Randomised controlled trial comparing hospital at home care with inpatient hospital care. I: three month follow up of health outcomes. The effectiveness, acceptability and costs of a hospital-at-home service compared with acute hospital care: a randomized controlled trial. Multicenter randomized controlled trial of an outreach nursing support program for recently discharged stroke patients. Randomised controlled trial comparing an acute paediatric hospital at home scheme with conventional hospital care. [Cooperation concerning admission to and discharge of elderly people from the hospital. 1. The coordinated contributions of home care personnel]. Randomised controlled trial of home based care of patients with chronic obstructive pulmonary disease. Meta-analysis of home-care effects on mortality and nursing-home placement. An outreach intervention to implement evidence based practice in residential care: a randomized controlled trial [ISRCTN67855475]. A cluster-randomized trial to improve stroke care in hospitals.
To compare hospital at home care with inpatient hospital care in terms of patient outcomes.
                Randomised controlled trial with three month follow up.
                District general hospital and catchment area of neighbouring community trust.
                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).
                Hospital at home care or inpatient hospital care.
                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.
                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.
                Few differences in outcome were detected. Thus, the cost of hospital at home compared with hospital care becomes a primary concern. To compare the safety, effectiveness, acceptability and costs of a hospital-at-home programme with usual acute hospital inpatient care.
                Patients aged 55 years or over being treated for an acute medical problem were randomized to receive either standard inpatient hospital care or hospital-at-home care. Follow-up was for 90 days after randomization. Health outcome measures included physical and mental function, self-rated recovery, health status as assessed by the SF-36, adverse events and readmissions to hospital. Acceptability was assessed using satisfaction surveys and the Carer Strain Index. Costs comprised hospital care, care in the home, community services, general practitioner services and personal health care expenses.
                In all, 285 people were randomized with a mean age of 80 years. There were no significant differences in health outcome measures between the two randomized groups. Significantly more patients receiving care at home reported high levels of satisfaction, as did more of their relatives. Relatives of the care-at-home group also reported significantly lower scores on the Carer Strain Index. However, the mean cost per patient was almost twice for patients treated at home (NZ 6524 dollars) as for standard hospital care (NZ 3525 dollars). A sensitivity analysis indicated that, if the service providing care in the home had been operating at full capacity, the mean cost per patient episode would have been similar for both modes of care.
                This hospital-at-home programme was found to be more acceptable and as effective and safe as inpatient care. While caring for patients at home was significantly more costly than standard inpatient care, this was largely due to the hospital-at-home programme not operating at full capacity. Many stroke patients and informal carers experience a decreased quality of life after discharge home and are dissatisfied with the care received. We assessed the effectiveness of an outreach nursing care program.
                In a multicenter trial, 536 stroke patients were randomized at discharge to standard care (n=273) or standard care plus outreach care (n=263). The outreach care consisted of 3 telephone calls and 1 home visit within 5 months after discharge by 1 of 13 stroke nurses. Patients were masked for the trial objectives. Six months after discharge, they assessed the 2 primary outcomes: quality of life (Short Form 36 [SF-36]) and dissatisfaction with care. Secondary measures of outcome were disability, handicap, depression, anxiety, and use of health care services and secondary prevention drugs. Informal carers assessed strain, and social support. Analysis was by intention to treat.
                Twelve patients died before follow-up, 38 declined outcome assessment, and 486 completed the primary outcome assessments. Outreach care patients had better scores on the SF-36 domain "Role Emotional" than controls (mean difference 7.9 [95% confidence limit, 0.1 to 15.7]). No statistically significant differences were found on the other primary outcome measures. For secondary outcomes, no statistically significant differences were found, except that intervention patients used fewer rehabilitation services (relative risk, 0.66 [0.44 to 1.00]) and had lower anxiety scores (median difference 1 [0.19 to 2.79]).
                This outreach nursing stroke care was not effective in improving quality of life and dissatisfaction with care of recently discharged patients. To assess the clinical effectiveness of a paediatric hospital at home service compared to conventional hospital care.
                A total of 399 children suffering from breathing difficulty (n = 202), diarrhoea and vomiting (n = 125), or fever (n = 72) were randomised to Hospital at Home or in-patient paediatric care. Main outcome measures were: comparative clinical effectiveness as measured by readmission rate within three months (used as a proxy for parental coping with illness); and length of stay/care and comparative satisfaction of both patients and carers.
                Clinical effectiveness of both services was not significantly different. Length of care was one day longer in the Hospital at Home group; however, most parents and children preferred home care.
                Hospital at Home is a clinically acceptable form of care for these groups of acute paediatric illness. Readmission rates within three months failed to show any advantage in terms of parental coping. Parents and patients expressed a strong preference for hospital at home. In cooperation between the home care system in the Municipality of Rødovre and four hospital departments in the County of Copenhagen, a controlled and randomized investigation was undertaken among the hospitalized patients of 65 years and over from the Municipality of Rødovre. A nurse employed by the Municipality particularly for this project visited the hospital daily and followed the 135 participants in the intervention group with the objects of obtaining information from the primary sector if necessary, discussing discharge with the patient and the hospital staff, coordinating possible supportive measures in the patient's home and visiting the patient in his home immediately after discharge from hospital in order to ensure continuity in care and treatment. The 138 participants in the control group underwent the usual procedures in connection with admission to hospital. In this article, the consequences of the contributions by the health visitor in the hospital are described in relation to the course of hospitalization. The intervention group had an average stay in hospital of 11.0 days as compared with 14.3 days in the control group (p greater than 0.05), and the total number of bed-days were 1,490 and 1,970, respectively. In addition, the two groups were compared as regards the number of diagnostic procedures during hospitalization, the number of deaths, the diagnoses on discharge and the functional capacity. No differences were observed in these respects between the two groups. Three patients from the control group were discharged to residential institutions as compared with none in the intervention group.(ABSTRACT TRUNCATED AT 250 WORDS) To evaluate usefulness of limited community based care for patients with chronic obstructive pulmonary disease after discharge from hospital. Design: Randomised controlled trial.
                Liverpool Health Service and Macarthur Health Service in outer metropolitan Sydney between September 1999 and July 2000.
                177 patients randomised into an intervention group (84 patients) and a control group (93 patients) which received current usual care.
                Home visits by community nurse at one and four weeks after discharge and preventive general practitioner care.
                Frequency of patients' presentation and admission to hospital; changes in patients' disease-specific quality of life, measured with St George's respiratory questionnaire, over three months after discharge; patients' knowledge of illness, self management, and satisfaction with care at discharge and three months later; frequency of general practitioner and nurse visits and their satisfaction with care.
                Intervention and control groups showed no differences in presentation or admission to hospital or in overall functional status. However, the intervention group improved their activity scores and the control group worsened their symptom scores. While intervention group patients received more visits from community nurses and were more satisfied with their care, involvement of general practitioners was much less (with only 31% (22) remembering receiving a care plan). Patients in the intervention group had higher knowledge scores and were more satisfied. There were no differences in general practitioner visits or management.
                This brief intervention after acute care improved patients' knowledge and some aspects of quality of life. However, it failed to prevent presentation and readmission to hospital. This meta-analysis was designed to illustrate how the relatively new discipline of meta-analysis could be employed in health-services research. In pursuit of this goal, the results of 13 studies on the effect of home care on mortality and nursing-home placements were examined. The analysis demonstrated a small, beneficial effect of home care on mortality, which fell short of statistical significance. Study-to-study variation in the odds ratio was found that was not strongly associated with differences in the study samples, designs, or interventions as categorized here. The analysis produced stronger evidence of a reduction in nursing-home placements. In this case, differences in study design explained much of the heterogeneity in results, with the randomized controlled trials showing considerably weaker effects. The analysis also provides insight into the benefits and limitations of alternative meta-analytic methods. The "odd man out" method recently described by Walker et al. detected statistically significant heterogeneity of effects across studies for nursing-home placement, but not for mortality. Loglinear modeling made it easier to detect and explore study-to-study variation in home-care effects. The aim of this project was to assess whether outreach visits would improve the implementation of evidence based clinical practice in the area of falls reduction and stroke prevention in a residential care setting.
                Twenty facilities took part in a randomized controlled trial with a seven month follow-up period. Two outreach visits were delivered by a pharmacist. At the first a summary of the relevant evidence was provided and at the second detailed audit information was provided about fall rates, psychotropic drug prescribing and stroke risk reduction practices (BP monitoring, aspirin and warfarin use) for the facility relevant to the physician. The effect of the interventions was determined via pre- and post-intervention case note audit. Outcomes included change in percentage patients at risk of falling who fell in a three month period prior to follow-up and changes in use of psychotropic medications. Chi-square tests, independent samples t-test, and logistic regression were used in the analysis.
                Data were available from case notes at baseline (n = 897) and seven months follow-up (n = 902), 452 residential care staff were surveyed and 121 physicians were involved with 61 receiving outreach visits. Pre-and post-intervention data were available for 715 participants. There were no differences between the intervention and control groups for the three month fall rate. We were unable to detect statistically significant differences between groups for the psychotropic drug use of the patients before or after the intervention. The exception was significantly greater use of "as required" antipsychotics in the intervention group compared with the control group after the pharmacy intervention (RR = 4.95; 95%CI 1.69-14.50). There was no statistically significant difference between groups for the numbers of patients "at risk of stroke" on aspirin at follow-up.
                While the strategy was well received by the physicians involved, there was no change in prescribing patterns. Patient care in residential settings is complex and involves contributions from the patient's physician, family and residential care staff. The project highlights challenges of delivering evidence based care in a setting in which there is a paucity of well controlled trial evidence but where significant health outcomes can be attained. We evaluated the effect of performance feedback on acute ischemic stroke care quality in Minnesota hospitals.
                A cluster-randomized controlled trial design with hospital as the unit of randomization was used. Care quality was defined as adherence to 10 performance measures grouped into acute, in-hospital, and discharge care. Following preintervention data collection, all hospitals received a report on baseline care quality. Additionally, in experimental hospitals, clinical opinion leaders delivered customized feedback to care providers and study personnel worked with hospital administrators to implement changes targeting identified barriers to stroke care. Multilevel models examined experimental vs control, preintervention and postintervention performance changes and secular trends in performance.
                Nineteen hospitals were randomized with a total of 1,211 acute ischemic stroke cases preintervention and 1,094 cases postintervention. Secular trends were significant with improvement in both experimental and control hospitals for acute (odds ratio = 2.7, p = 0.007) and in-hospital (odds ratio = 1.5, p < 0.0001) care but not discharge care. There was no significant intervention effect for acute, in-hospital, or discharge care.
                There was no definite intervention effect: both experimental and control hospitals showed significant secular trends with performance improvement. Our results illustrate the potential fallacy of using historical controls for evaluating quality improvement interventions.
                This study provides Class II evidence that informing hospital leaders of compliance with ischemic stroke quality indicators followed by a structured quality improvement intervention did not significantly improve compliance more than informing hospital leaders of compliance with stroke quality indicators without a quality improvement intervention.
We performed meta-analyses where there was sufficient similarity among the trials and where common outcomes had been measured. There is no evidence from the analysis to suggest that admission avoidance hospital at home leads to outcomes that differ from inpatient hospital care.