Home and Community Care Digest

Home and Community Care Digest December 2002 : 0-0

Hospital at Home not cheaper than in-hospital care

Abstract

This international literature review did not find substantial evidence to support the development of hospital at home services as a cheaper substitute for in-patient care within health care systems with developed primary care services. On the other hand, there was no evidence found to recommend discontinuation of existing hospital at home programs for patients with terminal illness, elderly medical patients, or following elective surgery.
Background: "Hospital at home" is a popular response to the increasing demand for acute hospital beds. Cutting costs by avoiding admission to hospital, and reducing hospital length of stay are central goals of such schemes. However, it is not known if patients admitted to hospital at home have better or equivalent health outcomes compared with patients receiving in-patient hospital care. Nor is it known if the provision of hospital at home results in a reduction, or increase, in costs to the health service. Hospital at home is defined as a timelimited service which provides in a patient's home active treatment by health care professionals of a condition that otherwise would require acute hospital in-patient care.

Method: This systematic review of the international literature addressed the following key questions related to hospital at home verses in-hospital care: (1) Do patient outcomes differ? (2) Does patient satisfaction differ? (3) Does the workload of doctors working in primary care change as a result of hospital at home? (4) Do readmission rates differ? (5) Do the costs to the health service change as a result of hospital at home? Outcome measures examined in this review included mortality, clinical complications, readmissions, cost, hospital days saved, health status, functional status, psychological well-being, patient satisfaction, caregiver satisfaction, caregiver burden and staff views. Multiple databases were searched for clinical trials related to home care. 16 research studies met selection criteria and were reviewed by both authors. Research on long-term care, outpatient settings, and self-care at home were not included in this review.

Findings: Cost Effectiveness: Overall hospital at home does not produce cost savings to the health service. One trial reported that home care significantly increased expenditure for some groups of patients (hysterectomy and COPD) following early discharge. No cost difference was detected for hip or knee replacement patients or among elderly medical patients. Hospital Days Saved: Early discharge + hospital at home reduced hospital length of stay, but the home care provision offset this reduction by increasing total length of care. Admission avoidance programs achieved a reduction in total length of stay. Patient Satisfaction: Compared to hospital care, hospital at home services increase patient satisfaction but the data do not indicate which aspects of home care particularly affect satisfaction. Caregiver Satisfaction: Compared to hospital care, caregivers for terminally ill patients reported greater satisfaction with home care; however, lower morale was experienced if the patient survived more than 30 days. Functional Status: Trials for stroke patients rendered conflicting results. One trial showed improved independence but another showed reduced psychological function and communication for home care patients.

Conclusions: This review does not support the widespread development of "hospital at home" services as a cheaper substitute for in-patient care within health care systems that have well developed primary care services. On the other hand, it does not recommend discontinuation of existing programs for patients with terminal illness, elderly medical patients, or following elective surgery. If the costs of running local hospitals are relatively high (e.g. teaching hospitals), hospital at home may provide a cost effective alternative.

Reference: Shepperd S and Iliffe S. Hospital at home versus in-patient hospital care. The Cochrane Database of Systematic Reviews 2002; 4.

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