satisfaction. Analysis of length of stay was complicated by variations in definition and measurement plus substantial statistical heterogeneity (I² = 85%). There was no indication that organised stroke unit care resulted in a longer hospital stay. Sensitivity analyses indicated that observed benefits remained when the analysis was restricted to securely randomised trials that used unequivocally blinded outcome assessment with a fixed period of follow-up. Outcomes appeared to be independent of patient age, sex, initial stroke severity, stroke type, and duration of follow-up. When calculated as the absolute risk difference for every 100 participants receiving stroke unit care, this equates to two extra survivors, six more living at home, and six more living independently. The analysis of different types of organised (stroke unit) care used both direct pairwise comparisons and NMA. Direct comparison of stroke ward versus general ward: 15 trials (3523 participants) compared care in a stroke ward with care in general wards. Stroke ward care showed a reduction in the odds of a poor outcome at the end of follow-up (OR 0.78, 95% CI 0.68 to 0.91; moderate-quality evidence). Direct comparison of mobile stroke team versus general ward: two trials (438 participants) compared care from a mobile stroke team with care in general wards. Stroke team care may result in little difference in the odds of a poor outcome at the end of follow-up (OR 0.80, 95% CI 0.52 to 1.22; low-quality evidence). Direct comparison of mixed rehabilitation ward versus general ward: six trials (630 participants) compared care in a mixed rehabilitation ward with care in general wards. Mixed rehabilitation ward care showed a reduction in the odds of a poor outcome at the end of follow-up (OR 0.65, 95% CI 0.47 to 0.90; moderate-quality evidence). In a NMA using care in a general ward as the comparator, the odds of a poor outcome were as follows: stroke ward - OR 0.74, 95% CI 0.62 to 0.89, moderate-quality evidence; mobile stroke team - OR 0.88, 95% CI 0.58 to 1.34, low-quality evidence; mixed rehabilitation ward - OR 0.70, 95% CI 0.52 to 0.95, low-quality evidence.

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that stroke patients who receive organised inpatient (stroke unit) care are more likely to be alive, independent, and living at home one year after the stroke. The apparent benefits were independent of patient age, sex, initial stroke severity, or stroke type, and were most obvious in units based in a discrete stroke ward. We observed no systematic increase in the length of inpatient stay, but these findings had considerable uncertainty.

Systematic Review and Meta-Analysis of Home-Based Rehabilitation on Improving Physical Function Among Home-Dwelling Patients With a Stroke

OBJECTIVE

To evaluate the effects of home-based rehabilitation on improving physical function in home-dwelling patients after a stroke.

DATA SOURCES

Various electronic databases, including PubMed, Cumulative Index to Nursing and Allied Health, Embase, the Cochrane Central Register of Controlled Trials, and 2 Chinese data sets (ie, Chinese Electronic Periodical Services and China Knowledge Resource Integrated) were searched for studies published before March 20, 2019.

STUDY SELECTION

Randomized controlled trials conducted to examine the effect of home-based rehabilitation on improving physical function in home-dwelling patients with a stroke and published in English or Chinese were included. In total, 49 articles in English (n=23) and Chinese (n=26) met the inclusion criteria.

DATA EXTRACTION

Data related to patient characteristics, study characteristics, intervention details, and outcomes were extracted by 2 independent reviewers.

DATA SYNTHESIS

A random-effects model with a sensitivity analysis showed that home-based rehabilitation exerted moderate improvements on physical function in home-dwelling patients with a stroke (g=0.58; 95% CI, 0.45∼0.70). Moderator analyses revealed that those patients with stroke of a younger age, of male sex, with a first-ever stroke episode, in the acute stage, and receiving rehabilitation training from their caregiver showed greater improvements in physical function.

CONCLUSIONS

Home rehabilitation can improve functional outcome in survivors of stroke and should be considered appropriate during discharge planning if continuation care is required.

Early supported discharge services for people with acute stroke

BACKGROUND

People with stroke conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed that offer people in hospital an early discharge with rehabilitation at home (early supported discharge: ESD).

OBJECTIVES

To establish if, in comparison with conventional care, services that offer people in hospital with stroke a policy of early discharge with rehabilitation provided in the community (ESD) can: 1) accelerate return home, 2) provide equivalent or better patient and carer outcomes, 3) be acceptable satisfactory to patients and carers, and 4) have justifiable resource implications use.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (January 2017), Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1) in the Cochrane Library (searched January 2017), MEDLINE in Ovid (searched January 2017), Embase in Ovid (searched January 2017), CINAHL in EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to December 2016), and Web of Science (to January 2017). In an effort to identify further published, unpublished, and ongoing trials we searched six trial registries (March 2017). We also performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists.

SELECTION CRITERIA

Randomised controlled trials (RCTs) recruiting stroke patients in hospital to receive either conventional care or any service intervention that has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care.

DATA COLLECTION AND ANALYSIS

The primary patient outcome was the composite end-point of death or long-term dependency recorded at the end of scheduled follow-up. Two review authors scrutinised trials, categorised them on their eligibility and extracted data. Where possible we sought standardised data from the primary trialists. We analysed the results for all trials and for subgroups of patients and services, in particular whether the intervention was provided by a co-ordinated multidisciplinary team (co-ordinated ESD team) or not. We assessed risk of bias for the included trials and used GRADE to assess the quality of the body of evidence.

MAIN RESULTS

We included 17 trials, recruiting 2422 participants, for which outcome data are currently available. Participants tended to be a selected elderly group of stroke survivors with moderate disability. The ESD group showed reductions in the length of hospital stay equivalent to approximately six days (mean difference (MD) -5.5; 95% confidence interval (CI) -3 to -8 days; P < 0.0001; moderate-grade evidence). The primary outcome was available for 16 trials (2359 participants). Overall, the odds ratios (OR) for the outcome of death or dependency at the end of scheduled follow-up (median 6 months; range 3 to 12) was OR 0.80 (95% CI 0.67 to 0.95, P = 0.01, moderate-grade evidence) which equates to five fewer adverse outcomes per 100 patients receiving ESD. The results for death (16 trials; 2116 participants) and death or requiring institutional care (12 trials; 1664 participants) were OR 1.04 (95% CI 0.77 to 1.40, P = 0.81, moderate-grade evidence) and OR 0.75 (95% CI 0.59 to 0.96, P = 0.02, moderate-grade evidence), respectively. Small improvements were also seen in participants' extended activities of daily living scores (standardised mean difference (SMD) 0.14, 95% CI 0.03 to 0.25, P = 0.01, low-grade evidence) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, P = 0.02, low-grade evidence). We saw no clear differences in participants' activities of daily living scores, patients subjective health status or mood, or the subjective health status, mood or satisfaction with services of carers. We found low-quality evidence that the risk of readmission to hospital was similar in the ESD and conventional care group (OR 1.09, 95% CI 0.79 to 1.51, P = 0.59, low-grade evidence). The evidence for the apparent benefits were weaker at one- and five-year follow-up. Estimated costs from six individual trials ranged from 23% lower to 15% greater for the ESD group in comparison to usual care.In a series of pre-planned analyses, the greatest reductions in death or dependency were seen in the trials evaluating a co-ordinated ESD team with a suggestion of poorer results in those services without a co-ordinated team (subgroup interaction at P = 0.06). Stroke patients with mild to moderate disability at baseline showed greater reductions in death or dependency than those with more severe stroke (subgroup interaction at P = 0.04).

AUTHORS' CONCLUSIONS

Appropriately resourced ESD services with co-ordinated multidisciplinary team input provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as reducing the length of hospital stay. Results are inconclusive for services without co-ordinated multidisciplinary team input. We observed no adverse impact on the mood or subjective health status of patients or carers, nor on readmission to hospital.

Admission avoidance hospital at home

BACKGROUND

Admission avoidance hospital at home provides active treatment by healthcare professionals in the patient's home for a condition that otherwise would require acute hospital inpatient care, and always for a limited time period. This is the third update of the original review.

OBJECTIVES

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

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, two other databases, and two trials registers on 2 March 2016. We checked the reference lists of eligible articles. We sought unpublished studies by contacting providers and researchers who were known to be involved in the field.

SELECTION CRITERIA

Randomised controlled trials recruiting participants aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital inpatient care.

DATA COLLECTION AND ANALYSIS

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 and reported comparable outcomes with sufficient data, requested individual patient data from trialists, and relied on published data when this was not available. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes.

MAIN RESULTS

We included 16 randomised controlled trials with a total of 1814 participants; three trials recruited participants with chronic obstructive pulmonary disease, two trials recruited participants recovering from a stroke, six trials recruited participants with an acute medical condition who were mainly elderly, 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. Admission avoidance hospital at home probably makes little or no difference on mortality at six months' follow-up (risk ratio (RR) 0.77, 95% confidence interval (CI) 0.60 to 0.99; P = 0.04; I2 = 0%; 912 participants; moderate-certainty evidence), little or no difference on the likelihood of being transferred (or readmitted) to hospital (RR 0.98, 95% CI 0.77 to 1.23; P = 0.84; I2 = 28%; 834 participants; moderate-certainty evidence), and may reduce the likelihood of living in residential care at six months' follow-up (RR 0.35, 95% CI 0.22 to 0.57; P < 0.0001; I2 = 78%; 727 participants; low-certainty evidence). Satisfaction with healthcare received may be improved with admission avoidance hospital at home (646 participants, low-certainty evidence); few studies reported the effect on caregivers. When the costs of informal care were excluded, admission avoidance hospital at home may be less expensive than admission to an acute hospital ward (287 participants, low-certainty evidence); there was variation in the reduction of hospital length of stay, estimates ranged from a mean difference of -8.09 days (95% CI -14.34 to -1.85) in a trial recruiting older people with varied health problems, to a mean increase of 15.90 days (95% CI 8.10 to 23.70) in a study that recruited patients recovering from a stroke.

AUTHORS' CONCLUSIONS

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 elderly patients requiring hospital admission. However, the evidence is limited by the small randomised controlled trials included in the review, which adds a degree of imprecision to the results for the main outcomes.

Cost-effectiveness of a Barcelona home care program for individuals with multimorbidity

To improve the efficiency and effectiveness of care and optimize healthcare resources, a home healthcare program was created for individuals with multiple chronic conditions. Demographic and clinical characteristics of the 261 individuals (mean age 84) included in the program from its inception in 2011 through 2013 (mean stay in the program 203±192 days) were prospectively analyzed. The number of hospital admissions, length of stay, and costs for individuals admitted to the program were compared for two time periods: the 6 months before admission to the program and their stay in the program. After admission to the program, the number of hospital admissions and the hospital length of stay per person per month decreased from 0.36±0.21 to 0.19±0.52 (P<.001) and from 3.5 to 1 day (P<.001), respectively. Surveys of randomly selected patients and caregivers showed high satisfaction with the program. Costs per person per day decreased from €54.65 (US$73.12) to €17.91 (US$23.96), a reduction of 67.1%. Fewer admissions and shorter hospital stays enabled the hospital to eliminate one acute bed for every 50 individuals admitted to the program. In conclusion, home care for individuals with chronic illness with multimorbidity reduced the number of hospital admissions and length of stay, resulting in good patient satisfaction and lower costs.

Stroke rehabilitation at home before and after discharge reduced disability and improved quality of life: a randomised controlled trial

OBJECTIVE

To evaluate if home-based rehabilitation of inpatients improved outcome compared to standard care.

DESIGN

Interventional, randomised, safety/efficacy open-label trial.

SETTING

University hospital stroke unit in collaboration with three municipalities.

SUBJECTS

Seventy-one eligible stroke patients (41 women) with focal neurological deficits hospitalised in a stroke unit for more than three days and in need of rehabilitation.

INTERVENTIONS

Thirty-eight patients were randomised to home-based rehabilitation during hospitalization and for up to four weeks after discharge to replace part of usual treatment and rehabilitation services. Thirty-three control patients received treatment and rehabilitation following usual guidelines for the treatment of stroke patients.

MAIN MEASURES

Ninety days post-stroke the modified Rankin Scale score was the primary endpoint. Other outcome measures were the modified Barthel-100 Index, Motor Assessment Scale, CT-50 Cognitive Test, EuroQol-5D, Body Mass Index and treatment-associated economy.

RESULTS

Thirty-one intervention and 30 control patients completed the study. Patients in the intervention group achieved better modified Rankin Scale score (Intervention median = 2, IQR = 2-3; Control median = 3, IQR = 2-4; P=0.04). EuroQol-5D quality of life median scores were improved in intervention patients (Intervention median = 0.77, IQR = 0.66-0.79; Control median = 0.66, IQR = 0.56 - 0.72; P=0.03). The total amount of home-based training in minutes highly correlated with mRS, Barthel, Motor Assessment Scale and EuroQol-5D™ scores (P-values ranging from P<0.00001 to P=0.01). Economical estimations of intervention costs were lower than total costs of standard treatment.

CONCLUSION

Early home-based rehabilitation reduced disability and increased quality of life. Compared to standard care, home-based stroke rehabilitation was more cost-effective.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

Organised inpatient (stroke unit) care for stroke

BACKGROUND

Organised stroke unit care is provided by multidisciplinary teams that exclusively manage stroke patients in a ward dedicated to stroke patients, with a mobile stroke team or within a generic disability service (mixed rehabilitation ward).

OBJECTIVES

To assess the effect of stroke unit care compared with alternative forms of care for people following a stroke.

SEARCH METHODS

We searched the trials registers of the Cochrane Stroke Group (January 2013) and the Cochrane Effective Practice and Organisation of Care (EPOC) Group (January 2013), MEDLINE (2008 to September 2012), EMBASE (2008 to September 2012) and CINAHL (1982 to September 2012). In an effort to identify further published, unpublished and ongoing trials, we searched 17 trial registers (January 2013), performed citation tracking of included studies, checked reference lists of relevant articles and contacted trialists.

SELECTION CRITERIA

Randomised controlled clinical trials comparing organised inpatient stroke unit care with an alternative service. After formal risk of bias assessment, we have now excluded previously included quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors initially assessed eligibility and trial quality. We checked descriptive details and trial data with the co-ordinators of the original trials.

MAIN RESULTS

We included 28 trials, involving 5855 participants, comparing stroke unit care with an alternative service. More-organised care was consistently associated with improved outcomes. Twenty-one trials (3994 participants) compared stroke unit care with care provided in general wards. Stroke unit care showed reductions in the odds of death recorded at final (median one year) follow-up (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.69 to 0.94; P = 0.005), the odds of death or institutionalised care (OR 0.78, 95% CI 0.68 to 0.89; P = 0.0003) and the odds of death or dependency (OR 0.79, 95% CI 0.68 to 0.90; P = 0.0007). Sensitivity analyses indicated that the observed benefits remained when the analysis was restricted to securely randomised trials that used unequivocally blinded outcome assessment with a fixed period of follow-up. Outcomes were independent of patient age, sex, initial stroke severity or stroke type, and appeared to be better in stroke units based in a discrete ward. There was no indication that organised stroke unit care resulted in a longer hospital stay.

AUTHORS' CONCLUSIONS

Stroke patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke. The benefits were most apparent in units based in a discrete ward. We observed no systematic increase in the length of inpatient stay.

Should alternatives to conventional hospitalisation be promoted in an era of financial constraint?

BACKGROUND

Because the current economic crisis has led to austerity in health policies, with severe restrictions on public health care, avoiding unnecessary admissions and shortening hospital stays is rapidly becoming an urgent priority. Alternatives to hospitalisation replace or shorten hospital processes, including diagnosis, monitoring, treatment and follow-up. This review aims to present the available evidence on alternatives to conventional hospitalisation for medical disorders; options for surgery, psychiatry and palliative care are largely excluded.

MATERIALS AND METHODS

Narrative review.

RESULTS

The main alternatives to conventional hospitalisation include day centres (DC), quick diagnosis units (QDU), hospital at home (HaH) and, in some circumstances, telemonitoring. DC increase patient comfort, reduce costs and can improve efficiency. In generally healthy patients with suspected severe disease, QDU may be a good alternative to hospitalisation for diagnostic procedures. However, their cost-effectiveness remains to be clearly proven. Randomised controlled trials have shown that hospital-at-home (HaH) can lead to earlier hospital discharges, improve outcomes and reduce costs in patients with prevalent chronic diseases. Although telemonitoring seems to be promising and its use is increasing, methodologically sounder studies with a higher level of evidence are needed to assess its clinical effectiveness.

CONCLUSIONS

Factors such as ageing, the need for an earlier diagnosis of suspected severe disease, the increasing complexity of medical care and the increasing costs of hospitalisation mean that, whenever possible, giving priority to less expensive alternatives to hospital admission, such as QDU, DC, HaH and telemedicine, is an urgent task in the current economic crisis.

A meta-analysis of "hospital in the home"

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.

Services for reducing duration of hospital care for acute stroke patients

BACKGROUND

Stroke patients conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed which offer patients in hospital an early discharge with rehabilitation at home (early supported discharge (ESD)).

OBJECTIVES

To establish the effects and costs of ESD services compared with conventional services.

SEARCH METHODS

We searched the trials registers of the Cochrane Stroke Group (January 2012) and the Cochrane Effective Practice and Organisation of Care (EPOC) Group, MEDLINE (2008 to 7 February 2012), EMBASE (2008 to 7 February 2012) and CINAHL (1982 to 7 February 2012). In an effort to identify further published, unpublished and ongoing trials we searched 17 trial registers (February 2012), performed citation tracking of included studies, checked reference lists of relevant articles and contacted trialists.

SELECTION CRITERIA

Randomised controlled trials recruiting stroke patients in hospital to receive either conventional care or any service intervention which has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care.

DATA COLLECTION AND ANALYSIS

The primary patient outcome was the composite end-point of death or long-term dependency recorded at the end of scheduled follow-up. Two review authors scrutinised trials and categorised them on their eligibility. We then sought standardised individual patient data from the primary trialists. We analysed the results for all trials and for subgroups of patients and services, in particular whether the intervention was provided by a co-ordinated multidisciplinary team (co-ordinated ESD team) or not.

MAIN RESULTS

Outcome data are currently available for 14 trials (1957 patients). Patients tended to be a selected elderly group with moderate disability. The ESD group showed significant reductions (P < 0.0001) in the length of hospital stay equivalent to approximately seven days. Overall, the odds ratios (OR) (95% confidence interval (CI)) for death, death or institutionalisation, death or dependency at the end of scheduled follow-up were OR 0.91 (95% CI 0.67 to 1.25, P = 0.58), OR 0.78 (95% CI 0.61 to 1.00, P = 0.05) and OR 0.80 (95% CI 0.67 to 0.97, P = 0.02) respectively. The greatest benefits were seen in the trials evaluating a co-ordinated ESD team and in stroke patients with mild to moderate disability. Improvements were also seen in patients' extended activities of daily living scores (standardised mean difference 0.12, 95% CI 0.00 to 0.25, P = 0.05) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, P = 0.02) but no statistically significant differences were seen in carers' subjective health status, mood or satisfaction with services. The apparent benefits were no longer statistically significant at five-year follow-up.

AUTHORS' CONCLUSIONS

Appropriately resourced ESD services provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as reducing the length of hospital stay. We observed no adverse impact on the mood or subjective health status of patients or carers.

Patients with uncomplicated diverticulitis and comorbidity can be treated at home

BACKGROUND

Patients with uncomplicated diverticulitis and comorbidity are usually hospitalized. We analyze the efficacy and safety of treating these patients in Hospital at Home.

METHODS

Prospective study since January 2007 to December 2009. Patients were transferred to the Hospital at Home after 12-24h at Emergency Department Observation Ward. All patients were treated with intravenous antibiotic until clinical condition improved.

RESULTS

176 patients were diagnosed with uncomplicated diverticulitis at the Emergency Department. 18% of them (33) had comorbidity. Twenty four patients were transferred to the Hospital at Home (seventeen patients had cardiopathy, four diabetes mellitus and three chronic renal failure). Mean age was 73.4 years. All patients had abdominal pain and 29.1% fever; 45.8% presented with leucocytosis. 20.8% had a previous history of diverticulitis. Mean stay of patients was 9 days. All patients had a favorable course. The home treatment was successfully completed in 100% of patients. 95% of the patients expressed their satisfaction with this type of treatment.

CONCLUSIONS

Treatment of patients with uncomplicated diverticulitis and comorbidity at home after a short period of observation in Hospital is safe and effective.

Delirium in elderly home-treated patients: a prospective study with 6-month follow-up

Delirium usually occurs during hospitalisation. The aims of this study were to evaluate the incidence of delirium in "hospital-at-home" compared to a traditional hospital ward and to assess mortality, hospital readmissions and institutionalisation rates at 6-month follow-up in elderly patients with intermediate/high risk for delirium at baseline according to the criteria of Inouye. We performed a prospective, non-randomised, observational study with 6-month follow-up on 144 subjects aged 75 years and older consecutively admitted to the hospital for an acute illness and followed in a geriatric hospital ward (GHW) or in a geriatric home hospitalisation service (GHHS). Baseline socio-demographic information, clinical data, functional, cognitive, nutritional status, mood, quality of life, and caregiver's stress scores were collected. Of the 144 participants, 14 (9.7%) had delirium during their initial hospitalisation: 4 were treated by GHHS and 10 in a GHW. The incidence of delirium was 16.6% in GHW and 4.7% in GHHS. All delirious patients were very old, with a high risk for delirium at baseline of 60%, according to the criteria of Inouye. In GHW, the onset of delirium occurred significantly earlier and the mean duration of the episode was significantly longer. The severity of delirium tended to be higher in GHW compared to GHHS. At 6-month follow-up, mortality was significantly higher among patients who suffered from an episode of delirium. Moreover, they showed a trend towards a greater institutionalisation rate. GHHS may represent a protective environment for delirium onset in acutely ill elderly patients.

Hospital at home

Although the acute hospital is the standard venue for treating acute serious illness, it is often a difficult environment for older adults who are highly susceptible to functional decline and other iatrogenic consequences of hospital care. Hospital care is also expensive. Providing acute hospital-level care at home, in lieu of usual institutional care, is viable. As an emerging service model, the definition of hospital at home (HaH) remains unsettled. Data favor HaH models that provide substantial physician inputs and are geared toward substituting for hospital care, provide service that is highly satisfying to patients and their caregivers, are associated with less iatrogenic complications, and are less expensive. Dissemination of HaH in integrated delivery systems is feasible. Widespread dissemination of HaH in the United States will require payment reform that acknowledges the role of HaH in the health care system.

Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data

BACKGROUND

Avoidance of admission through provision of hospital care at home is a scheme whereby health care professionals provide active treatment in the patient's home for a condition that would otherwise require inpatient treatment in an acute care hospital. We sought to compare the effectiveness of this method of caring for patients with that type of in-hospital care.

METHODS

We searched the MEDLINE, EMBASE, CINAHL and EconLit databases and the Cochrane Effective Practice and Organisation of Care Group register from the earliest date in each database until January 2008. We included randomized controlled trials that evaluated a service providing an alternative to admission to an acute care hospital. We excluded trials in which the program did not offer a substitute for inpatient care. We performed meta-analyses for trials for which the study populations had similar characteristics and for which common outcomes had been measured.

RESULTS

We included 10 randomized trials (with a total of 1327 patients) in our systematic review. Seven of these trials (with a total of 969 patients) were deemed eligible for meta-analysis of individual patient data, but we were able to obtain data for only 5 of these trials (with a total of 844 patients [87%]). There was no significant difference in mortality at 3 months for patients who received hospital care at home (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.54-1.09, p = 0.15). However, at 6 months, mortality was significantly lower for these patients (adjusted HR 0.62, 95% CI 0.45-0.87, p = 0.005). Admissions to hospital were greater, but not significantly so, for patients receiving hospital care at home (adjusted HR 1.49, 95% CI 0.96-2.33, p = 0.08). Patients receiving hospital care at home reported greater satisfaction than those receiving inpatient care. These programs were less expensive than admission to an acute care hospital ward when the analysis was restricted to treatment actually received and when the costs of informal care were excluded.

INTERPRETATION

For selected patients, avoiding admission through provision of hospital care at home yielded similar outcomes to inpatient care, at a similar or lower cost.

Admission avoidance hospital at home

BACKGROUND

Admission avoidance hospital at home is a service that provides active treatment by health care professionals in the patient's home for a condition that otherwise would require acute hospital in-patient 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 health care professionals to take an active part in the patients' care. If hospital at home were not available then the patient would be admitted to an acute hospital ward. Many countries are adopting this type of care in an attempt to reduce the demand for acute hospital admission.

OBJECTIVES

To determine, in the context of a systematic review and meta analysis, the effectiveness and cost of managing patients with admission avoidance hospital at home compared with in-patient hospital care.

SEARCH STRATEGY

The following databases were searched through to January 2008: MEDLINE, EMBASE, CINAHL, EconLit and the Cochrane Effective Practice and Organisation of Care Group (EPOC) register. We checked the reference lists of articles identified electronically for evaluations of hospital at home and obtained potentially relevant articles. Unpublished studies were sought by contacting providers and researchers who were known to be involved in this field.

SELECTION CRITERIA

Randomised controlled trials recruiting patients aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital in-patient care. The admission avoidance hospital at home interventions may admit patients directly from the community thereby avoiding physical contact with the hospital, or may admit from the emergency room.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed study quality. Our statistical analyses sought to include all randomised patients and were done on an intention to treat basis. We requested individual patient data (IPD) from trialists, and relied on published data when we did not receive trial data sets or the IPD did not include the relevant outcomes. When combining outcome data was not possible because of differences in the reporting of outcomes we have presented the data in narrative summary tables.For the IPD meta-analysis, where at least one event was reported in both study groups in a trial, Cox regression models were used to calculate the log hazard ratio and its standard error for mortality and readmission separately for each data set (where both outcomes were available). We included randomisation group (admission avoidance hospital at home versus control), age (above or below the median), and gender in the models. The calculated log hazard ratios were combined using fixed effects inverse variance meta analysis. If there were no events in one group we used the Peto odds ratio method to calculate a log odds ratio from the sum of the log-rank test 'O-E' statistics from a Kaplan Meier survival analysis. Statistical significance throughout was taken at the two-sided 5% level (p<0.05) and data are presented as the estimated effect with 95% confidence intervals. For each comparison using published data for dichotomous outcomes we calculated risk ratios using a fixed effects model to combine data.

MAIN RESULTS

We included 10 RCTs (n=1333), 7 of which were eligible for the IPD. Five out of these seven trials contributed to the IPD meta-analysis (n=850/975; 87%). There was a non significant reduction in mortality at three months for the admission avoidance hospital at home group (adjusted HR 0.77, 95% CI 0.54 to 1.09; p=0.15), which reached significance at six months follow-up (adjusted HR 0.62, 95% CI 0.45 to 0.87; p=0.005). A non significant increase in admissions was observed for patients allocated to hospital at home (adjusted HR 1.49, 95% CI 0.96 to 2.33; p=0.08). Few differences were reported for functional ability, quality of life or cognitive ability. Patients reported increased satisfaction with admission avoidance hospital at home. Two trials conducted a full economic analysis, when the costs of informal care were excluded admission avoidance hospital at home was less expensive than admission to an acute hospital ward.

AUTHORS' CONCLUSIONS

We performed meta-analyses where there was sufficient similarity among the trials and where common outcomes had been measured. There is no evidence from the analysis to suggest that admission avoidance hospital at home leads to outcomes that differ from inpatient hospital care.

Interventions for treating depression after stroke

BACKGROUND

Depression is an important consequence of stroke that impacts on recovery yet is often not detected or inadequately treated. This is an update of a Cochrane review first published in 2004.

OBJECTIVES

To determine whether pharmaceutical, psychological, or electroconvulsive treatment (ECT) of depression in patients with stroke can improve outcome.

SEARCH STRATEGY

We searched the trials registers of the Cochrane Stroke Group (last searched October 2007) and the Cochrane Depression Anxiety and Neurosis Group (last searched February 2008). In addition, we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2008), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), CINAHL (1982 to May 2006), PsycINFO (1967 to May 2006) and other databases. We also searched reference lists, clinical trials registers, conference proceedings and dissertation abstracts, and contacted authors, researchers and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials comparing pharmaceutical agents with placebo, or various forms of psychotherapy or ECT with standard care (or attention control), in patients with stroke, with the intention of treating depression.

DATA COLLECTION AND ANALYSIS

Two review authors selected trials for inclusion and assessed methodological quality; three review authors extracted, cross-checked and entered data. Primary analyses were the prevalence of diagnosable depressive disorder at the end of treatment. Secondary outcomes included depression scores on standard scales, physical function, death, recurrent stroke and adverse effects.

MAIN RESULTS

Sixteen trials (17 interventions), with 1655 participants, were included in the review. Data were available for 13 pharmaceutical agents, and four trials of psychotherapy. There were no trials of ECT. The analyses were complicated by the lack of standardised diagnostic and outcome criteria, and differing analytic methods. There was some evidence of benefit of pharmacotherapy in terms of a complete remission of depression and a reduction (improvement) in scores on depression rating scales, but there was also evidence of an associated increase in adverse events. There was no evidence of benefit of psychotherapy.

AUTHORS' CONCLUSIONS

A small but significant effect of pharmacotherapy (not psychotherapy) on treating depression and reducing depressive symptoms was found, as was a significant increase in adverse events. More research is required before recommendations can be made about the routine use of such treatments.

Organised inpatient (stroke unit) care for stroke

BACKGROUND

Organised stroke unit care is provided by multidisciplinary teams that exclusively manage stroke patients in a dedicated ward (stroke, acute, rehabilitation, comprehensive), with a mobile stroke team or within a generic disability service (mixed rehabilitation ward).

OBJECTIVES

To assess the effect of stroke unit care compared with alternative forms of care for patients following a stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register (last searched April 2006), the reference lists of relevant articles, and contacted researchers in the field.

SELECTION CRITERIA

Randomised and prospective controlled clinical trials comparing organised inpatient stroke unit care with an alternative service.

DATA COLLECTION AND ANALYSIS

Two review authors initially assessed eligibility and trial quality. Descriptive details and trial data were then checked with the co-ordinators of the original trials.

MAIN RESULTS

Thirty-one trials, involving 6936 participants, compared stroke unit care with an alternative service; more organised care was consistently associated with improved outcomes. Twenty-six trials (5592 participants) compared stroke unit care with general wards. Stroke unit care showed reductions in the odds of death recorded at final (median one year) follow up (odds ratio (OR) 0.86; 95% confidence interval (CI) 0.76 to 0.98; P = 0.02), the odds of death or institutionalised care (OR 0.82; 95% CI 0.73 to 0.92; P = 0.0006) and death or dependency (OR 0.82; 95% CI 0.73 to 0.92; P = 0.001). Sensitivity analyses indicated that the observed benefits remained when the analysis was restricted to trials that used formal randomisation procedures with blinded outcome assessment. Outcomes were independent of patient age, sex or stroke severity, but appeared to be better in stroke units based in a discrete ward. There was no indication that organised stroke unit care resulted in a longer hospital stay.

AUTHORS' CONCLUSIONS

Stroke patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke. The benefits were most apparent in units based in a discrete ward. No systematic increase was observed in the length of inpatient stay.

Reducing Hospitalizations From Long-Term Care Settings

Hospital spending represents approximately one third of total national health spending, and the majority of hospital spending is by public payers. Elderly individuals with long-term care needs are at particular risk for hospitalization. While some hospitalizations are unavoidable, many are not, and there may be benefits to reducing hospitalizations in terms of health and cost. This article reviews the evidence from 55 peer-reviewed articles on interventions that potentially reduce hospitalizations from formal long-term care settings. The interventions showing the strongest potential are those that increase skilled staffing, especially through physician assistants and nurse practitioners; improve the hospital-to-home transition; substitute home health care for selected hospital admissions; and align reimbursement policies such that providers do not have a financial incentive to hospitalize. Much of the evidence is weak and could benefit from improved research design and methodology.

Clinical outcomes in elderly demented patients and caregiver's stress: a 2-year follow-up study

We have conducted a study on 82 elderly patients with advanced dementia admitted to the Geriatric Department of S. Giovanni Battista Hospital of Torino in order to evaluate mortality, functional and cognitive impairment and caregiver's stress at 2-year follow-up. Patients were examined using a standardized protocol which included demographic characteristics, comorbidity, duration and type of dementia, severity of disease (clinical dementia rating scale: CDR), behavioral disturbances (neuro-psychiatric inventory: NPI), functional status (activities of daily living: ADL, and instrumental activities of daily living: IADL), cognitive status (short portable mental status questionnaire: SPMSQ). Characteristics of primary caregivers were evaluated and their level of stress was assessed by the relatives' stress scale (RSS). After two years, mortality in the total sample was 61%; the mean age of survivors was 81.3+/-5.3 years; 88% of the sample was still living at home with a relative (76%) or with paid personnel (24%). A statistically significant worsening of the cognitive status was detected (baseline SPMSQ=7.5+/-1.7; follow-up SPMSQ=8.4+/-1.8; p<0.05). Functional status did not change significantly, since it resulted already seriously compromised at the beginning of the study. Most caregivers (80%) were the same as two years before and their stress level was very high (baseline RSS=36.6+/-13.9; follow-up RSS=33.2+/-14). In conclusion, most of the patients included in the follow-up were still living at home, despite the high caregiver's burden and the increasing severity of the disease. Therefore, there is a strong need to further improve health services for the patients with advanced dementia living in their homes.

A Randomized Controlled Trial of Modified Constraint-Induced Movement Therapy for Elderly Stroke Survivors: Changes in Motor Impairment, Daily Functioning, and Quality of Life

OBJECTIVE

To examine the benefits of modified constraint-induced movement therapy (mCIMT) on motor function, daily function, and health-related quality of life (HRQOL) in elderly stroke survivors.

DESIGN

Two-group randomized controlled trial, with pretreatment and posttreatment measures.

SETTING

Rehabilitation clinics.

PARTICIPANTS

Twenty-six elderly stroke patients (mean age, 72 y) with 0.5 to 31 months postonset of a first-ever cerebrovascular accident.

INTERVENTIONS

Twenty-six patients received either mCIMT (restraint of the unaffected limb combined with intensive training of the affected limb) or traditional rehabilitation for a period of 3 weeks.

MAIN OUTCOME MEASURES

Outcome measures included the Fugl-Meyer Assessment (FMA), FIM instrument, Motor Activity Log (MAL), and Stroke Impact Scale (SIS). The FMA evaluated the severity of motor impairment; the FIM instrument and MAL reported daily function; and the SIS detected HRQOL.

RESULTS

The mCIMT group exhibited significantly greater improvements in motor function, daily function, and the physical domain of HRQOL than the traditional rehabilitation group. Patients in the mCIMT group perceived significantly greater percent of recovery after treatment than patients in the traditional rehabilitation group.

CONCLUSIONS

These findings suggest mCIMT is a promising intervention for improving motor function, daily function, and physical aspects of HRQOL in elderly patients with stroke. The mCIMT was well tolerated by the elderly patients even though it is a rigorous training program.

Depressive symptoms and quality of life in elderly patients with exacerbation of chronic obstructive pulmonary disease or cardiac heart failure: Preliminary data of a randomized controlled trial

Aim of the study was to evaluate mortality and functional, cognitive, affective status in elderly patients (>or=75 years) with exacerbation of chronic obstructive pulmonary disease (COPD) or acute congestive heart failure (CHF) admitted to the emergency department (ED) of S. Giovanni Battista Hospital of Torino and randomly assigned to the geriatric home hospitalization service (GHHS) or to a general medical ward (GMW). All patients were evaluated on admission, on discharge and at 6 months, using a standardized study protocol. We excluded patients with unstable medical conditions. The total sample included 73 patients: 35 with COPD exacerbation (19 GHHS, 16 GMW) and 38 with CHF (19 GHHS, 19 GMW). Mean age was 81.7+/-8.0 years. At baseline, no significant differences in demographic, social and clinical conditions were found between the two groups of patients. 56.7% of COPD patients had a severe exacerbation, according to Anthonisen criteria; 65% of CHF patients were NYHA-III and 35% NYHA-IV (according to the criteria of the New York Heart Association) (FE<35% in 40% of patients). On admission all patients were partially dependent in ADLs and IADLs, with a moderate impairment of depression score and a fairly good quality of life. On discharge depression score and quality of life were significantly better only in GHHS patients. Mortality was similar in the two setting of care. Patients managed at home had a significantly longer length of treatment. At 6-month follow-up we did not observe a difference in mortality, but we observed a higher readmission rate in patients previously treated in hospital. In conclusion, our study indicates that home-treated patients with COPD or CHF have better depressive scores and quality of life and a lower rate of hospital readmission after six months.

Geriatric emergency medicine and the 2006 Institute of Medicine reports from the Committee on the Future of Emergency Care in the U.S. health system

Three recently published Institute of Medicine reports, Hospital-Based Emergency Care: At the Breaking Point, Emergency Medical Services: At the Crossroads, and Emergency Care for Children: Growing Pains, examined the current state of emergency care in the United States. They concluded that the emergency medicine system as a whole is overburdened, underfunded, and highly fragmented. These reports did not specifically discuss the effect the aging population has on emergency care now and in the future and did not discuss special needs of older patients. This report focuses on the emergency care of older patients, with the intent to provide information that will help shape discussions on this issue.

Closure of a home hospital program: impact on hospitalization rates

Home hospitalization (HH), as a substitute to in-patient care, is an area of growing interest, particularly amongst the elderly. Debate nonetheless exists concerning its economic justification. This study describes a natural experiment that arose following spending cuts and closure of the 400 patient Jerusalem HH program. It examines the hypothesis that HH closure would cause increasing geriatric and general medical hospital utilization amongst the 45,000 beneficiaries of the Jerusalem Clalit Health Fund (HMO) aged 65 years and over. Hospitalization rates were measured prior to and following HH closure, and analysis of variance confirmed the significance of the differences in both geriatric (p<0.0001) and general medical hospitalization rates (p=0.02) over the study period. Linear regression analyses of the hospitalization rates prior to HH closure were performed to determine the expected trajectory of hospitalization rates following HH closure. The observed hospital utilization in the year following HH closure cost 6.2 million US dollars in excess of predicted expenditure; closure of the HH resulted in the saving of 1.3 million USdollars. The ratio of direct increased costs to savings was 5:1 thus confirming the hypothesis that HH closure would result in increased hospital utilization rates among the local elderly population.

Does home treatment affect delirium? A randomised controlled trial of rehabilitation of elderly and care at home or usual treatment (The REACH-OUT trial)

BACKGROUND

delirium is a frequent adverse consequence of hospitalisation for older patients, but there has been little research into its prevention. A recent study of Hospital in the Home (admission substitution) noted less delirium in the home-treated group.

SETTING

a tertiary referral teaching hospital in Sydney, Australia.

METHODS

we randomised 104 consecutive patients referred for geriatric rehabilitation to be treated in one of two ways, either in Hospital in the Home (early discharge) or in hospital, in a rehabilitation ward. We compared the occurrence of delirium measured by the confusion assessment method. Secondary outcome measures were length of stay, hospital bed days, cost of acute care and rehabilitation, functional independence measure (FIM), Mini-Mental State Examination (MMSE) and geriatric depression score (GDS) assessed on discharge and at 1- and 6-month follow-up and patient satisfaction.

RESULTS

the home group had lower odds of developing delirium during rehabilitation [odds ratio (OR) = 0.17; 95% confidence interval 0.03-0.65], shorter duration of rehabilitation (15.97 versus 23.09 days; P = 0.0164) and used less hospital bed days (20.31 versus 40.09, P < or = 0.0001). The cost was lower for the acute plus rehabilitation phases (7,680 pounds versus 10,598 pounds; P = 0.0109) and the rehabilitation phase alone (2,523 pounds versus 6,100 pounds; P < or = 0.0001). There was no difference in FIM, MMSE or GDS scores. the home group was more satisfied (P = 0.0057).

CONCLUSIONS

home rehabilitation for frail elderly after acute hospitalisation is a viable option for selected patients and is associated with a lower risk of delirium, greater patient satisfaction, lower cost and more efficient hospital bed use.

Hospital at home versus in-patient hospital care

BACKGROUND

Hospital at home is defined as a service that provides active treatment by health care professionals, in the patient's home, of a condition that otherwise would require acute hospital in-patient care, always for a limited period.

OBJECTIVES

To assess the effects of hospital at home compared with in-patient hospital care.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register (November 2004), MEDLINE (1966 to 1996), EMBASE (1980 to 1995), Social Science Citation Index (1992 to 1995), Cinahl (1982 to 1996), EconLit (1969 to 1996), PsycLit (1987 to 1996), Sigle (1980 to 1995) and the Medical Care supplement on economic literature (1970 to 1990).

SELECTION CRITERIA

Randomised trials of hospital at home care compared with acute hospital in-patient care. The participants were patients aged 18 years and over.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Twenty two trials are included in this update of the review. Among trials evaluating early discharge hospital at home schemes we found an odds ratio (OR) for mortality of 1.79 95% CI 0.85 to 3.76 for elderly medical patients (age 65 years and over) (n = 3 trials); OR 0.58; 95% CI 0.29 to 1.17 for patients with chronic obstructive pulmonary disease (COPD) (n = 5 trials); and OR 0.78; 95%CI 0.52 to 1.19 for patients recovering from a stroke (n = 4 trials). Two trials evaluating the early discharge of patients recovering from surgery reported an OR 0.43 (95% CI 0.02 to 10.89) for patients recovering from a hip replacement and an OR 1.01 (95% CI 0.37 to 2.81) for patients with a mix of conditions at three months follow-up. For readmission to hospital we found an OR 1.76; 95% CI 0.78 to 3.99 at 3 months follow-up for elderly medical patients (n = 2 trials); OR 0.81; 95% CI 0.55 to 1.19 for patients with COPD (n = 5 trials); and OR 0.96; 95% CI 0.63 to 1.45 for patients recovering from a stroke (n = 3 trials). No significant heterogeneity was observed. One trial recruiting patients following surgery for hernia or varicose veins reported 0/117 versus 2/121 patients were re admitted (Ruckley 1978); another that 2/37 (5%) versus 1/49 (2%) (difference 3%, 95% CI -5% to 12%) of patients recovering from a hip replacement, 4/47 (9%) versus 1/39 (3%) (difference 6%, 95% CI -3% to 15%) of patients recovering from a knee replacement, and 7/114 (6%) versus 13/124 (10%) (difference -4% 95% CI -11% to 3%) of patients recovering from a hysterectomy were readmitted. A third trial analysing surgical and medical patients together reported that 42/159 versus 17/81 patients were readmitted at 3 months (OR 1.34 95% CI 0.66 to 2.20). Allocation to hospital at home resulted in a small reduction in hospital length of stay, but hospital at home increased overall length of care. Patients allocated to hospital at home expressed greater satisfaction with care than those in hospital, while the view of carers was mixed.

AUTHORS' CONCLUSIONS

Despite increasing interest in the potential of hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit. Early discharge schemes for patients recovering from elective surgery and elderly patients with a medical condition may have a place in reducing the pressure on acute hospital beds, providing the views of the carers are taken into account. For these clinical groups hospital length of stay is reduced, although this is offset by the provision of hospital at home. Future primary research should focus on rigorous evaluations of admission avoidance schemes and standards for original research should aim at assisting future meta-analyses of individual patient data from these and future trials.