Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care

BMJ 1998;316:1796-1801 ( 13 June )

General Practice

Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care

Editorial by IliffeGeneral practice p 1786, 1791, 1802

Suzanne H Richards, research associate, ^a Joanna Coast, lecturer in health economics, ^a David J Gunnell, senior lecturer in epidemiology and public health medicine, ^a Tim J Peters, reader in medical statistics, ^a John Pounsford, consultant physician, care of the elderly, ^b Mary-Anne Darlow, hospital at home team coordinator. ^c

^a Department of Social Medicine, University of Bristol, Bristol BS8 2PR, ^b Day Hospital, Frenchay Hospital, Bristol BS16 1LE, ^c Hospital-at-Home, Downend Clinic, Bristol BS16 5TW

Correspondence to: Suzanne Richards suzanne.richards{at}bris.ac.uk

Objective: To compare effectiveness and acceptability of early discharge to a hospital at home scheme with that ofroutine discharge from acute hospital.
Design: Pragmatic randomised controlled trial.
Setting: Acute hospital wards and community in north of Bristol, with a catchment population of about 224 000 people.
Subjects: 241 hospitalised but medically stable elderly patients who fulfilled criteria for early discharge to hospital at home scheme and who consented to participate.
Interventions: Patients' received hospital at home care or routine hospital care.
Main outcome measures: Patients' quality of life, satisfaction, and physical functioning assessed at 4 weeks and 3months after randomisation to treatment; length of stay in hospitaland in hospital at home scheme after randomisation; mortalityat 3 months.
Results: There were no significant differences in patient mortality, quality of life, and physical functioning between the two arms of the trial at 4 weeks or 3 months. Only one of11 measures of patient satisfaction was significantly different:hospital at home patients perceived higher levels of involvementin decisions. Length of stay for those receiving routine hospitalcare was 62% (95% confidence interval 51% to 75%) of length ofstay in hospital at home scheme.
Conclusions: The early discharge hospital at home scheme was similar to routine hospital discharge in terms of effectivenessand acceptability. Increased length of stay associated with thescheme must be interpreted with caution because of different organisationalcharacteristics of the services.

Key messages

Pressure on hospital beds, the increasing age of the population, and high costs associated with acute hospital care have fuelled the search for alternatives to inpatient hospital care
There were no significant differences between early discharge to hospital at home scheme and routine hospital care in terms of patient quality of life, physical functioning, and most measures of patient satisfaction
Length of stay for hospital patients was significantly shorter than that of hospital at home patients, but, owing to qualitative differences between the two interventions, this does not necessarily mean differences in effectiveness
Early discharge to hospital at home provides an acceptable alternative to routine hospital care in terms of effectiveness and patient acceptability

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