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

Abstract

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.

Keywords: copd exacerbations.

Conflict of interest statement

Competing interests: SCB reports grants from NIHR: Research for Patient Benefit Programme, during the conduct of the study; HTA funding, grants from Philips Respironics and Pfizer Open Air, personal fees from Pfizer and AstraZeneca, outside the submitted work. JG reports grants from NIHR Research for Patient Benefit, during the conduct of the study. CE, GJG, TH, AJS and JS have no competing interests to declare.

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Figures

Figure 1

CONSORT diagram. CONSORT, Consolidated Standards of Reporting Trials; HAH, Hospital at Home.

Figure 2

Length of stay and cost difference (£) between HAH and UC. One-sided CIs for the mean difference in 90-day health and social care costs between UC and HAH are shown for the trial population (UC=3 days) and the sensitivity analysis adjusting for a longer hospital stay in UC (UC=4 days and UC=5 days); Δ=£150, α=£340. HAH, Hospital at Home; UC, usual care.

Figure 3

Cost-effectiveness plane (A) and cost-effectiveness acceptability curve (B). The cost-effectiveness plane for HAH and UC, with the diagonal line representing the NICE cut-off at £30 000 per QALY. Area 1=HAH cheaper and more effective; area 2=HAH more effective and more expensive but less than the NICE cut-off; and area 3=UC is more effective but more expensive and exceeds the NICE cut-off. (B) The probability of cost-effectiveness is shown over a range of willingness to pay for a QALY, to inform decisions to accept or reject new technologies. There is a 90% probability HAH will be cost-effective at the NICE threshold (vertical line). HAH, Hospital at Home; NICE, National Institute for Health and Care Excellence; QALY, quality-adjusted life year; UC, usual care.