Hospital-At-home interventions vs in-hospital stay for patients with chronic disease who present to the emergency department

Abstract

IMPORTANCE Hospitalizations are costly and may lead to adverse events; hospital-At-home interventions could be a substitute for in-hospital stays, particularly for patients with chronic diseases who use health services more than other patients. Despite showing promising results, heterogeneity in past systematic reviews remains high. OBJECTIVE To systematically review and assess the association between patient outcomes and hospital-At-home interventions as a substitute for in-hospital stay for community-dwelling patients with a chronic disease who present to the emergency department and are offered at least 1 home visit from a nurse and/or physician. DATA SOURCES Databases were searched from date of inception to March 4, 2019. The databases were Ovid MEDLINE, Ovid Embase, Ovid PsycINFO, CINAHL, Health Technology Assessment, the Cochrane Library, OVID Allied and Complementary Medicine Database, theWorld Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. STUDY SELECTION Randomized clinical trials in which the experimental group received hospital-Athome interventions and the control group received the usual in-hospital care. Patientswere 18 years or older with a chronic disease who presented to the emergency department and received home visits from a nurse or physician. DATA EXTRACTION AND SYNTHESIS Risk of bias was assessed, and a meta-Analysis was conducted for outcomes that were reported by at least 2 studies using comparable measures. Risk ratios (RRs) were reported for binary outcomes and mean differences for continuous outcomes. Narrative synthesis was performed for other outcomes. MAIN OUTCOMES AND MEASURES Outcomes of interest were patient outcomes, which included mortality, long-Term care admission, readmission, length of treatment, out-of-pocket costs, depression and anxiety, quality of life, patient satisfaction, caregiver stress, cognitive status, nutrition, morbidity due to hospitalization, functional status, and neurological deficits. RESULTS Nine studies were included, providing data on 959 participants (median age, 71.0 years [interquartile range, 70.0-79.9 years]; 613 men [63.9%]; 346 women [36.1%]). Mortality did not differ between the hospital-At-home and the in-hospital care groups (RR, 0.84; 95%CI, 0.61-1.15; I2 = 0%). Risk of readmission was lower (RR, 0.74; 95%CI, 0.57-0.95; I2 = 31%) and length of treatment was longer in the hospital-At-home group than in the in-hospital group (mean difference, 5.45 days; 95%CI, 1.91-8.97 days; I2 = 87%). In addition, the hospital-At-home group had a lower risk of long-Term care admission than the in-hospital care group (RR, 0.16; 95%CI, 0.03-0.74; I2 = 0%).