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

Abstract

Background Evidence is required to guide the redesign of health care for older people who require hospital admission. Objectives 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. Design 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. Setting Participants were recruited from primary care or acute hospital assessment units from nine sites across the UK. Participants Older people who required hospital admission because of an acute change in health. Intervention Geriatrician-led admission avoidance hospital at home with comprehensive geriatric assessment. Main outcome measures 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. Results 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. Limitations The findings are most applicable to patients referred from an acute hospital assessment unit. Conclusions 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. Trial registration This trial is registered as ISRCTN60477865. Funding 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.

Stakeholders' experiences of comprehensive geriatric assessment in an inpatient hospital setting: a qualitative systematic review and meta-ethnography

“…Despite innovations in international healthcare systems seeking to expand the application of CGA [17,18,45], older adults and caregivers' level of participation in the management of acute illness and their interface with HCPs is not always recognised [46,47]. Our ndings draw parallels with those outlined in a scoping review of 13 studies, which explored informal caregivers' views on their perceived levels of involvement in collaborative discussions with HCPs [48].…”

“…Qualitative research has identi ed important contradictions between the aims of CGA and patients' experiences, for example, a study, which explored older adults' experiences of CGA in an outpatient setting, revealed a dominant focus on illness symptoms and limitations related to ageing [16]. It is increasingly important to understand older adults' perspectives as international healthcare systems continue to evolve and recon gure to meet increased demand for resources [17][18][19].…”

Virtual wards for people with frailty: what works, for whom, how and why—a rapid realist review

“…We included eight core documents from the first search [ 16 , 17 , 32–37 ] and 20 documents from stage 2 (nine peer-reviewed [ 15 , 30 , 38–44 ] and 11 grey literature [ 6 , 28 , 29 , 45–52 ]). Ten documents report on four studies [ 15–17 , 29 , 30 , 36–38 , 44 , 49 ].…”

Effectiveness of a home health monitoring and education program for complex chronic patients, led by primary care nurses

“…Finally, although it is true that an economic evaluation of the program has not been carried outwhich is one of the limitations of our study-it can be assured that while in specialized care, the program resulted in savings, in primary care, the costs would have increased due to the increase in home visits. The difference has been found to be cost-effective when related to avoided hospital admissions (33,46).…”