Patient preference and satisfaction in hospital-at-home and usual hospital care for COPD exacerbations: Results of a randomised controlled trial

Background: In the absence of clear differences in effectiveness and cost-effectiveness between hospital-at-home schemes and usual hospital care, patient preference plays an important role. This study investigates patient preference for treatment place, associated factors and patient satisfaction with a community-based hospital-at-home scheme for COPD exacerbations. Methods: The study is part of a larger randomised controlled trial. Patients were randomised to usual hospital care or early assisted discharge which incorporated discharge at day 4 and visits by a home care nurse until day 7 of treatment (T + 4 days). The hospital care group received care as usual and was discharged from hospital at day 7. Patients were followed for 90 days (T+90 days). Patient preference for treatment place and patient satisfaction (overall and per item) were assessed quantitatively and qualitatively using questionnaires at T + 4 days and T + 90 days. Factors associated with patient preference were analysed in the early assisted discharge group. Results: 139 patients were randomised. No difference was found in overall satisfaction. At T + 4 days, patients in the early assisted discharge group were less satisfied with care at night and were less able to resume normal daily activities. At T + 90 days there were no differences for the separate items. Patient preference for home treatment at T + 4 days was 42% in the hospital care group and 86% in the early assisted discharge group and 35% and 59% at T+90 days. Patients' mental state was associated with preference. Conclusion: Results support the wider implementation of early assisted discharge for COPD exacerbations and this treatment option should be offered to selected patients that prefer home treatment

Cost-Effectiveness of Early Assisted Discharge for COPD Exacerbations in The Netherlands

AbstractObjectivesHospital admissions for exacerbations of chronic obstructive pulmonary disease are the main cost drivers of the disease. An alternative is to treat suitable patients at home instead of in the hospital. This article reports on the cost-effectiveness and cost-utility of early assisted discharge in The Netherlands.MethodsIn the multicenter randomized controlled Assessment of GOing Home under Early Assisted Discharge trial (n = 139), one group received 7 days of inpatient hospital treatment (HOSP) and one group was discharged after 3 days and treated at home by community nurses for 4 days. Health care resource use, productivity losses, and informal care were recorded in cost questionnaires. Microcosting was performed for inpatient day costs.ResultsSeven days after admission, mean change from baseline Clinical Chronic Obstructive Pulmonary Disease Questionnaire score was better for HOSP, but not statistically significantly: 0.29 (95% confidence interval [CI]−0.04 to 0.61). The difference in the probability of having a clinically relevant improvement was significant in favor of HOSP: 19.0%-point (95% CI 0.5%–36.3%). After 3 months of follow-up, differences in effectiveness had almost disappeared. The difference in quality-adjusted life-years was 0.0054 (95% CI−0.021 to 0.0095). From a health care perspective, early assisted discharge was cost saving:−€244 (treatment phase, 95% CI−€315 to−€168) and−€168 (3 months, 95% CI−€1253 to €922). Societal perspective:−€65 (treatment phase, 95% CI−€152 to €25) and €908 (3 months, 95% CI−€553 to €2296). The savings per quality-adjusted life-year lost were €31,111 from a health care perspective. From a societal perspective, HOSP was dominant.ConclusionsNo clear evidence was found to conclude that either treatment was more effective or less costly

Global mortality and readmission rates following COPD exacerbation-related hospitalization:a meta-analysis of 65945 individual patients

Background Exacerbations of COPD (ECOPD) have a major impact on patients and healthcare systems across the world. Precise estimates of the global burden of ECOPD on mortality and hospital readmission are needed to inform policy makers and aid preventive strategies to mitigate this burden. The aims of the present study were to explore global in-hospital mortality, post-discharge mortality and hospital readmission rates after ECOPD-related hospitalisation using an individual patient data meta-analysis (IPDMA) design. Methods A systematic review was performed identifying studies that reported in-hospital mortality, post-discharge mortality and hospital readmission rates following ECOPD-related hospitalisation. Data analyses were conducted using a one-stage random-effects meta-analysis model. This study was conducted and reported in accordance with the PRISMA-IPD statement. Results Data of 65 945 individual patients with COPD were analysed. The pooled in-hospital mortality rate was 6.2%, pooled 30-, 90- and 365-day post-discharge mortality rates were 1.8%, 5.5% and 10.9%, respectively, and pooled 30-, 90- and 365-day hospital readmission rates were 7.1%, 12.6% and 32.1%, respectively, with noticeable variability between studies and countries. Strongest predictors of mortality and hospital readmission included noninvasive mechanical ventilation and a history of two or more ECOPD-related hospitalisations <12 months prior to the index event. Conclusions This IPDMA stresses the poor outcomes and high heterogeneity of ECOPD-related hospitalisation across the world. Whilst global standardisation of the management and follow-up of ECOPD-related hospitalisation should be at the heart of future implementation research, policy makers should focus on reimbursing evidence-based therapies that decrease (recurrent) ECOPD