Systematic literature review on the effectiveness and safety of paediatric hospital-at-home care as a substitute for hospital care.

The hospital landscape is shifting to new care models to meet current challenges in demand, technology, available budgets and staffing. These challenges also apply to the paediatric population, leading to a reduction in paediatric hospital beds and occupancy rates. Paediatric hospital-at-home (HAH) care is used to substitute hospital care in an attempt to bring hospital services closer to children's homes. In addition, these models attempt to avoid fragmentation of care between hospitals and the community. An important prerequisite for this paediatric HAH care is that it is safe and at least as effective as standard hospital care. The aim of this systematic review is to analyse the evidence on the impact of paediatric HAH care on hospital utilisation, patient outcomes and costs. Four bibliographic databases (Medline, Embase, Cinahl and Cochrane Library) were systematically searched for RCTs and pseudo-RCTs that studied the effectiveness and safety of short-term paediatric HAH care with a focus on models as an alternative to acute hospital admissions. Pseudo-RCTs are defined as observational studies that mimic the design of an RCT, but without randomisation. Outcomes of interest were the length of stay, acute (re)admissions, adverse health outcomes, therapy adherence, parental satisfaction or experience and costs. Only articles written in English, Dutch and French conducted in upper-middle and high-income countries and published between 2000 and 2021 were included. Quality assessment was carried out by two assessors using the Cochrane Collaboration's tool for assessing the risk of bias. Reporting is done in accordance with the PRISMA guidelines. We identified 18 (pseudo) RCTs and 25 publications of low to very low quality. Most of the included RCTs focused on the neonatal population: phototherapy for neonatal jaundice, early discharge after birth combined with outpatient neonatal care. Other RCTs focused on chemotherapy for acute lymphoblastic leukaemia, diabetes type 1 education, oxygen therapy for acute bronchiolitis, an outpatient service for children with infectious diseases and antibiotic treatment for low-risk febrile neutropenia, cellulitis and perforated appendicitis. The identified study results show that paediatric HAH care is not associated with more adverse events or hospital readmissions. The impact of paediatric HAH care on costs is less clear.  Conclusions: This review suggests that paediatric HAH care is not associated with more adverse events or hospital readmissions for various clinical indications compared to a standard hospital. Because of the low to very low level of evidence, it is worthwhile to further investigate safety, efficacy and cost effects under strict and well-controlled conditions. This systematic review provides guidance on the essential elements that should be included in HAH care programmes for each type of indication and/or intervention. What is Known: • The hospital landscape is shifting new models of care to meet current challenges in demand, technology, staffing and models of care. Paediatric HAH care is one of these models. Previous literature reviews are inconclusive whether this is a safe and effective way of providing care. What is New: • New evidence suggests that paediatric HAH care for various clinical indications is not associated with adverse events or hospital readmissions compared to a standard hospital. Current evidence is characterised by a low level of quality.  • The current review provides guidance on the essential elements that should be included in HAH care programmes for each type of indication and/or intervention.

Non-surgical interventions for late rectal problems (proctopathy) of radiotherapy in people who have received radiotherapy to the pelvis.

BACKGROUND: This is an update of a Cochrane review first published in 2002, and previously updated in 2007. Late radiation rectal problems (proctopathy) include bleeding, pain, faecal urgency, and incontinence and may develop after pelvic radiotherapy treatment for cancer. OBJECTIVES: To assess the effectiveness and safety of non-surgical interventions for managing late radiation proctopathy. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 11, 2015); MEDLINE (Ovid); EMBASE (Ovid); CANCERCD; Science Citation Index; and CINAHL from inception to November 2015. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing non-surgical interventions for the management of late radiation proctopathy in people with cancer who have undergone pelvic radiotherapy for cancer. Primary outcomes considered were: episodes of bowel activity, bleeding, pain, tenesmus, urgency, and sphincter dysfunction. DATA COLLECTION AND ANALYSIS: Study selection, 'Risk of bias' assessment, and data extraction were performed in duplicate, and any disagreements were resolved by involving a third review author. MAIN RESULTS: We identified 1221 unique references and 16 studies including 993 participants that met our inclusion criteria. One study found through the last update was moved to the 'Studies awaiting classification' section. We did not pool outcomes for a meta-analysis due to variation in study characteristics and endpoints across included studies.Since radiation proctopathy is a condition with various symptoms or combinations of symptoms, the studies were heterogeneous in their intended effect. Some studies investigated treatments targeted at bleeding only (group 1), some investigated treatments targeted at a combination of anorectal symptoms, but not a single treatment (group 2). The third group focused on the treatment of the collection of symptoms referred to as pelvic radiation disease. In order to enable some comparison of this heterogeneous collection of studies, we describe the effects in these three groups separately.Nine studies assessed treatments for rectal bleeding and were unclear or at high risk of bias. The only treatments that made a significant difference on primary outcomes were argon plasma coagulation (APC) followed by oral sucralfate versus APC with placebo (endoscopic score 6 to 9 in favour of APC with placebo, risk ratio (RR) 2.26, 95% confidence interval (CI) 1.12 to 4.55; 1 study, 122 participants, low- to moderate-quality evidence); formalin dab treatment (4%) versus sucralfate steroid retention enema (symptom score after treatment graded by the Radiation Proctopathy System Assessments Scale (RPSAS) and sigmoidoscopic score in favour of formalin (P = 0.001, effect not quantified, 1 study, 102 participants, very low- to low-quality evidence), and colonic irrigation plus ciprofloxacin and metronidazole versus formalin application (4%) (bleeding (P = 0.007, effect not quantified), urgency (P = 0.0004, effect not quantified), and diarrhoea (P = 0.007, effect not quantified) in favour of colonic irrigation (1 study, 50 participants, low-quality evidence).Three studies, of unclear and high risk of bias, assessed treatments targeted at something very localised but not a single pathology. We identified no significant differences on our primary outcomes. We graded all studies as very low-quality evidence due to unclear risk of bias and very serious imprecision.Four studies, of unclear and high risk of bias, assessed treatments targeted at more than one symptom yet confined to the anorectal region. Studies that demonstrated an effect on symptoms included: gastroenterologist-led algorithm-based treatment versus usual care (detailed self help booklet) (significant difference in favour of gastroenterologist-led algorithm-based treatment on change in Inflammatory Bowel Disease Questionnaire-Bowel (IBDQ-B) score at six months, mean difference (MD) 5.47, 95% CI 1.14 to 9.81) and nurse-led algorithm-based treatment versus usual care (significant difference in favour of the nurse-led algorithm-based treatment on change in IBDQ-B score at six months, MD 4.12, 95% CI 0.04 to 8.19) (1 study, 218 participants, low-quality evidence); hyperbaric oxygen therapy (at 2.0 atmospheres absolute) versus placebo (improvement of Subjective, Objective, Management, Analytic - Late Effects of Normal Tissue (SOMA-LENT) score in favour of hyperbaric oxygen therapy (HBOT), P = 0.0019) (1 study, 150 participants, moderate-quality evidence, retinol palmitate versus placebo (improvement in RPSAS in favour of retinol palmitate, P = 0.01) (1 study, 19 participants, low-quality evidence) and integrated Chinese traditional plus Western medicine versus Western medicine (grade 0 to 1 radio-proctopathy after treatment in favour of integrated Chinese traditional medicine, RR 2.55, 95% CI 1.30 to 5.02) (1 study, 58 participants, low-quality evidence).The level of evidence for the majority of outcomes was downgraded using GRADE to low or very low, mainly due to imprecision and study limitations.  AUTHORS' CONCLUSIONS: Although some interventions for late radiation proctopathy look promising (including rectal sucralfate, metronidazole added to an anti-inflammatory regimen, and hyperbaric oxygen therapy), single small studies provide limited evidence. Furthermore, outcomes important to people with cancer, including quality of life (QoL) and long-term effects, were not well recorded. The episodic and variable nature of late radiation proctopathy requires large multi-centre placebo-controlled trials (RCTs) to establish whether treatments are effective. Future studies should address the possibility of associated injury to other gastro-intestinal, urinary, or sexual organs, known as pelvic radiation disease. The interventions, as well as the outcome parameters, should be broader and include those important to people with cancer, such as QoL evaluations.

Defining pathways.

AIMS AND BACKGROUND: The term 'clinical pathway' is internationally accepted in all settings of healthcare management. The way in which clinical pathways have been developed in the United Kingdom differs from that in the USA. Besides the international differences in the purpose, many alternative names also can be found. These have led to confusion. There is no single, widely accepted definition of a clinical pathway. The aim of the study was to survey the definitions used in describing the concept and to derive key characteristics of clinical pathways. METHOD: Using the PubMed, we conducted a review of literature published between January 2000 and December 2003 using the following terms: critical pathway, clinical pathway, integrated care pathway, care pathway and care map. All reports reviewed had to use the concept, as defined by the Medical Subject Headings term, to be considered. To assess all definitions, the concept analysis method was used. RESULTS: In 82 of the 263 eligible articles, the definition of pathway was given. Totally, we found 84 different definitions. Each definition was rephrased by taking into consideration the following three features inherent to pathways: nouns, characteristics and aims and outcomes. Every feature was further divided into categories. CONCLUSIONS: A clinical pathway is a method for the patient-care management of a well-defined group of patients during a well-defined period of time. A clinical pathway explicitly states the goals and key elements of care based on Evidence Based Medicine (EBM) guidelines, best practice and patient expectations by facilitating the communication, coordinating roles and sequencing the activities of the multidisciplinary care team, patients and their relatives; by documenting, monitoring and evaluating variances; and by providing the necessary resources and outcomes. The aim of a clinical pathway is to improve the quality of care, reduce risks, increase patient satisfaction and increase the efficiency in the use of resources.