Authors' objectives:

The objective of the report was to assess the usefulness of home care in patients with community-acquired pneumonia, stroke, upper urinary tract infections and patients in post-operative recovery.

Authors' results and conclusions: Pneumonia Two systematic reviews (one of them from the Cochrane Collaboration) and 3 RCTs - not included in the abovementioned systematic reviews - were found. Community-acquired Pneumonia The systematic review published by Cochrane did not include any RCT conducted on pneumonia. In 2005, Richards et al showed that 55 patients with mild to moderate pneumonia took significantly longer to be discharged when treated with home care (median = 4 days) than those who were admitted to hospital (median=2 days). No differences were observed as regards length of intravenous or oral antibiotic therapy. Although both groups showed high rates of satisfaction, these were higher in the home care group (100% were \"very satisfied\" versus 60% in the hospital care group). Stroke The review conducted by Cochrane showed no significant differences in mortality (OR 0.78; CI95% 0.52-1.19). No differences were found in the rate of readmission of patients with stroke (OR 0.96; CI95% 0.63-1.45). Two trials assessing the patient s satisfaction found significant differences for home care (one of them showed a difference of 14%; CI 95%: 1% to 27%). Larsen et al carried out one health technology evaluation with a systematic review and meta-analysis conducted on the data obtained. The results of this publication show that home care would reduce the probability of institutionalization [OR = 0.45 (CI 95% 0.31 0.96) and NNT=20], with no differences in mortality rate. However, this evaluation is based on early discharge and home follow up rather than in home care from the beginning. Also, other two RCTs were found. One RCT published in 2005 by Thorsen et al evaluated 83 patients with mild to moderate sequelae, 5 to 7 days after an acute event occurred. Forty two of them were randomized to home rehabilitation while 41 received standard rehabilitation. After a 5-year follow-up, only 65% of them were evaluated. Though somehow, improvement was found in the group treated with home care, the high rate of loss to follow-up restricts the possibility to draw conclusions for this study. No differences were found in social, recreational activities and in the possibility to ambulate. One study published by Ricauda et al randomized 120 patients with ischemic stroke, to be managed using hospital or home care. Mean age was 82 years. Patients managed with home care had a longer admission period (38.1 28.6 vs. 22.2 11.5 days; P<0.001). There were no differences in survival after the first 6 months (65% versus 60%, P=0.53). Neither were there significant differences in functional evaluations or infection complications. Only lower levels on depression scales were found in home care managed patients (p<0.01). After 6 months, 16 cases of those in hospital care and three in home care required admission in a nursing home (p<0.01).

Authors' recommendations: Home care is a therapeutic alternative for several pathologies. As their diagnosis, treatment and prognosis differ, conclusions on its usefulness should be drawn separately. There are still no agreed recommendations on what cases would benefit the most from this management in the different scenarios assessed. Only one study evaluated mild to moderate pneumonia, with no differences in efficacy or complications. Evidence is not enough to draw valid conclusions. In patients with stroke, home care seems to be an alternative at least as effective as acute care hospital hospitalizations. Some authors even suggest that some results assessed as regards patient s satisfaction and depression parameters would be better than in standard hospitalizations. No good quality evidence was found on home care both for upper urinary tract infections and infections during post-operative periods. In spite of what has been said, it is important to mention some important facts as regards the validity of the results exposed: a) the study design did not allow to detect small differences between the interventions; b) as studies are conducted in developed countries, rates of satisfaction are not likely to be subject to generalization; c) systematic reviews included studies with heterogeneous populations; d) it is likely that the included patients do no represent the general population.

Authors' methods: Overview

Project Status: Completed

URL for project: http://www.iecs.org.ar/

Year Published: 2007

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Argentina

Organisation Name: Institute for Clinical Effectiveness and Health Policy

Contact Address: Dr. Emilio Ravignani 2024, Buenos Aires - Argentina, C1414 CABA

Contact Name: info@iecs.org.ar

Contact Email: info@iecs.org.ar

Copyright: Institute for Clinical Effectiveness and Health Policy (IECS)