EVIDENCE SYNTHESIS

Efficacy of hospital in the home services providing care for patients admitted from emergency departments: an integrative review Jane Varney BSc, PhD, 1 Tracey J. Weiland BBSc (Hons), MPsych/PhD 1,2 and George Jelinek MBBS, MD 1,2 1

St Vincent’s Hospital, Melbourne, Victoria, Australia, 2The University of Melbourne, Melbourne, Victoria, Australia

ABSTRACT Introduction: Increases in emergency department (ED) demand may compromise patient outcomes, leading not only to overcrowding in the ED, increased ED waiting times and increased ED length of stay, but also compromising patient safety; the risk of adverse events is known to rise in the presence of overcrowding. Hospital in the home (HiTH) services may offer one means of reducing ED demand. Aim: This integrative review sought to assess the efficacy of admission-avoidance HiTH services that admit patients directly from the ED. Methods: Papers published between 1995 and 2013 were identified through searches of Medline, CINAHL and Google. English-language studies that assessed the efficacy of a HiTH service and that recruited at least one-third of the participants directly from the ED were included in the review. A HiTH service was considered one that provided health professional support to patients at home for a time-limited period, thus avoiding the need for hospitalization. Results: Twenty-two articles met the inclusion criteria for this review. The interventions were diverse in terms of the clinical interventions delivered, the range and intensity of health professional input and the conditions treated. The studies included in the review found no effect on clinical outcomes, rates of adverse events or complications, although patient satisfaction and costs were consistently and favourably affected by HiTH treatment. Conclusion: Given evidence suggesting that HiTH services which recruit patients directly from the ED contribute to cost-savings, greater patient satisfaction and safety and efficacy outcomes that are at least equivalent to those associated with hospital-based care, the expansion of such programmes might therefore be considered a priority for policy makers. Key words: accident and emergency, public health, service delivery Int J Evid Based Healthc 2014; 12:128–141.

Background

T

he increasing demand for both inpatient and emergency department (ED) care is well documented. Increases in ED demand may compromise patient outcomes, leading not only to ED overcrowding,1 increased ED waiting times and increased ED length of stay (LOS),2 but also compromising patient safety; the risk of adverse events is known to rise in the presence of overcrowding.3 Described as ‘access block,’ this occurs when ‘patients in Correspondence: Tracey J. Weiland, St Vincent’s Hospital, Melbourne, Fitzroy, Victoria, Australia. E-mail: [email protected] DOI: 10.1097/XEB.0000000000000011

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the ED requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable timeframe.’4 Access block results in congestion within EDs and protracted patient waiting times. Hospital in the home (HiTH) services may offer one means of reducing ED demand. They may also facilitate the more efficient use of inpatient beds, providing an alternative to in-hospital admission and enabling patients to be transferred home earlier, thereby increasing inpatient bed availability.5 The potential to avoid the significant capital costs associated with building and running large hospitals, through the utilization of HiTH services, was highlighted in a study which estimated that

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EVIDENCE SYNTHESIS an additional 500 beds would have been required in Victoria in 2008–2009 to accommodate all patients treated by HiTH services annually.6 Hospital in the home services have been defined as those that provide ‘an alternative to admission to a hospital or an opportunity for earlier relocation to the home than would otherwise be possible.’7 There is not a single, standardized approach to HiTH service delivery. Rather, HiTH services deliver a range of interventions (intravenous antibiotics, antivirals, antifungals, fluids, blood products, inotropes, steroids, and enzyme replacement agents), to a range of patient cohorts (neonatal, paediatric, adult and elderly), requiring treatment for a range of conditions (community-acquired acute infections; hospital-acquired, multi-resistant and complicated infections; acute venous thromboembolism; perioperative anticoagulation; chemotherapy and other cancer care; heart failure management, wound management and mental health care).7 Staffing structures also vary between HiTH services; most are dominated by nursing staff, but others are also utilizing medical and allied health professionals.8 An important distinction to make between HiTH services is between those that completely substitute the inpatient stay (admission-avoidance HiTH)9 and those that facilitate a reduction in the inpatient LOS (early-discharge HiTH).10 Whereas admission-avoidance HiTH programmes commonly recruit patients directly from the community or ED, thereby avoiding the inhospital admission, early-discharge HiTH programmes commonly recruit patients following their in-hospital stay.11 The relevance of this distinction relates not only to the clinical complexity of patients who are more likely to receive admission-avoidance or early-discharge HiTH services,11 but also to the cost of these services, with numerous studies identifying greater cost-savings associated with HiTH services that completely substitute the in-hospital stay.12,13 Distinguishing between admission-avoidance and early-discharge HiTH services might also be important in determining the impact of HiTH on outcomes such as iatrogenic infections, an effect which might only be observed if the hospital admission is avoided entirely. Whereas HiTH services are available to patients in most Australian states and territories, Victoria is the biggest provider of HiTH services, accounting for 75% of all HiTH activity in 2009.14 In 2012, 41 Victorian hospitals provided HiTH services,15 and in the 2010– 2011 financial year, Victorian public hospitals undertook more than 25000 HiTH separations, representing approximately 2% of all Victorian public hospital separations.16

Despite the widespread availability of HiTH services, numerous reports have recommended that the service capacity and utilization of HiTH services be expanded as a strategy to increase inpatient bed availability, reduce ED demand and reduce access block.11,17 In particular, there is potential that certain presentation types might be particularly amenable to HiTH treatment, including pulmonary embolus, cellulitis and venous thrombosis.11 Identifying these groups and developing care pathways that facilitate their direct admission from the ED into HiTH might improve ED efficiency and increase inpatient bed availability. In view of these priorities, consideration should be given to the effectiveness and cost-effectiveness of admission-avoidance HiTH services that recruit patients directly from the ED. Whilst numerous Cochrane Reviews have assessed the efficacy of HiTH services, one of these focussed only on early-discharge HiTH services,10 another included both admission-avoidance and earlydischarge HiTH studies,18 and several took a diseasespecific focus, assessing the efficacy of admission-avoidance HiTH programmes that recruited participants with chronic obstructive pulmonary disease (COPD).19,20 Whilst one Cochrane review has assessed the efficacy of admission-avoidance HiTH programmes that recruited participants with various diagnoses, only 7 of the 10 studies included in the review recruited participants directly from the ED, the remainder recruiting participants from the community. This review also only considered data from randomised-controlled trials (RCTs), thus ignoring qualitative data, data from observational studies and the grey literature.9 The integrative review presented here takes a broader perspective, considering findings from RCTs, observational studies, meta-analyses, systematic reviews and the grey literature. Integrative reviews are considered the broadest category of research review, enabling the inclusion of diverse research methodologies, such as qualitative and quantitative research, as well as discussion papers and grey literature.21 This type of review was considered necessary to adequately assess the HiTH literature, given the diversity in research designs that have assessed this topic. Furthermore, a criticism of previous HiTH reviews has been their exclusion of observational studies.22,23 Observational studies are capable of recruiting considerably more participants and of measuring outcomes associated with interventions delivered under ‘real world’ conditions. This both avoids biases associated with the Hawthorn effect,24 and facilitates the recruitment of considerably more participants over a shorter time, enhancing statistical power to detect rare events such as mortality.25 Observational studies may also

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provide a more realistic estimation of the cost of HiTH services.22

Aim To assess the efficacy of admission-avoidance HiTH services that admit patients with various conditions, directly from the ED. Efficacy was operationalized to include mortality, clinical outcomes, safety, patient satisfaction, adverse events, costs and LOS.

Search strategy Electronic searches of Medline and CINAHL were carried out with results limited to English-language studies published between 1995 and 2013. A combination of medical subject headings terms and keywords were used in these databases including: [(’hospital at home’ or ’hospital in the home’ or ’HiTH’ or ’hospital care at home’) or (MM ‘Home Care Services, Hospital-Based’ or MM ‘Home Care Services’)] and [(’emergency department’) or (MH ‘Emergency Service, Hospital’ or MH ‘Emergency Medical Services’ or MH ‘Evidence-Based Emergency Medicine’)]. In addition, a search was undertaken using Google to identify papers from the grey literature, including government reports and discussion papers.

Methods of the review The results from both databases were combined and duplicates removed, leaving 269 results. From these, 256 results were excluded because they did not fit the following inclusion criteria: any English-language study that assessed the efficacy of a HiTH service that recruited at least one-third of the participants directly from the ED. All study designs were included. A HiTH service was considered one that provided health professional support to patients at home for a time-limited period, thus avoiding the need for hospitalization. The remaining 13 papers were reviewed by a single reviewer. In addition to this search strategy, the reference lists of all identified articles were scanned, revealing five relevant papers. Finally, the grey literature was reviewed using a Google search, revealing two relevant papers, both of which were included in the review. Preferred reporting items for systematic reviews and meta-analyses guidelines26 were used to critique the quality of RCTs included in the review. The quality of all remaining papers was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.21 In light of the diverse representation of primary sources, all papers were evaluated on the basis of two criteria: methodological rigour and data relevance, using the two-point scale (high/low) described by Whittemore 130

and Knafl.27 An additional dichotomous rating for risk of bias (high/low) was then made based on this information. No reports were excluded based on this rating system, but those in which risk of bias was deemed to be high contributed less to the analysis process. Meta-analysis was not feasible owing to variation between studies in terms of the interventions delivered and the outcomes measured. The papers were read and re-read. The studies were examined in terms of their study design, the intervention they delivered, the outcomes they measured and their effectiveness.

Results Twenty-two articles met the inclusion criteria for this review, including 10 RCTs,28–37 five observational studies,24,38–41 one cost analysis,42 one case-controlled study,43 three Cochrane reviews9,19,20 and two papers from the grey literature.11,15 Table 1 summarizes findings from these papers. The majority of these studies were conducted in Australia,24,28–31,38,39,41 with the remainder conducted in New Zealand (n ¼ 2),32,37 the United Kingdom (n ¼ 2),33,34 Spain (n ¼ 3)35,40,43 and Italy (n ¼ 1).36 Sample sizes varied, from 24 in the smallest study,40 to 3423 in the largest,24 although sample size calculations were reported by only five studies.32–35,37 Whereas some studies targeted participants with a single condition such as COPD,19,20,31,33,34 cellulites37,41 or pneumonia,32,38 others targeted participants with various conditions such as pneumonia, cellulitis, deep vein thrombosis (DVT) and urinary sepsis.9,24,28–30,39,43 The most commonly targeted conditions were respiratory infection, cellulitis, COPD and DVT. All studies included in this review measured the effectiveness of an admissionavoidance HiTH programme, and all studies recruited participants from the ED; however, some studies recruited up to 60% of participants from the community, via general practitioner (GP) referral.9,24,41 Collectively, the studies included in this review examined outcomes including mortality, clinical outcomes, quality of life (QOL), rates of adverse events and/or complications, patient satisfaction, costs and LOS. The interventions delivered in these studies were diverse, in terms of the clinical interventions delivered, the range and intensity of health professional input and the conditions treated. LOS varied considerably, mean and median LOS ranging from 6 to 11 days24,28–30,35,37,38,40,42,43 and 4 to 7 days,32,34,39 respectively. Care was provided by community staff in two studies;32,37 hospital outreach staff in nine studies24,28–30,35,36,38,40 –43 and a combination of hospital outreach and community staff in three studies.31,33,34 With the exception of one study that did not describe the

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International Journal of Evidence-Based Healthcare ß 2014 University of Adelaide, Joanna Briggs Institute RCT (drew on data from the study by Caplan et al.28); tertiary referral hospital RCT; tertiary referral hospitals

To compare the effect of HiTH versus hospital-based treatment on physical and cognitive function

To compare the cost of HiTH versus hospital-based treatment

To measure the effectiveness and acceptability of HiTH versus hospital-based care for patients with community-acquired pneumonia

To measure the safety and efficacy of HiTH versus hospital-based care for ED patients presenting with an acute exacerbation of COPD To measure the safety, effectiveness and patient acceptability of HiTH versus hospital-based treatment of COPD

Caplan et al.,30 Australia

Nicholson et al.,31 Australia

Richards et al.,32 New Zealand

Davies et al.,33 United Kingdom

Skwarska et al.,34 United Kingdom

RCT (drew on data from the study by Caplan et al.28); tertiary referral hospital

To compare the cost of HiTH versus hospital-based care

Board et al.,29 Australia

RCT; university teaching hospital

RCT; university teaching hospital

RCT; tertiary referral hospital

RCT; tertiary referral hospital

To compare the effect of HiTH versus hospital-based care on geriatric complications, patient safety and patient and carer satisfaction

Caplan et al.,28 Australia

Design, setting

Study objectives

Author, country

184 patients presenting to the ED with an acute exacerbation of their COPD

150 patients requiring admission for an acute COPD exacerbation

55 patients presenting to the ED with communityacquired pneumonia

100 patients requiring hospital admission for pneumonia, urinary tract infections, cellulitis, endocarditis or DVT 25 patients requiring admission for an acute COPD exacerbation

100 patients requiring hospital admission for pneumonia, urinary tract infections, cellulitis, endocarditis or DVT

100 patients requiring hospital admission for pneumonia, urinary tract infections, cellulitis, endocarditis or DVT

Sample size, participant characteristics

LOS Patient and GP satisfaction Costs Respiratory function QOL Hospital re-admission

Readmission rates Respiratory function Mortality

Days to discharge Patient satisfaction Days on intravenous antibiotics Patient-rated symptom scores Level of functioning Mortality Adverse events

Costs

Physical function Cognitive function

Geriatric complications (bowel and urinary complications, confusion, falls, constipation, phlebitis) Patient and carer satisfaction Adverse events Death Cost per episode of care

Main outcomes

Median LOS in the HiTH versus the hospital-based treatment group 7 versus 5 days (P < 0.01) 95% of HiTHtreated patients and 100% of GPs satisfied with HiTH treatment The mean cost per patient £877 versus £1753 in the HiTH versus hospital-treated group (P-value not provided) No effect on other outcomes

HiTH treatment contributed to a lower incidence of confusion, fewer urinary and bowel complications and greater patient and carer satisfaction No effect on mortality or adverse events Significant cost-savings associated with HiTH treatment, mean (95% CI costs) $1764 (1416 to 2111) versus $3614 (2881 to 4347, P
0.001) Greater improvement in physical function among HiTH treated participants No effect on cognitive function Cost-savings associated with HiTH $745 (95% CI 595– 895) versus $2543 (95% CI 1766–3321, P < 0.01) Median (range) no of days to discharge in HiTH versus hospital-treated group 4 (1–4) versus 2 (0–10, P ¼ 0.004) Greater patient satisfaction among HiTH treated participants (P < 0.001) No effect on other outcomes No effect on readmission rates, respiratory function or mortality

Key findings

High

High

High

High

High

High

High

High

High

Data relevance (high/low)

High

High

High

High

High

Methodological rigour (high/low)

Table 1. Literature summary (part 1: participants admitted to hospital in the home directly from emergency department)

(Continued )

Low

Low

Low

Low

Low

Low

Low

Risk of bias (high/ low)

EVIDENCE SYNTHESIS

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132 RCT; university teaching hospital

To compare the cost and effectiveness of HiTH versus hospital-based treatment for ED patients with heart failure

Mendoza et al.,35 Spain

Retrospective clinical audit; private hospital

Retrospective, observational study

To compare the efficacy, safety and acceptability of HiTH versus hospital-based treatment of cellulitis

To measure the safety and efficacy of HiTH for ED patients presenting with pneumonia

To characterize the nature and incidence of adverse events and complications among patients admitted to HITH directly from the ED

To measure the safety and efficacy of HiTH versus hospital-based treatment for patients presenting to the ED with diverticulitis

Corwin et al.,37 New Zealand

Montalto,38 Australia

Liu and Taylor,39 Australia

Rodrı´guezCerrillo et al.,40 Spain Prospective, observational study

RCT; tertiary referral hospital

To compare the effect of HiTH versus hospital-based treatment in patients with advanced dementia

Tibaldi et al.,36 Italy

RCT

Design, setting

Study objectives

Author, country

Table 1. (Continued)

24 patients who presented to the ED with uncomplicated diverticulitis and comorbidity

357 patients admitted to HiTH from the ED with various diagnoses (cellulitis, DVT, pneumonia, pyelonephritis and exacerbation of multiple sclerosis)

44 ED patients referred to HiTH for management of their pneumonia

200 ED patients requiring i.v. antibiotics for cellulitis

109 ED patients with advanced dementia and requiring hospital admission for an acute illness

80 patients; presenting to the ED with decompensated heart failure

Sample size, participant characteristics

Complications LOS Patient satisfaction

Adverse events Complications Hospital re-admissions Mortality

Patient satisfaction Days to no advancement of cellulites Days on antibiotics LOS Complications Physical function Pain LOS HiTH admission versus discharge diagnosis Unplanned hospital readmission post HiTH discharge

Behavioural disturbances Caregiver stress Mortality

Costs Mortality Hospital re-admissions Physical function QOL Cardiovascular events

Main outcomes

HiTH treatment associated with cost-savings; mean (SD) cost of the initial treatment episode s4502 (2153) versus 2541 (1334, P
0.001) No effect on other outcomes HiTH treatment associated with fewer behavioural disturbances (P
0.001) Caregiver stress reduced in HiTH-treated group (P
0.001), no change in hospital-treated group No effect on mortality More HiTH than hospital treated patients satisfied with the location of their care, 93 vs. 66%; P
0.0001 No effect on other outcomes Mean LOS 6.2 days 3 (7%) patients had a discharge diagnosis unrelated to their admission diagnosis 2 (5%) patients required an unplanned hospital readmission within 1 month of HiTH discharge 15% of patients experienced an adverse event (most commonly DVT or wound infection) 94 (26%) of patients experienced a complication (most commonly phlebitis or constipation) 31 (8.7%) of patients had an unplanned hospital re-admission 2 (1%) of patients died within 28 days of HiTH discharge Nil complications or unexpected hospital re-admissions Mean LOS 9 days 95% of participants satisfied with HiTH treatment

Key findings

High

High

High

High

High

High

High

High

Data relevance (high/low)

High

High

Low

High

Methodological rigour (high/low)

High

Low

Low

Low

High

Low

Risk of bias (high/ low)

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Systematic review and meta-analysis

Case-controlled study

To compare the effectiveness of HiTH to hospital-based treatment among patients presenting to the ED with acute exacerbations of their COPD

To measure the effectiveness and patient acceptability of HiTH versus hospital-based treatment for patients; presenting to the ED with various respiratory diagnoses

To measure the effect of HiTH versus hospital-based treatment on costs and patient satisfaction among patients presenting to the ED with DVT and requiring treatment with lowmolecular-weight heparin

To evaluate Victorian HiTH programmes in terms of their workforce, case-mix, case complexity, governance structures and funding arrangements

Jeppesen et al.,20 various – Spain, UK, Australia, Denmark and Italy

Gonzalez Barcala et al.,43 Spain

Smith et al.,42 Australia

DLA Phillips Fox,11 Australia Literature review and evaluation

Cost analysis

Systematic review and meta-analysis

To compare the effectiveness of HiTH to hospital-based treatment among patients presenting to the ED with acute exacerbations of their COPD

Ram et al.,19 various – Spain, UK and Australia

Victorian HiTH services

58 patients presenting to the ED with DVT and requiring treatment with lowmolecular-weight heparin

75 patients with various respiratory diagnoses (25 cases assigned to HiTH treatment and 50 sex-matched controls assigned to hospitalbased treatment)

8 RCTs, including 870 participants who presented to the ED with an acute COPD exacerbation

7 RCTs, including 754 participants who presented to the ED with an acute COPD exacerbation

HiTH workforce, case-mix, case complexity, governance structures and funding arrangements

Costs Patient satisfaction

Mortality Readmissions LOS Patient satisfaction

Readmission rate Mortality QOL Respiratory function Patient and carer satisfaction Costs

Re-admission rate Mortality QOL Respiratory function Patient and carer satisfaction Costs No effect on readmission rates or mortality Patient and caregiver satisfaction high Patients and carers preferred HiTH treatment Insufficient data to draw conclusions regarding the effect on QOL, respiratory function or costs Risk of readmission lower among HiTH-treated patients (RR 0.76, 95% CI 0.59 to 0.99, P ¼ 0.04) No effect on mortality Insufficient data to determine the effect on QOL, respiratory function, patient or carer satisfaction or costs No effect on mortality or re-admission rate Shorter mean (SD) LOS among HiTH patients; 7.0 days (2.8) versus 12.2 days (8.2), P ¼ 0.001 Patient satisfaction with HiTH high; 22 (95%) of respondents would happily receive HiTH treatment again Mean (SE) costs lower among HiTH-treated participants than controls; $756 (76) versus $2208 (146) (P-value not provided) 22 (77%) of respondents described HiTH treatment as excellent, the remainder described it as adequate HiTH services are generally staffed by nursing and allied health staff. Most also provide medical input Wide range of conditions potentially HiTH suitable Admission-avoidance HiTH programmes commonly treat uncomplicated diagnoses, whereas early-discharge HiTH services treat more complex diagnoses Low

High

High

High

High

High

High

High

High

High

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High

Low

Low

Low

Low

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Low

CI, confidence interval; COPD, chronic obstructive pulmonary disease; ED, emergency department; HiTH, hospital in the home; i.v., intravenous; LOS, length of stay; QOL, quality of life.

High High Metro, regional, sub-regional and rural HiTH services see on average 25, 15, 4 and 1 patients per day Half of all metro HITH services provided medical home review Approximately one-third of HiTH services directly employed doctors 30 (85%) of HiTH services accepted referrals directly from the ED Staffing dominated by nurses Number of patients seen per day Medical input Referral source Staffing Victorian HiTH services (n ¼ 41) of which n ¼ 35 contributed data to the report To assess Victorian HiTH service provision against HiTH guidelines. To evaluate HITH services in terms of staffing, service provision and models of care Victorian Department of Health,15 Australia

Survey

Study objectives Author, country

Table 1. (Continued)

Design, setting

Sample size, participant characteristics

Main outcomes

Key findings

Methodological rigour (high/low)

Data relevance (high/low)

Risk of bias (high/ low)

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HiTH service delivered,39 all of the HiTH interventions incorporated nursing care,9,19,20,24,28–38,40–43 with input from allied health professionals (occupational therapists, physiotherapists, speech therapists, social workers and dieticians) also commonly available.9,19,20,28–31,36 Most HiTH services provided medical input;9,19,20,24,28–32,34–38,40–43 however, arrangements for medical review varied, with some programmes providing regular home medical review by hospital medical staff,24,34–36,40,43 some relying on GPs to provide medical review32,37,42 and others requiring patients to attend the ED or outpatient clinic for medical review.31,41 The most commonly measured outcome was mortality, although none of the five RCTs that measured this outcome found any effect on this parameter.28,32,33,35,36 These findings contradict those of the Cochrane reviews, one of which reported that admission-avoidance HiTH programmes favourably affect mortality risk [hazard ratio 0.62, 95% confidence interval (CI) 0.45–0.87; P ¼ 0.005] rates,9 and one of which reported a trend towards lower mortality in the HiTHtreated group [relative risk (RR) 0.65, 95% CI 0.40–1.04, P ¼ 0.07].20 RCTs included in this review found no effect of HiTH treatment on clinical outcomes32–35 or QOL.33–35 Similarly, the Cochrane reviews that measured clinical outcomes (respiratory function) and QOL, either reported no effect on these parameters,9 or reported that insufficient data existed to draw firm conclusions concerning the effect of HiTH treatment on these outcomes.19,20 The safety of HiTH treatment was also commonly measured by studies included in this review; RCTs were consistent in observing that rates of adverse events and/or complications were unaffected by HiTH treatment,28,32,37 and observational studies were consistent in their conclusions that for patients presenting to the ED with particular conditions (respiratory infection, skin infection, DVT and diverticulitis), HiTH is a well tolerated treatment option. Observational studies that drew conclusions concerning the safety of HiTH treatment did so having observed low rates of unplanned hospital admissions,24,38,40,41 low rates of adverse events and complications,24,39,40 few unexpected deaths24 and few patients with an admission diagnosis unrelated to their admission diagnosis.38 The Cochrane reviews included in this review did not consider the effect of HiTH treatment on rates of adverse events and/or complications. Patient satisfaction, measured using a multi-category ordinal scale, was consistently and favourably affected by HiTH treatment. Three RCTs found that patient satisfaction was greater among HiTH than hospital-treated

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EVIDENCE SYNTHESIS participants,28,32,37 whereas one RCT reported high levels of patient satisfaction among HiTH-treated participants, but failed to make between-group comparisons.34 The two observational studies that measured patient satisfaction also found that patient satisfaction associated with HiTH treatment was high; 95% of the participants were satisfied with the HiTH treatment they received.40,43 Consistent with these findings, the Cochrane reviews also generally reported favourable findings regarding patient satisfaction, one reporting that patient satisfaction associated with HiTH treatment was high and that patients expressed a preference for HiTH over hospital-based care,19 and another reporting that patient satisfaction was greater among HiTH than among hospital-treated patients.9 The studies included in this review also generally reported favourable findings regarding the effect of HiTH treatment on costs, several reporting significant cost-savings associated with HiTH treatment,9,29,31,35 and two reporting cost-savings but failing to report P-values.34,42 Mindful of these data, two Cochrane reviews reported there were insufficient data to draw conclusions concerning the impact of HiTH treatment on costs.19,20 The effect of HiTH treatment on LOS was measured in three studies – two RCTs reporting that LOS was greater among HiTH-treated participants32,34,37 and one reporting a trend towards a longer LOS among HiTH-treated participants.32,34,37 Findings from the grey literature were also considered in this review. These papers highlighted the scope of services delivered by Victorian HiTH programmes. For instance, a 2010 Victorian Department of Health-commissioned evaluation of Victorian HiTH services highlighted that whereas admission-avoidance HiTH programmes commonly treat conditions that are frequently presenting, uncomplicated, easily diagnosed and with well defined treatment pathways (such as respiratory, skin, joint and soft tissue infections and thrombo-embolic disorders), early-discharge HiTH services commonly treat more complex diagnoses, such as post-surgical care following coronary artery bypass graft or knee replacement surgery. The evaluation also highlighted that whereas collectively, Victorian HiTH services treat a diverse case-mix, individual HiTH services treat a narrower range of conditions. This finding prompted the recommendation that individual HiTH services should extend the scope of their services to improve equity of service provision and to reduce pressures on inpatient bed capacity, citing estimates that if the admission of patients into HiTH for cellulitis increased from a current rate of 25% of all cellulitis presentations to a target rate

of 60%, an additional 2700 patients could be treated at home and more than 11 000 hospital bed-days could be saved annually. Likewise, the authors estimated that if the proportion of all DVT presentations admitted to HiTH increased from 58% currently, to an international target of 90%, an additional 600 patients could be treated at home and an additional 2400 hospital bed-days could be saved annually.11 A more recent government review of HiTH services conducted in 2012 found that 41 HiTH services were in operation in Victoria, the majority operating in metropolitan areas (n ¼ 15), and a smaller number operating in regional (n ¼ 6), sub-regional (n ¼ 10) and rural areas (n ¼ 4). Among the 35 HiTH services that contributed data to the review, 30 (85%) accepted direct referrals from the ED. Referrals from the ED were commonly in addition to referrals from other sources, including inpatient units, outpatient departments, sub-acute services, residential aged care services and GPs.15

Discussion Proponents of HiTH services have argued that HiTH programmes facilitate a more efficient use of inpatient beds, providing an alternative to in-hospital admission and enabling patients to be transferred home earlier, therefore reducing ED demand and increasing inpatient bed availability.5 Other benefits commonly ascribed to HiTH services have included cost-savings, improvements in patient satisfaction and clinical outcomes that are at least equivalent to hospital-based care. This review aimed to determine the extent to which such claims are supported by evidence from the HiTH literature, in particular, focussing on the effectiveness of admissionavoidance HiTH services that recruit patients directly from the ED. One clear finding from this review is that there is not a single, standardized approach to HiTH service delivery. Rather, HiTH services are diverse, delivering a range of interventions, to a range of patient cohorts, requiring treatment for a range of conditions. Although arrangements for medical review varied between studies, most provided medical input.9,19,20,24,28–32,34–38,40–43 The provision of medical care by HiTH services is consistent with recommendations to increase the medical input into HiTH services, both in leadership and clinical service delivery roles. The purported advantages of doing so include the potential to reduce LOS, increase the acuity of patients treated, reduce re-admission rates and improve patient and carer satisfaction.44–47 Incorporating medical input into HiTH services might also increase the number of HiTH admissions directly from the ED and

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avoid patients needing to attend hospital outpatient clinics or EDs for medical review.48 Another clear finding was that admission-avoidance HiTH programmes are not only associated with high levels of patient satisfaction,19,34,40,43 but that patient satisfaction is greater among participants who receive HiTH treatment compared with participants who receive routine, hospital-based care.9,28,32,37 These findings of greater patient satisfaction associated with randomization to HiTH treatment might not be considered surprising given that in their own homes, patients remain in a familiar environment, have uninterrupted sleep, have their privacy protected, have access to their usual meals and avoid exposure to nosocomial infection.49 Whereas previous HiTH studies have suggested that patient satisfaction is related to the availability of medical home visits,8,46,47 no such evidence of this association was provided by studies included in this review. Although findings of greater patient satisfaction associated with randomization to HiTH treatment are important and might be used to support a case to expand HiTH service capacity, the views of patients must be balanced against the views of carers who may experience a greater burden if a patient receives HiTH treatment. The literature appears mixed with respect to this outcome, however, with one Cochrane review reporting greater carer satisfaction associated with HiTH treatment,19,28 and two Cochrane reviews reporting there was insufficient data to draw firm conclusions concerning the effect of HiTH treatment on carer satisfaction.9,20 The RCTs included in this review were also consistent in observing that clinical outcomes32 –35 and rates of adverse events and complications28,32,37 were equivalent among participants randomized to HiTH or hospitalbased care. Given data from observational studies indicating that rates of adverse events and complications were low,24,38–41 for particular presentation types, HiTH admission directly from the ED might be considered a well tolerated and effective treatment option. Of course, these data do not suggest that HiTH programmes offer a safer or more effective alternative than hospital-based care. It would also appear that admission-avoidance HiTH programmes that recruit patients from the ED are cost-saving compared with hospital-based care, with four studies observing significant cost-savings associated with HiTH compared with hospital-based treatment,9,29,31,35 and a number indicating a trend towards lower costs among HiTH compared with hospital-treated participants.19,34,42 Findings of cost-savings associated with admission-avoidance HiTH are consistent with those of a 2011 economic evaluation that 136

compared the cost of HiTH treatment with the cost of hospital-based care for six conditions commonly managed by Australian HiTH services (cellulitis, venous thrombosis, pulmonary embolus, respiratory infection/ inflammation, COPD and knee replacement). Across all six conditions, HiTH was found to cost 22 and 32% less per hospital separation compared with in-hospital care when costs were considered from societal and government perspectives, respectively.14 Findings of cost-savings associated with admissionavoidance HiTH programmes might not be considered surprising, with numerous studies finding that costsavings increase as the level of substitution for in-hospital care increases. For instance, a Victorian cost analysis found lower costs associated with HiTH compared with hospital-based care, with cost-savings found to increase as the level of substitution for in-hospital care increased. Whereas costs were 38% lower among HiTHtreated patients when the HiTH episode completely replaced the in-hospital episode (as is the case with admission-avoidance HiTH programmes), smaller costsavings of only 9% were apparent when HiTH did not completely replace the in-hospital episode.12 Indeed, one author noted that ‘where HITH is not a substitute for in-hospital care, but merely add-on care, (services) are bound to be more expensive, no matter how sophisticated the economic analysis.’23 This sentiment was supported by findings from an Australian cost analysis that compared costs incurred by patients managed either in hospital, or by a HiTH service; cost-savings were found to increase as the level of substitution for hospital-based care increased.13 The review revealed surprising findings regarding the effect of HiTH on LOS; several studies suggesting that admission-avoidance HiTH programmes contribute to a longer LOS compared with hospital-based care.32,34,37 In one RCT, for instance, the median (range) number of days to discharge was 4 (1 to 14) in the hospital-treated group, versus 2 (0–10, P ¼ 0.004) in the HiTH group.32 These findings contradict those of an RCT which found that patients randomized to admission-avoidance HITH had a shorter LOS compared with those randomized to hospitalbased care (8 versus 14.5 days; P ¼ 0.026).50 Our findings also contradict the findings of a Department of Health Review of Victorian HiTH services which concluded that, compared with matched, non-HITH admissions, admission-avoidance HiTH programmes contribute to a shorter LOS, whereas early-discharge HiTH services contribute to a prolonged LOS.11 Discrepancies between the findings of these studies may reflect heterogeneity of the study populations, whereby the effect of HiTH treatment is in part determined by the condition being treated.

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EVIDENCE SYNTHESIS Findings concerning the effect of HiTH programmes on mortality were mixed. Whereas RCTs observed no change in mortality risk associated with HiTH treatment,28,32,33,35,36 one Cochrane review concluded that admission-avoidance HiTH programmes reduced mortality (hazard ratio 0.62, 95% CI 0.45–0.87, P ¼ 0.005)9 and one reported a trend towards lower mortality in the HiTH-treated group (RR 0.65, 95% CI 0.40–1.04, P ¼ 0.07).20 These Cochrane review findings are consistent with those of a meta-analysis that included data from 61 RCTs which compared the outcomes of participants randomized to HITH or hospital-based care. The metaanalysis found that HiTH services contributed to reductions in mortality [odds ratio (OR) 0.81, 95% CI 0.69–0.95, P ¼ 0.008], an effect which the authors speculated may have been driven by reductions in delirium, falls, iatrogenic infections and adverse events.51 Differences in the findings of this review and that of Caplan et al. may reflect methodological differences between the studies; our review having considered a smaller (n ¼ 22) and methodologically more diverse array of studies compared to Caplan et al.’s meta-analysis that considered the findings of 61 studies, all of which are RCTs. The failure of RCTs included in our review to observe an effect on mortality may therefore have more to do with under-powering, and less to do with the absence of an effect. Given evidence suggesting that HiTH programmes contribute to cost-savings, greater levels of patient satisfaction and equivalent safety and efficacy outcomes, the expansion of such programmes might be considered a priority for policy makers. This conclusion is in keeping with the recommendations of numerous government reports that have recommended that the utilization of HiTH services should be increased as a strategy to improve efficiency and to reduce the burden on Victorian EDs and inpatient beds.11,14,17,52 For instance, a 2001 report from the Patient Management Task Force recommended that to avoid unnecessary inpatient admissions, all metropolitan hospitals should increase their utilization of HiTH services for patients admitted via EDs.17 Accordingly, a 2009 Department of Health audit that assessed the availability of ambulatory emergency care services to patients attending Victorian EDs, recommended that awareness of and access to HITH services should be improved.52 The potential to achieve large cost-savings by channelling particular presentations into HiTH services was identified in a 2011 economic evaluation of HiTH that compared the cost of HiTH treatment with the cost of hospitalbased treatment. The report estimated that a 10% increase in HiTH public hospital separations for cellulitis,

venous thrombosis, pulmonary embolus, respiratory infection/inflammation, COPD and knee replacement would result in government savings of $1.7 million. The report also estimated that diverting all public hospital separations into HiTH treatment would result in savings of over $108 million.14 Consistent with this estimate, a 2010 Victorian Department of Health report indicated that a considerable number of bed-days could be saved annually if the number of patients admitted to HiTH services with diagnoses such as cellulitis and DVT were increased.11 Taken collectively, these figures suggest that for particular presentation types, HiTH is currently underutilized. They also indicate the potential of HiTH services to expand inpatient bed capacity, at relatively low capital expenditure.

Strengths and limitations Numerous studies have measured the effectiveness and cost-effectiveness of HiTH services; however, many of these studies have either focussed on early discharge HiTH10 or have failed to distinguish between studies assessing early-discharge and admission-avoidance HiTH services.18 This review has taken a narrower focus, assessing the effectiveness of admission-avoidance HiTH programmes that admit patients directly from the ED. Effectiveness was measured in terms of the interventions’ effects on mortality, clinical outcomes, safety, patient satisfaction, adverse events, costs and LOS. This review has also considered the findings of RCTs and observational studies; observational studies, when large enough, were better placed to detect rare complications and to estimate costs.22,23 Although some studies were rated by ourselves as having a high risk of bias, these comprised a small proportion of included studies and contributed to a lesser degree to the analysis of evidence. The limitations of the HiTH literature are important to consider. One criticism levelled at this literature is the considerable variation between studies in terms of the interventions delivered, the conditions treated, the range and intensity of health professional input and the arrangements for medical review. This inconsistency may confound efforts to compare findings between different studies and make the identification of mechanisms that drive intervention benefits difficult.23 It may also limit the generalizability of cost estimates derived from HiTH studies, a problem exacerbated by HiTH studies that have considered the cost of various combinations of resource items, such as the inpatient stay, the HiTH service, medications, diagnostic tests, transport, GP visits, ED visits and lost income. Furthermore, because HiTH studies were conducted in various countries, cost

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To assessed the safety and efficacy of HiTH and to identify factors that contribute to HiTH failure

To measure the safety and efficacy of HiTH treatment for patients presenting to the ED with cellulitis and requiring i.v. antibiotics

Montalto et al.24, Australia

Donald et al.41, Australia Retrospective, observational study

Observational study; private hospital

Systematic review and metaanalysis

Design, setting

124 patients who presented to the ED with cellulitis and required i.v. antibiotics

3423 HiTH admissions for various diagnoses (skin infection, DVT, respiratory infection) over 7 years

10 RCTs, including 1333 participants with various diagnoses including COPD, stroke, cellulitis, dementia and pneumonia

Sample size, participant characteristics

Readmission rate LOS Complications

LOS Adverse events (unplanned telephone calls, staff callouts and returns to hospital) Unexpected death

Mortality Patient and carer satisfaction QOL Hospital utilization Functional capacity Costs

Main outcomes

Lower mortality risk in HiTH-treated group at 6 months; HR 0.62, 95% CI 0.45–0.87; P ¼ 0.005 Patient satisfaction greater in HiTH than hospital-treated group Insufficient data to determine effect on carer satisfaction Cost-savings associated with HiTH treatment (based on data from two studies) No effect on re-admission rates, functional ability, QOL or cognitive function The mean (SD) LOS for ED versus inpatient unit referred patients 5.1 (3.4) versus 12.5 (11.8) days (P-value not provided) 607 (18%) of patients made unplanned telephone calls 177 (5%) of admissions required unplanned staff callout 143 (4%) of care episodes required an unplanned return to hospital 5 unexpected deaths 19 (15%) of patients re-admitted Mean LOS 6 days 1 (1%) patient developed a complication

Key findings

High

High

High

Methodological rigour (high/low)

CI, confidence interval; COPD, chronic obstructive pulmonary disease; ED, emergency department; HiTH, hospital in the home; i.v., intravenous; LOS, length of stay; QOL, quality of life.

To measure the effectiveness and cost of admission avoidance HiTH versus hospital-based care

Study objectives

Shepperd et al.9, various – UK, Italy, Australia, and New Zealand

Author, country

High

High

High

Data relevance (high/low)

Low

Low

Low

Risk of bias (high/ low)

Table 2. Literature summary (part 2: participants admitted to hospital in the home directly from emergency department or via general practitioner referral)

J Varney et al.

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©2014 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

EVIDENCE SYNTHESIS comparisons might be invalid owing to international differences in health systems and healthcare costs.53 The HiTH literature is also dogged by small, underpowered studies that delivered brief interventions and provided short-term follow-up.28,32,50 This may have obscured the detection of rare events and outcomes more likely to be detected over the longer term, such as changes in disease progression, mortality and adverse events. Detecting rare events such as mortality generally requires large numbers of participants; however, the resource demands of running such trials commonly preclude their conduct.54 Whereas this review focussed on admission-avoidance HiTH programmes that admit patients directly from the ED, a number of studies also included participants admitted to HiTH via their GP (Table 2). It is of course impossible to say with certainty that patients admitted to HiTH via their GP would otherwise have been admitted to hospital; however, the three studies which included participants admitted to HiTH by GPs evaluated HiTH services that treated patients for acute conditions that would ordinarily require hospital care. Studies included in this review also failed to blind participants to randomization outcome. This was presumably for practical reasons, as a participant’s receipt of the HiTH intervention would have made clear they were in the intervention group. Nonetheless, it is possible that favourable expectations related to randomization to the intervention group may have affected psychological and physiological responses to the intervention, as well as treatment compliance and attrition.55

Conclusion Implications for practice Findings from this review indicate that HiTH services that recruit patients directly from the ED contribute to costsavings, greater patient satisfaction and safety and efficacy outcomes that are at least equivalent to those associated with hospital-based care. Given the increasing pressures on EDs and inpatient beds, strategies that facilitate the increased utilization of HiTH services might be considered a priority for policy makers. Implications for research Several questions concerning the effectiveness of admission-avoidance HiTH services that recruit patients directly from the ED remain unanswered and these might be the focus of future research efforts. One such question relates to the cost-effectiveness of HiTH. Whereas numerous HiTH studies have conducted cost analyses, no cost-effectiveness or cost-utility analyses that measured costs relative to benefits were

identified. Measuring both costs and effects, particularly when effects are measured in generic units such as quality adjusted life years and daily adjusted life years, enables outcomes of economic evaluations to be compared between disparate treatments for the same and/or different conditions. Such outcomes also enable judgements regarding value for money. Therefore, well designed economic evaluations are needed to establish the cost-effectiveness of HiTH relative to hospitalbased care. The HiTH literature might also be enhanced by establishing a clearer definition regarding what constitutes a HiTH service. Doing so might assist in determining the optimal level of intervention required to deliver intervention benefits and in determining which model of care is best suited to particular diagnostic groups. Numerous studies included in this review included participants with various diagnoses.9,24,28–30,39,43 This variability within the study populations may have masked benefits to patients suffering particular conditions. Indeed, it has been suggested that HiTH services might be best suited to specific diagnostic groups, such as cellulitis, COPD and DVT.22 Therefore, future HiTH research might recruit participants with homogenous diagnoses (such as stroke or DVT), or alternatively, might recruit participants with various diagnoses in sufficient quantity to enable sub-group analyses based on diagnosis type. Finally, given that commonly touted benefits of admission-avoidance HiTH services include the potential to increase inpatient bed availability, reduce ED demand and prevent iatrogenic infections, these outcomes should be empirically measured in future HiTH research.

Acknowledgements This study was funded by the Department of Health, Victoria. The authors report no conflicts of interest.

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