Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial

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 .

Effects of Transitional Care after Hospital Discharge in Patients with Chronic Obstructive Pulmonary Disease: An Updated Systematic Review and Meta-Analysis

This study aimed to systematically review the effects of transitional care programs on healthcare use and quality of life in patients with chronic obstructive pulmonary disease (COPD). Several databases were searched for randomized controlled trials conducted over the past five years, and their quality was evaluated using the Cochrane Risk of Bias 2.0 tool. For indicators with available statistical information, a meta-analysis was performed using RevMan 5.4, and a narrative review was performed for the rest of the results. In the meta-analysis, no statistically significant difference was observed between the intervention and control groups in the number of readmissions and emergency room visits due to COPD. The relative risk (RR) of readmission for COPD was lower in the intervention group. Respiratory-related quality of life tended to be better in the intervention group, though not significantly. Physical capacity was improved in the intervention group. Considering the characteristics of the complex intervention, the context and factors of cases where the expected results could be obtained and cases where the expected results could not be obtained were reviewed and discussed. Based on the results of the analysis, implications for the development of better protocols were presented.

Temporal patient trajectories: long stories in short admissions

Purpose

The purpose of this paper is to explain how trajectory management in hospitals is challenged by the introduction of accelerated discharge schemes. The patient trajectory is formed by short stays within health-care organizations, which requires a substantial effort for professionals to be successful in clarifying each patient's medical situation. The patients, at the same time, often have complicated illness stories, and professionals only see a limited part of the patient's trajectory.

Design/methodology/approach

This paper is based on extensive ethnographic studies in a newly established cardiac day unit introducing same-day discharge schemes for patients with ischemic and arrhythmic heart disease.

Findings

The findings demonstrate that the patient trajectory becomes a “temporal patient trajectory” and encounters a short-term reality, where tensions arise between admission time and the trajectory as a whole. In managing temporal patient trajectories, formal organizing and patient experiences intersect in events that emerge from conversations and span past, present and future in relation to patient treatment. Professionals engage in articulation work to maintain coherence by allowing patients to hold different events together over time.

Originality/value

The paper provides new insights into the challenges of managing trajectories in same-day discharge schemes where the pressure to move quickly and ensure patient discharge is intense. The paper offers a novel theoretical perspective on trajectory management as an ongoing temporal process. The analysis displays temporal tensions between patient experiences and the accelerated discharge scheme and how professionals manage to overcome these tensions by bridging the patient's long illness story and the short trajectory within the cardiac day unit.

Models of care across the continuum of exacerbations for patients with chronic obstructive pulmonary disease

Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with significant morbidity and mortality, and treatments require a multidisciplinary approach to address patient needs. This review considers different models of care across the continuum of exacerbations (1) chronic care and self-management interventions with the action plan, (2) domiciliary care for severe exacerbation and the impact on readmission prevention and (3) the discharge care bundle for management beyond the acute exacerbation episode. Self-management strategies include written action plans and coaching with patient and family support. Self-management interventions facilitate the delivery of good care, can reduce exacerbations associated with admission, be cost-effective and improve quality of life. Hospitalization as a complication of exacerbation is not always unavoidable. Domiciliary care has been proposed as a solution to replace part, and perhaps even all, of the patient’s in-hospital stay, and to reduce hospital bed days, readmission rates and costs; low-risk patients can be identified using risk stratification tools. A COPD discharge bundle is another potentially important approach that can be considered to improve the management of COPD exacerbations complicated by hospital admission; it comprised treatments that have demonstrated efficacy, such as smoking cessation, personalized pharmacotherapy and non-pharmacotherapy such as pulmonary rehabilitation. COPD bundles may also improve the transition of care from the hospital to the community following exacerbation and may reduce readmission rates. Future models of care should be personalized – providing patient education aiming at behaviour changes, identifying and treating co-morbidities, and including outcomes that measure quality of care rather than focusing only on readmission quantity within 30 days.

Introducing a clinically effective allied health rapid discharge team within a complex aged subacute in-patient cohort on a cost recovery basis: the Supported Patient centred Early Discharge (SPeED) initiative

This case study reports the outcomes of an early supported discharge program. This model of care was trialled after Victoria introduced subacute weighted inlier equivalent separations funding to subacute in-patients in 2016. An allied health team (Supported Patient centred Early Discharge (SPeED)) managed patients suitable for assessment, intervention and early supported discharge (ESD). The SPeED cohort was compared to a matched historical control. Data included no advantage financially (NAF) days, length of stay (LOS), functional independence measure (FIM) scores and 30-day readmission rates. Staff and patient experiences were collected through surveys and call-back data. Regression analysis compared quantitative data, whereas a broad thematic approach compared qualitative data. There were no differences between the study cohort and historical control in age or sex (P>0.05). The SPeED cohort had lower median NAF days (F=-21.38; 95% confidence interval (CI) -37.70, -15.00; P<0.001), shorter LOS (F)=4.65; 95% CI -0.41, -0.02; P=0.034), fewer readmissions within 30 days (odds ratio 0.14; 95% CI -0.03, 0.68; P=0.014) and greater change in FIM scores during admission (F=4.20; 95% CI 0.16, 10.74; P=0.044). Staff morale was high in recognition of improved patient care. Patient satisfaction remained positive across the SPeED cohort and historical control group. The introduction of a dedicated allied health ESD team within a geriatric evaluation and management population is effective and enhances patient outcomes.

Respiratory acute discharge service: a hospital in the home programme for chronic obstructive pulmonary disease exacerbations (RADS study)

BACKGROUND

Respiratory Acute Discharge Service (RADS) is a novel early discharge service with nurse-led community based recovery in selected patients with acute exacerbations of chronic obstructive pulmonary disease.

AIM

This pilot study aimed to determine the efficacy and safety of the programme in an Australian tertiary hospital.

METHODS

All patients who were recruited to RADS at Sunshine Coast University Hospital over a 6 months period from June to November 2018 were included. The co-primary outcomes were length of hospital days saved and rate of readmission within 30 days from discharge.

RESULTS

A total of 166 patients (median age 74 years (interquartile range 70-80 years)) was recruited to the programme over the study period. The mean forced expiratory volume in one second (FEV1%) of the patients was 42% (standard deviation 19). The median length-of-stay prior to discharge on the RADS programme was 1 day (range 0-5), compared to a previous average of 5.8 days in our health service. Patients were on the programme for a median of 4 days (range 1-6). A total of 613 hospital bed days was saved over the study period, with significant cost savings. Forty-one (24.7%) patients represented to hospital within 30 days, the majority (64%) were due to recurrent symptoms. The rate of 30-day all-cause mortality for the study population was 1 (0.6%).

CONCLUSION

Early supported discharge care model with nurse-led community based recovery after an acute exacerbation of chronic obstructive pulmonary disease in selected patients is safe, and has the potential to provide greater flow through the hospital systems with cost effective care.

A systematic review of the effectiveness of clinical nurse specialist interventions in patients with chronic obstructive pulmonary disease (COPD)

Objective

This review aimed to examine the effectiveness of clinical nurse specialist (CNS) interventions in patients with chronic obstructive pulmonary disease (COPD). COPD significantly affects people’s health worldwide. With the development in nursing, CNSs are playing increasingly important roles in different departments. However, the studies on the effectiveness of CNSs in COPD are not as well organized as the studies on the effectiveness of CNSs in bronchiectasis and asthma. Therefore, this review aims to find some updated evidence on the CNS interventions for patients with COPD and on whether these interventions are effective.

Methods

A narrative analysis of the data was performed for the eligible studies. Four databases were chosen: CINAHL, MEDLINE, British Nursing Index, and Cochrane Library. Other websites such as the National Institute for Health and Clinical Excellence, National Health Service Evidence, Association of Respiratory Nurse Specialists, and National Association of Clinical Nurse Specialist were searched as well. Two reviewers performed study identification independently, and all the retrieved articles were stored using the EndNote X7 software. The risk of bias in the included studies was assessed using the Cochrane Collaboration’s risk of bias tool.

Results

A total of nine studies were included in this review. There were five current interventions by CNSs for patients with COPD. These interventions were home nursing support, CNS’s supported discharge, multidisciplinary cooperation programs, nurse-led care programs, and self-care management education. The effectiveness of these five interventions was evaluated individually. There is low- to moderate-quality evidence indicating that home nursing support interventions may have a positive effect on mortality and quality of life. No significant difference in quality of life has been found between the CNS-supported discharge intervention and the usual service. The multidisciplinary cooperation program probably had a positive effect on quality of life in patients with COPD. Both nurse-led care and self-care management education intervention had a positive effect on mortality of patients with COPD.

Conclusions

The findings of this review provide updated evidence on the effectiveness of CNS interventions for patients with COPD. Although nine trials were included and five types of interventions were identified, there is still lack of high-quality evidence.

Meta-Analysis of Clinical Trials That Evaluate the Effectiveness of Hospital-Initiated Postdischarge Interventions on Hospital Readmission

Under pressure to avoid readmissions, hospitals are increasingly employing hospital-initiated postdischarge interventions (HiPDI), such as home visits and follow-up phone calls, to help patients after discharge. This study was conducted to assess the effectiveness of HiPDI on reducing hospital readmissions using a systematic review of clinical trials published between 1990 and 2014. We analyzed twenty articles on HiPDI (from 503 reviewed abstracts) containing 7,952 index hospitalizations followed for a median 3 months (range 1-24) after discharge for readmission. The two most common HiPDI included follow-up phone calls (n = 14, 70%) or home visits (n = 11, 55%); eighty-five percent (n = 17) of studies had multiple HiPDI. In meta-analysis, exposure to HiPDI was associated with a lower likelihood of readmission (odds ratio [OR], 0.8 [95% CI, 0.7-0.9]). Patients receiving ≥2 postdischarge home visits or ≥2 follow-up phone calls had the lowest likelihood of readmission (OR, 0.5 [95% CI, 0.4-0.8]). Hospital-initiated postdischarge interventions seem to have an effect on reducing hospital readmissions. Together, multiple home visits and follow-up phone calls may be the most effective HiPDI to reduce hospital readmission.

Home treatment of COPD exacerbation selected by DECAF score: a non-inferiority, randomised controlled trial and economic evaluation

Background

Previous models of Hospital at Home (HAH) for COPD exacerbation (ECOPD) were limited by the lack of a reliable prognostic score to guide patient selection. Approximately 50% of hospitalised patients have a low mortality risk by DECAF, thus are potentially suitable.

Methods

In a non-inferiority randomised controlled trial, 118 patients admitted with a low-risk ECOPD (DECAF 0 or 1) were recruited to HAH or usual care (UC). The primary outcome was health and social costs at 90 days.

Results

Mean 90-day costs were £1016 lower in HAH, but the one-sided 95% CI crossed the non-inferiority limit of £150 (CI −2343 to 312). Savings were primarily due to reduced hospital bed days: HAH=1 (IQR 1–7), UC=5 (IQR 2–12) (P=0.001). Length of stay during the index admission in UC was only 3 days, which was 2 days shorter than expected. Based on quality-adjusted life years, the probability of HAH being cost-effective was 90%. There was one death within 90 days in each arm, readmission rates were similar and 90% of patients preferred HAH for subsequent ECOPD.

Conclusion

HAH selected by low-risk DECAF score was safe, clinically effective, cost-effective, and preferred by most patients. Compared with earlier models, selection is simpler and approximately twice as many patients are eligible. The introduction of DECAF was associated with a fall in UC length of stay without adverse outcome, supporting use of DECAF to direct early discharge.

Trial registration number

Registered prospectively ISRCTN29082260.

Characterization of Chronic Obstructive Pulmonary Disease Patients with a Long Length of Stay: A Retrospective Observational Cohort Study

OBJECTIVES

Chronic obstructive pulmonary disease (COPD) exacerbation is one of the most common reasons for hospital admission. Patients with COPD with a long length of stay (LoS) occupy a disproportionately high fraction of hospital bed-days. The objective of this study was to identify associations of long LoS in patients admitted with COPD exacerbation.

MATERIAL AND METHODS

From December 2012 until June 2013, 499 patients were admitted to Queens Hospital, Romford, UK, with COPD exacerbation. Mean LoS was 7 days, with a median of 5 days, and a 90th percentile of 14 days. In this retrospective observational cohort study, 64 patients with a short LoS were compared with 62 patients with a long LoS.

RESULTS

Relative to the short LoS, patients with long LoS had significantly lower arterial blood pH, higher arterial PaCO2 and HCO3, higher white cell count, higher globulin and more frequent chest X-ray changes, lower albumin levels, and lower Barthel and Braden scores. They were less likely to have seen the hospital COPD specialist nurse, more likely to require escalation of social care on discharge, and more likely to die during admission. Nearly 66% of the long LoS patients remained in hospital beyond the time of being medically fit for discharge. Commonly cited reasons for delayed discharge were the wait for therapy and social services assessments and the wait for commencement of community social care.

CONCLUSION

Meticulous targeting of features peculiar to long LoS patients has the potential to reduce future hospital bed-days for patients with COPD in our and other hospitals.

Effectiveness and safety of outpatient parenteral antimicrobial therapy in acute exacerbation of chronic obstructive pulmonary disease

AIM

We analysed the effectiveness and safety of outpatient parenteral antibiotic therapy (OPAT) in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in patients admitted to home hospitalisation units (HHU).

METHODS

Retrospective multicentre study of patients with AECOPD included in the Spanish OPAT Registry during 2 years period.

RESULTS

Twenty-seven hospitals included 562 episodes in 361 patients diagnosed COPD GOLD III-IV. The most frequently isolated pathogen was Pseudomonas aeruginosa (38%) and the most frequently used antibiotic was piperacillin-tazobactam (20%). The effectiveness of OPAT defined as the rate of improvement or recovery was 93.4%. The safety of OPAT defined as no adverse drug events and no infectious or catheter-related complications was 89.3%. Moreover, the risk of hospital readmission was not greater in patients with AECOPD aged >80 years. No differences in the effectiveness or safety were observed when OPAT was administered by patients and/or caregivers.

CONCLUSION

Patients with AECOPD who require parenteral antimicrobial therapy can be managed effectively and safely in HHU, avoiding hospital stays, readmissions and complications.

Association between length of stay and readmission for COPD

OBJECTIVES

Recent financial penalties for high risk-adjusted chronic obstructive pulmonary disease (COPD) readmissions are causing hospitals to search for ways to reduce COPD readmissions. Although some have advocated for increasing the length of stay (LOS) as a method to decrease readmissions, the association between LOS and readmission is unclear. Our primary objective was to examine the association between LOS and readmission among patients admitted for COPD.

STUDY DESIGN

We conducted an observational study of 33,558 veterans admitted to 130 Veterans Affairs hospitals for COPD from October 1, 2008, to September 30, 2011.

METHODS

We used multivariable regression to separately examine the associations of patient and hospital LOS with 30-day all-cause readmission.

RESULTS

At the patient level, compared with short LOS (<3 days), a longer LOS was associated with increased risk for readmission. The adjusted odds ratio was 1.39 (95% confidence interval [CI], 1.18-1.63) for medium LOS (3-4 days) and 2.03 (95% CI, 1.72-2.40) for long LOS (>4 days). On the hospital level, there was no association between LOS and readmission.

CONCLUSIONS

On a patient level, a longer LOS for COPD hospitalizations was associated with higher risk for readmission, which is likely confounded by the severity of the illness. On a hospital level, LOS was not associated with readmission. These findings imply that, independent of other transitional care practices, altering the hospital LOS may not influence the risk of readmission.

Early discharge hospital at home

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

Randomised trials comparing early discharge hospital at home with acute hospital inpatient care for adults. We excluded obstetric, paediatric and mental health hospital at home schemes.   DATA COLLECTION AND ANALYSIS: We followed the standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes.

MAIN RESULTS

We included 32 trials (N = 4746), six of them new for this update, mainly conducted in high-income countries. We judged most of the studies to have a low or unclear risk of bias. The intervention was delivered by hospital outreach services (17 trials), community-based services (11 trials), and was co-ordinated by a hospital-based stroke team or physician in conjunction with community-based services in four trials.Studies recruiting people recovering from strokeEarly discharge hospital at home probably makes little or no difference to mortality at three to six months (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.57 to 1.48, N = 1114, 11 trials, moderate-certainty evidence) and may make little or no difference to the risk of hospital readmission (RR 1.09, 95% CI 0.71 to 1.66, N = 345, 5 trials, low-certainty evidence). Hospital at home may lower the risk of living in institutional setting at six months (RR 0.63, 96% CI 0.40 to 0.98; N = 574, 4 trials, low-certainty evidence) and might slightly improve patient satisfaction (N = 795, low-certainty evidence). Hospital at home probably reduces hospital length of stay, as moderate-certainty evidence found that people assigned to hospital at home are discharged from the intervention about seven days earlier than people receiving inpatient care (95% CI 10.19 to 3.17 days earlier, N = 528, 4 trials). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).Studies recruiting people with a mix of medical conditionsEarly discharge hospital at home probably makes little or no difference to mortality (RR 1.07, 95% CI 0.76 to 1.49; N = 1247, 8 trials, moderate-certainty evidence). In people with chronic obstructive pulmonary disease (COPD) there was insufficient information to determine the effect of these two approaches on mortality (RR 0.53, 95% CI 0.25 to 1.12, N = 496, 5 trials, low-certainty evidence). The intervention probably increases the risk of hospital readmission in a mix of medical conditions, although the results are also compatible with no difference and a relatively large increase in the risk of readmission (RR 1.25, 95% CI 0.98 to 1.58, N = 1276, 9 trials, moderate-certainty evidence). Early discharge hospital at home may decrease the risk of readmission for people with COPD (RR 0.86, 95% CI 0.66 to 1.13, N = 496, 5 trials low-certainty evidence). Hospital at home may lower the risk of living in an institutional setting (RR 0.69, 0.48 to 0.99; N = 484, 3 trials, low-certainty evidence). The intervention might slightly improve patient satisfaction (N = 900, low-certainty evidence). The effect of early discharge hospital at home on hospital length of stay for older patients with a mix of conditions ranged from a reduction of 20 days to a reduction of less than half a day (moderate-certainty evidence, N = 767). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).Studies recruiting people undergoing elective surgeryThree studies did not report higher rates of mortality with hospital at home compared with inpatient care (data not pooled, N = 856, low-certainty evidence; mainly orthopaedic surgery). Hospital at home may lead to little or no difference in readmission to hospital for people who were mainly recovering from orthopaedic surgery (N = 1229, low-certainty evidence). We could not establish the effects of hospital at home on the risk of living in institutional care, due to a lack of data. The intervention might slightly improve patient satisfaction (N = 1229, low-certainty evidence). People recovering from orthopaedic surgery allocated to early discharge hospital at home were discharged from the intervention on average four days earlier than people allocated to usual inpatient care (4.44 days earlier, 95% CI 6.37 to 2.51 days earlier, , N = 411, 4 trials, moderate-certainty evidence). It is uncertain whether hospital at home has an effect on cost (very low-certainty evidence).

AUTHORS' CONCLUSIONS

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

Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline

This document provides clinical recommendations for treatment of chronic obstructive pulmonary disease (COPD) exacerbations.Comprehensive evidence syntheses, including meta-analyses, were performed to summarise all available evidence relevant to the Task Force's questions. The evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation approach and the results were summarised in evidence profiles. The evidence syntheses were discussed and recommendations formulated by a multidisciplinary Task Force of COPD experts.After considering the balance of desirable and undesirable consequences, quality of evidence, feasibility, and acceptability of various interventions, the Task Force made: 1) a strong recommendation for noninvasive mechanical ventilation of patients with acute or acute-on-chronic respiratory failure; 2) conditional recommendations for oral corticosteroids in outpatients, oral rather than intravenous corticosteroids in hospitalised patients, antibiotic therapy, home-based management, and the initiation of pulmonary rehabilitation within 3 weeks after hospital discharge; and 3) a conditional recommendation against the initiation of pulmonary rehabilitation during hospitalisation.The Task Force provided recommendations related to corticosteroid therapy, antibiotic therapy, noninvasive mechanical ventilation, home-based management, and early pulmonary rehabilitation in patients having a COPD exacerbation. These recommendations should be reconsidered as new evidence becomes available.

The Efficacy of Telemedicine-Supported Discharge Within an In Home Model of Care

OBJECTIVE

To determine if mobile videoconferencing technology can facilitate the discharge of low-acuity patients receiving in-home care without compromising short-term health outcomes.

METHODS

A 6-month trial commenced in July 2015 with 345 patients considered unsuited to Criteria Led Discharge (CLD) receiving in-home care included as participants. Nurses providing clinical support to patients in their homes were supplied with a tablet computer (Apple iPad) with Internet connectivity (Telstra 4G Network) and videoconferencing software (Cisco Jabber for Telepresence). Device usage data combined with hospital admission records were collected to determine (a) instances where a telemedicine-facilitated discharge occurred and (b) if the accepted measure of short-term health outcomes (readmission within 28 days) was adversely affected by this alternative method.

RESULTS

Telemedicine technology facilitated the discharge of 10.1% (n = 35) of patients considered unsuitable for CLD from the Hospital in the Home model during the trial period. Statistically insignificant differences in rates of readmission between patients discharged in person versus those participating in the telemedicine-supported model suggest that the clinical standards of the service have been maintained.

CONCLUSION

The results of evaluating telemedicine support for nurses providing low-acuity in-home care indicate that patients may be discharged remotely while maintaining the existing clinical standards of the service.

Prevalence and Risk Factors of Chronic Obstructive Pulmonary Disease among Nonsmokers: Fifth Korea National Health and Nutrition Examination Survey (2010-2012)

OBJECTIVES

The purpose of this study was to determine the prevalence of COPD among non-smoking adults, and to investigate the risk factors that affect disease occurrence.

METHODS

The data from the 5th Korea national health and nutrition examination survey (KNHNES) has been used, and 5,489 non-smoking adults aged between 40 to 79 years with diagnosable FEV1/FVC were selected therefrom as the subjects of this study.

RESULTS

The prevalence of COPD in non-smokers was observed to be 6.9%. The development of the COPD showed statistically significant difference among groups; males showed about 2.54 times (95% CI: 1.410∼146.612) higher rates compared to females, subjects aged 70-79 showed about 3.08 times (95% CI: 1.823∼11.437) higher rates compared to those aged 40-49, subjects whose education level was elementary school or less showed about 5.36 times (95% CI: 1.341∼21.393) higher rates compared to those who are college or more, and subjects who are middle school showed about 4.72 times (95% CI: 1.374∼16.217) higher rates compared to the college or more.

CONCLUSION

It is confirmed that development of the COPD in non-smokers reach significance. For the prevention of the disease, there is a need to identify COPD-related risk factors in males and the elderly and provide appropriate nursing intervention, and to develop health-related education programs for those with low educational background to take in order to promote the improvement of lung health.

Preventing Hospitalizations From Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Chronic obstructive lung disease is among the leading causes of adult hospital admissions and readmissions in the United States. Preventing acute exacerbations is the primary approach in therapy. Combinations of smoking cessation, pulmonary rehabilitation, vaccinations and inhaled and oral medications may all reduce the overall risk of acute exacerbations. When prevention is unsuccessful, treatment of exacerbations often does not require hospitalization but can be safely executed in the outpatient setting. In the patient who does not require mechanical ventilation or who manifests respiratory acidosis, oxygen supplementation, frequent short-acting inhaled bronchodilators, oral corticosteroids and often antibiotics can abort the decompensation and sometimes return the patient to his or her pre-attack baseline lung function. Several models exist for delivering this care in the ambulatory setting. Follow-up care after an exacerbation has resolved is important, though there are few hard data suggesting which approach is best in this setting.

Effect of PaO2 and social circumstances on outcomes in out-patient treatment of COPD exacerbations

The current British Thoracic Society guidelines on COPD recommend that patients with COPD exacerbations should be admitted to hospital if they either have partial pressure of arterial oxygen of <7.0 kilopascals (kPa) or if they are living alone. This study was carried out to see if either of these factors have any effect on the outcome in patients presenting with COPD exacerbation in the setting of well established COPD services. This study was to see if patients with PaO 2 < 7.0 kPa or those living alone were readmitted more frequently or had higher mortality than other patients discharged through the same scheme. A retrospective analysis was carried out on 1078 patients with acute exacerbation of COPD who were discharged home through Wigan “hospital at home” scheme in the period between November 1999 and February 2004 prior to the introduction of the new guidelines. This study found that there was no statistically significant difference in the rates of readmissions in patients with low PaO2 or those living in adverse social circumstances compared to other groups of patients. The number of patients dying in this period was too small to analyse with adequate power. This study indicates that such patients can be safely managed at home in the context of well established COPD services. Chronic Respiratory Disease 2007; 4: 191—194

Early Supported Discharge/Hospital At Home For Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Review and Meta-Analysis

A systematic review and meta-analysis was performed to assess the safety, efficacy and cost of Early Supported Discharge (ESD) and Hospital at Home (HAH) compared to Usual Care (UC) for patients with acute exacerbation of COPD (AECOPD). The structure of ESD/HAH schemes was reviewed, and analyses performed assuming return to hospital during the acute period (prior to discharge from home treatment) was, and was not, considered a readmission. The pre-defined search strategy completed in November 2014 included electronic databases (Medline, Embase, Amed, BNI, Cinahl and HMIC), libraries, current trials registers, national organisations, key respiratory journals, key author contact and grey literature. Randomised controlled trials (RCTs) comparing ESD/HAH to UC in patients admitted with AECOPD, or attending the emergency department and triaged for admission, were included. Outcome measures were mortality, all-cause readmissions to 6 months and cost. Eight RCTs were identified; seven reported mortality and readmissions. The structure of ESD/HAH schemes, particularly selection criteria applied and level of support provided, varied considerably. Compared to UC, ESD/HAH showed a trend towards lower mortality (RRMH = 0.66; 95% CI 0.40-1.09, p = 0.10). If return to hospital during the acute period was not considered a readmission, ESD/HAH was associated with fewer readmissions (RRMH = 0.74, 95% CI: 0.60-0.90, p = 0.003), but if considered a readmission, the benefit was lost (RRMH = 0.84; 95% CI 0.69-1.01, p = 0.07). Costs were lower for ESD/HAH than UC. ESD/HAH is safe in selected patients with an AECOPD. Further research is required to define optimal criteria to guide patient selection and models of care.

Understanding variation in length of hospital stay for COPD exacerbation: European COPD audit

Chronic obstructive pulmonary disease (COPD) care across Europe has high heterogeneity with respect to cost and the services available. Variations in length of stay (LOS) may be attributed to patient characteristics, resource and organisational characteristics, and/or the so-called hospital cluster effect. The European COPD Audit in 13 countries included data from 16 018 hospitalised patients. The recorded variables included information on patient and disease characteristics, and resources available. Variables associated with LOS were evaluated by a multivariate, multilevel analysis. Mean±sd LOS was 8.7±8.3 days (median 7 days, interquartile range 4-11 days). Crude variability between countries was reduced after accounting for clinical factors and the clustering effect. The main factors associated with LOS being longer than the median were related to disease or exacerbation severity, including GOLD class IV (OR 1.77) and use of mechanical ventilation (OR 2.15). Few individual resource variables were associated with LOS after accounting for the hospital cluster effect. This study emphasises the importance of the patients' clinical severity at presentation in predicting LOS. Identifying patients at risk of a long hospital stay at admission and providing targeted interventions offers the potential to reduce LOS for these individuals. The complex interactions between factors and systems were more important that any single resource or organisational factor in determining differences in LOS between hospitals or countries.

The development of an evaluation framework for a Hospital at Home service

Purpose

– The purpose of this paper is to share good practice with interested professionals, commissioners and health service managers regarding the development of an evidence-based approach to evaluation of an integrated care service providing acute level care for patients in their own homes in South London called the Guys and St Thomas’ @home service.

Design/methodology/approach

– A literature review related to Hospital at Home (HH) schemes was carried out with an aim of scoping approaches used during previous evaluations of HH type interventions to inform the development of an evaluation strategy for @home. The results of the review were then applied to the Donabedian conceptual model: Structure; Process; and Outcome and contextualised to the population being served by the scheme to ensure a robust, practical and comprehensive approach to evaluation.

Findings

– Due to the heterogeneity of the studies it was not possible to conduct a systematic review or meta-analysis. In total, 28 studies were identified that met the inclusion criteria and included both HH to facilitate early discharge and admission prevention across a wide range of conditions. The key finding was there is a dearth of literature evaluating staff preparation to work on HH, models of delivery, specifically integrated care and trans-disciplinary working and few studies included the experiences of family carers.

Originality/value

– This paper will be of value to those involved in the commissioning and delivery of HH and other models of integrated care services type services and will help to inform evaluation strategies that are practical, evidence based and include all stakeholder perspectives.

Has variation in length of stay in acute hospitals decreased? Analysing trends in the variation in LOS between and within Dutch hospitals

Background

We aimed to get better insight into the development of the variation in length of stay (LOS) between and within hospitals over time, in order to assess the room for efficiency improvement in hospital care.

Methods

Using Dutch national individual patient-level hospital admission data, we studied LOS for patients in nine groups of diagnoses and procedures between 1995 and 2010. We fitted linear mixed effects models to the log-transformed LOS to disentangle within and between hospital variation and to evaluate trends, adjusted for case-mix.

Results

We found substantial differences between diagnoses and procedures in LOS variation and development over time, supporting our disease-specific approach. For none of the diagnoses, relative variance decreased on the log scale, suggesting room for further LOS reduction. Except for two procedures in the same specialty, LOS of individual hospitals did not correlate between diagnoses/procedures, indicating the absence of a hospital wide policy. We found within-hospital variance to be many times greater than between-hospital variance. This resulted in overlapping confidence intervals across most hospitals for individual hospitals’ performances in terms of LOS.

Conclusions

The results suggest room for efficiency improvement implying lower costs per patient treated. It further implies a possibility to raise the number of patients treated using the same capacity or to downsize the capacity. Furthermore, policymakers and health care purchasers should take into account statistical uncertainty when benchmarking LOS between hospitals and identifying inefficient hospitals.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1087-6) contains supplementary material, which is available to authorized users.

Chronic obstructive pulmonary disease mobile care: A participant-focussed and human rights-based evaluation

To reduce healthcare costs associated with chronic obstructive pulmonary disease (COPD) and vacate hospital beds without compromising patient satisfaction with healthcare, alternatives for hospital treatment have been developed; however, few studies have qualitatively investigated patients’ experiences of these alternatives. This study aimed, first, to explore patients’ experiences of Sweden’s first COPD mobile care programme through semi-structured interviews with twelve patients, and, second, to evaluate if a human rights-based analysis could provide additional information. Data were, first, analysed using latent content analysis, resulting in three themes: security (effective follow-up, positive encounters), availability (convenience), and suggestions for improvement (increased amount of personnel, longer enrolment period, continued follow-up upon discharge from the programme). Security and availability contributed to high acceptability of and satisfaction with the programme; COPD mobile care can, thus, constitute an acceptable alternative to inpatient care for COPD patients. Findings were then further analysed using the AAAQ framework (availability, accessibility, acceptability, and quality) to determine how the COPD mobile care programme corresponds to the Right to health. This human rights-based analysis enabled the uncovering of certain groups being excluded from the programme, thereby generating valuable information for improving the programme by ensuring equal access and care for all COPD patients.

Hospital management of acute exacerbations of chronic obstructive pulmonary disease

The course of chronic obstructive pulmonary disease (COPD) is often complicated by episodes of acute worsening of respiratory symptoms, which may lead to escalation of therapy and occasionally emergency department visits and hospitalization. Acute exacerbations of COPD (AECOPD) have a negative impact on quality of life and hasten the decline of lung function. They also significantly contribute to the direct and indirect healthcare costs of this disease. Severe exacerbations (those leading to hospital admission) have been associated with significant poor outcomes including an increased risk of readmissions and mortality. COPD is currently the fourth leading cause of hospital readmission in the United States. In this review, we will provide a broad overview on the etiology, assessment, management, discharge planning, and follow-up care of patients hospitalized with AECOPD.

Developing a specialist-nurse-led 'COPD in-reach service'

AIM

To develop and implement a respiratory clinical-nurse-specialist-led chronic obstructive pulmonary disease (COPD) 'in-reach service' for an emergency admission unit within a large acute county hospital.

METHOD

Data collected during the service development were compared with existing data when no COPD in-reach service was available. Data were compared on average length of stay, readmission rates, 'early assisted discharge' and patient experience.

FINDINGS

The COPD in-reach service reduced average length of stay for COPD patients by 2.53 days and readmission rates were reduced by an average of 4.5 per month; 17% of patients were discharged on an early assisted discharge scheme, and overall patients felt more prepared and ready for discharge.

CONCLUSION

The COPD in-reach service has been proven to be of great benefit both financially and in terms of patient experience.

Feasibility study for early supported discharge in adults with respiratory infection in the UK

Background

Many patients with pneumonia and lower respiratory tract infection that could be treated as outpatients according to their clinical severity score, are in fact admitted to hospital. We investigated whether, with medical and social input, these patients could be discharged early and treated at home.

Objectives: (1) To assess the feasibility of providing an early supported discharge scheme for patients with pneumonia and lower respiratory tract infection (2) To assess the patient acceptability of a study comprising of randomisation to standard hospital care or early supported discharge scheme.

Methods

Design: Randomised controlled trial.

Setting: Liverpool, UK. Two University Teaching hospitals; one city-centre, 1 suburban in Liverpool, a city with high deprivation scores and unemployment rates.

Participants: 200 patients screened: 14 community-dwelling patients requiring an acute hospital stay for pneumonia or lower respiratory tract infection were recruited.

Intervention: Early supported discharge scheme to provide specialist respiratory care in a patient’s own home as a substitute to acute hospital care.

Main outcome measures: Primary - patient acceptability. Secondary – safety/mortality, length of hospital stay, readmission, patient/carer (or next of kin) satisfaction, functional status and symptom improvement.

Results

42 of the 200 patients screened were eligible for early supported discharge; 10 were only identified at the point of discharge, 18 declined participation and 14 were randomised to either early supported discharge or standard hospital care. The total hospital length of hospital stay was 8.33 (1–31) days in standard hospital care and 3.4 (1–7) days in the early supported discharge scheme arm. In the early supported discharge scheme arm patient carers reported higher satisfaction with care and there were less readmissions and hospital-acquired infections.

Limitations: A small study in a single city. This was a feasibility study and therefore not intended to compare outcome data.

Conclusions

An early supported discharge scheme for patients with pneumonia and lower respiratory tract infection was feasible. Larger numbers of patients would be eligible if future work included patients with dementia and those residing in care homes.

Trial registration

ISRCTN25542492.

Admission prevention in COPD: non-pharmacological management

Exacerbations of chronic obstructive pulmonary disease (COPD) are one of the commonest causes of hospital admission in Europe, Australasia, and North America. These adverse events have a large effect on the health status of the patients and impose a heavy burden on healthcare systems. While we acknowledge the contribution of pharmacotherapies to exacerbation prevention, our interpretation of the data is that exacerbations continue to be a major burden to individuals and healthcare systems, therefore, there remains great scope for other therapies to influence exacerbation frequency and preservation of quality of life. In this review, the benefits and limitations of pulmonary rehabilitation, non-invasive ventilation, smoking cessation, and long-term oxygen therapy are discussed. In addition, supported discharge, advanced care coordination, and telehealth programs to improve clinical outcome are reviewed as future directions for the management of COPD.

The effect of real-time teleconsultations between hospital-based nurses and patients with severe COPD discharged after an exacerbation

We investigated the effect of daily real-time teleconsultations for one week between hospital-based nurses specialised in respiratory diseases and patients with severe COPD discharged after acute exacerbation. Patients admitted with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) at two hospitals were recruited at hospital discharge. They were randomly assigned to intervention or control. The telemedicine equipment consisted of a briefcase with built-in computer including a web camera, microphone and measurement equipment. The primary outcome was the mean number of total hospital readmissions within 26 weeks of discharge. A total of 266 patients (mean age 72 years) were allocated to either intervention (n = 132) or control (n = 134). There was no significant difference in the unconditional total mean number of hospital readmissions after 26 weeks: mean 1.4 (SD 2.1) in the intervention group and 1.6 (SD 2.4) in the control group. In a secondary analysis, there was no significant difference between the two groups in mortality, time to readmission, mean number of total hospital readmissions, mean number of readmissions with AECOPD, mean number of total hospital readmission days or mean number of readmission days with AECOPD calculated at 4, 8, 12 and 26 weeks. Thus the addition of one week of teleconsultations between hospital-based nurses and patients with severe COPD discharged after hospitalisation did not significantly reduce readmissions or affect mortality.

Patient safety analysis of the ED care of patients with heart failure and COPD exacerbations: a multicenter prospective cohort study

OBJECTIVES

For emergency department (ED) patients with acute exacerbations of heart failure and chronic obstructive pulmonary disease (COPD), we aimed to assess the adherence to evidence-based care and determine the proportion that experienced adverse events.

METHODS

An expert panel identified critical actions for ED care of heart failure and COPD patients based on clinical practice guidelines. We collected outcome data for discharged ED patients >age 50 with acute heart failure or COPD in a multicenter prospective cohort study at five academic EDs. We measured 3 flagged outcomes: return ED visit, admission, or death within 14 days. Three trained physician reviewers reviewed case summaries for adverse event determination (flagged outcomes related to healthcare received). We evaluated health records for adherence to the critical actions for each condition.

RESULTS

We identified 122 (7.0%) flagged outcomes among 1,718 enrolled patients (61 heart failure, 59 COPD and 2 dual diagnoses). The mean age was 74.2 (SD 10.4) and 44.3% were female. Among 10 critical actions for heart failure and 13 for COPD, a mean proportion of 9.4/10 and 11.0/13 were adhered to respectively. We identified 12 adverse events (9.8%, 95%CI: 5.6-16.5%), all of which were deemed preventable, including 1 death. The most common contributors were unsafe disposition decisions (10/12, 83.3%) and diagnostic issues (5/12, 41.7%). Patients who died with heart failure were statistically significantly less likely to have guideline adherent care (P = .02).

CONCLUSIONS

A small proportion of return ED visits were related to index care. We believe there is need for improvement around disposition decision making for both conditions to reduce the highly preventable and clinically significant adverse events we found.

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.

Patients with acute exacerbation of chronic obstructive pulmonary disease feel safe when treated at home: a qualitative study

BACKGROUND

The design of new interventions to improve health care for patients with chronic obstructive pulmonary disease (COPD) requires knowledge about what patients with an acute exacerbation experience as important and useful. The objective of the study was to explore patients' experiences of an early discharge hospital at home (HaH) treatment programme for exacerbations in COPD.

METHODS

Six exacerbated COPD patients that were randomised to receiving HaH care and three patients randomised to receiving traditional hospital care were interviewed in semi-structured in-depth interviews. Four spouses were present during the respective patients' interviews. The interviews were audio-taped, transcribed and analysed by a four-step method for systematic text condensing.

RESULTS

Despite limited assistance from the health care service, the patients and their spouses experienced the HaH treatment as safe. They expressed that information that was adapted to specific situations in their daily lives and given in a familiar environment had positive impact on their self-management of COPD.

CONCLUSION

The results contribute to increased knowledge and awareness about what the patients experienced as important aspects of a HaH treatment programme. How adapted input from health services can make patients with exacerbation of COPD feel safe and better able to manage their disease, is important knowledge for developing new and effective health services for patients with chronic disease.

Hospital management of patients with exacerbation of severe chronic obstructive pulmonary disease

The article assesses the originally developed criteria of clinical stability and treatment protocol in the hospital management and discharge procedures of patients with exacerbations of severe chronic obstructive pulmonary disease (COPD). The study included 34 patients (26 males, 8 females), aged 58-80 years, hospitalized due to exacerbation of severe (23 patients) and very severe (11 patients) COPD. On admission, the mean FEV1 was 0.78 ± 0.22 L (31.7% ± 8.2% of predicted), FVC 2.52 ± 0.87 L (77.9% ± 9.8% of predicted) and FEV1/FVC 33.17% ± 10.84%. Before hospitalization, 10 out of the 34 patients were diagnosed with chronic respiratory failure. All patients were treated according the same treatment protocol which included the developed criteria of clinical stability. Meeting all these criteria in a 24-h observation period was the basis to slash the dose of systemic glucocorticosteroids by half. The maintenance of the stability criteria through the subsequent 24 h allowed discharging a patient from the hospital. Every patient was supplied with a detailed plan of out-of-hospital treatment. The results show that the mean duration of hospitalization was 6.4 ± 4.8 days. Only one patient required readmission within 4 weeks after discharge. Two patients died; one during the hospitalization time and the other after discharge. In the latter case, death was not directly related to the COPD exacerbation. In conclusion, the protocol of treatment and the criteria of stability used for patients with COPD exacerbation enabled to optimize the hospitalization time. A shortening of hospitalization was not associated with increased risk of readmission within 4 weeks after discharge.

Hospital at home for acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Hospital at home schemes are a recently adopted method of service delivery for the management of acute exacerbations of chronic obstructive pulmonary disease (COPD) aimed at reducing demand for acute hospital inpatient beds and promoting a patient-centred approach through admission avoidance. However, evidence in support of such a service is contradictory.

OBJECTIVES

To evaluate the efficacy of hospital at home compared to hospital inpatient care in acute exacerbations of COPD.

SEARCH METHODS

Trials were identified from searches of electronic databases, including CENTRAL, MEDLINE, EMBASE, and the Cochrane Airways Group Register (CAGR). The review authors checked the reference lists of included trials. The CAGR was searched up to February 2012. The additional databases were searched up to October 2010.

SELECTION CRITERIA

We considered randomised controlled trials where patients presented to the emergency department with an exacerbation of their COPD. Studies must not have recruited patients for whom treatment at home is usually not viewed as an responsible option (e.g. patients with an impaired level of consciousness, acute confusion, acute changes on the radiograph or electrocardiogram, arterial pH less than 7.35, concomitant medical conditions).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected articles for inclusion, assessed the risk of bias and extracted data for each of the included trials.

MAIN RESULTS

Eight trials with 870 patients were included in the review and showed a significant reduction in readmission rates for hospital at home compared with hospital inpatient care of acute exacerbations of COPD (risk ratio (RR)0.76; 95% confidence interval (CI) from 0.59 to 0.99; P=0.04). Moreover, we observed a trend towards lower mortality in the hospital at home group, but the pooled effect estimate did not reach statistical significance (RR 0.65, 95% CI 0.40 to 1.04, P = 0.07). For health-related quality of life, lung function (FEV1) and direct costs, the quality of the available evidence is in general too weak to make firm conclusions.

AUTHORS' CONCLUSIONS

Selected patients presenting to hospital emergency departments with acute exacerbations of COPD can be safely and successfully treated at home with support from respiratory nurses. We found evidence of moderate quality that hospital at home may be advantageous with respect to readmission rates in these patients. Treatment of acute exacerbation of COPD in hospital at home also show a trend towards reduced mortality rate when compared with conventional inpatient treatment, but these results did not reach statistical significance (moderate quality evidence). For other outcomes than readmission and mortality rate, we assessed the evidence to be of low or very low quality.

Hospital-at-home programs for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD): an evidence-based analysis

In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions. After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses. The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html. Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework. Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Long-term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Home Telehealth for Patients with Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Cost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy Model. Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature. For more information on the qualitative review, please contact Mita Giacomini at: http://fhs.mcmaster.ca/ceb/faculty_member_giacomini.htm. For more information on the economic analysis, please visit the PATH website: http://www.path-hta.ca/About-Us/Contact-Us.aspx. The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: http://theta.utoronto.ca/static/contact. OBJECTIVE: The objective of this analysis was to compare hospital-at-home care with inpatient hospital care for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) who present to the emergency department (ED). CLINICAL NEED: CONDITION AND TARGET POPULATION: ACUTE EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE: Chronic obstructive pulmonary disease is a disease state characterized by airflow limitation that is not fully reversible. This airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. The natural history of COPD involves periods of acute-onset worsening of symptoms, particularly increased breathlessness, cough, and/or sputum, that go beyond normal day-to-day variations; these are known as acute exacerbations. Two-thirds of COPD exacerbations are caused by an infection of the tracheobronchial tree or by air pollution; the cause in the remaining cases is unknown. On average, patients with moderate to severe COPD experience 2 or 3 exacerbations each year. Exacerbations have an important impact on patients and on the health care system. For the patient, exacerbations result in decreased quality of life, potentially permanent losses of lung function, and an increased risk of mortality. For the health care system, exacerbations of COPD are a leading cause of ED visits and hospitalizations, particularly in winter. TECHNOLOGY: Hospital-at-home programs offer an alternative for patients who present to the ED with an exacerbation of COPD and require hospital admission for their treatment. Hospital-at-home programs provide patients with visits in their home by medical professionals (typically specialist nurses) who monitor the patients, alter patients’ treatment plans if needed, and in some programs, provide additional care such as pulmonary rehabilitation, patient and caregiver education, and smoking cessation counselling. There are 2 types of hospital-at-home programs: admission avoidance and early discharge hospital-at-home. In the former, admission avoidance hospital-at-home, after patients are assessed in the ED, they are prescribed the necessary medications and additional care needed (e.g., oxygen therapy) and then sent home where they receive regular visits from a medical professional. In early discharge hospital-at-home, after being assessed in the ED, patients are admitted to the hospital where they receive the initial phase of their treatment. These patients are discharged into a hospital-at-home program before the exacerbation has resolved. In both cases, once the exacerbation has resolved, the patient is discharged from the hospital-at-home program and no longer receives visits in his/her home. In the models that exist to date, hospital-at-home programs differ from other home care programs because they deal with higher acuity patients who require higher acuity care, and because hospitals retain the medical and legal responsibility for patients. Furthermore, patients requiring home care services may require such services for long periods of time or indefinitely, whereas patients in hospital-at-home programs require and receive the services for a short period of time only. Hospital-at-home care is not appropriate for all patients with acute exacerbations of COPD. Ineligible patients include: those with mild exacerbations that can be managed without admission to hospital; those who require admission to hospital; and those who cannot be safely treated in a hospital-at-home program either for medical reasons and/or because of a lack of, or poor, social support at home. The proposed possible benefits of hospital-at-home for treatment of exacerbations of COPD include: decreased utilization of health care resources by avoiding hospital admission and/or reducing length of stay in hospital; decreased costs; increased health-related quality of life for patients and caregivers when treated at home; and reduced risk of hospital-acquired infections in this susceptible patient population. ONTARIO CONTEXT: No hospital-at-home programs for the treatment of acute exacerbations of COPD were identified in Ontario. Patients requiring acute care for their exacerbations are treated in hospitals. RESEARCH QUESTION: What is the effectiveness, cost-effectiveness, and safety of hospital-at-home care compared with inpatient hospital care of acute exacerbations of COPD? RESEARCH METHODS: LITERATURE SEARCH: SEARCH STRATEGY: A literature search was performed on August 5, 2010, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database for studies published from January 1, 1990, to August 5, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists and health technology assessment websites were also examined for any additional relevant studies not identified through the systematic search. INCLUSION CRITERIA: English language full-text reports; health technology assessments, systematic reviews, meta-analyses, and randomized controlled trials (RCTs); studies performed exclusively in patients with a diagnosis of COPD or studies including patients with COPD as well as patients with other conditions, if results are reported for COPD patients separately; studies performed in patients with acute exacerbations of COPD who present to the ED; studies published between January 1, 1990, and August 5, 2010; studies comparing hospital-at-home and inpatient hospital care for patients with acute exacerbations of COPD; studies that include at least 1 of the outcomes of interest (listed below). Cochrane Collaboration reviews have defined hospital-at-home programs as those that provide patients with active treatment for their acute exacerbation in their home by medical professionals for a limited period of time (in this case, until the resolution of the exacerbation). If a hospital-at-home program had not been available, these patients would have been admitted to hospital for their treatment. EXCLUSION CRITERIA: < 18 years of age; animal studies; duplicate publications; grey literature. OUTCOMES OF INTEREST: PATIENT/CLINICAL OUTCOMES: mortality; lung function (forced expiratory volume in 1 second); health-related quality of life; patient or caregiver preference; patient or caregiver satisfaction with care; complications. HEALTH SYSTEM OUTCOMES: hospital readmissions; length of stay in hospital and hospital-at-home. ED visits; transfer to long-term care; days to readmission; eligibility for hospital-at-home. STATISTICAL METHODS: When possible, results were pooled using Review Manager 5 Version 5.1; otherwise, results were summarized descriptively. Data from RCTs were analyzed using intention-to-treat protocols. In addition, a sensitivity analysis was done assigning all missing data/withdrawals to the event. P values less than 0.05 were considered significant. A priori subgroup analyses were planned for the acuity of hospital-at-home program, type of hospital-at-home program (early discharge or admission avoidance), and severity of the patients’ COPD. Additional subgroup analyses were conducted as needed based on the identified literature. Post hoc sample size calculations were performed using STATA 10.1. QUALITY OF EVIDENCE: The quality of each included study was assessed, taking into consideration allocation concealment, randomization, blinding, power/sample size, withdrawals/dropouts, and intention-to-treat analyses. The quality of the body of evidence was assessed as high, moderate, low, or very low according to the GRADE Working Group criteria. The following definitions of quality were used in grading the quality of the evidence: [Table: see text] SUMMARY OF FINDINGS: Fourteen studies met the inclusion criteria and were included in this review: 1 health technology assessment, 5 systematic reviews, and 7 RCTs. The following conclusions are based on low to very low quality of evidence. The reviewed evidence was based on RCTs that were inadequately powered to observe differences between hospital-at-home and inpatient hospital care for most outcomes, so there is a strong possibility of type II error. Given the low to very low quality of evidence, these conclusions must be considered with caution. Approximately 21% to 37% of patients with acute exacerbations of COPD who present to the ED may be eligible for hospital-at-home care. Of the patients who are eligible for care, some may refuse to participate in hospital-at-home care. Eligibility for hospital-at-home care may be increased depending on the design of the hospital-at-home program, such as the size of the geographical service area for hospital-at-home and the hours of operation for patient assessment and entry into hospital-at-home. Hospital-at-home care for acute exacerbations of COPD was associated with a nonsignificant reduction in the risk of mortality and hospital readmissions compared with inpatient hospital care during 2- to 6-month follow-up. Limited, very low quality evidence suggests that hospital readmissions are delayed in patients who received hospital-at-home care compared with those who received inpatient hospital care (mean additional days before readmission comparing hospital-at-home to inpatient hospital care ranged from 4 to 38 days). There is insufficient evidence to determine whether hospital-at-home care, compared with inpatient hospital care, is associated with improved lung function. The majority of studies did not find significant differences between hospital-at-home and inpatient hospital care for a variety of health-related quality of life measures at follow-up. However, follow-up may have been too late to observe an impact of hospital-at-home care on quality of life. A conclusion about the impact of hospital-at-home care on length of stay for the initial exacerbation (defined as days in hospital or days in hospital plus hospital-at-home care for inpatient hospital and hospital-at-home, respectively) could not be determined because of limited and inconsistent evidence. Patient and caregiver satisfaction with care is high for both hospital-at-home and inpatient hospital care.

Early assisted discharge with generic community nursing for chronic obstructive pulmonary disease exacerbations: results of a randomised controlled trial

OBJECTIVES

To determine the effectiveness of early assisted discharge for chronic obstructive pulmonary disease (COPD) exacerbations, with home care provided by generic community nurses, compared with usual hospital care.

DESIGN

Prospective, randomised controlled and multicentre trial with 3-month follow-up.

SETTING

Five hospitals and three home care organisations in the Netherlands.

PARTICIPANTS

Patients admitted to the hospital with an exacerbation of COPD. Patients with no or limited improvement of respiratory symptoms and patients with severe unstable comorbidities, social problems or those unable to visit the toilet independently were excluded.

INTERVENTION

Early discharge from hospital after 3 days inpatient treatment. Home visits by generic community nurses. Primary outcome measure was change in health status measured by the Clinical COPD Questionnaire (CCQ). Treatment failures, readmissions, mortality and change in generic health-related quality of life (HRQL) were secondary outcome measures.

RESULTS

139 patients were randomised. No difference between groups was found in change in CCQ score at day 7 (difference in mean change 0.29 (95% CI -0.03 to 0.61)) or at 3 months (difference in mean change 0.04 (95% CI -0.40 to 0.49)). No difference was found in secondary outcomes. At day 7 there was a significant difference in change in generic HRQL, favouring usual hospital care.

CONCLUSIONS

While patients' disease-specific health status after 7-day treatment tended to be somewhat better in the usual hospital care group, the difference was small and not clinically relevant or statistically significant. After 3 months, the difference had disappeared. A significant difference in generic HRQL at the end of the treatment had disappeared after 3 months and there was no difference in treatment failures, readmissions or mortality. Early assisted discharge with community nursing is feasible and an alternative to usual hospital care for selected patients with an acute COPD exacerbation.

TRIAL REGISTRATION

NetherlandsTrialRegister NTR 1129.

Changes in NHS organization of care and management of hospital admissions with COPD exacerbations between the national COPD audits of 2003 and 2008

BACKGROUND

The 2003 UK Chronic Obstructive Pulmonary Disease (COPD) audit revealed wide variability between hospital units in care delivered.

AIMS

To assess whether processes of care, patient outcomes and organization of care have improved since 2003.

DESIGN

A UK national audit was performed in 2008 to survey the organization and delivery of clinical care provided to patients admitted to hospital with COPD.

METHODS

All UK acute hospital Trusts (units) were invited to participate. Each unit completed cross-sectional resource and organization questionnaires and a prospective clinical audit comprising up to 60 consecutively admitted cases of COPD exacerbation. Comparison between 2003 and 2008 includes aggregated statistics for units participating in both audit rounds.

RESULTS

A total of 192 units participated in both audit rounds (6197 admissions in 2003 and 8170 in 2008). In 2008, patients were older and of a poorer functional class. Overall mortality was unchanged but adjusting for age and performance status, inpatient mortality (P = 0.05) and 90-day mortality (P = 0.001) were both reduced in 2008. More patients were discharged under a respiratory specialist (P < 0.01), treated with non-invasive ventilation if acidotic (P < 0.001) and accepted onto early discharge schemes (P < 0.01) while median length of stay fell from 6 to 5 days (P < 0.001). Within these mean data, however, there remains considerable inter-unit variation in organization, resources and outcomes.

CONCLUSION

Overall improvements in resources and organization are accompanied by reduced mortality, shorter admissions and greater access to specialist services. There remains, however, considerable variation in the quality of secondary care provided between units.

Effectiveness and cost-effectiveness of early assisted discharge for chronic obstructive pulmonary disease exacerbations: the design of a randomised controlled trial

BACKGROUND

Exacerbations of chronic obstructive pulmonary disease (COPD) are the main cause for hospitalisation. These hospitalisations result in a high pressure on hospital beds and high health care costs. Because of the increasing prevalence of COPD this will only become worse. Hospital at home is one of the alternatives that has been proved to be a safe alternative for hospitalisation in COPD. Most schemes are early assisted discharge schemes with specialised respiratory nurses providing care at home. Whether this type of service is cost-effective depends on the setting in which it is delivered and the way in which it is organised.

METHODS/DESIGN

GO AHEAD (Assessment Of Going Home under Early Assisted Discharge) is a 3-months, randomised controlled, multi-centre clinical trial. Patients admitted to hospital for a COPD exacerbation are either discharged on the fourth day of admission and further treated at home, or receive usual inpatient hospital care. Home treatment is supervised by general nurses. Primary outcome is the effectiveness and cost effectiveness of an early assisted discharge intervention in comparison with usual inpatient hospital care for patients hospitalised with a COPD exacerbation. Secondary outcomes include effects on quality of life, primary informal caregiver burden and patient and primary caregiver satisfaction. Additionally, a discrete choice experiment is performed to provide insight in patient and informal caregiver preferences for different treatment characteristics. Measurements are performed on the first day of admission and 3 days, 7 days, 1 month and 3 months thereafter. Ethical approval has been obtained and the study has been registered.

DISCUSSION

This article describes the study protocol of the GO AHEAD study. Early assisted discharge could be an effective and cost-effective method to reduce length of hospital stay in the Netherlands which is beneficial for patients and society. If effectiveness and cost-effectiveness can be proven, implementation in the Dutch health care system should be considered.

TRIAL REGISTRATION

Netherlands Trial Register NTR1129.

Cost analysis of an integrated care model in the management of acute exacerbations of chronic obstructive pulmonary disease

Home treatment models for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) proved to be a safe alternative to hospitalization. These models have the potential to free up resources; however, in the United Kingdom, it remains unclear to whether they provide cost savings compared with hospital treatment. Over a 12-month period from August 2003, 130 patients were selected for the integrated care group (total admissions with AECOPD = 546). These patients were compared with 95 retrospective controls in the hospital treatment group. Controls were selected from admissions during the previous 12 months (total of 662 admissions) to match the integrated care group in age, sex, and postal code. Resource use data were collected for both groups and compared using National Health Service (NHS) perspective for cost minimization analysis. In the integrated care group (130 patients), 107 (82%) patients received home support with average length of stay 3.3 (SD 3.9) days compared with 10.4 (SD 7.7) in the hospital group (95 patients). Average number of visits per patients in the integrated care group was 3.08 (SD = 0.95; 95% CI = 2.9—3.2). Cost per patient in the integrated care group was £1653 (95% CI, £1521—1802) compared with £2256 (95% CI, £2126— 2407) in the hospital group. The integrated care group resulted in cost saving of approximately £600 (P < 0.001) per patient. This integrated care model for the management of patients with AECOPD offered cost savings of £600 per patient over the conventional hospital treatment model using the new NHS tariff from an acute trust provider perspective.

Timely discharge of older patients from hospital: improving the process

Elderly patients represent a large number of admissions to hospital, accounting for a disproportionate number of hospital bed days. Discharge planning can improve the safety and appropriateness of discharge from hospital, and can have a positive impact on length of stay and efficiency. Despite this, discharge planning is often neglected. This review, both evidence and experience based, is provided to aid with the safe discharge of elderly patients back into the community.