Hospital at home versus in-patient hospital care.
Shepperd S., Iliffe S.
BACKGROUND: Hospital at home is defined as a service that provides active treatment by health care professionals, in the patient's home, of a condition that otherwise would require acute hospital in-patient care, always for a limited period. OBJECTIVES: To assess the effects of hospital at home compared with in-patient hospital care. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register, MEDLINE (1966 to 1996), EMBASE (1980 to 1995), Social Science Citation Index (1992 to 1995), Cinahl (1982 to 1996), EconLit (1969 to 1996), PsycLit 1987 to 1996), Sigle (1980 to 1995), and the Medical Care supplement on economic literature (1970 to 1990). SELECTION CRITERIA: Randomised trials of hospital at home care compared with acute hospital in-patient care. The participants were patients aged 18 years and over. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: For the update, 11 trials were added to the five included in the original review. Trials evaluating hospital at home for elderly patients with a mix of medical conditions and those recovering from elective surgery failed to detect a difference for patient health outcomes. The data for those recovering from a stroke was conflicting. One trial reported an increase in independence for those allocated to hospital at home, and another decreased communication and psychosocial well being at three months follow-up but not at six months follow-up. Patients allocated to hospital at home expressed greater satisfaction with care than those in hospital. Carers however expressed less satisfaction with hospital at home compared with hospital care. Allocation to hospital at home resulted in a reduction in hospital length of stay, but hospital at home increased overall length of care. REVIEWER'S CONCLUSIONS: This review does not support the development of hospital at home services as a cheaper alternative to in-patient care. Early discharge schemes for patients recovering from elective surgery and elderly patients with a medical condition may have a place in reducing the pressure on acute hospital beds, providing the views of the carers are taken into account. For these clinical groups hospital length of stay is reduced, although this is offset by the provision of hospital at home. The evidence supporting hospital at home for patients recovering from a stroke is conflicting. There is some evidence that admission avoidance schemes may provide a less costly alternative to hospital care. Future research should focus on admission avoidance schemes, and the effect of early discharge hospital at home schemes for patients recovering from a stroke.