title: Efficacy of Hospital at Home in Patients with Heart Failure: A Systematic Review and Meta-Analysis.
abstract: BACKGROUND
  Heart failure (HF) is the commonest cause of hospitalization in older adults. Compared to routine hospitalization (RH), hospital at home (HaH)--substitutive hospital-level care in the patient's home--improves outcomes and reduces costs in patients with general medical conditions. The efficacy of HaH in HF is unknown.
  
  
  RESULTS
  We searched MEDLINE, Embase, CINAHL, and CENTRAL, for publications from January 1990 to October 2014. We included prospective studies comparing substitutive models of hospitalization to RH in HF. At least 2 reviewers independently selected studies, abstracted data, and assessed quality. We meta-analyzed results from 3 RCTs (n = 203) and narratively synthesized results from 3 observational studies (n = 329). Study quality was modest. In RCTs, HaH increased time to first readmission (mean difference (MD) 14.13 days [95% CI 10.36 to 17.91]), and improved health-related quality of life (HrQOL) at both, 6 months (standardized MD (SMD) -0.31 [-0.45 to -0.18]) and 12 months (SMD -0.17 [-0.31 to -0.02]). In RCTs, HaH demonstrated a trend to decreased readmissions (risk ratio (RR) 0.68 [0.42 to 1.09]), and had no effect on all-cause mortality (RR 0.94 [0.67 to 1.32]). HaH decreased costs of index hospitalization in all RCTs. HaH reduced readmissions and emergency department visits per patient in all 3 observational studies.
  
  
  CONCLUSIONS
  In the context of a limited number of modest-quality studies, HaH appears to increase time to readmission, reduce index costs, and improve HrQOL among patients requiring hospital-level care for HF. Larger RCTs are necessary to assess the effect of HaH on readmissions, mortality, and long-term costs.
authors.affiliation: Department of Medicine, Queen's University, Kingston, Ontario, Canada.
authors.forename: Amro
authors.initials: A
authors.lastname: Qaddoura
authors.affiliation: Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Payam
authors.initials: P
authors.lastname: Yazdan-Ashoori
authors.affiliation: Dalla Lana School of Public Health, Division of Epidemiology, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Conrad
authors.initials: C
authors.lastname: Kabali
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Lehana
authors.initials: L
authors.lastname: Thabane
authors.affiliation: Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: R Brian
authors.initials: RB
authors.lastname: Haynes
authors.affiliation: Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Connolly
authors.affiliation: Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Harriette Gillian Christine
authors.initials: HG
authors.lastname: Van Spall
mesh_terms: D004636:Emergency Service, Hospital; D005500:Follow-Up Studies; D006333:Heart Failure / Q000453:epidemiology* / Q000401:mortality; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay; D010359:Patient Readmission / Q000191:economics / Q000706:statistics & numerical data; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic / Q000706:statistics & numerical data; D015203:Reproducibility of Results; D016896:Treatment Outcome