A multi-centre randomised trial to compare the effectiveness of geriatrician-led admission avoidance hospital at home versus inpatient admission

Abstract

BackgroundThere is concern that existing models of acute hospital care will become unworkable as the health service admits an increasing number of frail older people with complex health needs, and that there is inadequate evidence to guide the planning of acute hospital level services. We aim to evaluate whether geriatrician-led admission avoidance to hospital at home is an effective alternative to hospital admission.Methods/DesignWe are conducting a multi-site randomised open trial of geriatrician-led admission avoidance hospital at home, compared with admission to hospital. We are recruiting older people with markers of frailty or prior dependence who have been referred to admission avoidance hospital at home for an acute medical event. This includes patients presenting with delirium, functional decline, dependence, falls, immobility or a background of dementia presenting with physical disease. Participants are randomised using a computerised random number generator to geriatrician-led admission avoidance hospital at home or a control group of inpatient admission in a 2:1 ratio in favour of the intervention. The primary endpoint ‘living at home’ (the inverse of death or living in a residential care setting) is measured at 6 months follow-up, and we also collect data on this outcome at 12 months. Secondary outcomes include the incidence of delirium, mortality, new long-term residential care, cognitive impairment, activities of daily living, quality of life and quality-adjusted survival, length of stay, readmission or transfer to hospital. We will conduct a parallel economic evaluation, and a process evaluation that includes an interview study to explore the experiences of patients and carers.DiscussionHealth systems around the world are examining how to provide acute hospital-level care to older adults in greater numbers with a fixed or shrinking hospital resource. This trial is the first large multi-site randomised trial of geriatrician-led admission avoidance hospital at home, and will provide evidence on alternative models of healthcare for older people who require hospital admission.Trial registration ISRCTN60477865: Registered on 10 March 2014. Trial Sponsor: University of Oxford. Version 3.1, 14/06/2016.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-017-2214-y) contains supplementary material, which is available to authorized users.

Should I stay or should I go? A retrospective propensity score-matched analysis using administrative data of hospital-at-home for older people in Scotland

“…A multicentre randomised trial that measures outcomes that are key to decision-makers (including informal care giving), and is accompanied by a process evaluation to help explain the findings, is necessary to provide clinicians and policy-makers with further evidence about the effectiveness and cost-effectiveness of admission avoidance hospital-at-home services across UK. The authors are involved in such a trial the results of which are expected to be available in 2019 24…”

A protocol for the process evaluation of a multi-centre randomised trial to compare the effectiveness of geriatrician-led admission avoidance hospital at home versus inpatient admission

“…Patients who have been recruited to the RCT may have reduced, fluctuating or absent capacity to consent to trial participation and requirements [ 21 ]. As capacity to consent refers to a time- and decision-specific ability [ 36 ], capacity is assessed for inclusion in the interview study as an additional consideration to consent for overall RCT participation.…”

“…The design of this process evaluation is included within the ethics application and overall protocol for the RCT [ 21 ]. Ethical approval for the trial was given by the Research Ethics Committee England, Wales and Northern Ireland (14/WA/1081) and Scotland (14/SS/1046).…”

“…We describe the methods of a process evaluation that we are conducting alongside a multi-site randomised trial of geriatrician-led admission avoidance HAH compared with hospital admission [ 21 ]. The main outcome will be ‘living at home’ at 6 months’ follow-up and other outcomes will include the incidence of delirium, mortality, new long-term residential care, cognitive impairment, activities of daily living, quality of life, quality-adjusted survival, length of stay, readmission or transfer to hospital and resource use.…”

“…The main outcome will be ‘living at home’ at 6 months’ follow-up and other outcomes will include the incidence of delirium, mortality, new long-term residential care, cognitive impairment, activities of daily living, quality of life, quality-adjusted survival, length of stay, readmission or transfer to hospital and resource use. The randomised controlled trial (RCT) protocol has been described in detail previously [ 21 ].…”