What is the clinical evidence from this study?

Study design: Systematic Review. Population: Conditions requiring acute hospital inpatient care (stroke, mixed medical conditions, elective surgery) (n=4746). Intervention: Early discharge hospital at home vs. Acute hospital inpatient care (usual care). Primary outcome: Mortality at 3-6 months (stroke patients) (RR 0.92, 95% CI 0.57-1.48).

What does this research mean for the field?

Early discharge hospital at home probably makes little or no difference to mortality or hospital readmission compared with in-hospital care, but probably reduces hospital length of stay without providing sufficient evidence of overall economic benefit. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

To evaluate the clinical effectiveness and economic impact of managing adult patients with early discharge hospital at home compared to acute inpatient hospital care.

June 26, 2017Cochrane libraryOpen Access

Early discharge hospital at home

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Key result

Early discharge hospital at home probably makes little or no difference to mortality or hospital readmission compared with in-hospital care, but probably reduces hospital length of stay.

Why the study?

Does early discharge hospital at home improve health outcomes or reduce costs compared to acute hospital inpatient care in adults?

Population

4,746 adults from 32 randomized trials requiring acute hospital inpatient care. Excluded: obstetric…

Comparison

Early discharge hospital at home vs Acute hospital inpatient care

Design

Meta-analysis, Randomised trials

Follow-up

3 to 6 months

Authors

DGDaniela C. GonçalvesStratasys (Israel)SISteve IliffeUniversity College London HDHelen DollFolkestone College

Discussion

Member takes

Implication

Supports hospital-at-home early discharge to shorten stays without mortality or readmission penalty; confirms safety in Level 1 evidence.

Key Points

To evaluate the clinical effectiveness and economic impact of managing adult patients with early discharge hospital at home compared to acute inpatient hospital care.
Searched Cochrane EPOC, CENTRAL, MEDLINE, Embase, CINAHL, EconLit, and clinical trials registries through January 2017.
Identified 32 randomized trials (N = 4,746 adults) evaluating early discharge hospital at home delivered by outreach or community teams across stroke recovery, mixed medical conditions, and elective surgery.
Evaluated methodological risk of bias and used the GRADE approach to evaluate certainty of evidence across primary outcomes.
In stroke recovery, early discharge hospital at home showed little or no difference in mortality (RR 0.92, 95% CI 0.57 to 1.48; N = 1114) or readmissions (RR 1.09, 95% CI 0.71 to 1.66; N = 345), while reducing institutional living at six months (RR 0.63, 96% CI 0.40 to 0.98; N = 574) and discharge time by ~7 days (95% CI 10.19 to 3.17 days earlier).
In mixed medical conditions, mortality was comparable (RR 1.07, 95% CI 0.76 to 1.49; N = 1247), readmission risk showed a possible increase (RR 1.25, 95% CI 0.98 to 1.58; N = 1276), and institutionalization was reduced (RR 0.69, 95% CI 0.48 to 0.99; N = 484).
Elective orthopaedic surgery patients were discharged an average of 4.44 days earlier (95% CI 6.37 to 2.51 earlier; N = 411), but economic impacts across all cohorts remained uncertain due to very low-certainty evidence.

Study Design

Type

Systematic Review (n=4,746)

Structured PICO

Does early discharge hospital at home improve health outcomes or reduce costs compared to acute hospital inpatient care in adults?

Population

4,746 adults from 32 randomized trials requiring acute hospital inpatient care (subgroups: stroke, mixed medical conditions including COPD, elective orthopaedic surgery). Excluded: obstetric, paediatric, and mental health hospital at home schemes.

Intervention

Early discharge hospital at home (active treatment by healthcare professionals in the patient's home, delivered by hospital outreach or community-based services)

Comparator

Acute hospital inpatient care

Outcome

Mortality and hospital readmissionhard clinical

Main Result

Effect estimate: RR 0.92 (95% CI 0.57-1.48)

Absolute Event Rate: 5.2% vs 5.6%

Early discharge hospital at home provides insufficient evidence of economic benefit or improved health outcomes compared to standard inpatient care, with no significant difference in mortality.

Limitations

Insufficient evidence of economic benefit
Imprecision due to wide confidence intervals for several outcomes
Inconsistency across trials for cost and resource use outcomes
Very low-certainty evidence for cost outcomes
Lack of data for certain outcomes such as risk of living in institutional care for surgery patients

Cite This Study

Gonçalves et al. (2017) conducted a systematic review in Conditions requiring acute hospital inpatient care (stroke, mixed medical conditions, elective surgery) (n=4,746). Early discharge hospital at home vs. Acute hospital inpatient care (usual care) was evaluated on Mortality at 3-6 months (stroke patients) (RR 0.92, 95% CI 0.57-1.48). Early discharge hospital at home probably makes little or no difference to mortality or hospital readmission compared with in-hospital care, but probably reduces hospital length of stay.

synapsesocial.com/papers/6a128d298edbaba0bf67800a https://doi.org/10.1002/14651858.cd000356.pub4

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Early discharge hospital at home

Discussion

Member takes

Implication

Key Points

Study Design

Structured PICO

Main Result

Limitations

Cite This Study

Early discharge hospital at home

Discussion

Member takes

Implication

Key Points

Study Design

Structured PICO

Main Result

Limitations

Cite This Study

Also Consider

Also Consider