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NIHR Signal People with COPD exacerbations prefer early discharge then treatment at home

Published on 11 December 2018

doi: 10.3310/signal-000691

People with flare-ups of COPD (chronic obstructive pulmonary disease) prefer to be managed at home rather than in hospital. Hospital stay was on average four days shorter when people were discharged early to the hospital at home scheme, and there was no noticeable increase in readmissions in this group.

This NIHR-funded trial aimed to establish the costs and outcomes of hospital at home compared with staying in hospital for treatment.

The findings support current guidance that hospital at home is suitable for selected patients and this study shows that the DECAF score is an effective way of selecting people, with a low risk of serious complications, who may be suitable.

There was a large reduction in number of days in hospital which should probably give cost savings, although the hoped for benefit of a reduction in readmissions was not realised.

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Why was this study needed?

Chronic obstructive pulmonary disease (COPD) is the name of a group of lung disorders that cause increasing difficulty in breathing over time. Almost 2% of people in England have COPD, mostly middle aged or older long term smokers.

COPD usually progresses slowly, but people can have sudden worsening known as an exacerbation. In 2017–18 in England, there were 34,980 hospital admissions for acute exacerbations of COPD, totalling 137,099 days in hospital.

Hospital at home services can provide much, but not all, of the care available in hospital and has been shown effective, but choosing appropriate patients has been difficult. This study aimed to see if treating people at home was effective and cheaper for people at low risk of dying from an exacerbation of COPD according to the DECAF clinical prediction tool (see Definitions tab).

What did this study do?

This randomised controlled trial included 120 people admitted to three hospitals in England with a COPD exacerbation who had a DECAF score of 0 or 1. This indicated a low risk of dying. People were assigned to either stay in hospital or have ‘hospital at home’.

People receiving hospital at home were visited by a respiratory specialist nurse once or twice a day. A respiratory consultant provided remote supervision. Patients had an emergency number to contact the team at any time and access to physiotherapy, occupational therapy, psychology, pharmacy, and short-term social support.

Patients had daily monitoring of their breathing rate, blood pressure, and blood oxygen levels, with blood tests if needed. Oral and intravenous treatments plus oxygen therapy were available.

This was a robust, well-designed trial and the results should be applicable to other NHS trusts.

What did it find?

  • Hospital at home costs about £1,016 less than usual care on average and has a high chance - 90% - of being cost effective at usual NHS willingness-to-pay thresholds.
  • Patients in the hospital at home group spent an average of one day in hospital and four days with treatment at home compared with five days in hospital with usual care.
  • About 90% of patients said they would prefer hospital at home during future exacerbations (54 of 60 people who had hospital at home and 51 of 57 who had usual care).
  • There was little difference in the proportion of re-admissions: 37% of people having hospital at home and 40% of people who stayed in hospital were readmitted within 90 days.
  • No patients in either group died in the two weeks after attending hospital with their exacerbation. One person in each group died within 90 days.

What does current guidance say on this issue?

NICE’s recent 2018 guideline on COPD recommends hospital at home and assisted-discharge schemes as safe and effective for people who would otherwise need to be admitted or stay in hospital. It notes, from its 2004 review, that evidence is insufficient to make specific recommendations on selecting people for such services.

The British Thoracic Society’s 2007 guideline on intermediate care with hospital at home in COPD provides detailed recommendations on hospital at home services. However, no standardised scoring tools were recommended for identifying which clinical characteristics made hospital at home a suitable option.

What are the implications?

This study supports the current move towards assisted-discharge schemes supported by hospital at home for selected people with exacerbations of COPD. The evidence adds data and notes it is preferred by those cared for at home. The DECAF score seems a practical choice for assessing risk.

Hospital at home may cost less than staying in hospital, driven by shorter hospital stay rather than fewer readmissions.

This was a relatively small study of 120 people in only three hospitals. Further information from other centres in the UK would be needed to be certain of the benefits to patients, and the savings in NHS costs. The DECAF score might be suitable for reviewing in the next update of guidelines.

Citation and Funding

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):713-22.

This project was funded by the National Institute for Health Research – Research for Patient Benefit Programme (project number PB-PG-0213-30105).

Bibliography

British Thoracic Society Guideline Development Group. Intermediate care—Hospital-at-Home in chronic obstructive pulmonary disease: British Thoracic Society guideline. Thorax 2007;62:200–10.

Health and Social Care Information Centre. Quality and Outcomes Framework – prevalence, achievements and exceptions report: England, 2014–15. London: Health and Social Care Information Centre; 2015.

Jeppesen E, Brurberg KG, Vist GE et al. Hospital at home for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;(5):CD003573.

NHS Digital. Hospital Episodes Statistics 2017-18: Diagnosis. NHS Digital; 2018.

NHS website. Chronic obstructive pulmonary disease (COPD). London: Department of Health and Social Care; updated 2016.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NG115. London: National Institute for Health and Care Excellence; 2018.

Why was this study needed?

Chronic obstructive pulmonary disease (COPD) is the name of a group of lung disorders that cause increasing difficulty in breathing over time. Almost 2% of people in England have COPD, mostly middle aged or older long term smokers.

COPD usually progresses slowly, but people can have sudden worsening known as an exacerbation. In 2017–18 in England, there were 34,980 hospital admissions for acute exacerbations of COPD, totalling 137,099 days in hospital.

Hospital at home services can provide much, but not all, of the care available in hospital and has been shown effective, but choosing appropriate patients has been difficult. This study aimed to see if treating people at home was effective and cheaper for people at low risk of dying from an exacerbation of COPD according to the DECAF clinical prediction tool (see Definitions tab).

What did this study do?

This randomised controlled trial included 120 people admitted to three hospitals in England with a COPD exacerbation who had a DECAF score of 0 or 1. This indicated a low risk of dying. People were assigned to either stay in hospital or have ‘hospital at home’.

People receiving hospital at home were visited by a respiratory specialist nurse once or twice a day. A respiratory consultant provided remote supervision. Patients had an emergency number to contact the team at any time and access to physiotherapy, occupational therapy, psychology, pharmacy, and short-term social support.

Patients had daily monitoring of their breathing rate, blood pressure, and blood oxygen levels, with blood tests if needed. Oral and intravenous treatments plus oxygen therapy were available.

This was a robust, well-designed trial and the results should be applicable to other NHS trusts.

What did it find?

  • Hospital at home costs about £1,016 less than usual care on average and has a high chance - 90% - of being cost effective at usual NHS willingness-to-pay thresholds.
  • Patients in the hospital at home group spent an average of one day in hospital and four days with treatment at home compared with five days in hospital with usual care.
  • About 90% of patients said they would prefer hospital at home during future exacerbations (54 of 60 people who had hospital at home and 51 of 57 who had usual care).
  • There was little difference in the proportion of re-admissions: 37% of people having hospital at home and 40% of people who stayed in hospital were readmitted within 90 days.
  • No patients in either group died in the two weeks after attending hospital with their exacerbation. One person in each group died within 90 days.

What does current guidance say on this issue?

NICE’s recent 2018 guideline on COPD recommends hospital at home and assisted-discharge schemes as safe and effective for people who would otherwise need to be admitted or stay in hospital. It notes, from its 2004 review, that evidence is insufficient to make specific recommendations on selecting people for such services.

The British Thoracic Society’s 2007 guideline on intermediate care with hospital at home in COPD provides detailed recommendations on hospital at home services. However, no standardised scoring tools were recommended for identifying which clinical characteristics made hospital at home a suitable option.

What are the implications?

This study supports the current move towards assisted-discharge schemes supported by hospital at home for selected people with exacerbations of COPD. The evidence adds data and notes it is preferred by those cared for at home. The DECAF score seems a practical choice for assessing risk.

Hospital at home may cost less than staying in hospital, driven by shorter hospital stay rather than fewer readmissions.

This was a relatively small study of 120 people in only three hospitals. Further information from other centres in the UK would be needed to be certain of the benefits to patients, and the savings in NHS costs. The DECAF score might be suitable for reviewing in the next update of guidelines.

Citation and Funding

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):713-22.

This project was funded by the National Institute for Health Research – Research for Patient Benefit Programme (project number PB-PG-0213-30105).

Bibliography

British Thoracic Society Guideline Development Group. Intermediate care—Hospital-at-Home in chronic obstructive pulmonary disease: British Thoracic Society guideline. Thorax 2007;62:200–10.

Health and Social Care Information Centre. Quality and Outcomes Framework – prevalence, achievements and exceptions report: England, 2014–15. London: Health and Social Care Information Centre; 2015.

Jeppesen E, Brurberg KG, Vist GE et al. Hospital at home for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;(5):CD003573.

NHS Digital. Hospital Episodes Statistics 2017-18: Diagnosis. NHS Digital; 2018.

NHS website. Chronic obstructive pulmonary disease (COPD). London: Department of Health and Social Care; updated 2016.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NG115. London: National Institute for Health and Care Excellence; 2018.

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

Published on 21 April 2018

C Echevarria, J Gray, T Hartley, J Steer, J Miller, A J Simpson, J Gibson, S Bourke

Thorax , 2018

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.

The DECAF score is an acrostic, in which each letter stands for a different characteristic associated with COPD. A patient scores points for the characteristics they have, with higher scores indicating worse COPD.

People scoring 0 or 1 were well enough to have hospital at home and could be included in the study.

D is for dyspnoea (breathlessness) before the exacerbation:

  • 1 point if the person could wash or dress themselves but needed help leaving the house
  • 2 points if the person cannot wash or dress themselves or leave the house without help

E is for eosinopenia (low numbers of a type of white blood cell):

  • 1 point if the person has fewer than 500 eosinophils per microlitre of blood

C is for consolidation on chest X-ray (fluid showing as whiter areas of the lungs):

  • 1 point if present

A is for acidaemia (change in blood acidity caused by lack of oxygen):

  • 1 point if the person’s blood pH is less than 7.3

F is for fibrillation (irregular heart rhythm):

  • 1 point if the person has atrial fibrillation.

Expert commentary

People who have an exacerbation or worsening of their chronic obstructive pulmonary disease (COPD) can be safely cared for in 'hospital at home' schemes or discharged from hospital more quickly if they are rated as low risk on a clinical scoring system called DECAF. Patients preferred to be cared for at home rather than being admitted to hospital and care was as safe as hospital and probably cheaper.

This means people with COPD who are assessed in emergency departments or admission units as being low risk can safely be discharged if a suitable home care service is available. There is a growing body of evidence in this area, and this trial adds weight to an integrated care approach that encourages care in the community wherever possible.

Professor Sarah Purdy, Head of School, Bristol Medical School, University of Bristol

The commentator declares no conflicting interests