Feasibility study for early supported discharge in adults with respiratory infection in the UK
Tóm tắt
Many patients with pneumonia and lower respiratory tract infection that could be treated as outpatients according to their clinical severity score, are in fact admitted to hospital. We investigated whether, with medical and social input, these patients could be discharged early and treated at home.
Objectives: (1) To assess the feasibility of providing an early supported discharge scheme for patients with pneumonia and lower respiratory tract infection (2) To assess the patient acceptability of a study comprising of randomisation to standard hospital care or early supported discharge scheme.
Design: Randomised controlled trial.
Setting: Liverpool, UK. Two University Teaching hospitals; one city-centre, 1 suburban in Liverpool, a city with high deprivation scores and unemployment rates.
Participants: 200 patients screened: 14 community-dwelling patients requiring an acute hospital stay for pneumonia or lower respiratory tract infection were recruited.
Intervention: Early supported discharge scheme to provide specialist respiratory care in a patient’s own home as a substitute to acute hospital care.
Main outcome measures: Primary - patient acceptability. Secondary – safety/mortality, length of hospital stay, readmission, patient/carer (or next of kin) satisfaction, functional status and symptom improvement. 42 of the 200 patients screened were eligible for early supported discharge; 10 were only identified at the point of discharge, 18 declined participation and 14 were randomised to either early supported discharge or standard hospital care. The total hospital length of hospital stay was 8.33 (1–31) days in standard hospital care and 3.4 (1–7) days in the early supported discharge scheme arm. In the early supported discharge scheme arm patient carers reported higher satisfaction with care and there were less readmissions and hospital-acquired infections.
Limitations: A small study in a single city. This was a feasibility study and therefore not intended to compare outcome data. An early supported discharge scheme for patients with pneumonia and lower respiratory tract infection was feasible. Larger numbers of patients would be eligible if future work included patients with dementia and those residing in care homes.
ISRCTN25542492
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Tài liệu tham khảo
Goss CH, Rubenfeld GD, Park DR, Sherbin VL, Goodman MS, Root RK: Cost and incidence of social comorbidities in low-risk patients with community-acquired pneumonia admitted to a public hospital. Chest. 2003, 124 (6): 2148-2155. 10.1378/chest.124.6.2148.
Wennberg JE, Freeman JL, Culp WJ: Are hospital services rationed in New Haven or over-utilised in Boston?. Lancet. 1987, 1 (8543): 1185-1189.
Wennberg JE, McPherson K, Caper P: Will payment based on diagnosis-related groups control hospital costs?. N Engl J Med. 1984, 311 (5): 295-300. 10.1056/NEJM198408023110505.
Lim WS, Woodhead M: British thoracic society adult community acquired pneumonia audit 2009/10. Thorax. 2011, 66 (6): 548-549. 10.1136/thoraxjnl-2011-200081.
Arnold FW, Ramirez JA, McDonald LC, Xia EL: Hospitalization for community-acquired pneumonia: the pneumonia severity index vs clinical judgment. Chest. 2003, 124 (1): 121-124. 10.1378/chest.124.1.121.
Masotti L, Ceccarelli E, Cappelli R, Barabesi L, Guerrini M, Forconi S: Length of hospitalization in elderly patients with community-acquired pneumonia. Aging (Milano). 2000, 12 (1): 35-41.
Choudhury G, Chalmers JD, Mandal P, Akram AR, Murray MP, Short P, Singanayagam A, Hill AT: Physician judgement is a crucial adjunct to pneumonia severity scores in low-risk patients. Eur Respir J. 2011, 38 (3): 643-648. 10.1183/09031936.00172910.
Welte T, Torres A, Nathwani D: Clinical and economic burden of community-acquired pneumonia among adults in Europe. Thorax. 2012, 67 (1): 71-79. 10.1136/thx.2009.129502. doi: 10.1136/thx.2009.129502. Epub 2010 Aug 20
Raut M, Schein J, Mody S, Grant R, Benson C, Olson W: Estimating the economic impact of a half-day reduction in length of hospital stay among patients with community-acquired pneumonia in the US. Curr Med Res Opin. 2009, 25 (9): 2151-2157. 10.1185/03007990903102743.
Torres OH, Munoz J, Ruiz D, Ris J, Gich I, Coma E, Gurgui M, Vazquez G: Outcome predictors of pneumonia in elderly patients: importance of functional assessment. J Am Geriatr Soc. 2004, 52 (10): 1603-1609. 10.1111/j.1532-5415.2004.52492.x.
Shepperd S, Iliffe S: Hospital at home versus in-patient hospital care. Cochrane Database Syst Rev. 2005, 3: CD000356
Goldberg AI, Faure EA: Home care for life-supported persons in England. The responaut program. Chest. 1984, 86 (6): 910-914. 10.1378/chest.86.6.910.
Davies L, Wilkinson M, Bonner S, Calverley PM, Angus RM: “Hospital at home” versus hospital care in patients with exacerbations of chronic obstructive pulmonary disease: prospective randomised controlled trial. BMJ. 2000, 321 (7271): 1265-1268. 10.1136/bmj.321.7271.1265.
Davison AG, Monaghan M, Brown D, Eraut CD, O'Brien A, Paul K, Townsend J, Elston C, Ward L, Steeples S, Cubitt L: Hospital at home for chronic obstructive pulmonary disease: an integrated hospital and community based generic intermediate care service for prevention and early discharge. Chron Respir Dis. 2006, 3 (4): 181-185. 10.1177/1479972306070074.
Ojoo JC, Moon T, McGlone S, Martin K, Gardiner ED, Greenstone MA, Morice AH: Patients’ and carers’ preferences in two models of care for acute exacerbations of COPD: results of a randomised controlled trial. Thorax. 2002, 57 (2): 167-169. 10.1136/thorax.57.2.167.
Aimonino Ricauda N, Tibaldi V, Leff B, Scarafiotti C, Marinello R, Zanocchi M, Molaschi M: Substitutive “hospital at home” versus inpatient care for elderly patients with exacerbations of chronic obstructive pulmonary disease: a prospective randomized, controlled trial. J Am Geriatr Soc. 2008, 56 (3): 493-500. 10.1111/j.1532-5415.2007.01562.x.
Cotton MM, Bucknall CE, Dagg KD, Johnson MK, MacGregor G, Stewart C, Stevenson RD: Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Thorax. 2000, 55 (11): 902-906. 10.1136/thorax.55.11.902.
Wilson A, Parker H, Wynn A, Jagger C, Spiers N, Jones J, Parker G: Randomised controlled trial of effectiveness of Leicester hospital at home scheme compared with hospital care. BMJ. 1999, 319 (7224): 1542-1546. 10.1136/bmj.319.7224.1542.
Nicholson C, Bowler S, Jackson C, Schollay D, Tweeddale M, O’Rourke P: Cost comparison of hospital- and home-based treatment models for acute chronic obstructive pulmonary disease. Aust Health Rev. 2001, 24 (4): 181-187. 10.1071/AH010181.
Ewig S, Welte T, Chastre J, Torres A: Rethinking the concepts of community-acquired and health-care-associated pneumonia. Lancet Infect Dis. 2010, 10 (4): 279-287. 10.1016/S1473-3099(10)70032-3.
Jenkinson C, Layte R, Jenkinson D, Lawrence K, Petersen S, Paice C, Stradling J: A shorter form health survey: can the SF-12 replicate results from the SF-36 in longitudinal studies?. J Public Health Med. 1997, 19 (2): 179-186. 10.1093/oxfordjournals.pubmed.a024606.
Lamping DL, Schroter S, Marquis P, Marrel A, Duprat-Lomon I, Sagnier PP: The community-acquired pneumonia symptom questionnaire: a new, patient-based outcome measure to evaluate symptoms in patients with community-acquired pneumonia. Chest. 2002, 122 (3): 920-929. 10.1378/chest.122.3.920.
Frick KD, Burton LC, Clark R, Mader SI, Naughton WB, Burl JB, Greenough WB, Steinwachs DM, Leff B: Substitutive hospital at home for older persons: effects on costs. Am J Manag Care. 2009, 15 (1): 49-56.
Richards DA, Toop LJ, Epton MJ, McGeoch GR, Town GI, Wynn-Thomas SM, Dawson RD, Hlavac MC, Werno AM, Abernethy PD: Home management of mild to moderately severe community-acquired pneumonia: a randomised controlled trial. Med J Aust. 2005, 183 (5): 235-238.
Santos-Eggimann B, Chavaz N, Larequi T, Lamy O, Yersin B: Heart failure and community-acquired pneumonia: cases for home hospital?. Int J Qual Health Care. 2001, 13 (4): 301-307. 10.1093/intqhc/13.4.301.
Loeb M, Carusone SC, Goeree R, Walter SD, Brazil K, Krueger P, Simor A, Moss L, Marrie T: Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia: a randomized controlled trial. JAMA. 2006, 295 (21): 2503-2510. 10.1001/jama.295.21.2503.
Collins AM, Wilks S, Wootton D, Gordon SB: Supported home-care schemes: the key to increasing outpatient care?. Eur Respir J. 2012, 39 (2): 508-10.1183/09031936.00165911.
Chalmers JD, Akram AR, Hill AT: Increasing outpatient treatment of mild community-acquired pneumonia: systematic review and meta-analysis. Eur Respir J. 2011, 37: 858-864. 10.1183/09031936.00065610.
Shepperd S, Wee B, Straus SE: Hospital at home: home-based end of life care. Cochrane Database Syst Rev. 2011, 7: CD009231
Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, Tyrer P: Framework for design and evaluation of complex interventions to improve health. BMJ. 2000, 321 (7262): 694-696. 10.1136/bmj.321.7262.694.
Leff B: Defining and disseminating the hospital-at-home model. CMAJ. 2009, 180 (2): 156-157. 10.1503/cmaj.081891.
The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2466/14/25/prepub