Low-risk COPD exacerbations can be managed at home

Tuesday, 19 Jun 2018

Managing patients in their own home is a safe and cost-effective alternative to inpatient care for some patients with COPD excarbations, UK research shows.

In a non-inferiority randomised control trial of 118 patients with a low-risk COPD exacerbation selected by DECAF score, ‘hospital at home’ (HAH) was a more cost-effective approach than usual care (UC), mainly due to a fivefold reduction in median hospital bed days over 90 days.

There was also a small, non-significant difference in QALYs favouring hospital at home , researchers wrote in Thorax.

No deaths were reported in either arm during the acute period and readmission rates over 90 days were comparable in intention-to-treat and per-protocol analyses.

“Crucially, 90% of patients across both arms stated they would prefer hospital at home to usual care for future exacerbations of similar severity” the researchers said.

Previous studies have shown the DECAF score can robustly predict inpatient mortality in patients admitted with COPD exacerbation, they wrote.

“Approximately 50% of hospitalised patients have a DECAF score of 0 or 1, which is associated with a low in-hospital mortality risk,” they wrote.

“Selection for hospital at home by DECAF offers the potential to more than double the proportion of eligible patients compared with earlier models, while simplifying the selection process.”

Lead author Dr Stephen Bourke, a respiratory medicine consultant with Northumbria Healthcare NHS Foundation Trust, said the team involved in the trial began offering a full hospital at home service to all eligible trust patients in September 2017.

In the HAH model trialled in the study, patients were admitted to hospital, identified as low risk by DECAF, and then returned home under the care of the hospital respiratory scheme, usually within 24 hours of admission.

The treatment period ended when the respiratory specialist nurse and consultant deemed the patient well enough to be discharged to GP care, typically after five days.

Cost savings predominantly came from reduced hospital bed days, Dr Bourke told the limbic, but formal social care costs were also lower in hospital at home .

“I suspect inactivity and deconditioning associated with hospital admission, compared to better maintenance of usual activities within hospital at home , plays a role here,” he said.

Hospitals unable to offer home-based care could still use the DECAF score as a guide to select patients for early supported discharge, researchers suggested.

“An important observation within the RCT was that the median length of stay in the usual care arm was two days shorter than expected without adverse outcome implying that low risk DECAF can inform early discharge in hospital,” Dr Bourke said.

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