People with flare-ups of COPD (chronic obstructive pulmonary disease) prefer to be managed at home rather than in hospital. Hospital stay was on average four days shorter when people were discharged early to the hospital at home scheme, and there was no noticeable increase in readmissions in this group.
This NIHR-funded trial aimed to establish the costs and outcomes of hospital at home compared with staying in hospital for treatment.
The findings support current guidance that hospital at home is suitable for selected patients and this study shows that the DECAF score is an effective way of selecting people, with a low risk of serious complications, who may be suitable.
There was a large reduction in number of days in hospital which should probably give cost savings, although the hoped for benefit of a reduction in readmissions was not realised.
Why was this study needed?
Chronic obstructive pulmonary disease (COPD) is the name of a group of lung disorders that cause increasing difficulty in breathing over time. Almost 2% of people in England have COPD, mostly middle aged or older long term smokers.
COPD usually progresses slowly, but people can have sudden worsening known as an exacerbation. In 2017–18 in England, there were 34,980 hospital admissions for acute exacerbations of COPD, totalling 137,099 days in hospital.
Hospital at home services can provide much, but not all, of the care available in hospital and has been shown effective, but choosing appropriate patients has been difficult. This study aimed to see if treating people at home was effective and cheaper for people at low risk of dying from an exacerbation of COPD according to the DECAF clinical prediction tool (see Definitions tab).
What did this study do?
This randomised controlled trial included 120 people admitted to three hospitals in England with a COPD exacerbation who had a DECAF score of 0 or 1. This indicated a low risk of dying. People were assigned to either stay in hospital or have ‘hospital at home’.
People receiving hospital at home were visited by a respiratory specialist nurse once or twice a day. A respiratory consultant provided remote supervision. Patients had an emergency number to contact the team at any time and access to physiotherapy, occupational therapy, psychology, pharmacy, and short-term social support.
Patients had daily monitoring of their breathing rate, blood pressure, and blood oxygen levels, with blood tests if needed. Oral and intravenous treatments plus oxygen therapy were available.
This was a robust, well-designed trial and the results should be applicable to other NHS trusts.
What did it find?
- Hospital at home costs about £1,016 less than usual care on average and has a high chance - 90% - of being cost effective at usual NHS willingness-to-pay thresholds.
- Patients in the hospital at home group spent an average of one day in hospital and four days with treatment at home compared with five days in hospital with usual care.
- About 90% of patients said they would prefer hospital at home during future exacerbations (54 of 60 people who had hospital at home and 51 of 57 who had usual care).
- There was little difference in the proportion of re-admissions: 37% of people having hospital at home and 40% of people who stayed in hospital were readmitted within 90 days.
- No patients in either group died in the two weeks after attending hospital with their exacerbation. One person in each group died within 90 days.
What does current guidance say on this issue?
NICE’s recent 2018 guideline on COPD recommends hospital at home and assisted-discharge schemes as safe and effective for people who would otherwise need to be admitted or stay in hospital. It notes, from its 2004 review, that evidence is insufficient to make specific recommendations on selecting people for such services.
The British Thoracic Society’s 2007 guideline on intermediate care with hospital at home in COPD provides detailed recommendations on hospital at home services. However, no standardised scoring tools were recommended for identifying which clinical characteristics made hospital at home a suitable option.
What are the implications?
This study supports the current move towards assisted-discharge schemes supported by hospital at home for selected people with exacerbations of COPD. The evidence adds data and notes it is preferred by those cared for at home. The DECAF score seems a practical choice for assessing risk.
Hospital at home may cost less than staying in hospital, driven by shorter hospital stay rather than fewer readmissions.
This was a relatively small study of 120 people in only three hospitals. Further information from other centres in the UK would be needed to be certain of the benefits to patients, and the savings in NHS costs. The DECAF score might be suitable for reviewing in the next update of guidelines.
Citation and Funding
Echevarria C, Gray J, Hartley T et al. Home treatment of COPD exacerbation selected by DECAF score: a non-inferiority, randomised controlled trial and economic evaluation. Thorax. 2018;73(8):713-22.
This project was funded by the National Institute for Health Research – Research for Patient Benefit Programme (project number PB-PG-0213-30105).
British Thoracic Society Guideline Development Group. Intermediate care—Hospital-at-Home in chronic obstructive pulmonary disease: British Thoracic Society guideline. Thorax 2007;62:200–10.
Health and Social Care Information Centre. Quality and Outcomes Framework – prevalence, achievements and exceptions report: England, 2014–15. London: Health and Social Care Information Centre; 2015.
Jeppesen E, Brurberg KG, Vist GE et al. Hospital at home for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;(5):CD003573.
NHS Digital. Hospital Episodes Statistics 2017-18: Diagnosis. NHS Digital; 2018.
NHS website. Chronic obstructive pulmonary disease (COPD). London: Department of Health and Social Care; updated 2016.
NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NG115. London: National Institute for Health and Care Excellence; 2018.
Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre