Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: systematic review of evidence
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《英国医生杂志》
1 National Collaborating Centre for Women and Children's Health, London NW1 4RG, 2 Academic Respiratory Medicine, St Bartholomew's and Royal London School of Medicine and Dentistry, London EC1A 7BE, 3 Department of Epidemiology and Public Health Medicine, Bradford Hospitals NHS Trust, West Yorkshire BD9 6RJ, 4 Medical Chest Unit, Castle Hill Hospital, Cottingham, East Yorkshire HU16 5JQ
Correspondence to: F S F Ram fsfram@yahoo.co.uk
Abstract
In the United Kingdom, chronic obstructive pulmonary disease (COPD) continues to be responsible for over 90 000 admissions to hospital every year. It is estimated that the mean duration of hospital stay for typical acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is 11 days, which means that about a million hospital bed days a year are taken up in the United Kingdom alone as a result of admissions for COPD.1 In addition, age adjusted admission rates for COPD have risen over 50% in the past nine years.2 Acute exacerbations of COPD are the most common cause of admission to hospital for respiratory illness3 and they account for about 10% of all acute medical admissions in the United Kingdom.4 This causes an increased demand on hospital beds especially during winter months. The annual cost of COPD to the NHS at 1996-7 prices is around ￡817.5m ($1505m, 1222m).5 Admission to hospital accounted for about 35% of this annual expenditure, despite the fact that less than 2% of patients with COPD were admitted in the year examined. The cost of a typical hospital admission was estimated as ￡3000.
The Royal College of Physicians of London has recommended the provision of respiratory care helpers to improve the management of patients with COPD at home.6 Selected patients currently admitted with acute exacerbations of COPD could safely be cared for at home with sufficient support. Mortality from these episodes is closely related to the degree of hypercapnia and acidosis at admission and to the presence of non-respiratory comorbidities.7-9 Many patients presently admitted to hospital do not have these features, and it may be possible to manage them equally well outside the hospital environment.
Hospital at home services are a recent innovation in the management of such acute exacerbations.10 The rationale is that such services increase patients' satisfaction and reduce costs without adverse effects on clinical outcome. Evidence in support of such a service is contradictory and has been extrapolated mainly from generic hospital at home schemes.11-14 Despite the paucity of objective evidence of efficacy, interest in hospital at home services for acute exacerbations has been considerable, with many respiratory departments establishing their own schemes in the United Kingdom,15 Spain,16 and Australia.17 We conducted a systematic review comparing hospital at home schemes with inpatient care to observe the effects of each type of care on mortality and readmissions to hospital.
Methods
Search for trials—We included seven randomised controlled trials in the review13 16 17 19-22 (fig 1). Two reviewers completely agreed on trial inclusion and quality grading.
Fig 1 Results of search for trials and reasons for excluding studies
Methodological quality of included trials—All included trials stated that the allocation of treatment was randomised. All except one trial17 adequately described the allocation concealment method used. We graded six trials as A and one as B. Double blind trial design was not possible because of the nature of the intervention. All except three trials13 16 17 adequately reported withdrawals and dropouts. The table shows further details of included trials.
Table 1 Characteristics of trials included in review
Efficacy variables—Included trials reported study outcome measures two to three months after the initial exacerbation. All seven trials with 754 participants provided data on the rate of readmission to hospital (fig 2). The rate of readmission to hospital was not significantly different in the hospital at home group compared with the inpatient group (relative risk 0.89, 95% confidence interval 0.72 to 1.12). Six trials with 729 participants reported mortality data (fig 3). Mortality was not significantly different in the two trial groups (0.61, 0.36 to 1.05).
Fig 2 Relative risk for readmission to hospital, calculated with fixed effect model with 95% confidence intervals. Square box indicates relative risk for each trial with line representing 95% confidence interval
Fig 3 Details of trials included for mortality outcome
Six trials provided data on the number of patients presenting with acute exacerbations of COPD who met the strict trial inclusion criteria. These six trials screened a total of 2786 patients presenting with acute exacerbations, 744 (26.7%) of whom met the strict study entry criteria. Most of patients who were not eligible for inclusion in the trials required immediate admission, had concomitant medical conditions (including underlying malignancy, pneumothorax, pneumonia, uncontrolled left ventricular failure, acute changes on electrocardiography), or were attending hospital for non-medical reasons.
Four trials reported cost analysis data, which showed substantial savings with hospital at home schemes. Hernandez et al16 and Nicholson et al17 both reported cost savings with hospital at home schemes compared with inpatient care (￡533 ($975, 807) and ￡649 ($1188, 967) per patient, respectively). Skwarska et al showed that the mean health service cost for hospital at home care was roughly half that of inpatient care (￡877 and ￡1753, respectively), and the authors went on to conclude that there could also be a notional saving of 433 bed days a year.22 Cotton et al reported a saving of 201 bed days a year with hospital at home schemes.19
Discussion
LAIA. Trends in COPD. London: Lung Asthma Information Agency, St George's Hospital Medical School, 2003 (No 1).
LAIA. Trends in emergency hospital admissions for lung disease. London: Lung Asthma Information Agency, St George's Hospital Medical School, 2001 (No 4).
NHS Executive. Burdens of disease: a discussion document. Leeds: Department of Health, 1996.
Kendrick S. The increase in the number of emergency admissions: age, diagnosis, frequency. Working paper for the acute beds research group. Edinburgh: Information and Statistics Division, NHSIS, 1994.
Guest JF. The annual cost of chronic obstructive pulmonary disease to the UK's National Health Service. Dis Manag Health Outcome, 1999;5: 93-100.
Royal College of Physicians. Disabling chest disease: prevention and care. J R Coll Physicians Lond 1981;15: 69-87.
Connors AF, Dawson NV, Thomas C, Harrell FE Jr, Desbiens N, Fulkerson WJ, et al. Outcomes following acute exacerbation of severe chronic obstructive lung disease. Am J Respir Crit Care Med 1996;154: 959-67.
Jeffrey AA, Warren PM, Flenley DC. Acute hypercapnic respiratory failure in patients with chronic obstructive pulmonary lung disease: risk factors and use of guidelines for management. Thorax 1992;47: 37-40.
Seneff MG, Wagner DP, Wagner RP, Zimmerman JE, Knaus WA. Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease. JAMA 1995;274: 1852-7.
Gravil JH, Al-Rawas OA, Cotton MM, Flanigan U, Irwin A, Stevenson RD. Home treatment of exacerbations of chronic obstructive pulmonary disease by an acute respiratory assessment service. Lancet 1998;351: 1853-5.
Hughes SL, Ulasevich AA, Weaver FM, Henderson W, Manheim L, Kubal JD, et al. Impact of home care on hospital days: a meta analysis. Health Serv Res 1997;32: 415-32.
Richards SH, Coast J, Gunnell DJ, Peters TJ, Poundsford J, Darlow MA. Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care. BMJ 1998;316: 1796-806.
Shepperd S, Harwood D, Gray A, Vessey M, Morgan P. Randomised controlled trial comparing hospital at home care with inpatient hospital care. II: cost minimisation analysis. BMJ 1998;316: 1791-6.
Wilson A, Parker H, Wynn A, Jagger C, Spiers N, Jones J, et al. Randomised controlled trial of effectiveness of Leicester hospital scheme compared with hospital care. BMJ 1999;319: 1542-6.
Johnson MK, Flanigan U, Fuld J, Irwin A, Stewart C, Stevenson RD. Hospital at home services for acute exacerbation of chronic obstructive pulmonary disease: a survey of British practice. Health Bull 2001;59: 6.
Hernandez C, Casas A, Escarrabill J, Alonso J, Puig-Junoy J, Farrero E, et al. Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients. Eur Respir J 2003;21: 58-67.
Nicholson C, Bowler S, Jackson C, Schollay D, Tweeddale M, O'Rourke P. Cost comparison of hospital and home based treatment models for acute chronic obstructive pulmonary disease. Aust Health Rev 2001;24: 181-7.
British Thoracic Society. British Thoracic Society guidelines for the management of chronic obstructive pulmonary disease. Thorax 1997;52(suppl 5): S1-28.
Cotton MM, Bucknall CE, Dagg KD, Johnson MK, MacGregor G, Stewart C, et al. Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Thorax 2000;55: 902-6.
Davies L, Wilkinson M, Bonner S, Calverley PM, Angus RM. "Hospital at home" versus hospital care in patients with exacerbations of chronic obstructive pulmonary disease: prospective randomised controlled trial. BMJ 2000;321: 1265-8.
Ojoo JC, Moon T, McGlone S, Martin K, Gardiner ED, Greenstone MA, et al. Patients' and carers' preferences in two models of care for acute exacerbations of COPD: results of a randomised controlled trial. Thorax 2002;57: 167-9.
Skwarska E, Cohen G, Skwarski KM, Lamb C, Bushell D, Parker S, et al. Randomized controlled trial of supported discharge in patients with exacerbations of chronic obstructive pulmonary disease. Thorax 2000;55: 907-12.
Shepperd S, Harwood D, Jenkinson C, Gray A, Vessey M, Morgan P. Randomised controlled trial comparing hospital at home care with inpatient hospital care. I: three month follow up of health outcomes. BMJ 1998;316: 1786-91.(Felix S F Ram, senior res)
Correspondence to: F S F Ram fsfram@yahoo.co.uk
Abstract
In the United Kingdom, chronic obstructive pulmonary disease (COPD) continues to be responsible for over 90 000 admissions to hospital every year. It is estimated that the mean duration of hospital stay for typical acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is 11 days, which means that about a million hospital bed days a year are taken up in the United Kingdom alone as a result of admissions for COPD.1 In addition, age adjusted admission rates for COPD have risen over 50% in the past nine years.2 Acute exacerbations of COPD are the most common cause of admission to hospital for respiratory illness3 and they account for about 10% of all acute medical admissions in the United Kingdom.4 This causes an increased demand on hospital beds especially during winter months. The annual cost of COPD to the NHS at 1996-7 prices is around ￡817.5m ($1505m, 1222m).5 Admission to hospital accounted for about 35% of this annual expenditure, despite the fact that less than 2% of patients with COPD were admitted in the year examined. The cost of a typical hospital admission was estimated as ￡3000.
The Royal College of Physicians of London has recommended the provision of respiratory care helpers to improve the management of patients with COPD at home.6 Selected patients currently admitted with acute exacerbations of COPD could safely be cared for at home with sufficient support. Mortality from these episodes is closely related to the degree of hypercapnia and acidosis at admission and to the presence of non-respiratory comorbidities.7-9 Many patients presently admitted to hospital do not have these features, and it may be possible to manage them equally well outside the hospital environment.
Hospital at home services are a recent innovation in the management of such acute exacerbations.10 The rationale is that such services increase patients' satisfaction and reduce costs without adverse effects on clinical outcome. Evidence in support of such a service is contradictory and has been extrapolated mainly from generic hospital at home schemes.11-14 Despite the paucity of objective evidence of efficacy, interest in hospital at home services for acute exacerbations has been considerable, with many respiratory departments establishing their own schemes in the United Kingdom,15 Spain,16 and Australia.17 We conducted a systematic review comparing hospital at home schemes with inpatient care to observe the effects of each type of care on mortality and readmissions to hospital.
Methods
Search for trials—We included seven randomised controlled trials in the review13 16 17 19-22 (fig 1). Two reviewers completely agreed on trial inclusion and quality grading.
Fig 1 Results of search for trials and reasons for excluding studies
Methodological quality of included trials—All included trials stated that the allocation of treatment was randomised. All except one trial17 adequately described the allocation concealment method used. We graded six trials as A and one as B. Double blind trial design was not possible because of the nature of the intervention. All except three trials13 16 17 adequately reported withdrawals and dropouts. The table shows further details of included trials.
Table 1 Characteristics of trials included in review
Efficacy variables—Included trials reported study outcome measures two to three months after the initial exacerbation. All seven trials with 754 participants provided data on the rate of readmission to hospital (fig 2). The rate of readmission to hospital was not significantly different in the hospital at home group compared with the inpatient group (relative risk 0.89, 95% confidence interval 0.72 to 1.12). Six trials with 729 participants reported mortality data (fig 3). Mortality was not significantly different in the two trial groups (0.61, 0.36 to 1.05).
Fig 2 Relative risk for readmission to hospital, calculated with fixed effect model with 95% confidence intervals. Square box indicates relative risk for each trial with line representing 95% confidence interval
Fig 3 Details of trials included for mortality outcome
Six trials provided data on the number of patients presenting with acute exacerbations of COPD who met the strict trial inclusion criteria. These six trials screened a total of 2786 patients presenting with acute exacerbations, 744 (26.7%) of whom met the strict study entry criteria. Most of patients who were not eligible for inclusion in the trials required immediate admission, had concomitant medical conditions (including underlying malignancy, pneumothorax, pneumonia, uncontrolled left ventricular failure, acute changes on electrocardiography), or were attending hospital for non-medical reasons.
Four trials reported cost analysis data, which showed substantial savings with hospital at home schemes. Hernandez et al16 and Nicholson et al17 both reported cost savings with hospital at home schemes compared with inpatient care (￡533 ($975, 807) and ￡649 ($1188, 967) per patient, respectively). Skwarska et al showed that the mean health service cost for hospital at home care was roughly half that of inpatient care (￡877 and ￡1753, respectively), and the authors went on to conclude that there could also be a notional saving of 433 bed days a year.22 Cotton et al reported a saving of 201 bed days a year with hospital at home schemes.19
Discussion
LAIA. Trends in COPD. London: Lung Asthma Information Agency, St George's Hospital Medical School, 2003 (No 1).
LAIA. Trends in emergency hospital admissions for lung disease. London: Lung Asthma Information Agency, St George's Hospital Medical School, 2001 (No 4).
NHS Executive. Burdens of disease: a discussion document. Leeds: Department of Health, 1996.
Kendrick S. The increase in the number of emergency admissions: age, diagnosis, frequency. Working paper for the acute beds research group. Edinburgh: Information and Statistics Division, NHSIS, 1994.
Guest JF. The annual cost of chronic obstructive pulmonary disease to the UK's National Health Service. Dis Manag Health Outcome, 1999;5: 93-100.
Royal College of Physicians. Disabling chest disease: prevention and care. J R Coll Physicians Lond 1981;15: 69-87.
Connors AF, Dawson NV, Thomas C, Harrell FE Jr, Desbiens N, Fulkerson WJ, et al. Outcomes following acute exacerbation of severe chronic obstructive lung disease. Am J Respir Crit Care Med 1996;154: 959-67.
Jeffrey AA, Warren PM, Flenley DC. Acute hypercapnic respiratory failure in patients with chronic obstructive pulmonary lung disease: risk factors and use of guidelines for management. Thorax 1992;47: 37-40.
Seneff MG, Wagner DP, Wagner RP, Zimmerman JE, Knaus WA. Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease. JAMA 1995;274: 1852-7.
Gravil JH, Al-Rawas OA, Cotton MM, Flanigan U, Irwin A, Stevenson RD. Home treatment of exacerbations of chronic obstructive pulmonary disease by an acute respiratory assessment service. Lancet 1998;351: 1853-5.
Hughes SL, Ulasevich AA, Weaver FM, Henderson W, Manheim L, Kubal JD, et al. Impact of home care on hospital days: a meta analysis. Health Serv Res 1997;32: 415-32.
Richards SH, Coast J, Gunnell DJ, Peters TJ, Poundsford J, Darlow MA. Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care. BMJ 1998;316: 1796-806.
Shepperd S, Harwood D, Gray A, Vessey M, Morgan P. Randomised controlled trial comparing hospital at home care with inpatient hospital care. II: cost minimisation analysis. BMJ 1998;316: 1791-6.
Wilson A, Parker H, Wynn A, Jagger C, Spiers N, Jones J, et al. Randomised controlled trial of effectiveness of Leicester hospital scheme compared with hospital care. BMJ 1999;319: 1542-6.
Johnson MK, Flanigan U, Fuld J, Irwin A, Stewart C, Stevenson RD. Hospital at home services for acute exacerbation of chronic obstructive pulmonary disease: a survey of British practice. Health Bull 2001;59: 6.
Hernandez C, Casas A, Escarrabill J, Alonso J, Puig-Junoy J, Farrero E, et al. Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients. Eur Respir J 2003;21: 58-67.
Nicholson C, Bowler S, Jackson C, Schollay D, Tweeddale M, O'Rourke P. Cost comparison of hospital and home based treatment models for acute chronic obstructive pulmonary disease. Aust Health Rev 2001;24: 181-7.
British Thoracic Society. British Thoracic Society guidelines for the management of chronic obstructive pulmonary disease. Thorax 1997;52(suppl 5): S1-28.
Cotton MM, Bucknall CE, Dagg KD, Johnson MK, MacGregor G, Stewart C, et al. Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Thorax 2000;55: 902-6.
Davies L, Wilkinson M, Bonner S, Calverley PM, Angus RM. "Hospital at home" versus hospital care in patients with exacerbations of chronic obstructive pulmonary disease: prospective randomised controlled trial. BMJ 2000;321: 1265-8.
Ojoo JC, Moon T, McGlone S, Martin K, Gardiner ED, Greenstone MA, et al. Patients' and carers' preferences in two models of care for acute exacerbations of COPD: results of a randomised controlled trial. Thorax 2002;57: 167-9.
Skwarska E, Cohen G, Skwarski KM, Lamb C, Bushell D, Parker S, et al. Randomized controlled trial of supported discharge in patients with exacerbations of chronic obstructive pulmonary disease. Thorax 2000;55: 907-12.
Shepperd S, Harwood D, Jenkinson C, Gray A, Vessey M, Morgan P. Randomised controlled trial comparing hospital at home care with inpatient hospital care. I: three month follow up of health outcomes. BMJ 1998;316: 1786-91.(Felix S F Ram, senior res)