Randomised controlled trial comparing hospital at home care with inpatient hospital care. I: three month follow up of health outcomesBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7147.1786 (Published 13 June 1998) Cite this as: BMJ 1998;316:1786
- Sasha Shepperd (), research officera,
- Diana Harwood, research assistantb,
- Crispin Jenkinson, deputy directorb,
- Alastair Gray, directorc,
- Martin Vessey, professor of public health and head of departmenta,
- Patrick Morgan, consultant in public health medicined
- aDivision of Public Health and Primary Health Care, University of Oxford, Institute of Health Sciences, Headington, Oxford OX3 7LF
- bHealth Services Research Unit, Division of Public Health and Primary Health Care, University of Oxford, Institute of Health Sciences
- cHealth Economics Research Centre, Division of Public Health and Primary Health Care, University of Oxford, Institute of Health Sciences
- dNorthamptonshire Health Authority, Northampton NN1 5DN
- Correspondence to: Sasha Shepperd
- Accepted 15 April 1998
Objectives: To compare hospital at home care with inpatient hospital care in terms of patient outcomes.
Design: Randomised controlled trial with three month follow up.
Setting:District general hospital and catchment area of neighbouring community trust.
Subjects: Patients recovering from hip replacement (n=86), knee replacement (n=86), and hysterectomy (n=238); elderly medical patients (n=96); and patients with chronic obstructive airways disease (n=32).
Interventions: Hospital at home care or inpatient hospital care.
Main outcome measures:Dartmouth COOP chart to measure patients' general health status; SF-36 to measure possible limitations in physical functioning of patients with hysterectomy; disease specific measures chronic respiratory disease questionnaire, Barthel index for elderly medical patients, Oxford hip score, and Bristol knee score; hospital readmission and mortality data; carer strain index to measure burden on carers; patients' and carers' preferred form of care.
Results: At follow up, there were no major differences in outcome between hospital at home care and hospital care for any of the patient groups except that those recovering from hip replacement reported a significantly greater improvement in quality of life with hospital at home care (difference in change from baseline value 0.50, 95% confidence interval 0.13 to 0.88). Hospital at home did not seem suitable for patients recovering from a knee replacement, as 14 (30%) of patients allocated to hospital at home remained in hospital. Patients in all groups preferred hospital at home care except those with chronic obstructive airways disease. No differences were detected for carer burden. Carers of patients recovering from knee replacement preferred hospital at home care, while carers of patients recovering from a hysterectomy preferred hospital care.
Conclusions: Few differences in outcome were detected. Thus, the cost of hospital at home compared with hospital care becomes a primary concern.
Hospital at home schemes are a popular alternative to standard hospital care, but there is uncertainty about their cost effectiveness
In our randomised controlled trial we compared hospital at home care with inpatient hospital care for patients recovering from hip replacement, knee replacement, and hysterectomy; elderly medical patients; and those with chronic obstructive airways disease
There were no major differences in patients' reported health outcomes between the two treatments, but, because of complications commonly needing hospitalisation, patients recovering from knee replacement did not seem suitable for hospital at home care
All patient groups except those with chronic obstructive airways disease preferred hospital at home care
Carers of patients recovering from a hysterectomy preferred hospital care, while those of patients recovering from a knee replacement preferred hospital at home care
Editorial by Iliffe
General practice pp 1791, 1796, 1802
There is an increasing demand for acute hospital beds, partly because of rising numbers of emergency medical admissions.1Increased provision of services in the community is one proposed method for reducing the pressure on acute hospitals. Hospital at home schemes provide care that is usually available only in hospital in a patient's home such as observation, administration of drugs, support, nursing care, and rehabilitation. The aim is to reduce costs to the health service by reducing length of stay in hospital or by avoiding admission altogether. A national survey of purchasing authorities has shown that most areas of the United Kingdom are providing some form of hospital at home scheme.2There is, however, considerable uncertainty about the costs and effectiveness of hospital at home care compared with hospital care. 3 4
A proposal for a new hospital at home scheme in Northamptonshire offered an opportunity to perform a rigorous evaluation of the service as it was introduced. The service provider (Rockingham Forest NHS Trust), the hospital trust (Kettering General Hospital NHS Trust), the purchasing authority (Northampton Health Authority), and local general practitioners agreed to collaborate in a randomised controlled trial. The aim of the trial was to evaluate the health outcomes and costs of the hospital at home scheme compared with inpatient hospital care, and patients could be admitted to the scheme only if they agreed to be randomised. We report here the effects of hospital at home care on health outcomes.
Patients and methods
Patients were recruited from the catchment area of Kettering General Hospital NHS Trust (about 699 km2), and 102 general practitioners from 26 practices participated in the trial. Ethical approval for the study was obtained from the local research ethics committee. After discussions with clinicians and service providers, and a review of the published reports of other hospital at home schemes,3 five groups of patients were considered suitable for the trial. These were patients recovering from a hip replacement, a knee replacement, or a hysterectomy; patients with chronic obstructive airways disease; and elderly patients with a mix of medical conditions. Patients were eligible for recruitment if
Their hospital consultant and general practitioner agreed that they were suitable to be discharged early from hospital to hospital at home care or that they could be admitted to hospital at home as an alternative to hospital care
Their home was suitable for hospital at home care (minimum requirements were hot and cold running water, indoor sanitary facilities, and room for the patient's bed to be moved downstairs if necessary)
Their carer (if one was identified) consented to participate in the trial.
Patients were excluded from the trial if
They were under 60 years old, except for women having a hysterectomy
They were having a hysterectomy for ovarian or uterine malignancy.
The Rockingham Forest NHS Trust provided hospital at home care as a direct alternative to inpatient care for patients who were clinically stable and did not require immediate access to diagnostic or specialist medical care. The services provided included nursing, physiotherapy, occupational therapy, pathology, and speech therapy. Patients were provided with a mobile phone if required. The type of care was more than is normally available in the community through NHS care. It consisted of observation, administration of drugs (including intravenous drugs), nursing care, and rehabilitation of patients in their home. Nursing care was available 24 hours a day in patients' home if necessary. General practitioners held clinical responsibility and were reimbursed for visits they made to patients admitted to the scheme. The decision to discharge patients from the hospital at home scheme was made by a senior nurse.
Before randomisation, a research nurse obtained informed consent from eligible patients and their carers. The randomisation schedule, which was not stratified, was generated by computer. Allocations to hospital or hospital at home were sealed in opaque envelopes. The allocations were revealed through a telephone randomisation service, independent of the service providers (see figure).
After patients were randomised, a research nurse collected demographic information and administered the modified mini-mental state examination.5 Patients were asked to complete the Dartmouth COOP chart,6 a questionnaire on general health status that is brief, easy to complete, and is sensitive to subjectively important change.7 Patients who had a hysterectomy were also asked to complete the SF-36 to capture possible limitations in physical functioning.8 Disease specific measures included the chronic respiratory disease questionnaire9 and the Barthel index10for elderly medical patients. Patients were asked to complete these questionnaires at one and three months' follow up. Patients having a hip or knee replacement completed the Oxford hip score11or Bristol knee score12 at one and three months. Data on hospital readmissions and mortality were collected.
Carers demographic information was collected at baseline. Carers were also asked to complete the carer strain index,13 a measure of carer burden, at baseline and at one and three months' follow up. Patients and carers were asked their preferred place of care, hospital at home or hospital, when they were discharged from care.
Data on cost and resource use are reported in our accompanying paper.14
When possible sample size calculations were based on a change in health status for each clinical condition. When this information was not available (for hip and knee replacements) the calculation of sample size was based on a change in cost thought to be important by the purchasing authority. Pre-trial estimates of treatment costs were obtained from the acute trusts in the former Oxford Regional Health Authority. Levels of and varied for each clinical condition according to the expected change for each of the five primary measures of outcome and by the number of patients predicted for each group.
Sample sizes for hip and knee replacements had a power of 80%, with an of 0.01, to detect a 20% change in healthcare cost. The sample size for patients having a hysterectomy had a power of 80%, with an of 0.05, to detect a change of 10 points on the physical functioning domain of the SF-36, based on a standard deviation of 18.7. Sample size for patients with chronic obstructive airways disease had a power of 80%, with an of 0.05, to detect a change of 4 points on the emotional functioning domain of the chronic respiratory disease questionnaire, based on a standard deviation of 3. Sample size for elderly patients with a medical condition had a power of 90%, with an of 0.01, to detect a difference of 3 points on the Barthel index, based on a standard deviation of 3.1.
After randomisation, the patients were analysed according to their clinical group hip replacement, knee replacement, hysterectomy, chronic obstructive airways disease, or elderly medical. Analysis was done on an intention to treat basis. The outcome measures from patients' self assessment generated multiple comparisons of data. To reduce the risk of reporting misleading significant results, we report only P values that are 0.01 unless the sample size was based on an of 0.05. Unpaired two tailed t tests were used to test for differences between normally distributed continuous variables. For continuous variables that showed a non-normal distribution, differences were tested with the two tailed Mann-Whitney U test. The 2 test was used to test for differences in proportions.
Between October 1994 and November 1996 we recruited 538 patients. For each clinical condition, the groups of patients allocated to the two types of care were broadly similar in distribution of sex, age, and social class (table 1). Sample size requirements were met for each of the five clinical conditions. We report differences between the two arms of the trial in terms of the change of score from baseline to the final follow up time at three months.
Five (14%) of the patients allocated to hospital at home remained in hospital because of postoperative complications. Table 2 shows outcomes after three months. Patients in the hospital at home group reported a significantly greater improvement in quality of life in the self reported Dartmouth COOP charts compared with those in the hospital group. There were no other significant differences in outcome. Two (5%) of the patients in the hospital at home group were readmitted to hospital compared with one (2%) patient in the hospital group (difference 3%, 95% confidence interval 5% to 12%). One patient in the hospital group died. More of the patients receiving hospital at home care reported that they had received their preferred form of care (difference 36%, 17% to 55%). No differences were detected between carers in the two groups for carer burden or preferred place of care (table 3).
Fourteen (30%) of the patients receiving hospital at home care remained in hospital, primarily because of postoperative complications. Table 4 shows outcomes at three months. No significant differences between the two groups were detected for any of the measures. Four (9%) patients in the hospital at home group were readmitted to hospital compared with one (3%) patient in the hospital group (difference 6%, 3% to 15%). There were no deaths. More patients in the hospital at home group reported that they had received their preferred form of care (difference 34%, 14% to 54%). No significant differences in carer burden were detected, but a greater proportion of carers in the hospital at home group expressed satisfaction with their place of care compared with those in the hospital group (difference 25%, 1% to 49%) (table 3).
Sixteen (14%) of the patients allocated to hospital at home remained in hospital, primarily because of postoperative complications. Table 5 shows outcomes at three months. No significant differences between the two groups were detected for any of the measures. Seven (6%) patients in the hospital at home group were readmitted to hospital during follow up compared with 13 (10%) in the hospital group (difference −4%, −11% to 3%). Of these seven hospital at home patients, four were readmitted during the course of their hospital at home care. There were no deaths. A greater proportion of patients in the hospital at home group reported that they had received their preferred type of care (difference 19%, 8% to 30%). In contrast, a lower proportion of carers in the hospital at home group described hospital at home as their preferred form of care (difference −27%, −40% to −14%) (table 3).
Elderly medical patients
Table 6 shows outcomes at three months. No significant differences were detected between the two groups of patients for any of the measures. During follow up, 13 (26%) of the patients in the hospital at home group were either admitted to hospital (if recruited in the community) or readmitted compared with five (11%) in the hospital group (difference 15%, 0% to 30%). Of these 13 hospital at home patients, seven were readmitted during their hospital at home care. Nine (18%) patients in the hospital at home group and four (9%) in the hospital group died (difference 9%, 4% to 23%). More patients in the hospital at home group reported that they had received their preferred form of care (difference 41%, 20% to 62%). No significant differences were detected between the two groups of carers (table 3).
Chronic obstructive airways disease
Table 7 shows outcomes at three months. No statistically significant differences between the two groups were detected for patient outcomes or preferred place of care. During follow up, eight (53%) of the patients in the hospital at home group were either admitted to hospital (if recruited in the community) or readmitted compared with six (35%) in the hospital group (difference 18%, −16% to 52%). Of these eight hospital at home patients, one was admitted during hospital at home care. Three (20%) of the patients in the hospital at home group died compared with three (18%) in the hospital group (difference 2%, −25% to 30%). No significant differences were detected between the two groups of carers (table 3).
There is growing interest in applying the methods of the randomised controlled trial to issues in delivering health services. We conducted such a trial to compare the effect of hospital at home care with inpatient hospital care. One of the most important issues in designing the trial was to define the service provided and the population to be studied. We hypothesised that both outcomes and costs would differ according to diagnosis and age and that valid conclusions could be drawn only by comparing similar patients. On the other hand, the service providers were under pressure to accept a wide range of patients to demonstrate the usefulness of the scheme. We therefore recruited patients with a range of clinical conditions to the service but determined a priori that they would be analysed according to their main diagnosis. Under a common administrative structure we effectively conducted clinical trials in five distinct groups of patients, of which three were patients discharged early after surgical procedures and two were patients with medical conditions.
Our results suggest that, for most of the clinical conditions we studied, there are no major differences in patient assessed health outcomes between hospital at home and hospital care. This is consistent with the results of other randomised controlled trials.15–19 Our trial did not have the power to detect differences in morbidity or mortality, and the number of patients recruited with chronic obstructive airways disease was small. However, our results suggest that patients recovering from a knee replacement are not suitable for hospital at home care: nearly a third of these patients experienced complications associated with their knee replacement that prevented early discharge. More elderly medical patients allocated to hospital at home care had to receive secondary care during the three month follow up than did those allocated to hospital.
Although there were few differences in outcome, most patients preferred hospital at home care. It is not clear how these preferences were formed, and further work is needed to explore this issue. It is possible that patients with a bold preference for hospital care may have declined to enter the study. Patients will always express a range of preferences for different forms of care, which providers of services should take into account. It is, however, interesting that greater levels of patient satisfaction did not lead to improved health outcomes, as found in other studies.20The preferences of carers were less bold than those of patients. Although the carers of patients recovering from a hysterectomy preferred hospital care, there was little difference for the other clinical conditions, suggesting that, with adequate support, care in the community does not necessarily mean an unacceptable burden for carers.
It is not unusual for purchasers to be faced with decisions that must be made in the absence of data on effectiveness. When a new initiative is part of a national trend it is hard to resist providing support, even though evidence for its effectiveness may be lacking. One solution is to develop the research role of purchasers. When presented with an option to support a new initiative, purchasers are in a bold position to insist that an evaluation be conducted to provide data. Not only will the evaluation answer questions about quality and effectiveness, but it will also provide a mechanism to curtail the funding of new services that are of no proved efficacy. Our study shows that, with careful planning and commitment, NHS purchasers and providers can collaborate to support rigorous evaluations of new services as they are introduced.
We thank the Rockingham Forest NHS Trust, Kettering General Hospital NHS Trust, Northamptonshire Health Authority, and the local general practitioners for supporting this research. We also thank Dr Henry McQuay and Dr J A Muir Gray for their help with planning the trial, Jean Pugh and Angela Howe for their diligent work as research nurses, Helen Doll for statistical advice, and Dr Tim Lancaster for comments on the manuscript.
Contributors: SS defined the research question, collaborated in designing the trial, coordinated the trial, analysed the data, and was the principal writer of the paper. DH contributed to the running of the trial, maintained the databases, and helped with writing the paper. CJ advised on the selection, analysis, and interpretation of outcome measures used and cowrote the initial draft of the article. AG discussed core ideas and participated in analysing and interpreting the data and writing the paper. MV collaborated in designing the trial, solving problems that occurred during the trial, and writing the paper. PM assisted with the study design, implementing the trial, and writing the results. SS is guarantor for the paper.
Funding: R&D Programme NHS Executive Anglia and Oxford and the National R&D Programme, Primary Secondary Care Interface, NHS Executive North Thames.
Conflict of interest: None.