Early discharge hospital at home as alternative to routine hospital care for older people: a systematic review and meta-analysis.

BACKGROUND: The global population of adults aged 60 and above surpassed 1 billion in 2020, constituting 13.5% of the global populace. Projections indicate a rise to 2.1 billion by 2050. While Hospital-at-Home (HaH) programs have emerged as a promising alternative to traditional routine hospital care, showing initial benefits in metrics such as lower mortality rates, reduced readmission rates, shorter treatment durations, and improved mental and functional status among older individuals, the robustness and magnitude of these effects relative to conventional hospital settings call for further validation through a comprehensive meta-analysis. METHODS: A comprehensive literature search was executed during April-June 2023, across PubMed, MEDLINE, Embase, Web of Science, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) to include both RCT and non-RCT HaH studies. Statistical analyses were conducted using Review Manager (version 5.4), with Forest plots and I2 statistics employed to detect inter-study heterogeneity. For I2 > 50%, indicative of substantial heterogeneity among the included studies, we employed the random-effects model to account for the variability. For I2 ≤ 50%, we used the fixed effects model. Subgroup analyses were conducted in patients with different health conditions, including cancer, acute medical conditions, chronic medical conditions, orthopedic issues, and medically complex conditions. RESULTS: Fifteen trials were included in this systematic review, including 7 RCTs and 8 non-RCTs. Outcome measures include mortality, readmission rates, treatment duration, functional status (measured by the Barthel index), and mental status (measured by MMSE). Results suggest that early discharge HaH is linked to decreased mortality, albeit supported by low-certainty evidence across 13 studies. It also shortens the length of treatment, corroborated by seven trials. However, its impact on readmission rates and mental status remains inconclusive, supported by nine and two trials respectively. Functional status, gauged by the Barthel index, indicated potential decline with early discharge HaH, according to four trials. Subgroup analyses reveal similar trends. CONCLUSIONS: While early discharge HaH shows promise in specific metrics like mortality and treatment duration, its utility is ambiguous in the contexts of readmission, mental status, and functional status, necessitating cautious interpretation of findings.

Hospital-Level Care at Home for Patients with Cirrhosis.

BACKGROUND: Patients with cirrhosis have a 30-day readmission rate of over 30%. Novel care delivery models are needed to reduce healthcare costs and utilization associated with cirrhosis care. One such model is Home Hospital (HH), which provides inpatient-level care at home. Limited evidence currently exists supporting HH for cirrhosis patients. AIMS: The aims of this study were to characterize patients with cirrhosis who received hospital-level care at home in a two-site clinical trial and to describe the care they received. Secondary aims included describing their outcomes, including adverse events, readmissions and mortality. METHODS: We identified all patients with cirrhosis who enrolled in HH as part of a two-site clinical trial between 2017 and 2022. HH services include daily clinician visits, intravenous and oral medications, continuous vital sign monitoring, and telehealth specialist consultation. We collected sociodemographic data and analyzed HH stays, including interventions, outcomes, adverse events, and follow-up. RESULTS: 22 patients with cirrhosis (45% Hispanic; 50% limited English proficiency, median MELD-Na 12) enrolled in HH during the study period. Interventions included lab chemistries (82%), intravenous medications (77%), specialist consultation (23%), and advanced diagnostics/procedures (23%). The median length of stay was 7 days (IQR 4-12); 186 bed-days were saved. Two patients (9%) experienced adverse events (AKI). No patients required escalation of care; 9% were readmitted within 30 days. CONCLUSIONS: In this two-site study, HH was feasible for patients with cirrhosis, holding promise as a hepatology delivery model. Future randomized trials are needed to further evaluate the efficacy of HH for patients with cirrhosis.

[Hospital-based Home Care for Children with Cancer from the Parents̓ Point of View - A Qualitative Exploration of Family Members]. / Die ambulant-aufsuchende Versorgung von an Krebs erkrankten Kindern aus Sicht der Erziehungsberechtigten.

BACKGROUND: About 2,200 children and adolescents in Germany per year are diagnosed with oncological diseases. Through now, there are almost no offers for home care services for these patients. There is a pilot program offering hospital-based home care for children and adolescents with cancer in Germany. The perspective of the parents will be researched by a qualitative exploring study. PATIENTS: In this interview study parents from children with cancer will be interviewed. METHOD: A qualitative exploring interview study, seeking the subjective perspective from parents on the hospital-based home care for children with cancer. The sample was drawn criterion-guided. The interviews were transcribed verbatim and analysed using qualitative content analysis. For socio- demographic characteristics the participants respond to an online questionnaire. RESULTS: Eleven women and three men aged between 30 and 60 years participated in the interviews. The average age of the ill children was 8.43 years. Five parents state that the children's illness did not lead to a reduction in working hours or to the termination of the employment relationship. Hospital-based home care results in subjectively perceived relief in everyday family life, especially in terms of time. Furthermore, a reduction in the psychological perception of stress is described. DISCUSSION/CONCLUSION: Due to the study design, the results presented here are to be regarded as indicative. In future studies the presented results should be supplemented by quantitative representative studies.

Overcoming barriers to implementation: mapping implementation strategies in four hospital in home programs within the Veterans Health Administration.

The Hospital at Home model, called Hospital-in-Home (HIH) in the Department of Veterans Affairs, delivers coordinated, high-value care aligned with older adult and caregiver preferences. Documenting implementation barriers and corresponding strategies to overcome them can address challenges to widespread adoption. To evaluate HIH implementation barriers and identify strategies to address them, we conducted interviews with 8 HIH staff at 4 hospitals between 2010 and 2013. We utilized qualitative directed content analysis guided by the Consolidated Framework for Implementation Research (CFIR) and mapped identified barriers to possible strategies using the CFIR-Expert Recommendations for Implementing Change (ERIC) Matching Tool. We identified 11 barriers spanning 5 CFIR domains. Three implementation strategies - identifying and preparing champions, conducting educational meetings, and capturing and sharing local knowledge - achieved high expert endorsement for each barrier. A mix of strategies targeting resources, organizational readiness and fit, and leadership engagement should be considered to support the sustainability and spread of HIH.

Nurses' Willingness and Demand for Internet+Home Care Services and the Associated Factors in Municipal Hospitals in China: Cross-Sectional Survey.

BACKGROUND: Developing Internet+home care (IHC) services is a promising way to address the problems related to population aging, which is an important global issue. However, IHC services are in their infancy in China. Limited studies have investigated the willingness and demand of nurses in municipal hospitals to provide IHC services. OBJECTIVE: This study aims to investigate the willingness and demand of nurses in municipal hospitals in China to provide IHC services and analyze the factors to promote IHC development in China. METHODS: This cross-sectional study used multistage sampling to recruit 9405 nurses from 10 hospitals in 5 regions of China. A self-designed questionnaire with good reliability and validity was used to measure nurses' willingness and demand for providing IHC services. Data analysis used the chi-square test, Welch t test, binary logistic regression analysis, and multiple linear regression analysis. RESULTS: Nurses were highly willing to provide IHC services and preferred service distances of <5 km and times from 8 AM to 6 PM. An individual share >60% was the expected service pay sharing. Job title, educational level, monthly income, and marital status were associated with nurses' willingness to provide IHC services in binary logistic regression analysis. Supervising nurses were 1.177 times more likely to express a willingness to provide IHC services than senior nurses. Nurses with a bachelor's degree had a 1.167 times higher likelihood of expressing willingness to provide IHC services than those with a junior college education or lower. Married nurses were 1.075 times more likely to express a willingness than unmarried nurses. A monthly income >¥10,000 increased the likelihood of nurses' willingness to provide IHC services, by 1.187 times, compared with an income <¥5000. Nurses' total mean demand score for IHC services was 17.38 (SD 3.67), with the highest demand being privacy protection. Multiple linear regression analysis showed that job title, monthly income, and educational level were associated with nurses' demand for IHC services. Supervising nurses (B=1.058, P<.001) and co-chief nurses or those with higher positions (B=2.574, P<.001) reported higher demand scores than senior nurses. Monthly incomes of ¥5000 to ¥10,000 (B=0.894, P<.001) and >¥10,000 (B=1.335, P<.001), as well as a bachelor's degree (B=0.484, P=.002) and at least a master's degree (B=1.224, P=.02), were associated with higher demand scores compared with a monthly income <¥5000 and junior college education or lower, respectively. CONCLUSIONS: Nurses in municipal hospitals showed a high willingness and demand to provide IHC services, with differences in willingness and demand by demographic characteristics. Accordingly, government and hospitals should regulate the service period, service distance, and other characteristics according to nurses' willingness and demand and establish relevant laws and regulations to ensure the steady and orderly development of IHC services.

Hospital at home for the management of COVID-19: preliminary experience with 63 patients.

Alternatives to conventional hospitalization are needed to increase health systems resilience in the face of COVID-19 pandemic. Herein, we describe the characteristics and outcomes of 63 patients admitted to a single HaH during the peak of COVID-19 in Barcelona. Our results suggest that HaH seems to be a safe and efficacious alternative to conventional hospitalization for accurately selected patients with COVID-19.

Validation of the Arabic Severe Respiratory Insufficiency Questionnaire.

BACKGROUND/OBJECTIVES: Assessment of Health-Related Quality of Life (HRQL) in patients with chronic respiratory insufficiency requiring Home Mechanical Ventilation (HMV) requires a valid measurement tool. The Severe Respiratory Insufficiency (SRI) questionnaire, originally developed in German, has been translated into different languages and tested in different contexts, but has so far not been in use in Arabic-speaking populations. The objective of this study is to validate the Arabic version of the SRI questionnaire in a sample of Arabic-speaking patients from Lebanon. METHODS: Following forward/backward translations, the finalized Arabic version was administered to 149 patients (53 males-96 females, age 69.80 ± 10 years) receiving HMV. Patients were recruited from outpatient clinics and visited at home. The Arabic SRI and the 36-Item Short-Form Health Survey (SF-36) were administered, in addition to questions on sociodemographics and medical history. Exploratory Factor Analysis (EFA) was used to explore dimensionality; internal consistency reliability of the unidimensional scale and its subscales was assessed using Cronbach's alpha. External nomological validity was examined by assessing the correlation between the SRI and SF-36 scores. RESULTS: The 49-item Arabic SRI scale showed a high internal consistency reliability (Cronbach alpha for the total scale was 0.897 and ranged between 0.73 and 0.87 for all subscales). Correlations between the SF-36-Mental Health Component MHC and SF-36-Physical Health Component with SRI-Summary Scale were 0.57 and 0.66, respectively, with higher correlations observed between the SF-36 and specific sub-scales such as the Physical Functioning and the Social Functioning subscales [r = 0.81 and r = 0.74 (P < 0.01), respectively]. CONCLUSION AND RECOMMENDATIONS: The Arabic SRI is a reliable and valid tool for assessing HRQL in patients with chronic respiratory insufficiency receiving home mechanical ventilation.

The Virtual Hospital: An Innovative Solution for Disaster Response.

Like any disaster, the COVID-19 pandemic has presented significant challenges to healthcare systems, especially the threat of insufficient bed capacity and resources. Hospitals have been required to plan for and implement innovative approaches to expand hospital inpatient and intensive care capacity. This article presents how one of the largest healthcare systems in the United States leveraged existing technology infrastructure to create a virtual hospital that extended care beyond the walls of the "brick and mortar" hospital.

Home-Based Interventions may Increase Recruitment, Adherence, and Measurement of outcomes in Clinical Trials of Stroke Rehabilitation.

OBJECTIVE: This study aimed to investigate the completion rates of a home-based randomized trial, which examined home-based high-intensity respiratory muscle training after stroke compared with sham intervention. MATERIALS AND METHODS: Completion was examined in terms of recruitment (enrolment and retention), intervention (adherence and delivery of home-visits) and measurement (collection of outcomes). RESULTS: Enrolment was 32% and retention was 97% at post-intervention and 84% at follow-up. Adherence to the intervention was high at 87%. Furthermore, 83% of planned home-visits were conducted and 100% of outcomes were collected from those attending measurement sessions. CONCLUSION: This home-based randomized trial demonstrated high rates of enrolment, retention, adherence, delivery of home-visits, and collection of outcomes. Home-based interventions may help to improve completion rates of randomized trials.

Direct and indirect effects of the SARS-CoV-2 pandemic on Gaucher Disease patients in Spain: Time to reconsider home-based therapies?

OBJECTIVE: An analysis of the SARS-CoV-2 pandemic impact in the Spanish Gaucher Disease (GD) community is presented here. PATIENTS & METHODS: The Spanish GD foundation (FEETEF) surveyed 113 GD patients from March 30 to April 27; all patients provided a verbal consent. RESULTS: 110 surveys were analyzed. The median age was 47 years old (y.o.), 31 patients were ≥ 60 y.o.; and 34% of patients reported comorbidities. 46% (51/110) of patients were treated by enzyme replacement therapy (ERT), 48 of them at hospitals; 45.1% (45/110) were on substrate reduction therapy (SRT) and 9% (10/110) receive no therapy. 25% (11/48) of ERT-hospital-based patients reported therapy interruptions, while SRT-patients did not report missing doses. No bone crises were reported. However, 50% (55/110) of patients reported being worried about their predisposition to a severe SARS-COV-2 infection and 29% (16/55) of them took anxiolytics or antidepressants for this. While 6 patients reported to have contact with an infected person, another two confirmed SARS-CoV-2 infections were reported in splenectomyzed patients, one of them (a 79-year-old diabetic) died. CONCLUSIONS: One quarter of the patients treated at hospitals reported dose interruptions. Home-based therapy may need to be considered in order to minimize the impact of the COVID-19 pandemic.

Evaluation of Home Phototherapy for Neonatal Hyperbilirubinemia.

OBJECTIVE: To characterize home phototherapy treatment for neonatal hyperbilirubinemia and assess the risk factors associated with the need for hospital admission during or after home phototherapy. STUDY DESIGN: This was a retrospective study of newborn infants born at ≥35 weeks of gestation who underwent comprehensive home phototherapy (that included daily in-home lactation support and blood draws) over an 18-month period. We excluded infants who lacked a recorded birth date or time, started treatment at age >14 days, or had a conjugated serum bilirubin level of ≥2 mg/dL (≥34.2 µmol/L). The primary study outcome was any hospital admission during or within 24 hours after completion of home phototherapy. Logistic regression was used to identify risk factors for hospitalization. RESULTS: Of the cohort of 1385 infants, 1324 met the inclusion criteria. At the time home phototherapy was initiated, 376 infants (28%) were at or above the American Academy of Pediatrics phototherapy threshold. Twenty-five infants required hospitalization (1.9%; 95% CI, 1.3%-2.8%). Hospital admission was associated with a younger age at phototherapy initiation (OR, 0.63 for each day older in age; 95% CI, 0.44-0.91) and a higher total serum bilirubin level relative to the treatment threshold at phototherapy initiation (OR, 1.71 for each 1 mg/dL above the treatment threshold; 95% CI, 1.40-2.08). CONCLUSIONS: Comprehensive home phototherapy successfully treated hyperbilirubinemia in the vast majority of the infants in this cohort.

Home Oxygen Use and 1-Year Readmission among Infants Born Preterm with Bronchopulmonary Dysplasia Discharged from Children's Hospital Neonatal Intensive Care Units.

OBJECTIVE: To determine associations between home oxygen use and 1-year readmissions for preterm infants with bronchopulmonary dysplasia (BPD) discharged from regional neonatal intensive care units. STUDY DESIGN: We performed a secondary analysis of the Children's Hospitals Neonatal Database, with readmission data via the Pediatric Hospital Information System and demographics using ZIP-code-linked census data. We included infants born <32 weeks of gestation with BPD, excluding those with anomalies and tracheostomies. Our primary outcome was readmission by 1 year corrected age; secondary outcomes included readmission duration, mortality, and readmission diagnosis-related group codes. A staged multivariable logistic regression was adjusted for center, clinical, and social risk factors; at each stage we included variables associated at P < .1 in bivariable analysis with home oxygen use or readmission. RESULTS: Home oxygen was used in 1906 of 3574 infants (53%) in 22 neonatal intensive care units. Readmission occurred in 34%. Earlier gestational age, male sex, gastrostomy tube, surgical necrotizing enterocolitis, lower median income, nonprivate insurance, and shorter hospital-to-home distance were associated with readmission. Home oxygen was not associated with odds of readmission (OR, 1.2; 95% CI, 0.98-1.56), readmission duration, or mortality. Readmissions for infants with home oxygen were more often coded as BPD (16% vs 4%); readmissions for infants on room air were more often gastrointestinal (29% vs 22%; P < .001). Clinical risk factors explained 72% of center variance in readmission. CONCLUSIONS: Home oxygen use is not associated with readmission for infants with BPD in regional neonatal intensive care units. Center variation in home oxygen use does not impact readmission risk. Nonrespiratory problems are important contributors to readmission risk for infants with BPD.

Accuracy of Hospital Discharge Codes in Medicare Claims for Knee and Hip Replacement Patients.

BACKGROUND: Despite the importance of the hospital discharge destination field ("discharge code" hereafter) for research and payment reform, its accuracy is not well established. OBJECTIVES: The aim of this study was to examine the accuracy of discharge codes in Medicare claims. DATA SOURCES: 2012-2015 Medicare claims of knee and hip replacement patients. RESEARCH DESIGN: We identified patients' discharge location in claims and compared it with the discharge code. We also used a mixed-effects logistic regression to examine the association of patient and hospital characteristics with discharge code accuracy. RESULTS: Approximately 9% of discharge codes were inaccurate. Long-term care hospital discharge codes had the lowest accuracy rate (41%), followed by acute care transfers (72%), inpatient rehabilitation facility (80%), and home discharges (83%). Most misclassifications occurred within 2 broad groups of postacute care settings: home-based and institutional care. The odds of inaccurate discharge codes were higher for Medicaid-enrolled patients and safety-net and low-volume hospitals. CONCLUSIONS: Inaccurate hospital discharge coding may have introduced bias in studies relying on these codes (eg, evaluations of Medicare bundled payment models). Inaccuracy was more common among Medicaid-enrolled patients and safety-net and low-volume hospitals, suggesting more potential bias in existing study findings pertaining to these patients and hospitals.

Intensity of Care, Expenditure, and Place of Death in French Women in the Year Before Their Death From Breast Cancer: A Population-Based Study.

Health care utilization of women with breast cancer (BC) during the last year of life, together with the causes and place of death and associated expenditure have been poorly described. Women treated for BC (2014-2015) with BC as a cause of death in 2015 and covered by the national health insurance general scheme (77% of the population) were identified in the French health data system (n = 6,696, mean age: 68.7 years, SD ± 15). Almost 70% died in short-stay hospitals (SSH), 4% in hospital-at-home (HaH), 9% in Rehab, 5% in skilled nursing homes (SNH) and 12% at home. One-third presented cardiovascular comorbidity. During the last year, 90% were hospitalized at least once in SSH, 25% in Rehab, 13% in HaH and 71% received hospital palliative care (HPC), but only 5% prior to their end-of-life stay. During the last month, 85% of women were admitted at least once to a SSH, 42% via the emergency department, 10% to an ICU, 24% received inpatient chemotherapy and 18% received outpatient chemotherapy. Among the 83% of women who died in hospital, independent factors for HPC use were cardiovascular comorbidity (adjusted odds ratio, aOR: 0.83; 95%CI: 0.72-0.95) and, in the 30 days before death, at least one SNH stay (aOR: 0.52; 95%CI: 0.36-0.76), ICU stay (aOR: 0.36; 95%CI: 0.30-0.43), inpatient chemotherapy (aOR: 0.55; 95%CI: 0.48-0.63), outpatient chemotherapy (aOR: 0.60; 95%CI: 0.51-0.70), death in Rehab (aOR: 1.4; 95%CI: 1.05-1.86) or HAH (aOR: 4.5; 95%CI: 2.47-8.1) vs SSH. Overall mean expenditure reimbursed per woman was €38,734 and €42,209 for those with PC. Women with inpatient or outpatient chemotherapy during the last month had lower rates of HPC, suggesting declining use of HPC before death. This study also indicates SSH-centered management with increased use of HPC in HaH and Rehab units and decreased access to HPC in SNH.

Home ward bound: features of hospital in the home use by major Australian hospitals, 2011-2017.

OBJECTIVE: To describe uptake of hospital in the home (HIH) by major Australian hospitals and the characteristics of patients and their HIH admissions; to assess change in HIH admission numbers relative to total hospital activity. DESIGN: Descriptive, retrospective study of HIH activity, analysing previously collected census data for all multi-day hospital inpatient admissions to included hospitals during the period 1 January 2011 - 31 December 2017. SETTING, PARTICIPANTS: Nineteen principal referrer hospital members of the Health Roundtable in Australia. MAIN OUTCOME MEASURES: HIH admissions by diagnosis-related group (DRG); patient and admission characteristics. RESULTS: 80 167 of 2 185 421 admissions to the 19 hospitals included HIH care, or 3.7% (95% CI, 3.6-3.7%) of all admissions. Median length of stay for admissions including HIH (7.3 days; IQR, 3.1-14 days) was longer than that for those that did not (2.7 days; IQR, 1.6-5.1 days). For HIH admissions, the proportion of men was higher (54.4% v 45.9%), the proportion of patients who died in hospital was lower (0.3% v 1.4%), and re-admission within 28 days was less frequent (2.3% v 3.6%). The 50 DRGs with greatest HIH activity encompassed 65 811 HIH admissions (82.1%), or 8.4% (95% CI, 8.4-8.5%) of all admissions in these DRGs. HIH admission numbers grew more rapidly than non-HIH admissions, but the difference was not statistically significant. CONCLUSIONS: HIH care is most frequently provided to patients requiring hospital treatment related to infections, venous thromboembolism, or post-surgical care. Its use could be expanded in clinical areas where it is currently used, and extended to others where it is not. HIH activity is growing. It should be systematically monitored and reported to allow better overview of its use and outcomes.

Two-Week Multimodal Prehabilitation Program Improves Perioperative Functional Capability in Patients Undergoing Thoracoscopic Lobectomy for Lung Cancer: A Randomized Controlled Trial.

BACKGROUND: Patients with lung cancer often experience reduced functional capacity and quality of life after surgery. The current study investigated the impact of a short-term, home-based, multimodal prehabilitation program on perioperative functional capacity in patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy for nonsmall cell lung cancer (NSCLC). METHODS: A randomized controlled trial was conducted with 73 patients. Patients in the prehabilitation group (n = 37) received a 2-week multimodal intervention program before surgery, including aerobic and resistance exercises, respiratory training, nutrition counseling with whey protein supplementation, and psychological guidance. Patients in the control group (n = 36) received the usual clinical care. The assessors were blinded to the patient allocation. The primary outcome was perioperative functional capacity measured as the 6-minute walk distance (6MWD), which was assessed at 1 day before and 30 days after surgery. A linear mixed-effects model was built to analyze the perioperative 6MWD. Other outcomes included lung function, disability and psychometric evaluations, length of stay (LOS), short-term recovery quality, postoperative complications, and mortality. RESULTS: The median duration of prehabilitation was 15 days. The average 6MWD was 60.9 m higher perioperatively in the prehabilitation group compared to the control group (95% confidence interval [CI], 32.4-89.5; P < .001). There were no differences in lung function, disability and psychological assessment, LOS, short-term recovery quality, postoperative complications, and mortality, except for forced vital capacity (FVC; 0.35 L higher in the prehabilitation group, 95% CI, 0.05-0.66; P = .021). CONCLUSIONS: A 2-week, home-based, multimodal prehabilitation program could produce clinically relevant improvements in perioperative functional capacity in patients undergoing VATS lobectomy for lung cancer.

The effectiveness and cost-effectiveness of hospital-based specialist palliative care for adults with advanced illness and their caregivers.

BACKGROUND: Serious illness is often characterised by physical/psychological problems, family support needs, and high healthcare resource use. Hospital-based specialist palliative care (HSPC) has developed to assist in better meeting the needs of patients and their families and potentially reducing hospital care expenditure. There is a need for clarity on the effectiveness and optimal models of HSPC, given that most people still die in hospital and also to allocate scarce resources judiciously. OBJECTIVES: To assess the effectiveness and cost-effectiveness of HSPC compared to usual care for adults with advanced illness (hereafter patients) and their unpaid caregivers/families. SEARCH METHODS: We searched CENTRAL, CDSR, DARE and HTA database via the Cochrane Library; MEDLINE; Embase; CINAHL; PsycINFO; CareSearch; National Health Service Economic Evaluation Database (NHS EED) and two trial registers to August 2019, together with checking of reference lists and relevant systematic reviews, citation searching and contact with experts to identify additional studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) evaluating the impact of HSPC on outcomes for patients or their unpaid caregivers/families, or both. HSPC was defined as specialist palliative care delivered by a palliative care team that is based in a hospital providing holistic care, co-ordination by a multidisciplinary team, and collaboration between HSPC providers and generalists. HSPC was provided to patients while they were admitted as inpatients to acute care hospitals, outpatients or patients receiving care from hospital outreach teams at home. The comparator was usual care, defined as inpatient or outpatient hospital care without specialist palliative care input at the point of entry into the study, community care or hospice care provided outside of the hospital setting. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We assessed risk of bias and extracted data. To account for use of different scales across studies, we calculated standardised mean differences (SMDs) with 95% confidence intervals (CIs) for continuous data. We used an inverse variance random-effects model. For binary data, we calculated odds ratio (ORs) with 95% CIs. We assessed the evidence using GRADE and created a 'Summary of findings' table. Our primary outcomes were patient health-related quality of life (HRQoL) and symptom burden (a collection of two or more symptoms). Key secondary outcomes were pain, depression, satisfaction with care, achieving preferred place of death, mortality/survival, unpaid caregiver burden, and cost-effectiveness. Qualitative data was analysed where available. MAIN RESULTS: We identified 42 RCTs involving 7779 participants (6678 patients and 1101 caregivers/family members). Twenty-one studies were with cancer populations, 14 were with non-cancer populations (of which six were with heart failure patients), and seven with mixed cancer and non-cancer populations (mixed diagnoses). HSPC was offered in different ways and included the following models: ward-based, inpatient consult, outpatient, hospital-at-home or hospital outreach, and service provision across multiple settings which included hospital. For our main analyses, we pooled data from studies reporting adjusted endpoint values. Forty studies had a high risk of bias in at least one domain. Compared with usual care, HSPC improved patient HRQoL with a small effect size of 0.26 SMD over usual care (95% CI 0.15 to 0.37; I2 = 3%, 10 studies, 1344 participants, low-quality evidence, higher scores indicate better patient HRQoL). HSPC also improved other person-centred outcomes. It reduced patient symptom burden with a small effect size of -0.26 SMD over usual care (95% CI -0.41 to -0.12; I2 = 0%, 6 studies, 761 participants, very low-quality evidence, lower scores indicate lower symptom burden). HSPC improved patient satisfaction with care with a small effect size of 0.36 SMD over usual care (95% CI 0.41 to 0.57; I2 = 0%, 2 studies, 337 participants, low-quality evidence, higher scores indicate better patient satisfaction with care). Using home death as a proxy measure for achieving patient's preferred place of death, patients were more likely to die at home with HSPC compared to usual care (OR 1.63, 95% CI 1.23 to 2.16; I2 = 0%, 7 studies, 861 participants, low-quality evidence). Data on pain (4 studies, 525 participants) showed no evidence of a difference between HSPC and usual care (SMD -0.16, 95% CI -0.33 to 0.01; I2 = 0%, very low-quality evidence). Eight studies (N = 1252 participants) reported on adverse events and very low-quality evidence did not demonstrate an effect of HSPC on serious harms. Two studies (170 participants) presented data on caregiver burden and both found no evidence of effect of HSPC (very low-quality evidence). We included 13 economic studies (2103 participants). Overall, the evidence on cost-effectiveness of HSPC compared to usual care was inconsistent among the four full economic studies. Other studies that used only partial economic analysis and those that presented more limited resource use and cost information also had inconsistent results (very low-quality evidence). Quality of the evidence The quality of the evidence assessed using GRADE was very low to low, downgraded due to a high risk of bias, inconsistency and imprecision. AUTHORS' CONCLUSIONS: Very low- to low-quality evidence suggests that when compared to usual care, HSPC may offer small benefits for several person-centred outcomes including patient HRQoL, symptom burden and patient satisfaction with care, while also increasing the chances of patients dying in their preferred place (measured by home death). While we found no evidence that HSPC causes serious harms, the evidence was insufficient to draw strong conclusions. Although these are only small effect sizes, they may be clinically relevant at an advanced stage of disease with limited prognosis, and are person-centred outcomes important to many patients and families. More well conducted studies are needed to study populations with non-malignant diseases and mixed diagnoses, ward-based models of HSPC, 24 hours access (out-of-hours care) as part of HSPC, pain, achieving patient preferred place of care, patient satisfaction with care, caregiver outcomes (satisfaction with care, burden, depression, anxiety, grief, quality of life), and cost-effectiveness of HSPC. In addition, research is needed to provide validated person-centred outcomes to be used across studies and populations.

Effects of Geriatric Interdisciplinary Home Rehabilitation on Independence in Activities of Daily Living in Older People With Hip Fracture: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effects of early discharge followed by geriatric interdisciplinary home rehabilitation for older people with hip fracture on independence in activities of daily living (ADL) compared with inhospital geriatric care according to a multifactorial rehabilitation program. DESIGN: Planned analysis of a randomized controlled trial with 3- and 12-month follow-ups. SETTING: Geriatric ward, ordinary housing, and residential care facilities. PARTICIPANTS: Of 466 people screened for eligibility, participants (N=205) with acute hip fracture, aged 70 years or older, including those with cognitive impairment and those living in residential care facilities, were randomized to intervention or control groups. INTERVENTION: Individually designed interdisciplinary home rehabilitation for a maximum of 10 weeks. The intervention aimed at early hospital discharge and focused on prevention of falls, independence in daily activities, and walking ability indoors and outdoors. MAIN OUTCOME MEASURES: Independence in ADL was measured using the Barthel ADL Index, and the ADL Staircase including the Katz ADL Index during hospital stay (prefracture performance) and at the follow-up visits in the participants' homes. RESULTS: There were no significant differences in ADL performance between the groups, and they recovered their prefracture level of independence in personal and instrumental ADL comparably. At 12 months, 33 (41.3%) in the intervention group vs 33 (41.8%) in the control group (P=.99) had regained or improved their prefracture ADL performance according to the Barthel ADL Index, and 27 (37.0%) vs 36 (48.6%) according to the ADL Staircase (P=.207). CONCLUSIONS: In older people with hip fracture, early discharge followed by geriatric interdisciplinary home rehabilitation resulted in a comparable recovery of independence in ADL at 3 and 12 months as inhospital geriatric care and rehabilitation.

Associations of Hospital Discharge Services With Potentially Avoidable Readmissions Within 30 Days Among Older Adults After Rehabilitation in Acute Care Hospitals in Tokyo, Japan.

OBJECTIVE: To examine the associations of 3 major hospital discharge services covered under health insurance (discharge planning, rehabilitation discharge instruction, and coordination with community care) with potentially avoidable readmissions (PARs) within 30 days in older adults after rehabilitation in acute care hospitals in Tokyo, Japan. DESIGN: Retrospective cohort study using a large-scale medical claims database of all Tokyo residents aged ≥75 years. SETTING: Acute care hospitals. PARTICIPANTS: Patients who underwent rehabilitation and were discharged to home (N=31,247; mean age in years ± SD, 84.1±5.7) between October 2013 and July 2014. INTERVENTIONS: None. MAIN OUTCOME MEASURE: 30-day PAR. RESULTS: Among the patients, 883 (2.9%) experienced 30-day PAR. A multivariable logistic generalized estimating equation model (with a logit link function and binominal sampling distribution) that adjusted for patient characteristics and clustering within hospitals showed that the discharge services were not significantly associated with 30-day PAR. The odds ratios were 0.962 (95% confidence interval [CI], 0.805-1.151) for discharge planning, 1.060 (95% CI, 0.916-1.227) for rehabilitation discharge instruction, and 1.118 (95% CI, 0.817-1.529) for coordination with community care. In contrast, the odds of 30-day PAR among patients with home medical care services were 1.431 times higher than those of patients without these services (P<.001), and the odds of 30-day PAR among patients with a higher number (median or higher) of rehabilitation units were 2.031 times higher than those of patients with a lower number (below median) (P<.001). Also, the odds of 30-day PAR among patients with a higher Hospital Frailty Risk Score (median or higher) were 1.252 times higher than those of patients with a lower score (below median) (P=.001). CONCLUSIONS: The insurance-covered discharge services were not associated with 30-day PAR, and the development of comprehensive transitional care programs through the integration of existing discharge services may help to reduce such readmissions.

Using Inferred Mobility Status to Estimate the Time to Major Depressive Disorder Diagnosis Post-Spinal Cord Injury.

OBJECTIVE: Estimate (1) prevalence of major depressive disorder (MDD) diagnosis; (2) risk factors associated with MDD diagnosis; (3) time at which MDD is diagnosed post-spinal cord injury (SCI); and (4) interaction of inferred mobility status (IMS) in a commercially insured population over 3 years. DESIGN: Retrospective longitudinal cohort design. SETTING: A commercial insurance claims database from January 1, 2010 to December 31, 2013. PARTICIPANTS: Individuals with an index cervical or thoracic SCI in 2011 or 2012, without history of MDD ≤30 days pre-SCI (N=1409). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Prevalence of, risk factors associated with, and time to MDD diagnosis post-SCI. A stratified survival analysis using IMS, based upon durable medical equipment (DME) claims, was also completed. RESULTS: Post-SCI, 294 out of 1409 (20.87%) were diagnosed with new-onset MDD. Significant (P<.05) risk factors included: employment, length of index hospitalization, discharge from index hospitalization with healthcare services, rehabilitation services post-SCI, and 2 of 5 IMS comparisons. Median time to MDD was 86 days. Survival analysis demonstrated a significant difference between 6 of 10 IMS comparisons. Regarding new-onset or recurring MDD, 432 out of 1409 (30.66%) were diagnosed post-SCI. Significant risk factors included: female, employment, length of index hospitalization, discharge from index hospitalization with healthcare services, rehabilitation services post-SCI, MDD>30 days pre-SCI, catheter claims, and 2 of 5 IMS comparisons. Median time to MDD was 74 days. Survival analysis demonstrated a significant difference between 4 of 10 IMS comparisons. CONCLUSIONS: Prevalence of MDD post-SCI is greater than the general population. Stratification by IMS illustrated that individuals with greater inferred reliance on DME are at a greater risk for MDD and have shorter time to MDD diagnosis post-SCI.