Admission avoidance hospital at home.

BACKGROUND: Admission avoidance hospital at home provides active treatment by healthcare professionals in the patient's home for a condition that would otherwise require acute hospital inpatient care, and always for a limited time period. This is the fourth update of this review. OBJECTIVES: To determine the effectiveness and cost of managing patients with admission avoidance hospital at home compared with inpatient hospital care. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL on 24 February 2022, and checked the reference lists of eligible articles. We sought ongoing and unpublished studies by searching ClinicalTrials.gov and WHO ICTRP, and by contacting providers and researchers involved in the field. SELECTION CRITERIA: Randomised controlled trials recruiting participants aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital inpatient care. DATA COLLECTION AND ANALYSIS: We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. We performed meta-analysis for trials that compared similar interventions, reported comparable outcomes with sufficient data, and used individual patient data when available. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes. MAIN RESULTS: We included 20 randomised controlled trials with a total of 3100 participants; four trials recruited participants with chronic obstructive pulmonary disease; two trials recruited participants recovering from a stroke; seven trials recruited participants with an acute medical condition who were mainly older; and the remaining trials recruited participants with a mix of conditions. We assessed the majority of the included studies as at low risk of selection, detection, and attrition bias, and unclear for selective reporting and performance bias. For an older population, admission avoidance hospital at home probably makes little or no difference on mortality at six months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.68 to 1.13; P = 0.30; I2 = 0%; 5 trials, 1502 participants; moderate-certainty evidence); little or no difference on the likelihood of being readmitted to hospital after discharge from hospital at home or inpatient care within 3 to 12 months' follow-up (RR 1.14, 95% CI 0.97 to 1.34; P = 0.11; I2 = 41%; 8 trials, 1757 participants; moderate-certainty evidence); and probably reduces the likelihood of living in residential care at six months' follow-up (RR 0.53, 95% CI 0.41 to 0.69; P < 0.001; I2 = 67%; 4 trials, 1271 participants; moderate-certainty evidence). Hospital at home probably results in little to no difference in patient's self-reported health status (2006 patients; moderate-certainty evidence). Satisfaction with health care received may be improved with admission avoidance hospital at home (1812 participants; low-certainty evidence); few studies reported the effect on caregivers. Hospital at home reduced the initial average hospital length of stay (2036 participants; low-certainty evidence), which ranged from 4.1 to 18.5 days in the hospital group and 1.2 to 5.1 days in the hospital at home group. Hospital at home length of stay ranged from an average of 3 to 20.7 days (hospital at home group only). Admission avoidance hospital at home probably reduces costs to the health service compared with hospital admission (2148 participants; moderate-certainty evidence), though by a range of different amounts and using different methods to cost resource use, and there is some evidence that it decreases overall societal costs to six months' follow-up. AUTHORS' CONCLUSIONS: Admission avoidance hospital at home, with the option of transfer to hospital, may provide an effective alternative to inpatient care for a select group of older people who have been referred for hospital admission. The intervention probably makes little or no difference to patient health outcomes; may improve satisfaction; probably reduces the likelihood of relocating to residential care; and probably decreases costs.

Exposure to behavioral regularities in everyday life predicts infants' acquisition of mental state vocabulary.

There are two broad views of children's theory of mind. The mentalist view is that it emerges in infancy and is possibly innate. The minimalist view is that it emerges more gradually in childhood and is heavily dependent on learning. According to minimalism, children initially understand behaviors rather than mental states, and they are assisted in doing so by recognizing repeating patterns in behavior. The regularities in behavior allow them to predict future behaviors, succeed on theory-of-mind tasks, acquire mental state words, and eventually, understand the mental states underlying behavior. The present study provided the first clear evidence for the plausibility of this view by fitting head cameras to 54 infants aged 6 to 25 months, and recording their view of the world in their daily lives. At 6 and 12 months, infants viewed an average of 146.5 repeated behaviors per hour, a rate consistent with approximately 560,000 repetitions in their first year, and with repetitions correlating with children's acquisition of mental state words, even after controlling for their general vocabulary and a range of variables indexing social interaction. We also recorded infants' view of people searching or searching for and retrieving objects. These were 92 times less common and did not correlate with mental state vocabulary. Overall, the findings indicate that repeated behaviors provide a rich source of information for children that would readily allow them to recognize patterns in behavior and help them acquire mental state words, providing the first clear evidence for this claim of minimalism. RESEARCH HIGHLIGHTS: Six- to 25-month-olds wore head cameras to record home life from infants' point-of-view and help adjudicate between nativist and minimalist views of theory-of-mind (ToM). Nativists say ToM is too early developing to enable learning, whereas minimalists say infants learn to predict behaviors from behavior patterns in environment. Consistent with minimalism, infants had an incredibly rich exposure (146.5/h, >560,000 in first year) to repeated behaviors (e.g., drinking from a cup repeatedly). Consistent with minimalism, more repeated behaviors correlated with infants' mental state vocabulary, even after controlling for gender, age, searches witnessed and non-mental state vocabulary.

Including random centre effects in design, analysis and presentation of multi-centre trials.

BACKGROUND: In large multicentre trials in diverse settings, there is uncertainty about the need to adjust for centre variation in design and analysis. A key distinction is the difference between variation in outcome (independent of treatment) and variation in treatment effect. Through re-analysis of the CRASH-2 trial (2010), this study clarifies when and how to use multi-level models for multicentre studies with binary outcomes. METHODS: CRASH-2 randomised 20,127 trauma patients across 271 centres and 40 countries to either single-dose tranexamic acid or identical placebo, with all-cause death at 4 weeks the primary outcome. The trial data had a hierarchical structure, with patients nested in hospitals which in turn are nested within countries. Reanalysis of CRASH-2 trial data assessed treatment effect and both patient and centre level baseline covariates as fixed effects in logistic regression models. Random effects were included to assess where there was variation between countries, and between centres within countries, both in underlying risk of death and in treatment effect. RESULTS: In CRASH-2, there was significant variation between countries and between centres in death at 4 weeks, but absolutely no differences between countries or centres in the effect of treatment. Average treatment effect was not altered after accounting for centre and country variation in this study. CONCLUSIONS: It is important to distinguish between underlying variation in outcomes and variation in treatment effects; the former is common but the latter is not. Stratifying randomisation by centre overcomes many statistical problems and including random intercepts in analysis may increase power and decrease bias in mean and standard error estimates. TRIAL REGISTRATION: Current Controlled Trials ISRCTN86750102 , ClinicalTrials.gov NCT00375258 , and South African Clinical Trial Register DOH-27-0607-1919.