Hospital at Home admission avoidance with comprehensive geriatric assessment to maintain living at home for people aged 65 years and over: a RCT

S. Shepperd, Andrea Cradduck-Bamford, Christopher C. Butler, G. Ellis, M. Godfrey, A. Gray, A. Hemsley, P. Khanna, P. Langhorne, Petra Mäkelä, S. Mort, Scott Ramsay, R. Schiff, Surya Singh, Susan Smith, D. Stott, A. Tsiachristas, A. Wilkinson, Ly-Mee Yu, J. Young
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Young","doi":"10.3310/htaf1569","DOIUrl":null,"url":null,"abstract":"\n \n Evidence is required to guide the redesign of health care for older people who require hospital admission.\n \n \n \n We assessed the clinical effectiveness and cost-effectiveness of geriatrician-led admission avoidance hospital at home with comprehensive geriatric assessment, the experiences of older people and their caregivers, and how the services differed.\n \n \n \n A multisite, randomised, open trial of comprehensive geriatric assessment hospital at home, compared with admission to hospital, using a 2 : 1 (hospital at home to hospital) ratio, and a parallel economic and process evaluation. Participants were randomised using a secure online system.\n \n \n \n Participants were recruited from primary care or acute hospital assessment units from nine sites across the UK.\n \n \n \n Older people who required hospital admission because of an acute change in health.\n \n \n \n Geriatrician-led admission avoidance hospital at home with comprehensive geriatric assessment.\n \n \n \n The main outcome, ‘living at home’ (the inverse of death or living in a residential care setting), was measured at 6-month follow-up. Secondary outcomes at 6 months were the incidence of delirium, mortality, new long-term residential care, cognitive impairment, ability to perform activities of daily living, quality-adjusted survival, length of stay and transfer to hospital. Secondary outcomes at 12 months were living at home, new long-term residential care and mortality.\n \n \n \n Participants were allocated to hospital at home (n = 700) or to hospital (n = 355). All reported relative risks (RRs) were adjusted and are reported for hospital at home compared with hospital. There were no significant differences between the groups in the proportions of patients ‘living at home’ at 6 months [528/672 (78.6%) vs. 247/328 (75.3%), RR 1.05, 95% confidence interval (CI) 0.95 to 1.15; p = 0.36] or at 12 months [443/670 (66.1%) vs. 219/325 (67.4%), RR 0.99, 95% CI 0.89 to 1.10; p = 0.80]; mortality at 6 months [114/673 (16.9%) vs. 58/328 (17.7%), RR 0.98, 95% CI 0.65 to 1.47; p = 0.92] or at 12 months [188/670 (28.1%) vs. 82/325 (25.2%), RR 1.14, 95% CI 0.80 to 1.62]; the proportion of patients with cognitive impairment [273/407 (67.1%) vs. 115/183 (62.8%), RR 1.06, 95% CI 0.93 to 1.21; p = 0.36]; or in ability to perform the activities of daily living as measured by the Barthel Index (mean difference 0.24, 95% CI –0.33 to 0.80; p = 0.411; hospital at home, n = 521 patients contributed data; hospital, n = 256 patients contributed data) or Comorbidity Index (adjusted mean difference 0.0002, 95% CI –0.15 to 0.15; p = 0.10; hospital at home, n = 474 patients contributed data; hospital, n = 227 patients contributed data) at 6 months. The varying denominator reflects the number of participants who contributed data to the different outcomes. There was a significant reduction in the RR of living in residential care at 6 months [37/646 (5.7%) vs. 27/311 (8.7%), RR 0.58, 95% CI 0.45 to 0.76; p < 0.001] and 12 months [39/646 (6.0%) vs. 27/311 (8.7%), RR 0.61, 95% CI 0.46 to 0.82; p < 0.001], a significant reduction in risk of delirium at 1 month [10/602 (1.7%) vs. 13/295 (4.4%), RR 0.38, 95% CI 0.19 to 0.76; p = 0.006] and an increased risk of transfer to hospital at 1 month [173/672 (25.7%) vs. 64/330 (19.4%), RR 1.32, 95% CI 1.06 to 1.64; p = 0.012], but not at 6 months [343/631 (54.40%) vs. 171/302 (56.6%), RR 0.95, 95% CI 0.86 to 1.06; p = 0.40]. Patient satisfaction was in favour of hospital at home. An unexpected adverse event that might have been related to the research was reported to the Research Ethics Committee. 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引用次数: 2

Abstract

Evidence is required to guide the redesign of health care for older people who require hospital admission. We assessed the clinical effectiveness and cost-effectiveness of geriatrician-led admission avoidance hospital at home with comprehensive geriatric assessment, the experiences of older people and their caregivers, and how the services differed. A multisite, randomised, open trial of comprehensive geriatric assessment hospital at home, compared with admission to hospital, using a 2 : 1 (hospital at home to hospital) ratio, and a parallel economic and process evaluation. Participants were randomised using a secure online system. Participants were recruited from primary care or acute hospital assessment units from nine sites across the UK. Older people who required hospital admission because of an acute change in health. Geriatrician-led admission avoidance hospital at home with comprehensive geriatric assessment. The main outcome, ‘living at home’ (the inverse of death or living in a residential care setting), was measured at 6-month follow-up. Secondary outcomes at 6 months were the incidence of delirium, mortality, new long-term residential care, cognitive impairment, ability to perform activities of daily living, quality-adjusted survival, length of stay and transfer to hospital. Secondary outcomes at 12 months were living at home, new long-term residential care and mortality. Participants were allocated to hospital at home (n = 700) or to hospital (n = 355). All reported relative risks (RRs) were adjusted and are reported for hospital at home compared with hospital. There were no significant differences between the groups in the proportions of patients ‘living at home’ at 6 months [528/672 (78.6%) vs. 247/328 (75.3%), RR 1.05, 95% confidence interval (CI) 0.95 to 1.15; p = 0.36] or at 12 months [443/670 (66.1%) vs. 219/325 (67.4%), RR 0.99, 95% CI 0.89 to 1.10; p = 0.80]; mortality at 6 months [114/673 (16.9%) vs. 58/328 (17.7%), RR 0.98, 95% CI 0.65 to 1.47; p = 0.92] or at 12 months [188/670 (28.1%) vs. 82/325 (25.2%), RR 1.14, 95% CI 0.80 to 1.62]; the proportion of patients with cognitive impairment [273/407 (67.1%) vs. 115/183 (62.8%), RR 1.06, 95% CI 0.93 to 1.21; p = 0.36]; or in ability to perform the activities of daily living as measured by the Barthel Index (mean difference 0.24, 95% CI –0.33 to 0.80; p = 0.411; hospital at home, n = 521 patients contributed data; hospital, n = 256 patients contributed data) or Comorbidity Index (adjusted mean difference 0.0002, 95% CI –0.15 to 0.15; p = 0.10; hospital at home, n = 474 patients contributed data; hospital, n = 227 patients contributed data) at 6 months. The varying denominator reflects the number of participants who contributed data to the different outcomes. There was a significant reduction in the RR of living in residential care at 6 months [37/646 (5.7%) vs. 27/311 (8.7%), RR 0.58, 95% CI 0.45 to 0.76; p < 0.001] and 12 months [39/646 (6.0%) vs. 27/311 (8.7%), RR 0.61, 95% CI 0.46 to 0.82; p < 0.001], a significant reduction in risk of delirium at 1 month [10/602 (1.7%) vs. 13/295 (4.4%), RR 0.38, 95% CI 0.19 to 0.76; p = 0.006] and an increased risk of transfer to hospital at 1 month [173/672 (25.7%) vs. 64/330 (19.4%), RR 1.32, 95% CI 1.06 to 1.64; p = 0.012], but not at 6 months [343/631 (54.40%) vs. 171/302 (56.6%), RR 0.95, 95% CI 0.86 to 1.06; p = 0.40]. Patient satisfaction was in favour of hospital at home. An unexpected adverse event that might have been related to the research was reported to the Research Ethics Committee. At 6 months, there was a mean difference in NHS, personal social care and informal care costs (mean difference –£3017, 95% CI –£5765 to –£269), and no difference in quality-adjusted survival. Older people and caregivers played a crucial role in supporting the delivery of health care. In hospital at home this included monitoring a patient’s health and managing transitional care arrangements. The findings are most applicable to patients referred from an acute hospital assessment unit. Comprehensive geriatric assessment hospital at home can provide a cost-effective alternative to hospitalisation for selected older people. Further research that includes a stronger element of carer support might generate evidence to improve health outcomes. This trial is registered as ISRCTN60477865. This project was funded by the National Institute for Health Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 2. See the NIHR Journals Library website for further project information.
通过全面的老年评估避免65岁及以上的人在家中生活:一项随机对照试验
需要证据来指导重新设计需要住院的老年人的保健服务。我们通过全面的老年病学评估、老年人及其护理人员的经验,以及服务的不同,评估了老年医生主导的家庭住院避免医院的临床效果和成本效益。一项多地点、随机、开放的综合老年评估在家医院与入院进行比较的试验,采用2:1(在家医院与医院)的比例,并进行平行经济和过程评估。参与者是通过一个安全的在线系统随机抽取的。参与者是从英国九个地点的初级保健或急性医院评估单位招募的。因健康状况发生严重变化而需要住院的老年人。以老年病医生为主导的住院避免在家进行全面的老年评估。主要结果“在家生活”(与死亡或住在养老院相反)是在6个月的随访中测量的。6个月时的次要结局是谵妄的发生率、死亡率、新的长期住院护理、认知障碍、进行日常生活活动的能力、质量调整生存率、住院时间和转院时间。12个月时的次要结果是住在家里、新的长期住宿护理和死亡率。参与者被分配到家庭医院(n = 700)或医院(n = 355)。对所有报告的相对风险(rr)进行了调整,并将家庭医院与医院的报告进行了比较。6个月时,两组患者“住在家里”的比例无显著差异[528/672(78.6%)比247/328 (75.3%),RR 1.05, 95%可信区间(CI) 0.95 ~ 1.15;p = 0.36]或12个月时[443/670(66.1%)比219/325 (67.4%),RR 0.99, 95% CI 0.89 ~ 1.10;p = 0.80];6个月死亡率[114/673(16.9%)比58/328 (17.7%),RR 0.98, 95% CI 0.65 ~ 1.47;p = 0.92]或12个月时[188/670(28.1%)比82/325 (25.2%),RR 1.14, 95% CI 0.80 ~ 1.62];认知障碍患者比例[273/407(67.1%)比115/183 (62.8%),RR 1.06, 95% CI 0.93 ~ 1.21;p = 0.36];或以Barthel指数衡量的日常生活活动能力(平均差0.24,95% CI -0.33至0.80;p = 0.411;家庭医院,n = 521例患者提供数据;医院,n = 256例患者提供数据)或合并症指数(调整后平均差0.0002,95% CI -0.15 ~ 0.15;p = 0.10;家庭医院,n = 474名患者提供数据;医院,n = 227例患者提供资料)6个月时。变化的分母反映了为不同结果提供数据的参与者的数量。6个月时住在养老院的相对危险度显著降低[37/646(5.7%)比27/311(8.7%),相对危险度0.58,95% CI 0.45 ~ 0.76;p < 0.001]和12个月[39/646(6.0%)比27/311 (8.7%),RR 0.61, 95% CI 0.46 ~ 0.82;p < 0.001], 1个月时谵妄的风险显著降低[10/602(1.7%)比13/295 (4.4%),RR 0.38, 95% CI 0.19 ~ 0.76;p = 0.006]和1个月转院风险增加[173/672(25.7%)比64/330 (19.4%),RR 1.32, 95% CI 1.06 ~ 1.64;p = 0.012],但6个月时无差异[343/631(54.40%)比171/302 (56.6%),RR 0.95, 95% CI 0.86 ~ 1.06;p = 0.40]。病人的满意度有利于家庭医院。一个可能与研究相关的意外不良事件被报告给研究伦理委员会。6个月时,NHS、个人社会护理和非正式护理费用的平均差异(平均差异为3017英镑,95% CI为5765英镑至269英镑),质量调整生存率无差异。老年人和护理人员在支持提供保健服务方面发挥了至关重要的作用。在家庭医院,这包括监测病人的健康状况和管理过渡性护理安排。研究结果最适用于从急性医院评估单位转介的患者。家庭综合老年评估医院可以为选定的老年人提供一种具有成本效益的替代住院治疗的方法。进一步的研究,包括更强的护理人员支持因素,可能会产生改善健康结果的证据。该试验注册号为ISRCTN60477865。该项目由国家卫生研究所(NIHR)卫生和社会保健提供研究方案资助,将全文发表在《卫生和社会保健提供研究》上;第10卷第2期请参阅NIHR期刊图书馆网站了解更多项目信息。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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