Patient, carer and health service outcomes of nurse-led early discharge after breast cancer surgery: a randomised controlled trial. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. Sooner and healthier: a randomised controlled trial and interview study of an early discharge rehabilitation service for older people. Evaluating hospital discharge planning: a randomized clinical trial. Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial. Early and late discharge after hospital birth. A comparative study of parental background characteristics. Early supported hospital discharge following acute stroke: pilot study results. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. The feasibility and efficacy of early discharge planning initiated by the admitting department in two acute care hospitals. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. A trial of early discharge with homecare compared to conventional hospital care for patients undergoing coronary artery bypass grafting. Perinatal care of low-risk mothers and infants. Early discharge with home care. Specialist nurse supported discharge in gynaecology: a randomised comparison and economic evaluation. Home or hospital for stroke Rehabilitation? Results of a randomized controlled trial : II: cost minimization analysis at 6 months. The effectiveness, acceptability and costs of a hospital-at-home service compared with acute hospital care: a randomized controlled trial. Randomised controlled trial to evaluate early discharge scheme for patients with stroke. Early supported discharge of patients with acute stroke: a randomized controlled trial. Cost comparison of domiciliary and hospital-based stroke rehabilitation. DOMINO Study Group. Medical and psychosocial effects of early discharge after surgery for breast cancer: randomised trial. Gloucester hospital-at-home: a randomized controlled trial. Early discharge from obstetrics-pediatrics at the Hospital de Valme, with domiciliary follow-up. Randomized controlled trial of an early discharge rehabilitation service: the Belfast Community Stroke Trial. Cost comparison of hospital- and home-based treatment models for acute chronic obstructive pulmonary disease. A randomized trial of the cost effectiveness of VA hospital-based home care for the terminally ill.
Patients with breast cancer who require axillary clearance traditionally remain in hospital until their wound drains are removed. Early discharge has been shown to improve clinical outcomes, but there has been little assessment of the psychosocial and financial impact of early discharge on patients, carers and the health service. This study aimed to evaluate the effectiveness of a nurse-led model of early discharge from hospital. Main outcome measures were quality of life and carer burden. Secondary outcomes included patient satisfaction, arm morbidity, impact on community nurses, health service costs, surgical cancellations and in-patient nursing dependency. A total of 108 patients undergoing axillary clearance with mastectomy or wide local excision for breast cancer were randomised to nurse-led early discharge or conventional stay. Nurse-led early discharge had no adverse effects on quality of life or patient satisfaction, had little effect on carer burden, improved communication between primary and secondary care, reduced cancellations and was safely implemented in a mixed rural/urban setting. In total, 40% of eligible patients agreed to take part. Nonparticipants were significantly older, more likely to live alone and had lower emotional well being before surgery. This study provides further evidence of the benefits of early discharge from hospital following axillary clearance for breast cancer. However, if given the choice, most patients prefer to stay in hospital until their wound drains are removed. Patients are routinely ill-prepared for the transition from hospital to home. Inadequate communication between Hospitalists and primary care providers can further compromise post-discharge care. Redesigning the discharge process may improve the continuity and the quality of patient care.
                To evaluate a low-cost intervention designed to promptly reconnect patients to their "medical home" after hospital discharge.
                Randomized controlled study. Intervention patients received a "user-friendly" Patient Discharge Form, and upon arrival at home, a telephone outreach from a nurse at their primary care site.
                A culturally and linguistically diverse group of patients admitted to a small community teaching hospital.
                Four undesirable outcomes were measured after hospital discharge: (1) no outpatient follow-up within 21 days; (2) readmission within 31 days; (3) emergency department visit within 31 days; and (4) failure by the primary care provider to complete an outpatient workup recommended by the hospital doctors. Outcomes of the intervention group were compared to concurrent and historical controls.
                Only 25.5% of intervention patients had 1 or more undesirable outcomes compared to 55.1% of the concurrent and 55.0% of the historical controls. Notably, only 14.9% of the intervention patients failed to follow-up within 21 days compared to 40.8% of the concurrent and 35.0% of the historical controls. Only 11.5% of recommended outpatient workups in the intervention group were incomplete versus 31.3% in the concurrent and 31.0% in the historical controls.
                A low-cost discharge-transfer intervention may improve the rates of outpatient follow-up and of completed workups after hospital discharge. Hospitals are under pressure from admissions of increasing numbers of older people. Older people may suffer unnecessary activity limitation after acute illnesses through lack of appropriate rehabilitation.
                To evaluate an early discharge and rehabilitation service for older people.
                A randomised controlled trial comparing an early discharge and rehabilitation with standard hospital aftercare. Outcome measures assessed at 3 and 12 months were the Barthel Index, Nottingham Extended Activities of Daily Living and EuroQol (for patients) the General Health Questionnaire (for patients and carers). Use of services over 12 months was recorded. An interview study of patients and staff was conducted.
                The early discharge and rehabilitation service offered a home-based rehabilitation and care programme for up to 4 weeks.
                370 hospitalised older medical and surgical patients were included in the randomised controlled trial. Twenty patients and 11 staff were interviewed.
                Subjects in the early discharge rehabilitation service group used fewer days in hospital at 3 months (mean difference 9, median difference 4 days, 95% CI of median difference 2-8). At 3 months the early discharge and rehabilitation service patients had better Barthel scores (mean difference 1.2, 95% CI 0.4-1.9), Nottingham Extended Activities of Daily Living kitchen scores (mean difference 1.2, 95% CI 0.2-2.3), Nottingham Extended Activities of Daily Living domestic scores (mean difference 1.1, 95% CI 0.2-2.0) and General Health Questionnaire scores (mean difference 2.4, 95% CI 0.7-4.1). Significant Nottingham Extended Activities of Daily Living domestic and General Health Questionnaire benefits remained at 12 months. The early discharge and rehabilitation service carers had better General Health Questionnaire scores at 3 months (mean difference 2.0, 95% CI 0.1-3.8). The interviews suggested that the early discharge and rehabilitation service was patient-centred, set clear goals, worked as a team, and considered physical, psychological, social and environmental issues. It was found to be highly satisfactory.
                Some older people can be discharged from hospital sooner, with better health outcomes using a well-staffed and organised patient-centred early discharge service providing rehabilitation. To select patients for early discharge planning, a randomized clinical trial evaluated a protocol that used risk factors identified upon hospital admission. The goal of the study was to determine if intervention with high-risk patients could reduce the need for hospital admission or skilled care. Of 13,255 patients screened, 835 study participants were identified as "at risk" for frequent health care resource use. Half of the high-risk patients were randomly assigned to the experimental group (n = 417) and received discharge planning from day 3 of their hospital stay, while the control group (n = 418) received discharge planning only if there was a written physician request. Those patients receiving early, systematic discharge planning experienced an increased likelihood of successful return to home after hospital admission and a decreased chance of unscheduled readmission for the 9-month study period. Length of the index hospital stay was not affected by early planning, however. The major clinical implication is the potential for discharge planners to decrease the need for, and use of, health care resources after hospital admission. To determine the impact of a hospital-coordinated discharge care plan, involving a multidisciplinary team of primary health care providers, on hospital length of stay, quality of life, and both patient and general practitioner inclusion in, and satisfaction with, discharge procedures.
                This investigation comprised a prospective, randomized, controlled, clinical trial.
                This multicentre and cross-jurisdictional study focused on areas of tertiary and primary health care as well as community allied health in Western Australia.
                Patients (n = 189) with chronic cardiorespiratory diagnoses were recruited from respiratory, cardiovascular, and general medical wards at two tertiary hospitals.
                Subjects were randomly assigned to one of two groups. Intervention group patients received a discharge care plan in accordance with that outlined in the Australian Enhanced Primary Care Package, completed before discharge and sent to the patient's general practitioner and other community service providers for review. Control patients were discharged under existing hospital processes. Outcome measures. Patients and general practitioners were surveyed pre-discharge and 7 days post-discharge for quality of life and opinion of discharge procedures. Hospital length of stay was also determined.
                Significant improvements in discharge planning involvement, health service access, confidence with discharge procedures, and opinion of discharge based on previous experience were seen for patients who received the discharge care plan. Further, improved perceptions of mental quality of life were observed within the first week post-discharge for intervention patients. Length of stay showed no difference between groups. Extent and speed of hospital-general practitioner communication were significantly improved via the intervention.
                Our results indicate that a multidisciplinary discharge care plan, initiated before separation, improves quality of life, involvement, and satisfaction with discharge care, and hospital-general practitioner integration. As such, it possesses benefits over current Western Australian hospital discharge procedures for the care of chronically ill populations. When an early postnatal discharge program was introduced in Falun, Sweden in 1984, with early discharge defined as discharge 24-48 hours after birth combined with home visits on the following days, an investigation into background characteristics of parents choosing to participate and not to participate in the evaluative study of the program was initiated. 164 participants were compared with 354 non-participants. Data were collected mainly from questionnaires, 8 weeks before term. The participants were a more heterogeneous group than was expected when starting the program. Compared with the non-participants, they were characterized by: a less positive attitude to post-partum care in hospital and greater self-confidence in terms of confidence when thinking of birth and parenthood. They were more often multipara and had experienced rather less complicated pregnancies. They were a little younger and somewhat less well educated as a group, but the proportion of well educated women was the same as among non-participants. They had attended antenatal classes this pregnancy to a lesser extent, but felt better prepared for the delivery. They had a greater number of supportive persons available in case of early discharge. There was no difference between participants and non-participants as regards economy, housing conditions, distance to hospital, proportion of immigrants, paternal interest in childbirth and parenthood, equality in parental relations, social contacts, and leisure activities. To establish the feasibility and method of evaluation of an early supported hospital discharge policy for patients with acute stroke.
                A randomized controlled trial comparing an early supported discharge service to conventional care.
                Three acute hospitals in Newcastle upon Tyne.
                Ninety-two eligible patients with acute stroke admitted between 1 February 1995 and 31 January 1996.
                Placement, length of stay, readmission rates, mortality, functional ability (Nottingham Extended Activities of Daily Living (ADL) Scale), handicap (Oxford Handicap Scale), global health status (Dartmouth Coop Function Charts) and carer stress (General Health Questionnaire 30 item).
                The median length of stay for patients randomized to early supported discharge was 13 days compared to 22 days in the conventional care group (p = 0.02). The median Barthel ADL index at seven days post stroke of patients randomized to early supported discharge was 15, and 13 for those randomized to conventional care (NS). At three months post stroke the median Nottingham EADL score of patients randomized to early supported discharge was 10 compared to 7 for those who received conventional care (NS). There were no statistically significant differences in the global health status of patients or carer stress.
                An early supported discharge service following acute stroke with individualized rehabilitation in the community is feasible and can be evaluated by a randomized controlled trial but a larger multicentre trial is needed before such a service is widely adopted. To study the effects of a comprehensive discharge planning protocol, designed specifically for the elderly and implemented by nurse specialists, on patient and caregiver outcomes and cost of care.
                Randomized clinical trial.
                Hospital of the University of Pennsylvania.
                276 patients and 125 caregivers. Patients were 70 years and older and were placed in selected medical and surgical cardiac diagnostic-related groups.
                Group differences in patient outcomes (length of initial hospital stay, length of time between initial hospital discharge and readmission, and rehospitalization rates) and charges for care (charges for initial hospitalization, rehospitalizations, health services after discharge, and nurse specialist services) were measured 2, 6, and 12 weeks after discharge.
                From the initial hospital discharge to 6 weeks after discharge, patients in the medical intervention group had fewer readmissions, fewer total days rehospitalized, lower readmission charges, and lower charges for health care services after discharge. No differences in these outcomes were found between the surgical intervention and control groups during this period.
                Study findings support the need for comprehensive discharge planning designed for the elderly and implemented by nurse specialists to improve their outcomes after hospital discharge and to achieve cost savings. The findings also suggest that this intervention had its greatest effect in delaying or preventing rehospitalization of patients in the medical intervention group during the first 6 weeks after discharge. To determine the feasibility and efficacy of early discharge planning, initiated by admitting department personnel, a randomized, controlled trial was undertaken in 2 acute care, university-affiliated hospitals. The intervention tested was referral of patients by admitting personnel to nursing, social work, physiotherapy, occupational therapy, or dietary services for potential discharge planning. A 1-page, 65-item questionnaire was designed to identify patients for referral to the various allied health services. A copy of this was sent to the appropriate service, according to predefined criteria. The questionnaire took an average of 4 min to complete. The criteria used were highly predictive of length of stay, the most important being age, followed by living outside St. John's, admission within the previous 3 months, emergency admission, and being in need of community services. In Hospital A, the cases (n = 421) referred for early discharge planning had significantly shorter length of stay (Mantel-Cox, p = 0.03) than controls (n = 420), who were identical for all factors predictive of prolonged length of stay. The reduction in length of stay amounted to a mean of 0.8 d. In Hospital B (n = 758), the intervention was less effective because of a lower proportion of patients with factors associated with prolonged hospital stay and, perhaps, because of inadequate implementation of the program. We conclude that identification, by admitting department personnel, of patients who may benefit from early discharge planning is feasible. This process will reduce length of hospital stay, but its effectiveness is dependent on case mix variables and enthusiastic implementation of the program. Emergency department visits and rehospitalization are common after hospital discharge.
                To test the effects of an intervention designed to minimize hospital utilization after discharge.
                Randomized trial using block randomization of 6 and 8. Randomly arranged index cards were placed in opaque envelopes labeled consecutively with study numbers, and participants were assigned a study group by revealing the index card.
                General medical service at an urban, academic, safety-net hospital.
                749 English-speaking hospitalized adults (mean age, 49.9 years).
                A nurse discharge advocate worked with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education with an individualized instruction booklet that was sent to their primary care provider. A clinical pharmacist called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications. Participants and providers were not blinded to treatment assignment.
                Primary outcomes were emergency department visits and hospitalizations within 30 days of discharge. Secondary outcomes were self-reported preparedness for discharge and frequency of primary care providers' follow-up within 30 days of discharge. Research staff doing follow-up were blinded to study group assignment.
                Participants in the intervention group (n = 370) had a lower rate of hospital utilization than those receiving usual care (n = 368) (0.314 vs. 0.451 visit per person per month; incidence rate ratio, 0.695 [95% CI, 0.515 to 0.937]; P = 0.009). The intervention was most effective among participants with hospital utilization in the 6 months before index admission (P = 0.014). Adverse events were not assessed; these data were collected but are still being analyzed.
                This was a single-center study in which not all potentially eligible patients could be enrolled, and outcome assessment sometimes relied on participant report.
                A package of discharge services reduced hospital utilization within 30 days of discharge.
                Agency for Healthcare Research and Quality and National Heart, Lung, and Blood Institute, National Institutes of Health. nan A family-centered perinatal-care program featuring collaboration by nurse practitioners, obstetricians, pediatricians, and paramedical personnel was developed to enhance family participation and achieve a shorter but safe hospital stay. Discharge from the hospital was permitted as early as 12 hours after delivery. A perinatal nurse practitioner made daily home visits. The program's safety, feasibility, and acceptability to patients was studied by comparison of 44 patients so treated (study group) with 44 receiving traditional care (controls). Twenty-one study families, but no controls, went home within 24 hours. The study and control groups had no significant differences or trends in numbers of types of morbidity during hospitalization or the six-week post-partum period. The expense of the program is approximately equaled by hospital costs saved through early discharge. The results indicate that early discharge with home-care follow-up observation as described is safe, economically feasible, and well accepted by patients. To determine the effect on quality of life and cost effectiveness of specialist nurse early supported discharge for women undergoing major abdominal and/or pelvic surgery for benign gynaecological disease compared with routine care.
                Randomised controlled trial comparing specialist nurse supported discharge with routine hospital care in gynaecology. The SF-36, a generic health status questionnaire, was used to measure women's evaluation of their health state before surgery and at 6 weeks after surgery. A further questionnaire scoring patient symptoms, milestones of recovery, information given and satisfaction, was administered prior to discharge from hospital and at 6 weeks thereafter.
                Gynaecology service at the Western Infirmary Glasgow, part of North Glasgow University, NHS Trust.
                One hundred and eleven women scheduled for major abdominal or pelvic surgery for benign gynaecological disease.
                SF-36 health survey questionnaire baseline scores were reported before surgery and at 6 weeks follow-up. Complications, length of hospital stay, readmission, information on discharge support and satisfaction of women were recorded at discharge from hospital and at 6 weeks follow-up. A cost consequence analysis was conducted based on the perspective of the NHS.
                The addition of a specialist nurse to routine hospital care in gynaecology significantly reduced the post-operative length of hospital stay p = 0.001, improved information delivery and satisfaction of women. The specialist nurse supported discharge group was associated with significantly lower total costs to the NHS than routine care resulting principally from the difference in the cost of the post-operative length of stay.
                Women undergoing major abdominal and pelvic surgery were discharged home earlier with provision of support from a specialist gynaecology nurse. The results of this study suggest that duration of hospital stay can be shortened by the introduction of a specialist nurse without introducing any adverse physical and psychological effects. This process of care is associated with receipt of information on health and lifestyle issues and maintenance of high levels of patient satisfaction and demonstrates the effectiveness of the specialist nurse role in the provision of health information for women. Earlier hospital discharge at 48 h after major abdominal and pelvic surgery is an acceptable, cost effective alternative to current routine practice in the absence of further randomised evidence. The goal of the present study was to examine the resource and economic implications of an early hospital discharge and home-based rehabilitation scheme for patients with acute stroke.
                A cost minimization analysis in conjunction with a randomized controlled trial was carried out at 2 affiliated teaching hospitals in the southern metropolitan region of Adelaide, South Australia, between 1997 and 1998. Eighty-six hospitalized patients with acute stroke who required rehabilitation were randomized to receive both early hospital discharge and home-based rehabilitation, or conventional in-hospital rehabilitation and community care. Direct and indirect costs related to stroke rehabilitation were calculated, including hospital bed days, home-based intervention program, community services, and personal expenses during the 6 months after randomization.
                The mean cost per patient was lower for patients randomized to the early hospital discharge and home-based rehabilitation ($8040) compared with those who received conventional care ($10 054). This cost saving was not statistically significant (P=0.14). However, sensitivity analyses indicated that the cost of home-based rehabilitation was consistently lower than that of conventional care except when hospital costs were assumed to be 50% less than those used in the main analysis. Multiple regression analysis demonstrated that the cost of the home-based program was significantly related to a patient's level of disability after adjustment for age, comorbidity, and the presence or absence of a caregiver.
                The early hospital discharge and home-based rehabilitation scheme was less costly than conventional hospital care for patients with stroke. Limitation of the provision of such services to patients with mild disability is likely to be most cost effective. 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. To assess the clinical effectiveness of an early discharge policy for patients with stroke by using a community based rehabilitation team.
                Randomised controlled trial to compare conventional care with an early discharge policy.
                Two teaching hospitals in inner London.
                331 medically stable patients with stroke (mean age 71) who lived alone and were able to transfer independently or who lived with a resident carer and were able to transfer with help.
                167 patients received specialist community rehabilitation for up to 3 months after randomisation. 164 patients continued with conventional hospital and community care.
                Barthel score at 12 months. Secondary outcomes measured impairment with motoricity index, minimental state examination, and Frenchay aphasia screening test; disability with the Rivermead activity of daily living scales, hospital anxiety and depression scale, and 5 m walk; handicap with the Nottingham health profile; carer stress with caregiver strain index and patient and carer satisfaction. The main process measure was length of stay after randomisation.
                One year after randomisation no significant differences in clinical outcomes were found apart from increased satisfaction with hospital care in the community therapy group. Length of stay after randomisation in the community therapy group was significantly reduced (12 v 18 days; P < 0.0001). Patients with impairments were more likely to receive treatment in the community therapy group.
                Early discharge with specialist community rehabilitation after stroke is feasible, as clinically effective as conventional care, and acceptable to patients. Considerable reductions in use of hospital beds are achievable. To evaluate the feasibility and effectiveness of early supported discharge (ESD) following acute stroke.
                An ESD scheme was compared to conventional rehabilitation in a randomized controlled trial. All patients admitted with acute stroke were considered for inclusion. Eighty-eight (20.2%) were found to be eligible and 82 were randomized either to early supported discharge (n = 42) or conventional rehabilitation (n = 40). The primary outcome measure was the Nottingham Extended Activities of Daily Living Scale. The General Health Questionnaire, the Montgomery Aasberg Depression Rating Scale, mortality, placement and patient and career satisfaction served as secondary outcome measures.
                Median length of stay was reduced from 31 days in the conventional hospital rehabilitation group to 22 days in the early supported discharge group (p = 0.09). No differences were found regarding primary outcome. The General Health Questionnaire score showed a significant difference in favour of the early supported discharge group at three months (19.5/24, p = 0.02), but not at six. At six months, the proportion of patients being dead or in institution showed a trend of being higher in the conventional rehabilitation group (OR 3.8, 95% CI 0.8-23).
                Early supported discharge after stroke is feasible and it is possible that it has benefits compared with conventional rehabilitation. The DOMINO study (DOMiciliary rehabilitation In NOttingham) was a randomized controlled trial comparing domiciliary and hospital-based rehabilitation for stroke patients after discharge from hospital, stratified according to the ward at hospital discharge. The outcomes of these patients have been reported previously. In this paper, we present estimates of health service costs of care. No difference in outcome had been found between the overall services, but we have found the hospital-based costs to be 27% cheaper. However, different cost-effectiveness patterns are observable when the strata are analysed. Patients from geriatric wards had been shown to be 2.4 times less likely to die or become institutionalized by 6 months if allocated to a day hospital service, although the cost of this service was 25% more than that of the domiciliary service. Patients from the Stroke Unit who had received domiciliary rehabilitation had been shown to have greater household and leisure abilities at 6 months than those treated in outpatient departments, but the domiciliary service was found to cost 2.6 times more. Patients from general medical wards had similar outcomes whether treated at home or in outpatient departments, but the cost of the latter service was 56% of the former. Some patients may be best cared for in day hospitals and others may do better if treated at home, but for these groups the clinical advantages are achieved at an expense greater than that incurred by the alternative services. Other patients may do as well if treated in outpatient departments as at home, but the former approach is cheaper. A range of services is required for stroke patients leaving hospital. To assess the medical and psychosocial effects of early hospital discharge after surgery for breast cancer on complication rate, patient satisfaction, and psychosocial outcomes.
                Randomised trial comparing discharge from hospital 4 days after surgery (with drain in situ) with discharge after drain removal (mean 9 days in hospital). Psychosocial measurements performed before surgery and 1 and 4 months after.
                General hospital and cancer clinic in Rotterdam with a socioeconomically diverse population.
                125 women with operable breast cancer.
                Incidence of complications after surgery for breast cancer, patient satisfaction with treatment, and psychosocial effects of short stay or long stay in hospital.
                Patient satisfaction with the short stay in hospital was high; only 4% (2/56 at 1 month after surgery and 2/52 at 4 months after surgery) of patients indicated that they would have preferred a longer stay. There were no significant differences in duration of drainage from the axilla between the short stay and long stay groups (median 8 v 9 days respectively, P=0.45) or the incidence of wound complications (10 patients v 9 patients). The median number of seroma aspirations per patient was higher for the long stay group (1 v 3.5, P=0.04). Leakage along the drain occurred more frequently in short stay patients (21 v 10 patients, P=0.04). The two groups did not differ in scores for psychosocial problems (uncertainty, anxiety, loneliness, disturbed sleep, loss of control, threat to self esteem), physical or psychological complaints, or in the coping strategies used. Before surgery, short stay patients scored higher on scales of depression (P=0.03) and after surgery they were more likely to discuss their disease with their families (at 1 month P=0.004, at 4 months P=0.04).
                Early discharge from hospital after surgery for breast cancer is safe and is well received by patients. Early discharge seems to enhance the opportunity for social support within the family. Hospital-at-Home schemes have been claimed to hasten the discharge of elderly orthopaedic patients, and are becoming increasingly popular with health service managers. In an attempt to measure the benefits of such a scheme when applied to elderly medical patients, we prospectively randomized 60 consecutive referrals of patients approaching discharge either to the Hospital-at-Home (HAH) rehabilitation team, or to conventional discharge (CD) preparation and domiciliary support. Patients allocated to HAH were discharged on average 5 days earlier than CD, while 64% of each group remained at home during 6 months follow-up. Improvements in independence were modest, and similar in the two groups, though a trend favoured HAH. This study was undertaken to evaluate the advantages and disadvantages of a program of early obstetric-pediatric discharge (24 hours postpartum) with domiciliary follow-up, compared with the traditional postpartum hospital stay (more than 48 hours), according to the criteria described by reviewers of the subject.
                A randomized controlled trial of early obstetric discharge for healthy mothers and term infants, with postpartum randomization, with no prenatal preparation and with observational and clinical follow-up was performed. The participants were mothers with healthy, term neonates (37-42 weeks) weighing more than 2500 g and produced via vaginal delivery and with a verified normal evolution before discharge. The sample consisted of 430 cases (213 cases with early discharge, and 217 control cases) in which the following variables were evaluated: existence of complications in the mother and/or child that required rehospitalization or a medical consultation, existence of maternal problems of fatigue or anxiety/depression after the birth, continuity of lactation and its problems, satisfaction of the mother and family, and relative costs.
                After demonstrating the homogeneity of the groups, no significant differences were found in the rates of maternal rehospitalization (1.9% in the early discharge group vs 2.3% in the control group, relative risk 0.81, 95% CI 0.21-3.03) or in the rates of rehospitalization of the neonates (1.4% in the early discharge group vs 2.3% in the control group, relative risk 0.16, 95% CI 0.15-2.56). No increases were observed in maternal or neonatal disease, puerperal fatigue, or maternal anxiety/depression. A prolongation of maternal lactation to 3 months was observed in the early discharge group (P=.016 <.05 Fisher exact test). When the cost of early discharge is compared with that of traditional discharge with a minimum of 48 hours hospital stay, we find a saving of 18% to 20%. The level of maternal satisfaction with early discharge is better than 90%. To compare a community-based multidisciplinary stroke team (CST) approach with hospital-based rehabilitation in terms of hospital stay, functioning, quality of life, and service use and costs.
                Stroke patients who met pre-agreed criteria were allocated randomly to the CST service (n=59) or to usual inpatient rehabilitation and follow-up care (n=54). Assessments were completed at randomization and 12 months later. Caregiver strain and satisfaction (n=55) were also assessed. Cost data were collected for a subsample of 38 patients.
                Almost 80% of surviving patients (n=691) were discharged home and a small number (n=55) were readmitted. Approximately 17% (113/649) were randomized. There were no statistically significant differences in hospital duration, costs, or outcome measures at baseline and 12 months except for higher satisfaction reported by CST patients. Overall, both groups recorded improvement in most domains over time. Carers reported a high level of satisfaction although the level of strain among carers is cause for concern. The community group (n=18) cost less than the hospital group (n=20).
                A mixed model of hospital-based and community-based rehabilitation services is likely to lead to increased patient choice and satisfaction and a potential reduction in bed pressures for less severe stroke patients. This trial compared the cost of an integrated home-based care model with traditional inpatient care for acute chronic obstructive pulmonary disease (COPD). 25 patients with acute COPD were randomised to either home or hospital management following request for hospital admission. The acute care at home group costs per separation ($745, CI95% $595-$895, n = 13) were significantly lower (p < 0.01) than the hospital group ($2543, CI95% $1766-$3321, n = 12). There was an improvement in lung function in the hospital-managed group at the Outpatient Department review, decreased anxiety in the Emergency Department in the home-managed group and equal patient satisfaction with care delivery. Acute care at home schemes can substitute for usual hospital care for some patients without adverse effects, and potentially release resources. A funding model that allows adequate resource delivery to the community will be needed if there is a move to devolve acute care to community providers. All admissions to a 1,100-bed Department of Veterans Affairs (VA) hospital were screened to identify 171 terminally ill patients with informal caregivers who were then randomly assigned to VA hospital-based team home care (HBHC, N = 85) or customary care (N = 86). Patient functioning, and patient and caregiver morale and satisfaction with care were measured at baseline, one month, and six months. Health services utilization was monitored over the six-month study period and converted to cost. Findings included no differences in patient survival, activities of daily living (ADL), cognitive functioning, or morale, but a significant increase in patient (p = .02) and caregiver (p = .005) satisfaction with care at one month. A substitution effect of HBHC was seen. Those in the experimental group used 5.9 fewer VA hospital days (p = .03), resulting in a $1,639 or 47 percent per capita saving in VA hospital costs (p = .02). As a result, total per capita health care costs, including HBHC, were $769 or 18 percent (n.s.) lower in the HBHC sample, indicating that expansion of VA HBHC to serve terminally ill veterans would increase satisfaction with care at no additional cost.
Despite increasing interest in the potential of early discharge hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit or improved health outcomes.