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Meta-Analysis
. 2012 May 16;2012(5):CD003573.
doi: 10.1002/14651858.CD003573.pub2.

Hospital at home for acute exacerbations of chronic obstructive pulmonary disease

Elisabeth Jeppesen  1 , Kjetil G Brurberg, Gunn E Vist, Jadwiga A Wedzicha, John J Wright, Michael Greenstone, Julia A E Walters
Affiliations
Meta-Analysis

Hospital at home for acute exacerbations of chronic obstructive pulmonary disease

Elisabeth Jeppesen et al. Cochrane Database Syst Rev. .

Abstract

Background: Hospital at home schemes are a recently adopted method of service delivery for the management of acute exacerbations of chronic obstructive pulmonary disease (COPD) aimed at reducing demand for acute hospital inpatient beds and promoting a patient-centred approach through admission avoidance. However, evidence in support of such a service is contradictory.

Objectives: To evaluate the efficacy of hospital at home compared to hospital inpatient care in acute exacerbations of COPD.

Search methods: Trials were identified from searches of electronic databases, including CENTRAL, MEDLINE, EMBASE, and the Cochrane Airways Group Register (CAGR). The review authors checked the reference lists of included trials. The CAGR was searched up to February 2012. The additional databases were searched up to October 2010.

Selection criteria: We considered randomised controlled trials where patients presented to the emergency department with an exacerbation of their COPD. Studies must not have recruited patients for whom treatment at home is usually not viewed as an responsible option (e.g. patients with an impaired level of consciousness, acute confusion, acute changes on the radiograph or electrocardiogram, arterial pH less than 7.35, concomitant medical conditions).

Data collection and analysis: Two review authors independently selected articles for inclusion, assessed the risk of bias and extracted data for each of the included trials.

Main results: Eight trials with 870 patients were included in the review and showed a significant reduction in readmission rates for hospital at home compared with hospital inpatient care of acute exacerbations of COPD (risk ratio (RR)0.76; 95% confidence interval (CI) from 0.59 to 0.99; P=0.04). Moreover, we observed a trend towards lower mortality in the hospital at home group, but the pooled effect estimate did not reach statistical significance (RR 0.65, 95% CI 0.40 to 1.04, P = 0.07). For health-related quality of life, lung function (FEV1) and direct costs, the quality of the available evidence is in general too weak to make firm conclusions.

Authors' conclusions: Selected patients presenting to hospital emergency departments with acute exacerbations of COPD can be safely and successfully treated at home with support from respiratory nurses. We found evidence of moderate quality that hospital at home may be advantageous with respect to readmission rates in these patients. Treatment of acute exacerbation of COPD in hospital at home also show a trend towards reduced mortality rate when compared with conventional inpatient treatment, but these results did not reach statistical significance (moderate quality evidence). For other outcomes than readmission and mortality rate, we assessed the evidence to be of low or very low quality.

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Conflict of interest statement

There are no known conflicts of interest.

Figures

1
1
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
2
2
Forest plot of comparison: 1 Hospital at Home versus Standard Inpatient Care, outcome: 1.1 Hospital inpatient readmissions.
3
3
Forest plot of comparison: 1 Hospital at Home versus Standard Inpatient Care, outcome: 1.2 Mortality.
1.1
1.1. Analysis
Comparison 1 Hospital at Home versus Standard Inpatient Care, Outcome 1 Hospital inpatient readmissions.
1.2
1.2. Analysis
Comparison 1 Hospital at Home versus Standard Inpatient Care, Outcome 2 Mortality.
1.3
1.3. Analysis
Comparison 1 Hospital at Home versus Standard Inpatient Care, Outcome 3 FEV1 (lung function).
1.4
1.4. Analysis
Comparison 1 Hospital at Home versus Standard Inpatient Care, Outcome 4 FVC (lung function).
1.5
1.5. Analysis
Comparison 1 Hospital at Home versus Standard Inpatient Care, Outcome 5 FEV1/FVC % (lung function).
1.6
1.6. Analysis
Comparison 1 Hospital at Home versus Standard Inpatient Care, Outcome 6 Health‐related quality of life measured with SGRQ.
1.7
1.7. Analysis
Comparison 1 Hospital at Home versus Standard Inpatient Care, Outcome 7 Satisfaction with care.
1.8
1.8. Analysis
Comparison 1 Hospital at Home versus Standard Inpatient Care, Outcome 8 Preference for "Hospital at home care".
1.9
1.9. Analysis
Comparison 1 Hospital at Home versus Standard Inpatient Care, Outcome 9 Average direct costs per patients.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Cotton 2000 {published data only}
    1. 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(11):902‐6. - PMC - PubMed
Davies 2000 {published data only}
    1. 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(7271):1265‐8. - PMC - PubMed
    1. 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. Revista Portuguesa de Pneumologia 2001;7(2):163‐5. - PMC - PubMed
Hernandez 2003 {published data only}
    1. Hernandez C, Casas A, Escarrabill J, Alonso J, Puig‐Junoy J, Farrero E, et al. Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients. European Respiratory Journal 2003;21(1):58‐67. - PubMed
    1. Puig‐Junoy J, Casas A, Font‐Planells J, Escarrabill J, Hernandez C, Alonso J, et al. The impact of home hospitalization on healthcare costs of exacerbations in COPD patients. European Journal of Health Economics 2007;8:325–32. - PubMed
Nicholson 2001 {published and unpublished data}
    1. Bowler S, Schollay D, Nicholson C, Jackson C, Serisier D, O'Rourke P, et al. A pilot study comparing substitutable care at home with usual hospital care for acute chronic obstructive pulmonary disease (COPD). National Demonstration Hospitals Program Phase 3, Health Services Research Reports, Mater Adult Hospital. Brisbane, Australia: Commonwealth department of health and aged care, 2001:235‐63.
    1. Bowler S, Schollay D, Nicholson C, Serisier D, Jackson C, Rice‐McDonald G, et al. Home vs hospital treatment of exacerbations of COPD: a randomised controlled trial. Respirology 2001;6 Suppl:A67.
    1. 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. Australia Health Review 2001;24(4):181‐7. [MEDLINE: ] - PubMed
Nissen 2007 {published and unpublished data}
    1. Nissen I, Jensen MS. Nurse‐supported discharge of patients with exacerbation of chronic obstructive pulmonary disease [Sygeplejeassisteret hjemmebehandling af eksacerbation i kronisk obstruktiv lungesygdom]. Ugeskrift for læger 2007;169:2220‐3. - PubMed
Ojoo 2002 {published data only}
    1. 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(2):167‐9. - PMC - PubMed
Ricauda 2008 {published data only}
    1. Ricauda NA, Tibaldi V, Leff B, Scarafiotti C, Marinello R, Zanocchi M, et al. Substitutive "Hospital at Home" Versus Inpatient Care for ElderlyPatients with Exacerbations of Chronic Obstructive PulmonaryDisease: A Prospective Randomized, Controlled Trial. Journal of the American Geriatrics Society 2008;56:493‐500. - PubMed
Skwarska 2000 {published data only}
    1. 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(11):907‐12. - PMC - PubMed

References to studies excluded from this review

Barber 2001 {published data only}
    1. Barber CM, Bradshaw LM, Buttery P, Fishwick D, Whyte MK, Higenbottam TW. Assisted discharge for patients with exacerbations of COPD. Thorax 2001;56(5):417‐8. - PMC - PubMed
Brown 1997 {published data only}
    1. Brown A, Caplan G. A post‐acute respiratory outreach service. Australian Journal of Advanced Nursing 1997;14(4):5‐11. - PubMed
Callaghan 1999 {published data only}
    1. Callaghan S. ACTRITE: Acute Chest Triage Rapid Intervention Team. Accident and Emergency Nursing 1999;7(1):42‐6. - PubMed
Caplan 1999 {published data only}
    1. Caplan GA, Ward JA, Brennan NJ, Coconis J, Board N, Brown A. Hospital in the home: a randomised controlled trial. Medical Journal of Australia 1999;170(4):156‐60. - PubMed
Farrero 2001 {published data only}
    1. Farrero E, Escarrabill J, Prats E, Maderal M, Manresa F. Impact of a hospital‐based home‐care program on the management of COPD patients receiving long‐term oxygen therapy. Chest 2001;119(2):364‐9. - PubMed
Gibbons 2001 {published data only}
    1. Gibbons D, Hamilton J, Maw G, Telford J. Developing a nurse‐led service for COPD patients. Professional Nurse 2001;16(4):1035‐7. - PubMed
Gravil 1998 {published data only}
    1. 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. - PubMed
Hermiz 2002 {published and unpublished data}
    1. Hermiz O, Comino E, Marks G, Daffurn K, Wilson S, Harris M. Randomised controlled trial of home based care of patients with chronic obstructive pulmonary disease. BMJ 2002;325(7370):1‐5. - PMC - PubMed
Hughes 1992 {published data only}
    1. Hughes SL, Cummings J, Weaver F, Manheim L, Braun B, Conrad K. A randomized trial of the cost effectiveness of VA hospital‐based home care for the terminally ill. Health Services Research 1992;26(6):801‐17. - PMC - PubMed
Hughes 2000 {published data only}
    1. Hughes SL, Weaver FM, Giobbie‐Hurder A, Manheim L, Henderson W, Kubal JD, et al. Effectiveness of team‐managed home‐based primary care: a randomized multicenter trial. JAMA 2000;284(22):2877‐85. - PubMed
Kirkegaard 2007 {unpublished data only}
    1. Kirkegaard N, Laursen LC. Nurse‐assisted medical management of COPD patients at home is cost effective and improves patients' satisfaction considerably. Unpublished 2007.
Leff 1999 {published data only}
    1. Leff B, Burton L, Guido S, Greenough WB, Steinwachs D, Burton JR. Home hospital program: a pilot study. Journal of the American Geriatric Society 1999;47(6):697‐702. - PubMed
Mair 2002 {published data only}
    1. Mair F, Boland A, Angus R, Haycox A, Hibbert D, Bonner S, et al. A randomized controlled trial of home telecare. Journal of Telemedicine and Telecare 2002;8(Suppl 2):58‐60. [PMID: 12217138] - PubMed
O'Reilly 2001 {published data only}
    1. O'Reilly J. Acute exacerbation of chronic obstructive pulmonary disease. Journal of Internal Medicine 2001;2(2):41‐5.
Richards 1998 {published data only}
    1. Richards SH, Coast J, Gunnell DJ, Peters TJ, Poundsford J, Darlow M‐A. Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care. BMJ 1998;316:1796‐806. - PMC - PubMed
Shepperd 1998 {published and unpublished data}
    1. 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(7147):1791‐6. - PMC - PubMed
    1. 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(7147):1786‐91. - PMC - PubMed
Smith 1999 {published data only}
    1. Smith BJ, Appleton SL, Bennett PW, Roberts GC, Fante P, Adams R, et al. The effect of a respiratory home nurse intervention in patients with chronic obstructive pulmonary disease (COPD). Australian and New Zealand Journal of Medicine 1999;29(5):718‐25. - PubMed
Wilson 1999 {published data only}
    1. 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. - PMC - PubMed

References to ongoing studies

NCT00317057 {published data only}
    1. Outpatient Management of Patients With Exacerbation of Chronic Obstructive Pulmonary Disease. http://clinicaltrials.gov/ct2/show/NCT00317057. [clinicaltrials.gov: NCT00317057]
NCT00702078 {published data only}
    1. Home‐based Treatment of Patients With Chronic Obstructive Pulmonary Disease (COPD) (COPD‐HOME). http://clinicaltrials.gov/ct2/show/NCT00702078. [clinicaltrials.gov: NCT00702078]

Additional references

Britton 2003
    1. Britton M. The burden of COPD in the U.K.: results from the Confronting COPD survey. Respir Med 2003;97:S71‐9. - PubMed
BTS 1997
    1. British Thoracic Society. BTS guidelines for the management of chronic obstructive pulmonary disease. Thorax 1997;52 Suppl 5:S1‐28. - PMC - PubMed
BTS 2006
    1. British Thoracic Society. The burden of lung disease. In: Partridge M editor(s). The burden of lung disease. Second Edition. London: The British Thoracic Society, 2006.
Connors 1996
    1. 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. American Journal of Respiratory and Critical Care Medicine 1996;154:959‐67. - PubMed
Higgins 2011
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions. In: Higgins JPT, Green S editor(s). Cochrane Handbook for Systematic Reviews of Interventions. 5.1.0. London: The Cochrane Collaboration and John Wiley & Sons Ltd, 2011.
Jeffrey 1992
    1. 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. - PMC - PubMed
Seneff 1995
    1. 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. - PubMed
Shepperd 2008
    1. Shepperd S, Doll H, Angus RM, Clarke MJ, Iliffe S, Kalra L, et al. Hospital at home admission avoidance. Cochrane Database of Systematic Reviews 2008, Issue 4. [DOI: 10.1002/14651858.CD007491] - DOI - PMC - PubMed
Shepperd 2009
    1. Shepperd S, Doll H, Broad J, Gladman J, Iliffe S, Langhorne P, et al. Hospital at home early discharge. Cochrane Database of Systematic Reviews 2009, Issue 1. [DOI: 10.1002/14651858.CD000356.pub3] - DOI - PMC - PubMed

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