NIHR Signal Early discharge ‘hospital-at-home’ gives similar outcomes to in-patient care

Published on 3 October 2017

Supported early discharge, where patients receive on-going hospital-level treatment in their own home, had no effect on mortality compared with standard in-patient care. Patients had shorter hospital stays, were more likely to be satisfied and less likely to end up in residential care.

This updated Cochrane review identified 32 international trials comparing early discharge hospital-at-home with hospital in-patient care. Most evidence related to people recovering from a stroke, where NICE already recommends supported discharge if this is appropriate. Other patient groups included those recovering from orthopaedic surgery and older people with various conditions. Trials were relatively small and the overall evidence quality was moderate to low.

The review aimed to see whether early discharge has an effect on NHS costs, but found insufficient evidence. Training, staffing and equipment costs need to be measured against patient outcomes in different therapy areas. Early supported discharge needs to be driven in areas where it can make the most difference and give the greatest benefit.

Early discharge ‘hospital-at-home’ gives similar outcomes to in-patient care

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Why was this study needed?

The number of hospital beds available in NHS organisations in England has fallen over the last five years, while the percentage of occupied beds has risen. One way to reduce the demand for hospital beds is to support earlier discharge of people and provide on-going health care services at home instead. This is already done for some conditions, such as stroke, chronic obstructive pulmonary disease and hip fracture.

However, it isn’t clear whether patients receiving such services have better or worse health outcomes than those who stay in hospital. It is also unknown if these services bring an increase or reduction in costs to the NHS.

This was an update of a 2009 Cochrane review on the topic.

What did this study do?

The review identified 32 trials, six of which were new for this update, including 4746 adults from 12 countries. Half of the trials came from the UK.

Trials compared acute hospital inpatient care with early discharge hospital-at-home. This was defined as services that provide time-limited active treatment by healthcare professionals in the patient’s home for a condition that would otherwise need acute inpatient care. Maternity, mental health and palliative care were excluded, as were people with long-term care needs.

Eleven trials included patients following stroke, eight covered elective surgery, and the remainder included older people with a mix of conditions.

Most trials had a low risk of bias. However, most had a small sample size (less than 100) and wide confidence intervals giving less certainty in the results.

What did it find?

  • Early discharge hospital-at-home made no difference to mortality at three to six months for any patient group:
    • After stroke: relative risk (RR) 0.92, 95% confidence interval (CI) 0.57 to 1.48 (moderate quality evidence from 11 trials, 1114 participants).
    • Older people with mixed conditions: RR 1.07, 95% CI 0.76 to 1.49 (moderate quality evidence, eight trials, 1247 participants).
    • Following elective surgery: no difference reported, data not pooled ( evidence, three orthopaedic trials in 856 participants).
  • There was a suggestion that early discharge may increase the risk of hospital readmission for older people with mixed conditions, but this just fell short of statistical significance (RR 1.25, 95% CI 0.98 to 1.58; evidence, nine trials, 1276). Early discharge made little or no difference to the of readmission following stroke (RR 1.09, 95% CI 0.71 to 1.66; evidence, five trials, 345 participants) or elective surgery (reported by five trials in 1229 participants).
  • Hospital-at-home reduced the of hospital stay. Patients recovering from stroke were discharged 6.68 days earlier than those in the inpatient group (95% CI 3.17 to 10.19 days; four trials, 528 participants). Older people with mixed conditions spent 0.36 to 22 fewer days in the (eight trials, 767 participants), and patients recovering from elective orthopaedic surgery were discharged 4.4 days earlier (95% CI 6.37 to 2.51 days; four trials, 411 participants).
  • Low-quality evidence suggests early discharge may reduce the risk of living in an institutional setting following stroke (RR 0.63, 95% CI 40 to 0.98; four trials, 574 people) and for older people with mixed conditions (RR 0.69, 95% CI 48 to 0.99; three trials, 484 people).
  • It is uncertain whether hospital-at-home is for the NHS. Not all trials reported and those that did and valued different healthcare resources.
  • Early discharge hospital at home may slightly improve satisfaction with health care received for patients recovering from a stroke (low-quality evidence)

Benefits of Hospital-at-Home

What does current guidance say on this issue?

There is no single piece of national guidance on early discharge hospital-at-home schemes, but they are covered in various condition-specific guidelines. The Royal College of Physicians and NICE guidelines on stroke recommend that patients who are able to transfer from bed to chair independently or with assistance are offered early supported discharge. This is where rehabilitation continues at home with the same intensity of multidisciplinary care as would be received in the hospital.

NICE’s guideline on chronic obstructive pulmonary disease states that hospital-at-home and assisted-discharge schemes are safe and effective and should be used as an alternative way of caring for patients who would otherwise need to stay in the hospital.

What are the implications?

The findings suggest that supported early discharge can be safe and beneficial for patients, particularly in established therapy areas such as stroke rehabilitation. The evidence is not able to examine the factors that are likely to influence the success of hospital-at-home, such as severity of illness or availability of carers.

Reduced duration of hospital stay may be expected to free NHS beds and save resources. But the review highlights the lack of evidence on cost-effectiveness. Further research needs to examine the costs of early discharge for different patient groups from the UK perspective especially as this type of service is relatively new in the UK.

Citation and Funding

Gonçalves-Bradley DC, Iliffe S, Doll HA, et al. Early discharge hospital at home. Cochrane Database Syst Rev. 2017;6:CD000356.

Cochrane UK and the Cochrane Effective Practice and Organisation of Care Group are supported by NIHR infrastructure funding. This project was supported by an NIHR Research Scientist in Evidence Synthesis Award.

Bibliography

NHS Choices. Hospital discharge. London: Department of Health. 2016.

NHS England. Bed availability and occupancy. Leeds: NHS England; 2017.

NICE. Stroke rehabilitation in adults. CG62. London: National Institute for Health and Care Excellence; 2013.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. CG101. London: National Institute for Health and Care Excellence; 2010.

NICE. Stroke in Adults. QS2. London: National Institute for Health and Care Excellence; 2010.

RCP. National clinical guideline for stroke (fifth edition). London: Royal College of Physicians Intercollegiate Stroke Working Party; 2016.

Why was this study needed?

The number of hospital beds available in NHS organisations in England has fallen over the last five years, while the percentage of occupied beds has risen. One way to reduce the demand for hospital beds is to support earlier discharge of people and provide on-going health care services at home instead. This is already done for some conditions, such as stroke, chronic obstructive pulmonary disease and hip fracture.

However, it isn’t clear whether patients receiving such services have better or worse health outcomes than those who stay in hospital. It is also unknown if these services bring an increase or reduction in costs to the NHS.

This was an update of a 2009 Cochrane review on the topic.

What did this study do?

The review identified 32 trials, six of which were new for this update, including 4746 adults from 12 countries. Half of the trials came from the UK.

Trials compared acute hospital inpatient care with early discharge hospital-at-home. This was defined as services that provide time-limited active treatment by healthcare professionals in the patient’s home for a condition that would otherwise need acute inpatient care. Maternity, mental health and palliative care were excluded, as were people with long-term care needs.

Eleven trials included patients following stroke, eight covered elective surgery, and the remainder included older people with a mix of conditions.

Most trials had a low risk of bias. However, most had a small sample size (less than 100) and wide confidence intervals giving less certainty in the results.

What did it find?

  • Early discharge hospital-at-home made no difference to mortality at three to six months for any patient group:
    • After stroke: relative risk (RR) 0.92, 95% confidence interval (CI) 0.57 to 1.48 (moderate quality evidence from 11 trials, 1114 participants).
    • Older people with mixed conditions: RR 1.07, 95% CI 0.76 to 1.49 (moderate quality evidence, eight trials, 1247 participants).
    • Following elective surgery: no difference reported, data not pooled ( evidence, three orthopaedic trials in 856 participants).
  • There was a suggestion that early discharge may increase the risk of hospital readmission for older people with mixed conditions, but this just fell short of statistical significance (RR 1.25, 95% CI 0.98 to 1.58; evidence, nine trials, 1276). Early discharge made little or no difference to the of readmission following stroke (RR 1.09, 95% CI 0.71 to 1.66; evidence, five trials, 345 participants) or elective surgery (reported by five trials in 1229 participants).
  • Hospital-at-home reduced the of hospital stay. Patients recovering from stroke were discharged 6.68 days earlier than those in the inpatient group (95% CI 3.17 to 10.19 days; four trials, 528 participants). Older people with mixed conditions spent 0.36 to 22 fewer days in the (eight trials, 767 participants), and patients recovering from elective orthopaedic surgery were discharged 4.4 days earlier (95% CI 6.37 to 2.51 days; four trials, 411 participants).
  • Low-quality evidence suggests early discharge may reduce the risk of living in an institutional setting following stroke (RR 0.63, 95% CI 40 to 0.98; four trials, 574 people) and for older people with mixed conditions (RR 0.69, 95% CI 48 to 0.99; three trials, 484 people).
  • It is uncertain whether hospital-at-home is for the NHS. Not all trials reported and those that did and valued different healthcare resources.
  • Early discharge hospital at home may slightly improve satisfaction with health care received for patients recovering from a stroke (low-quality evidence)

Benefits of Hospital-at-Home

What does current guidance say on this issue?

There is no single piece of national guidance on early discharge hospital-at-home schemes, but they are covered in various condition-specific guidelines. The Royal College of Physicians and NICE guidelines on stroke recommend that patients who are able to transfer from bed to chair independently or with assistance are offered early supported discharge. This is where rehabilitation continues at home with the same intensity of multidisciplinary care as would be received in the hospital.

NICE’s guideline on chronic obstructive pulmonary disease states that hospital-at-home and assisted-discharge schemes are safe and effective and should be used as an alternative way of caring for patients who would otherwise need to stay in the hospital.

What are the implications?

The findings suggest that supported early discharge can be safe and beneficial for patients, particularly in established therapy areas such as stroke rehabilitation. The evidence is not able to examine the factors that are likely to influence the success of hospital-at-home, such as severity of illness or availability of carers.

Reduced duration of hospital stay may be expected to free NHS beds and save resources. But the review highlights the lack of evidence on cost-effectiveness. Further research needs to examine the costs of early discharge for different patient groups from the UK perspective especially as this type of service is relatively new in the UK.

Citation and Funding

Gonçalves-Bradley DC, Iliffe S, Doll HA, et al. Early discharge hospital at home. Cochrane Database Syst Rev. 2017;6:CD000356.

Cochrane UK and the Cochrane Effective Practice and Organisation of Care Group are supported by NIHR infrastructure funding. This project was supported by an NIHR Research Scientist in Evidence Synthesis Award.

Bibliography

NHS Choices. Hospital discharge. London: Department of Health. 2016.

NHS England. Bed availability and occupancy. Leeds: NHS England; 2017.

NICE. Stroke rehabilitation in adults. CG62. London: National Institute for Health and Care Excellence; 2013.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. CG101. London: National Institute for Health and Care Excellence; 2010.

NICE. Stroke in Adults. QS2. London: National Institute for Health and Care Excellence; 2010.

RCP. National clinical guideline for stroke (fifth edition). London: Royal College of Physicians Intercollegiate Stroke Working Party; 2016.

Early discharge hospital at home

Published on 27 June 2017

Goncalves-Bradley, D. C.,Iliffe, S.,Doll, H. A.,Broad, J.,Gladman, J.,Langhorne, P.,Richards, S. H.,Shepperd, S.

Cochrane Database Syst Rev Volume 6 , 2017

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.

Expert commentary

This updated Cochrane review explores an important question; do patients who are discharged from hospital early and cared for at home instead of remaining in hospital experience better outcomes and is this type of care cheaper?

Whilst there was insufficient evidence of economic benefit or improved health outcomes, this review can help decision-making in this area. It is possible certain patients would benefit from possible increased satisfaction and reduced likelihood of admission to institutional care if discharged early.

It may also change assumptions about the cost of care at home versus inpatient care, although more research is needed.

Dr Katherine Perryman, Research Fellow, University of Manchester (Patient Safety)

Expert commentary

For some hospital is a place of refuge, a safe place to weather the storm of illness - for others it’s seen as detrimental to recovery. This review does little to objectively clarify the relative merits of ‘early discharge hospital-at-home’ and standard hospital care.

In this context, the value of these approaches should continue to be investigated. As well as looking for straightforward evidence of relative benefits, evaluators should recognise the complexity of these interventions and also consider the variety of forms that these interventions can take and the contexts in which they are provided.

Patrick Phillips, Research Associate / Nurse, University of Sheffield

Categories

  •   Health management, Later life, Nursing, Primary care, Acute and general medicine