Service delivery interventions

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1 Service delivery interventions S A S H A S H E P P E R D D E P A R T M E N T O F P U B L I C H E A L T H, U N I V E R S I T Y O F O X F O R D CO- C O O R D I N A T I N G E D I T O R C O C H R A N E E P O C R E V I E W G R O U P

2 Service delivery interventions Admission avoidance hospital at home Early discharge hospital at home End of life care hospital at home Funded by NIHR Evidence Synthesis Award & NIHR Cochrane Programme Grant

3 DEFINITION Hospital at home is defined as a service that provides active treatment by health care professionals, in the patient s home, of a condition that otherwise would require acute hospital in-patient care, always for a limited period Policy aim: reduce reliance on hospital beds, health outcomes, cost

4 History of Cochrane review of hospital at home Date of first review 1997: 5 trials 1 st update 2000: 11 trials 2 nd update 2005: 22 trials 3 rd update completed 2009: IPD meta-analysis 4 th update on-going:

5 Why obtain individual patient data for each trial? Define and group study populations by medical condition/severity at baseline Incorporate the time of the event for the outcomes readmission and mortality into the meta-analysis Adjust for baseline differences in age and sex Create new variables to account for resources used Disadvantage: time to receive data, organising the data sets

6 Types of intervention Admission avoidance schemes (N=10 RCT) Early discharge to hospital at home of patients with a medical condition and following surgery (N=26 RCT) End of life care at home (N=4 RCT)

7 Primary outcomes Mortality Transfer to hospital Living at home Analysis: we performed meta-analyses where there was sufficient similarity among the trials and where common outcomes had been measured.

8 Cochrane Review Admission Avoidance Hospital at Home S H E P P E R D S, D O L L H, A N G U S R M, C L A R K E MJ, I L I F F E S, K A L R A L, R I C A U D A N A, W I L S O N A D. A D M I S S I O N A V O I D A N C E H O S P I T A L A T H O M E. C O C H R A N E D A T A B A S E O F S Y S T E M A T I C R E V I E W S , I S S U E 4. A R T. N O. : C D D O I : / C D

9 Brief description of the 10 included studies Study population Chronic obstructive pulmonary disease (2 trials) Patients recovering from a moderately severe stroke who were clinically stable (2 trials) Older patients with an acute medical condition (3 trials) Acute short term condition or significant cognitive impairment Cellulitis Community-acquired pneumonia Frail elderly patients with dementia

10 Description of included trials Intervention route of admission Emergency department transferred the patients to the hospital-at-home program (7 trials) Patients were managed directly in hospital-at-home following referral by the primary care physician (3 trials) Hospital out reach team (5 trials) A mix of outreach and community staff or the general practitioner and community nursing staff (3 trials) An independent association of general practitioners provided the intervention (2 trials)

11 Fixed-effects meta-analysis of individual patient data: mortality at 6 months (adjusted for age and sex) HR % CI 0.45 to 0.87; N=607 participants

12 But.. Small study effect Control group care

13 Other outcomes Increase transfer to hospital Increase in satisfaction Residential care high level of heterogeneity Cost Length of stay Admission avoidance mean difference ranged from -13 days to -5 days

14 Implications of this research: Admission avoidance hospital at home can provide an effective alternative to inpatient care for a selected group of older patients requiring hospital admission. However, determining which groups of patients are most likely to benefit and to which other groups the results apply is not simple Access to hospital for transfer (in one trial this was up to 33% of patients within two weeks of randomisation) Low volume of patients

15 Cochrane Review Early Discharge Hospital at Home S H E P P E R D S, D O L L H, B R O A D J, I L I F F E S, G L A D M A N J, L A N G H O R N E P, R I C H A R D S S, M A R T I N F, H A R R I S R. E A R L Y D I S C H A R G E H O S P I T A L A T H O M E : A S Y S T E M A T I C R E V I E W A N D I N D I V I D U A L P A T I E N T D A T A M E T A - A N A L Y S I S. C O C H R A N E D A T A B A S E O F S Y S T E M A T I C R E V I E W S I S S U E 1

16 Description of the included trials: early discharge hospital at home 13 trials early discharge supported care (ED) was provided in the patients' homes by a hospital outreach service 8 trials ED care was provided by community services (1 trained Red Cross volunteers) 4 trials ED care was coordinated by a hospital based stroke team or physician in conjunction with community based services 1 unclear

17 Brief description of the 10 included studies Study population Chronic obstructive pulmonary disease (3 RCTs) Patients recovering from a moderately severe stroke who were clinically stable (11 RCTs) Older patients with an acute medical condition (7 RCTs) Knee replacement Hip fracture Coronary surgery Acute short term condition or condition no longer requiring hospital admission Hernia and varicose veins

18 Description of included trials Intervention Hospital out reach team (13 RCTs) A mix of outreach and community staff or the general practitioner and community nursing staff (4 RCTs) Community services (9 RCTs)

19 Older people with a mix of medical conditions: mortality at 3 months follow-up Patients recovering from a stroke HR % CI 0.32 to 1.91 [n=7 trials; 494 participants]

20 Other outcomes Increase transfer to hospital for those allocated to hospital at home Increase satisfaction Length of stay (mean difference of 0.5 to days) Residential care (early discharge)

21 Residential care for patient recovering from a stroke at 6 months follow up

22 Residential care older people with a medical condition (an average of 7 months follow-up)

23 Volume of patients 20% were both eligible and consented to take part in the trial (staff estimated it would be 36%) (Crotty 2000) Cunliffe and colleagues reported that just 2% of all medical admissions of older people to hospital were referred to an early discharge hospital at home scheme, Crotty et al concluded that their hospital at home service was suitable for the least disabled group of patients and remains an unacceptable option for some patients and their families.

24 Implications of this research This review does not support the widespread development of early discharge hospital at home services as a cheaper substitute for in-patient care within health care systems that have well developed primary care services: The provision of early discharge HAH at home can offset any reduction in hospital length of stay by increasing total length of care Readmission rate to hospital is increased The degree to which substitution could occur is limited by the relatively low volume of patients The degree to which substitution could occur may be further restricted by carers' willingness to take on the responsibilities associated with hospital at home

25 Implications of this research The closure of a ward in favour of hospital at home becomes even less realistic if, as is often the case, patients are admitted to hospital at home from a variety of different wards and across a number of clinical areas. Although this has the advantage of increasing the number of patients admitted to hospital at home it makes it difficult to release resources from secondary care.

26 Cochrane Review End of life care at home S A S H A S H E P P E R D * B E E W E E S H A R O N S T R A U S * D E P A R T M E N T O F U B L I C H E A L T H, U N I V E R S I T Y O F O X F O R D

27 Differences in key concepts Different health systems Financing Service configurations for end of life care Different terms and definitions End of life care Palliative care

28 European Association for Palliative Care (EAPC) Task Force on the Development of Palliative Care in Europe A diversity in the types of services within different countries and a lack of universal standards and accepted definitions of each type of available resource. What is understood by the term Hospice or how resources such as Home Care and Inpatient Unit are defined and quantified, varies considerably between different countries and between different regions. An additional factor was the different interpretations of what was considered to be a specialist palliative care resource. Palliative Medicine 2007

29 European Association of Palliative Care We use the term end of life care when patients and families require intense intervention by the palliative team as the patient commences the dying process. No time line to be put in. (Expert from Cyprus) PC specialist can see the patient at the last day/ hours or constantly 1-2 years. Therefore, may be better to say... in the period extended from a day, months or 1-2 years. (Expert from Latvia) End of life care is the care provided to people in the very last phase of their illness where their prognosis is in days rather than weeks. In our area it has replaced the term terminal. (Expert from the United Kingdom) 752

30 Cochrane Review: end of life care at home End of life care vs hospital or inpatient hospice care End of life care at home is a service that provides active treatment for continuous periods of time by healthcare professionals in the patient's home for patients who would otherwise require hospital or hospice inpatient end of life care Age > 18 years

31 Review questions Are patients who receive end of life care at home more likely to die at home? Do patients who receive end of life care at home have better symptom control? Does patient and care giver satisfaction differ? Do the costs to health services alter as a result of providing end of life care at home? Do patients receiving end of life care at home have an increased risk of unplanned or precipitous admission to hospital?

32 Outcomes Place of death Patients preferred place of death Control of symptoms (pain, breathlessness, nausea and vomiting, constipation, terminal agitation) Delay in care (medical, nursing or domiciliary care) from point of referral to intervention (end of life home care/hospice at home or inpatient care) Family or care giver stress Family or care giver unable to continue caring Patient anxiety Family/care giver anxiety Unplanned/precipitous admission or discharge

33 Study Number recruited Stage of illness Brumley 2007 T=155 C=155 Included studies Late-stage chronic obstructive pulmonary disease (COPD) (21%); congestive heart failure (CHF) (33%) or cancer with a life-expectancy of 12 months or less (47%). Life expectancy assessed by question 'Would you be surprised if this patient died in the next year?' Grande 2000 Hughes 1992 Jordhoy 2000 T=186 C=43 T=83 C=85 T=235 C=199 3 paired clusters Requiring terminal care; 86% diagnosis of cancer Estimated life expectancy of <6 months; 76% diagnosis of cancer incurable malignancy (excluding haematological malignancies); life expectancy 2 to 9 months

34 Study Brumley 2007 Intervention Multidisciplinary team, core team of physician, specialist nurse and social worker. 24 hour care available, no time limit. Included studies 2 non for profit HMOs (Colorado, Hawaii) Grande 2000 Nurse led, most had Marie Curie experience; access to PHC (GP); 24 hour care; maximum of 2 weeks UK Hughes 1992 Multidisciplinary, physician led home care VA, Jordhoy 2000 Outreach hospital based palliative care team working with primary care, multidisciplinary specialist palliative care nurses; limited 24 hour care; Trondheim, Norway

35 High quality evidence Dying at home

36 Moderate quality evidence Admitted to hospital

37 Carer burden 2 studies N=155 Low quality of evidence 1 study reported lower level of psychological well being if patient survived > 30 days 1 study reported no difference

38 Patient outcomes Symptoms Little data 2 trials Responses varied by assessor (primary care physician, district nurse, care givers) Care givers assessed less pain GPs and nurses more depression and anxiety Patient satisfaction 2 trials report increased satisfaction at 1 month Low quality evidence

39 Summary Specialised service increases number of people dying at home Transfers to hospital cost implications 24 hour care Skilled staff Burden on care givers

40 Problems encountered Methodological and ethical difficulties In one of the trials included in this analysis 61% (n = 113/186) of patients allocated to end of life home care actually received this form of care (Grande 2000) Attrition of participants because of early death, difficulties with recruitment, consent to randomisation, data collection, and timing of outcome assessment (Mcwhinney 1994)

41 Variation in place of death Relatively high number of people dying in hospital in the UK: 58% of all deaths are in acute hospitals (18% at home) Decrease in number dying in hospital in the USA (Medicare), Canada and Australia

42 Munday et al 2009 BMJ 17 GPs and 19 nurses Preferences often unclear Preferences change over time, sometimes quickly Sometimes are not explicitly discussed but inferred

43 Policy implications Demographic challenges People living longer with more complex needs as they approach the end of life Health service planning Move to community based care

44 Policy implications Place of death Used by policy makers and those planning health services Is this a good outcome measure? Interpretation Difficulties Exercising choice - practical and emotional difficulties Changing needs and preferences Preferences of people without caregivers less clear

45 Summary Skills and training Symptom control Communication Information needs 24 hour care? Cultural factors

46 Research questions? QUESTIONS?

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