Abstract
BackgroundHeart 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.Methods and ResultsWe 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.ConclusionsIn 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.
Highlights
Heart failure (HF) is associated with substantial morbidity and mortality, and is the commonest cause of hospitalization in patients over the age of 65 in developed countries [1]
In randomized controlled trials (RCTs), hospital at home (HaH) increased time to first readmission (mean difference (MD) 14.13 days [95% confidence intervals (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])
Larger RCTs are necessary to assess the effect of HaH on readmissions, mortality, and long-term costs
Summary
Heart failure (HF) is associated with substantial morbidity and mortality, and is the commonest cause of hospitalization in patients over the age of 65 in developed countries [1]. HF hospitalizations burden the health care system, accounting for more than 70% of the annual cost of HF care [4,5]. Care processes as patients transition from hospital to home are often suboptimal, and account for a significant proportion of readmissions and health care utilization [6]. With the growing prevalence of HF, there is substantial motivation to explore models of care other than routine hospitalization (RH) that may improve HrQOL, facilitate seamless transitions from the hospital to the post-discharge phase, and improve clinical outcomes. 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. Academic Editor: Pasquale Abete, University of Naples Federico II, ITALY
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