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Research overview
Systematic review

Intermediate care units and Hospital at home for acute exacerbations of COPD

The Norwegian Directorate of Health has appointed a working group to develop national guidelines for COPD treatment, and as a part of this process the Norwegian Knowledge Centre for Health Services was commissioned to evaluate the efficacy of treatment of acute exacerbations of COPD in intermediate units or "hospital at home” as compared to traditional hospital care.


  • Year: 2011
  • By: Norwegian Knowledge Centre for the Health Services
  • Authors Jeppesen E, Brurberg KG, Lidal IB, Holte HH, Vist GE.

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Key message

Chronic Obstructive Pulmonary Disease (COPD) refers to a group of closely related diseases recognized by irreversibly impaired lung function and airflow obstructions. The World Health Organization (WHO) has estimated that COPD will be found on the list of the six most frequent causes of death worldwide by 2020. More than 200 000 Norwegians are now diagnosed with COPD, and the prevalence is increasing. Thus, COPD constitutes a major future challenge for health services, and it is important to promote effective prevention and treatment of the disease.

The Norwegian Directorate of Health has appointed a working group to develop national guidelines for COPD treatment, and as a part of this process the Norwegian Knowledge Centre for Health Services was commissioned to evaluate the efficacy of treatment of acute exacerbations of COPD in intermediate units or "hospital at home” as compared to traditional hospital care.

  • Treatment of acute exacerbation of COPD in “hospital at home” may lead to fewer readmissions when compared to conventional treatment in hospital.
  • Treatment of acute exacerbation of COPD in “hospital at home” may show a trend for lowering of mortality rate when compared to conventional treatment in hospital, these results did not reach significant differences.
  • It is uncertain whether patients, as well as their relative, seem to prefer treatment in “hospital at home” rather than conventional hospital treatment.
  • No studies met the inclusion criteria when it came to evaluate the efficacy of intermediate care units for treatment of acute exacerbation of COPD.

Summary

Background
Chronic Obstructive Pulmonary Disease (COPD) refers to a group of closely related diseases recognized by irreversibly impaired lung function and airflow obstructions. The World Health Organization (WHO) has estimated that COPD will be found on the list of the six most frequent causes of death worldwide by 2020. More than 200 000 Norwegians are now diagnosed with COPD, and the prevalence is increasing. Thus, COPD constitutes a major future challenge for health services, and it is important to promote effective prevention and treatment of the disease.

Acute COPD exacerbation is a frequent cause of admissions to Norwegian hospitals, but the severity of the acute deterioration varies. Thus, some patients with acute COPD exacerbations don’t need the highly specialized services that are offered in the hospital, but they are too ill to take care of themselves at home. In such situations, admissions to an intermediate unit or “hospital at home” may constitute good alternatives to admissions to highly specialized hospital wards.

“Hospital at home” may for example include regular home visits by trained health personnel and telephone support. The use of “hospital at home” has some potential benefits. Individual patients and their relatives may experience increased satisfaction with care, and treatment costs may be reduced without negatively affecting clinical outcomes. In this report we want to summarize how the use of intermediate care units and “hospital at home” affect various clinical outcomes.

Methods
We have prepared a systematic overview to answer two main questions:

1. What is the effect of “hospital-at-home” for follow-up of patients with acute COPD exacerbation when compared to conventional hospital treatment.

2. What is the effect of intermediate care and observational units for follow-up of patients with acute COPD exacerbation when compared to conventional hospital treatment.

For both questions we searched relevant bibliographic databases for systematic reviews and primary studies. Two reviewers independently screened all titles and abstracts. The quality of relevant systematic reviews was evaluated using predefined checklist, whereas the risk of bias in primary studies was assessed by completing risk of bias tables. Data were extracted by two reviewers, and finally the quality of the evidence was assessed using GRADE. Main outcomes were: hospital readmission, mortality, satisfaction, quality of life, lung function (FEV1), and direct costs. If appropriate, results were pooled in meta-analysis using a random effects model.

Results

“Hospital at home”
The search for studies revealed a total of  2 423 unique references of which 21 randomized controlled trials and seven systematic reviews were selected as potentially relevant. We finally included eight randomized controlled trials, and all were considered to have low risk of bias.  All studies included patients who presented at emergency rooms with acute exacerbation of COPD. Discharge from hospital and subsequent readmission to “hospital at home” was accomplished within 72 hours following the initial hospital admission. Approximately 25 % of the patients with chronic obstructive pulmonary disease who presented at the emergency room with acute exacerbations were considered as appropriate candidates for treatment at home.

Patients with acute exacerbation of COPD who were randomized to treatment in home hospitals showed a significant reduction in the readmission rate compared with patients who were randomized to conventional treatments in hospital. There was no difference in mortality between the two groups, and there is a lack of evidence to give an answer if patients and their relatives are more or less satisfied with “hospital at home” compared to inpatient care. For health-related quality of life, lung function (FEV1) and direct costs we found no difference or only minor differences in favour of home treatment. For the latter outcomes, however, it should be emphasized that the quality of the evidence is low or very low.

Intermediate units and observation posts
We searched for systematic reviews, randomized controlled trials, non-randomized controlled trials, prospective observational studies with control group, and interrupted time series studies. No studies met our inclusion criteria.

Discussion
Traditionally, patients with acute COPD exacerbations have been admitted to hospital, but in this review we have demonstrated that treatment in home hospital may be a safe alternative for some of these patients. Home hospital did not seem to affect mortality, and for readmission rates there was even a little improvement in favour “hospital at home”. This suggests that selected patients presenting at hospital emergency departments with acute exacerbations of COPD can be safely and successfully treated at home if they receive appropriate support and follow-up from qualified health personnel. Three studies included cost analyses and, as expected, they suggested reduced costs for hospital at home services as compared to inpatient care.

It is important to emphasize that only ~25 % of the patients were found appropriate for treatment in “hospital at home” in the studies we have included. A large fraction of the patients with COPD exacerbations are not expected to be appropriate for treatment in home hospital because their lung function is too poor, because they suffer from severe co morbidity (e.g. heart disease), or due to other factors (e.g. confusion).

We have included studies from different countries, and because the organisation of health care varies considerably between different countries, it is difficult to transfer the results for costs. Interestingly, a Norwegian study is currently recruiting patients, and the results of this study may give valuable information regarding the applicability of the results in a Norwegian setting.

Conclusions
Treatment of acute exacerbations of COPD in “hospital at home” may lead to fewer readmissions when compared to conventional treatment in hospital. Treatment of acute exacerbation of COPD in “hospital at home” may show a trend for lowering of mortality rate when compared to conventional treatment in hospital, these results did not reach significant differences. It is uncertain whether treatment in "hospital at home" provides a difference in whether the patient and their relatives are pleased to be treated in the "hospital at home" compared to ordinary hospitalization. For health-related quality of life, lung function (FEV1) and direct costs, we found no difference or small differences in favor of home treatment, but the evidence is weak for these outcomes. We have no documentation to assess the effect of intermediate units or observation wards in the treatment of patients with acute exacerbation of COPD.
We need more studies to assess the cost-effectiveness of treatment in the "home hospital" for selected patients with acute exacerbation of COPD. We need more studies with robust design to evaluate the efficacy of intermediate care units for treatment of acute exacerbation of COPD.



This is a publication from the Norwegian Knowledge Centre for the Health Services. The Knowledge Centre became part of the Norwegian Institute of Public Health 01/01/2016.