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
Geneviève Arsenault-Lapierre, Mary Henein, Dina Gaid, Mélanie Le Berre, Genevieve Gore, Isabelle Vedel, Geneviève Arsenault-Lapierre, Mary Henein, Dina Gaid, Mélanie Le Berre, Genevieve Gore, Isabelle Vedel
Abstract
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.
Conflict of interest statement
Conflict of Interest Disclosures: None reported.
Figures
![Figure 1.. Preferred Reporting Items for Systematic…](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/8188269/bin/jamanetwopen-e2111568-g001.jpg)
![Figure 2.. Risk of Bias Quality Appraisal…](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/8188269/bin/jamanetwopen-e2111568-g002.jpg)
References
- Forster AJ, Clark HD, Menard A, et al. . Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170(3):345-349.
- Sharek PJ, Parry G, Goldmann D, et al. . Performance characteristics of a methodology to quantify adverse events over time in hospitalized patients. Health Serv Res. 2011;46(2):654-678. doi:10.1111/j.1475-6773.2010.01156.x
- Brennan TA, Leape LL, Laird NM, et al. ; Harvard Medical Practice Study I . Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. 1991. Qual Saf Health Care. 2004;13(2):145-151. doi:10.1136/qshc.2002.003822
- Klevens RM, Edwards JR, Richards CL Jr, et al. . Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160-166. doi:10.1177/003335490712200205
- Vasilevskis EE, Han JH, Hughes CG, Ely EW. Epidemiology and risk factors for delirium across hospital settings. Best Pract Res Clin Anaesthesiol. 2012;26(3):277-287. doi:10.1016/j.bpa.2012.07.003
- Friedman B, Jiang HJ, Elixhauser A. Costly hospital readmissions and complex chronic illness. Inquiry. 2008-2009;45(4):408-421. doi:10.5034/inquiryjrnl_45.04.408
- Public Health Agency of Canada . Economic burden of illness in Canada, 2010. Accessed November 1, 2019.
- Anderson G, Horvath J. The growing burden of chronic disease in America. Public Health Rep. 2004;119(3):263-270. doi:10.1016/j.phr.2004.04.005
- Coley CM, Li Y-H, Medsger AR, et al. . Preferences for home vs hospital care among low-risk patients with community-acquired pneumonia. Arch Intern Med. 1996;156(14):1565-1571. doi:10.1001/archinte.1996.00440130115012
- Fried TR, van Doorn C, O’Leary JR, Tinetti ME, Drickamer MA. Older person’s preferences for home vs hospital care in the treatment of acute illness. Arch Intern Med. 2000;160(10):1501-1506. doi:10.1001/archinte.160.10.1501
- Leff B, Montalto M. Home hospital-toward a tighter definition. J Am Geriatr Soc. 2004;52(12):2141. doi:10.1111/j.1532-5415.2004.52579_1.x
- Gonçalves-Bradley DC, Iliffe S, Doll HA, et al. Early discharge hospital at home. Cochrane Database Syst Rev. 2017;6(6):CD000356. doi:10.1002/14651858.CD000356.pub4
- Shepperd S, Doll H, Angus RM, et al. Admission avoidance hospital at home. Cochrane Database Syst Rev. 2008;(4):CD007491. doi:10.1002/14651858.CD007491
- Shepperd S, Iliffe S. The effectiveness of hospital at home compared with in-patient hospital care: a systematic review. J Public Health Med. 1998;20(3):344-350. doi:10.1093/oxfordjournals.pubmed.a024778
- Qaddoura A, Yazdan-Ashoori P, Kabali C, et al. . Efficacy of hospital at home in patients with heart failure: a systematic review and meta-analysis. PLoS One. 2015;10(6):e0129282. doi:10.1371/journal.pone.0129282
- Conley J, O’Brien CW, Leff BA, Bolen S, Zulman D. Alternative strategies to inpatient hospitalization for acute medical conditions: a systematic review. JAMA Intern Med. 2016;176(11):1693-1702. doi:10.1001/jamainternmed.2016.5974
- Pigott T, Shepperd S. Identifying, documenting, and examining heterogeneity in systematic reviews of complex interventions. J Clin Epidemiol. 2013;66(11):1244-1250. doi:10.1016/j.jclinepi.2013.06.013
- Shepperd S, Doll H, Broad J, et al. Early discharge hospital at home. Cochrane Database of Syst Rev. 2009;(1):CD000356.
- Echevarria C, Brewin K, Horobin H, et al. . Early supported discharge/hospital at home for acute exacerbation of chronic obstructive pulmonary disease: a review and meta-analysis. COPD. 2016;13(4):523-533. doi:10.3109/15412555.2015.1067885
- Shepperd S, Doll H, Angus RM, et al. . Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data. CMAJ. 2009;180(2):175-182. doi:10.1503/cmaj.081491
- Coster JE, Turner JK, Bradbury D, Cantrell A. Why do people choose emergency and urgent care services? a rapid review utilizing a systematic literature search and narrative synthesis. Acad Emerg Med. 2017;24(9):1137-1149. doi:10.1111/acem.13220
- Le Berre M, Maimon G, Sourial N, Guériton M, Vedel I. Impact of transitional care services for chronically Ill older patients: a systematic evidence review. J Am Geriatr Soc. 2017;65(7):1597-1608. doi:10.1111/jgs.14828
- Bogaisky M, Dezieck L. Early hospital readmission of nursing home residents and community-dwelling elderly adults discharged from the geriatrics service of an urban teaching hospital: patterns and risk factors. J Am Geriatr Soc. 2015;63(3):548-552. doi:10.1111/jgs.13317
- Epstein AM, Jha AK, Orav EJ. The relationship between hospital admission rates and rehospitalizations. N Engl J Med. 2011;365(24):2287-2295. doi:10.1056/NEJMsa1101942
- Bell CM, Brener SS, Gunraj N, et al. . Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA. 2011;306(8):840-847. doi:10.1001/jama.2011.1206
- Vogeli C, Shields AE, Lee TA, et al. . Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med. 2007;22(suppl 3):391-395. doi:10.1007/s11606-007-0322-1
- Buhler-Wilkerson K. Care of the chronically ill at home: an unresolved dilemma in health policy for the United States. Milbank Q. 2007;85(4):611-639. doi:10.1111/j.1468-0009.2007.00503.x
- Smith DM, Giobbie-Hurder A, Weinberger M, et al. ; Department of Veterans Affairs Cooperative Study Group on Primary Care and Readmissions . Predicting non-elective hospital readmissions: a multi-site study. J Clin Epidemiol. 2000;53(11):1113-1118. doi:10.1016/S0895-4356(00)00236-5
- Partnership to Fight Chronic Disease. The growing crisis of chronic disease in the United States. Accessed February 1, 2021.
- Higgins JPT, Thomas J, Chandler J, et al, eds. Cochrane Handbook for Systematic Reviews of Interventions. Vol 6. Cochrane; 2019.
- Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group . Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. doi:10.1371/journal.pmed.1000097
- Godard-Sebillotte C, Le Berre M, Karunananthan S, Hong QN, Vedel I. A digital media strategy to obtain unpublished data for a systematic review yields a very high author response rate. J Clin Epidemiol. 2018;104:141-143.
- Popay J, Roberts H, Sowden A, et al. . Guidance on the Conduct of Narrative Synthesis in Systematic Reviews. Lancaster University; 2006.
- Mendoza H, Martín MJ, García A, et al. . ‘Hospital at home’ care model as an effective alternative in the management of decompensated chronic heart failure. Eur J Heart Fail. 2009;11(12):1208-1213. doi:10.1093/eurjhf/hfp143
- Echevarria C, Gray J, Hartley T, et al. . Home treatment of COPD exacerbation selected by DECAF score: a non-inferiority, randomised controlled trial and economic evaluation. Thorax. 2018;73(8):713-722. doi:10.1136/thoraxjnl-2017-211197
- Levine DM, Ouchi K, Blanchfield B, et al. . Hospital-level care at home for acutely ill adults: a pilot randomized controlled trial. J Gen Intern Med. 2018;33(5):729-736. doi:10.1007/s11606-018-4307-z
- Vianello A, Savoia F, Pipitone E, et al. . “Hospital at home” for neuromuscular disease patients with respiratory tract infection: a pilot study. Respir Care. 2013;58(12):2061-2068. doi:10.4187/respcare.02501
- Aimonino Ricauda N, Tibaldi V, Leff B, et al. . Substitutive “hospital at home” versus inpatient care for elderly patients with exacerbations of chronic obstructive pulmonary disease: a prospective randomized, controlled trial. J Am Geriatr Soc. 2008;56(3):493-500. doi:10.1111/j.1532-5415.2007.01562.x
- Ricauda NA, Bo M, Molaschi M, et al. . Home hospitalization service for acute uncomplicated first ischemic stroke in elderly patients: a randomized trial. J Am Geriatr Soc. 2004;52(2):278-283. doi:10.1111/j.1532-5415.2004.52069.x
- Tibaldi V, Isaia G, Scarafiotti C, et al. . Hospital at home for elderly patients with acute decompensation of chronic heart failure: a prospective randomized controlled trial. Arch Intern Med. 2009;169(17):1569-1575. doi:10.1001/archinternmed.2009.267
- Hernandez C, Casas A, Escarrabill J, et al. ; CHRONIC project . Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients. Eur Respir J. 2003;21(1):58-67. doi:10.1183/09031936.03.00015603
- Davies L, Wilkinson M, Bonner S, Calverley PM, Angus RM. “Hospital at home” versus hospital care in patients with exacerbations of chronic obstructive pulmonary disease: prospective randomised controlled trial. BMJ. 2000;321(7271):1265-1268. doi:10.1136/bmj.321.7271.1265
- United Nations . World Population Ageing 2017. Accessed November 1, 2019.
- Jeppesen E, Brurberg KG, Vist GE, et al. . Hospital at home for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Syst Rev. 2012;(5):CD003573.
- Varney J, Weiland TJ, Jelinek G. Efficacy of hospital in the home services providing care for patients admitted from emergency departments: an integrative review. Int J Evid Based Healthc. 2014;12(2):128-141. doi:10.1097/XEB.0000000000000011
- Levine DM, Ouchi K, Blanchfield B, et al. . Hospital-level care at home for acutely ill adults: a randomized controlled trial. Ann Intern Med. 2020;172(2):77-85. doi:10.7326/M19-0600
- Jacobs JM, Cohen A, Rozengarten O, et al. . Closure of a home hospital program: impact on hospitalization rates. Arch Gerontol Geriatr. 2007;45(2):179-189. doi:10.1016/j.archger.2006.10.009
- Jones J, Wilson A, Parker H, et al. . Economic evaluation of hospital at home versus hospital care: cost minimisation analysis of data from randomised controlled trial. BMJ. 1999;319(7224):1547-1550. doi:10.1136/bmj.319.7224.1547
- McCurdy BR. Hospital-at-home programs for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD): an evidence-based analysis. Ont Health Technol Assess Ser. 2012;12(10):1-65.
- Caplan GA, Sulaiman NS, Mangin DA, Aimonino Ricauda N, Wilson AD, Barclay L. A meta-analysis of “hospital in the home”. Med J Aust. 2012;197(9):512-519. doi:10.5694/mja12.10480
- Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. doi:10.1056/NEJMsa0803563
- Cameron KA, Song J, Manheim LM, Dunlop DD. Gender disparities in health and healthcare use among older adults. J Womens Health (Larchmt). 2010;19(9):1643-1650. doi:10.1089/jwh.2009.1701
- Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M; Medical Research Council Guidance . Developing and evaluating complex interventions: the new medical research council guidance. BMJ. 2008;337:a1655. doi:10.1136/bmj.a1655
- Coffey A, Leahy-Warren P, Savage E, et al. . Interventions to promote early discharge and avoid inappropriate hospital (re)admission: a systematic review. Int J Environ Res Public Health. 2019;16(14):2457. doi:10.3390/ijerph16142457
- Nundy S, Patel K. Hospital-at-home to support COVID-19 surge—time to bring down the walls? JAMA Health Forum. Published online May 1, 2020. doi:10.1001/jamahealthforum.2020.0504
Source: PubMed