Evaluation of home care utility: pneumonia, cerebrovascular disease, urinary tract infections and postsurgical infections

AUGUSTOVSKI, F.; PICHON RIVIERE, A.; ALCARAZ, A.; BARDACH, A.; FERRANTE, D.; GARCIA MARTI, S.; GLUJOVSKY, D.; LOPEZ, A.; REGUEIRO, A.

Documentos de Evaluación de Tecnologías Sanitarias

IECS

Año: 2007 p. 1 - 30

1668-2793

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.A bibliographic search was carried out on the main databases (MEDLINE, EMBASE, Cochrane, DARE, NHS EED), on general Internet engines, in health technology evaluation agencies and health sponsors. Priority was given to the inclusion of systematic reviews; controlled, randomized clinical trials (RCTs); assessment of sanitary technologies and economic evaluations; clinical practice guidelines and coverage policies of other health systems.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).Ricauda et al performed a cost analysis. The results do not show differences in total costs: $ 6,413 versus $ 6,504 (US dollars, 2005) per hospital stay. It is worth pointing out that after admission, 50% of the hospital admitted patients had not completed rehabilitation whereas all the home care managed patients had done so. The stroke management guidelines prepared by the New Zealand s Guidelines Group suggest that evidence is not enough to assess the risks and benefits of home care in these cases and suggests hospital care unless the patient/family prefers to be managed at home. Upper urinary track infections No concluding evidence was found as regards home care in patients with upper urinary tract infections. Infection Evolution during the Post-operative period No concluding evidence was found as regards home care in patients with infections during post-operative periods.