Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. Two of the Cochrane Reviews that investigate different ways to deliver health and social care services look at the qualitative and quantitative research into a strategy called hospital at home. In this podcast, Roses Parker, Cochrane's Commissioning Editor talks with lead author of the March 2024 qualitative evidence synthesis of implementing hospital at home, Jason Wallis, a physiotherapist and researcher at Monash University in Australia, and Sasha Shepperd, researcher at Oxford Population Health, University of Oxford in the UK who led the Cochrane review of the quantitative effects of admission avoidance hospital at home, which was updated in March 2024.

Roses: Hi, Jason, hi Sasha. To begin, please would you tell us about hospital at home? What is it?

Jason: Hi, Roses. Hospital at home is a service designed for people whose condition would normally need treatment in a hospital bed. It typically involves them staying at home with visits from a doctor, nurse and allied health professionals, such as a physiotherapist, who they would see if they were in hospital. One type, called admission avoidance hospital at home, is to avoid admission to hospital, with patients referred by emergency physicians or general practitioners. The other main type is early discharge, designed to shorten the time that patients need to stay in hospital.

Roses: Thanks, would you like to say more about why and how did you do your qualitative evidence synthesis of issues around the implementation of hospital at home?

Jason: Hospital at home has been an important service for some time, but there was a rapid acceleration during the Covid-19 pandemic, with the increased demand for hospital beds. However, despite increasing certainty about the benefits of hospital at home on patient outcomes and cost, there is little guidance on how to implement and sustain it on a wide scale. This led us to try to find and analyse qualitative research evidence that explored implementation of these services from all stakeholder perspectives.

Roses: So, did you find the evidence you needed?

Jason: Yes, we found 52 qualitative studies from 13 countries. These had interviewed more than 2000 people, including patients with a variety of conditions such as stroke or pneumonia, family caregivers, health professionals delivering or referring to hospital at home, as well as health managers and a few policy makers.

Roses: And what do these studies tell us?

Jason: Firstly, we learnt about several barriers to hospitals admitting their first patient to hospital to home. Arguably the most important finding was the reluctance of hospital specialists to refer patients to the service and they also found it challenging to identify eligible patients.

Roses: How did hospitals manage this challenge?

Jason: The key was very early engagement with the hospital specialists and emergency physicians who refer the patients and whose trust needs to be built so that they become comfortable to refer patients to hospital at home.

Roses: Were there any other challenges for services to get started?

Jason: Yes, there were. Regulations were a barrier that stopped services getting started and admitting patients. This means that health service leaders need to understand any regulatory requirements to deliver hospital at home, or specific components. For example, in a study in the US, regulatory approval was needed if the service was to deliver medications to a patient's home, and it was challenging for some services to gain that approval.
There were also financial barriers. Although we know that it's likely to be cheaper to treat someone at home rather than in hospital, policy makers and those responsible for hospital finances need clear evidence of financial benefit (or at least not costing more). However, some services found it really difficult to measure the financial impact of hospital at home for their hospital. This was particularly so for private hospital services that had multiple payers to deal with. Some overcame this by starting small with a limited number of eligible patients before expanding.

Roses: Turning to you, Sasha, can you tell us more about the evidence on costs and patient outcomes in your Cochrane review and how it fits with Jason's?

Sasha: Thanks Roses, by happy coincidence we were able to update the admission avoidance hospital at home review while collaborating on the qualitative evidence synthesis. This helped with the interpretation of the trial evidence in our review and identified questions that could be answered by the qualitative evidence synthesis.
This included the difficulty with the cost-effectiveness evidence because trials used different approaches to costing resource use, and unit costs varied by country and sometimes within a country. For example, in the UK randomised trial I was involved with, which we included in the review's update, we found that hospital at home was a cost-effective alternative to hospital admission for an older population. This was mainly driven by a reduction in the time patients spent in hospital and fewer people in the hospital at home group had a new admission to residential care. However, it's difficult to say if this would be replicated in other health systems. Overall, for the review, 12 studies reported cost data, and in general, hospital at home appeared less costly than hospital, but with a range of different values and follow-up times.

Roses: What about other outcomes? For instance, is hospital at home safe for patients?

Sasha: In terms of effectiveness, while few studies reported on adverse events, we are moderately confident that for an older population, admission avoidance hospital at home does not make a difference to the number of people who died when compared to in-hospital care. Similarly, we are moderately confident that the risk of a new admission to residential care was reduced for an older population who were allocated to hospital at home rather than admission to hospital. Few studies reported on patient satisfaction and as is often the case, data on length of stay varied among trials.

Roses: Coming back to you Jason, did other key themes arise from your qualitative evidence synthesis?

Jason: Yes, several, let's start with safety. This was probably the number one concern for patients considering having hospital at home and a physician's decision to refer them to it. For example, patients were concerned about being alone when unwell and not having round the clock staff supervision that they would have in a hospital bed. On the other hand, there were also privacy concerns with patients not wanting staff in their homes.
Another major theme related to the specific workforce, skills and processes needed to deliver hospital at home. What helped was having a hospital at home manager and clinical champion who drove the service, had experience of working in a hospital and could instil a positive culture and confidence in the team. The manager could encourage their team to generate innovative ways to make hospital at home more efficient and ensure protected time for staff training.

Roses: What did caregivers think about the patient being at home? Did this matter?

Jason: Yes indeed. The impact of hospital at home on the caregiver was very interesting. While the impact could be positive, such as they didn't have to travel to see their loved one in hospital. What really surprised us was that the impact could be particularly negative on caregivers. They reported disruptions to their sleep and usual routines such as work, feeling stressed, untrained, unsupported and unpaid.

Roses: So, lastly, what about growing the service and making it sustainable?

Jason: This was another key theme. For sustainability, established services expanded the referral options to include more conditions, more acute wards or departments and more primary care practices. Interestingly, some leaders felt it was easy to recruit staff because they wanted to work in hospital at home, which was seen as an attractive role. But, one study conducted in rural settings, did report dissatisfaction with the amount of travel in the car.

Roses: Thanks. Sasha, can you sum up what this all means for health service leaders.

Sasha: Firstly, from the updated quantitative review, hospital at home seems to be an effective alternative to treating patients in hospital. From the qualitative evidence synthesis, there are several things for healthcare leaders to think about. These include strategies to address uncertainty from specialists regarding referrals to hospital at home; the staff training that is needed, including advanced training to expand the roles of staff and increase the capacity for medical care in the home; and defining, recognizing and discussing the caregivers' role.

Roses: Thanks to both of you. If listeners would like to read the reviews, how can they get hold of them?

Sasha: They're online at Cochrane Library dot com and links to both appear with a simple search for "hospital at home".