Home treatment of COPD exacerbation selected by DECAF score: a non-inferiority, randomised controlled trial and economic evaluation

Abstract

Background: Previous models of Hospital at Home (HAH) for COPD exacerbation (ECOPD) were limited by the lack of a reliable prognostic score to guide patient selection. Approximately 50% of hospitalised patients have a low mortality risk by DECAF, thus are potentially suitable.

Methods: In a non-inferiority randomised controlled trial, 118 patients admitted with a low-risk ECOPD (DECAF 0 or 1) were recruited to HAH or usual care (UC). The primary outcome was health and social costs at 90 days.

Results: Mean 90-day costs were £1016 lower in HAH, but the one-sided 95% CI crossed the non-inferiority limit of £150 (CI -2343 to 312). Savings were primarily due to reduced hospital bed days: HAH=1 (IQR 1-7), UC=5 (IQR 2-12) (P=0.001). Length of stay during the index admission in UC was only 3 days, which was 2 days shorter than expected. Based on quality-adjusted life years, the probability of HAH being cost-effective was 90%. There was one death within 90 days in each arm, readmission rates were similar and 90% of patients preferred HAH for subsequent ECOPD.

Conclusion: HAH selected by low-risk DECAF score was safe, clinically effective, cost-effective, and preferred by most patients. Compared with earlier models, selection is simpler and approximately twice as many patients are eligible. The introduction of DECAF was associated with a fall in UC length of stay without adverse outcome, supporting use of DECAF to direct early discharge.

Trial registration number: Registered prospectively ISRCTN29082260.

Keywords: copd exacerbations.

Figure 1

CONSORT diagram. CONSORT, Consolidated Standards of Reporting Trials; HAH, Hospital at Home.

Figure 2

Length of stay and cost difference (£) between HAH and UC. One-sided CIs for the mean difference in 90-day health and social care costs between UC and HAH are shown for the trial population (UC=3 days) and the sensitivity analysis adjusting for a longer hospital stay in UC (UC=4 days and UC=5 days); Δ=£150, α=£340. HAH, Hospital at Home; UC, usual care.

Figure 3

Cost-effectiveness plane (A) and cost-effectiveness acceptability curve (B). The cost-effectiveness plane for HAH and UC, with the diagonal line representing the NICE cut-off at £30 000 per QALY. Area 1=HAH cheaper and more effective; area 2=HAH more effective and more expensive but less than the NICE cut-off; and area 3=UC is more effective but more expensive and exceeds the NICE cut-off. (B) The probability of cost-effectiveness is shown over a range of willingness to pay for a QALY, to inform decisions to accept or reject new technologies. There is a 90% probability HAH will be cost-effective at the NICE threshold (vertical line). HAH, Hospital at Home; NICE, National Institute for Health and Care Excellence; QALY, quality-adjusted life year; UC, usual care.