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Practice NIHR Signals

People with chronic obstructive pulmonary disease exacerbations prefer early discharge, then treatment at home

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.k5339 (Published 19 February 2019) Cite this as: BMJ 2019;364:k5339

Editorial

NIHR’s research signals in The BMJ

  1. Rob Cook, clinical director1,
  2. Vaughan Thomas2,
  3. Rosie Martin, clinical specialist1
  4. on behalf of the NIHR Dissemination Centre
  1. 1Bazian, Economist Intelligence Unit healthcare, London, UK
  2. 2Wessex Institute, University of Southampton, Southampton, UK
  1. Correspondence to R Cook rob.cook{at}bazian.com

The study

Home treatment of COPD exacerbation selected by DECAF score: a non-inferiority, randomised controlled trial and economic evaluation

Echevarria C, Gray J, Hartley T, Miller J, Simpson AJ, Gibson GJ, Bourke SC

Published on 24 April 2018 Thorax 2018;73:713-22

This project was funded by the National Institute for Health Research—Research for Patient Benefit Programme (project number PB-PG-0213-30105).

To read the full NIHR Signal, go to: https://discover.dc.nihr.ac.uk/content/signal-000691/hospital-at-home-treatment-for-copd-flare-ups

Why was this study needed?

Chronic obstructive pulmonary disease (COPD) causes increasing difficulty in breathing over time. Almost 2% of people in England have COPD, most of them are middle aged or older long term smokers.

COPD progresses slowly, but people can have an exacerbation. In 2017-18 in England, there were 34 980 hospital admissions for acute exacerbations of COPD, totalling 137 099 days in hospital.

Hospital at home services can provide much, but not all, of the care available in hospital and are shown to be effective, but choosing appropriate patients has been difficult. People with exacerbations of COPD prefer to be managed at home rather than in hospital.

This study aimed to see if treating people at home was effective and cheaper for those at low risk of dying from an exacerbation of COPD according to the DECAF clinical prediction tool (box 1).

What did this study do?

This randomised controlled trial included 120 people admitted to three hospitals in England with a COPD exacerbation who had a DECAF score of 0 or 1. This indicated a low risk of dying; about half of people fall into this category. People were assigned to either stay in hospital or have “hospital at home.”

People receiving hospital at home were visited by a respiratory specialist nurse once or twice a day. A respiratory consultant provided remote supervision. Patients had an emergency number to contact the team at any time and access to physiotherapy, occupational therapy, psychology, pharmacy, and short term social support.

Patients had daily monitoring of their breathing rate, blood pressure, and blood oxygen levels, with blood tests if needed. Oral and intravenous treatments plus oxygen therapy were available.

This was a well designed trial and the results should be applicable to other NHS trusts, if the service can be replicated.

What did it find?

• Hospital at home costs about 20% (£1016) less than usual care on average and has a 90% chance of being cost effective at usual NHS willingness-to-pay thresholds.

• Patients in the hospital at home group spent an average of one day in hospital and four days with treatment at home compared with five days in hospital with usual care.

• About 90% of patients said they would prefer hospital at home during future exacerbations (54 of 60 people who had hospital at home and 51 of 57 who had usual care).

• There was little difference in the proportion of readmissions: 37% of people having hospital at home and 40% of people who stayed in hospital were readmitted within 90 days.

• No patients in either group died in the two weeks after attending hospital with their exacerbation. One person in each group died within 90 days.

What does current guidance say on this issue?

The 2018 guideline from the National Institute for Health and Care Excellence (NICE) on COPD recommends hospital at home and assisted discharge schemes as safe and effective for people who would otherwise need to be admitted or stay in hospital. From its 2004 review, NICE notes that evidence is insufficient to make specific recommendations on selecting people for such services.

The British Thoracic Society’s 2007 guideline on intermediate care with hospital at home in COPD provides detailed recommendations on hospital at home services. However, it did not recommend any standardised scoring tools for identifying which clinical characteristics made hospital at home a suitable option.

What are the implications?

This study supports the current move towards assisted discharge schemes supported by hospital at home for selected people with exacerbations of COPD. The evidence adds data, and the authors note that those cared for at home prefer this option. The DECAF score seems a practical choice for assessing risk.

Hospital at home may cost less than staying in hospital, driven by shorter hospital stay rather than fewer readmissions.

This was a relatively small study of 120 people in only three hospitals. Further information from other centres in the UK would be needed to be certain of the benefits to patients, and the savings in NHS costs. The DECAF score might be suitable for reviewing in the next update of guidelines.

DECAF score

The DECAF score is an acrostic, in which each letter stands for a different characteristic associated with COPD. A patient scores points for the characteristics they have, with higher scores indicating worse COPD.

  • People scoring 0 or 1 were well enough to have hospital at home and could be included in the study.

  • D is for dyspnoea (breathlessness) before the exacerbation:

  • 1 point if the person could wash or dress themselves but needed help leaving the house

  • 2 points if the person cannot wash or dress themselves or leave the house without help.

  • E is for eosinopenia (low numbers of a type of white blood cell):

  • 1 point if the person has fewer than 500 eosinophils per microlitre of blood.

  • C is for consolidation on chest radiography (fluid showing as whiter areas of the lungs):

  • 1 point if present.

  • A is for acidaemia (change in blood acidity caused by lack of oxygen):

  • 1 point if the person’s blood pH is less than 7.3.

  • F is for fibrillation (irregular heart rhythm):

  • 1 point if the person has atrial fibrillation.

Education into Practice

  • How is the severity of a patient's COPD assessed during an exacerbation in your organisation?

  • What factors determine which setting is most appropriate for care during an exacerbation?

  • How might this evidence inform services locally?

Footnotes

  • Competing interestsThe BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none.

  • Further details of The BMJ policy on financial interests is here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests

  • Contributors All authors contributed to development and review of this summary, as part of the wider NIHR Signals editorial team (https://www.bmj.com/NIHR-signals). RC is guarantor.

  • Disclaimer NIHR Signals are owned by the Department of Health and Social Care and are made available to the BMJ under licence. NIHR Signals report and comment on health and social care research but do not offer any endorsement of the research. The NIHR assumes no responsibility or liability arising from any error or omission or from the use of any information contained in NIHR Signals.

  • Permission to reuse these articles should be directed to disseminationcentre{at}nihr.ac.uk.

References

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