Hospital-at-home versus in-patient hospital care.
BACKGROUND
Hospital-at-home is defined as a service that provides active treatment by health care professionals, in the patient's home, of a condition that otherwise would require acute hospital in-patient care, always for a limited period. Hospital-at-home has become a popular response to the increasing demand for acute hospital beds.


OBJECTIVE
To assess the effects of hospital-at-home compared with in-patient hospital care for patients.


METHODS
We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, the Cochrane Controlled Trials Register, MEDLINE to 1996, EMBASE to 1995, Cinahl to 1996, the Social Science Citation Index (1992 to 1995), EconLit (1969 to 1996), PsycLit (1987 to 1996), Sigle (1980 to 1995), the Medical Care supplement on economic literature (1979 to 1990), and reference lists of articles.


METHODS
Randomised trials of hospital-at-home care compared with acute hospital in-patient care. The participants were patients aged 18 years and over. The outcomes were mortality, clinical complications, re-admissions, cost (to the patient and family, to general practice, to the hospital and to the community), hospital days saved from the provision of hospital-at-home, discharge destination from hospital-at-home, general and disease specific health status, functional status, psychological well-being, patient satisfaction, carer satisfaction, carer burden, and staff views (including the satisfaction of doctors working in primary care).


METHODS
Two reviewers independently extracted data and assessed study quality.


RESULTS
Five studies were included involving 866 patients. All studies were small and lacked power. No statistically significant differences were detected for patient health outcomes. Patients discharged early from hospital to hospital-at-home following elective surgery expressed greater satisfaction with care than those who remained in hospital. Carers however expressed less satisfaction with hospital-at-home compared with hospital care. Only one trial formally tested for a difference in cost, with no statistically significant difference detected for overall health care costs.


CONCLUSIONS
There is insufficient evidence to assess the effects of hospital-at-home on patient outcomes or the cost to the health service. Given the heterogeneity of what hospital-at-home encompasses and the uncertainty over its effects, future research should clearly specify the type of service being provided, both at home and at hospital, and the specific patient groups. Patient health outcomes, patient and carer satisfaction, and costs should be measured, and studies should include a formal, planned economic analysis. Studies should be large enough to detect important differences and to ensure generalisability of the results.
Shepperd
S
S
Department of General Practice, Imperial College of Science, Technology & Medicine, St Mary's Campus, Norfolk Place, London, UK, W2 1PG. s.shepperd@ic.ac.uk
Iliffe
S
S
D006699:Home Care Services / Q000592:standards; D018575:Home Care Services, Hospital-Based / Q000592:standards*; D006760:Hospitalization; D006801:Humans; D005791:Patient Care / Q000592:standards