The effectiveness of hospital at home compared with in-patient hospital care: a systematic review

BACKGROUND: Despite the widespread adoption of hospital at home services it is not known if these services represent an effective way to manage patients, compared with in-patient hospital care. METHOD: A systematic review was carried out of randomized controlled trials comparing hospital at home care with acute hospital in-patient care for patients age 18 years and over, excluding those with long-term care needs, obstetric patients, and those requiring mental health services. The following databases were searched: Medline, Embase, Social Science Citation Index, CINAHL, EconLit, PsychLit, SIGLE, Medical Care supplement on economic literature, and the EPOC (Cochrane Effective Practice and Organization of Care Review Group) register. Data were extracted for the following outcomes: mortality, clinical complications, re-admissions, costs, hospital days saved from the provision of hospital at home, discharge destination from hospital at home, functional status, psychological well-being, patient satisfaction and carer satisfaction. Data analysis and quality assessment were undertaken independently by two reviewers using a data checklist, following standard methods described by the EPOC group. RESULTS: Five trials were included in the review. No statistically significant differences were detected for patient health outcomes. Patients discharged early from hospital to hospital at home following elective surgery expressed greater satisfaction with care than those who remained in hospital. Carers, however, expressed less satisfaction with hospital at home compared with hospital care. Only one trial, which recruited patients requiring terminal care, formally tested for a difference in cost. No statistically significant difference was detected for overall net health costs. CONCLUSIONS: This review does not support the widespread adoption of hospital at home, nor the discontinuation of existing schemes for elderly medical patients, patients who have had elective surgery, or those with a terminal illness. There is insufficient evidence to determine the effect of hospital at home on patient outcomes, or cost to the health service.