Early Supported Discharge/Hospital At Home For Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Review and Meta-Analysis

Figures & data

Figure 1. Result of the search strategy and reasons for excluding trials from the review.

Table 1. Inclusion and exclusion criteria for trials included in the mortality and readmission analysis

		Exclusion criteria
	Additional AECOPD inclusion
Study	criteria	Clinical indices	Co-morbidities	Demographic and social
Cotton 2000	Not reported	Acidaemia (H^+ > 45 nM); Pneumonia or lung cancer on CXR	Other medical conditions, including: Chest pain suggesting MI or PE; Anaemia; Gastrointestinal or endocrine disorders; Musculoskeletal disease; Nausea, vomiting and dehydration	Non-Glasgow resident; Homeless or Hostel dwellers; Unable to consent; No telephone; Discharge already planned; Primary social admission
Davies 2000	FEV1 < 80% predicted; FEV1/FVC < 70%; HR < 100, SBP >100; pH > 7.35, PaO2 > 7.3; PaCO2 < 8; WCC 4–20 × 10 g/l; MMSS>7	Marked use of accessory muscles; Uncontrolled LVF; Acute changes on echocardiogram; Need for intravenous therapy; Suspected malignancy, pneumothorax, or pneumonia on CXR	Asthma	Require full-time nursing care
Skwarska 2000	Not reported	Impaired LOC or acute confusion pH < 7.35; Acute changes on CXR	Other serious medical conditions, e.g., Ischaemic cardiac pain; Cardiac failure	Social reasons
Ojoo 2002	FEV1/FVC < 70%; Previous FEV1 reversibility to salbutamol < 15%.	Acidosis or new type 2 respiratory failure; Cor pulmonale; Acute changes on CXR	Concomitant medical conditions requiring medical admission.	Age >18; no telephone; Resident >15 miles from hospital; Poor home support or lives alone
Nissen 2007	FEV1 < 80%; FEV1/FVC < 70% with lack of reversibility 30 mins after bronchodilator therapy PaO2 > 7.3	Need for intravenous therapy; Need for NIV or ventilation; ECG changes; Pneumonia on CXR	Unstable heart failure; Confusion; Other severe medical disorder	Inadequate social conditions; No telephone; Lives outside the hospital area; Previously participated in the study; Participant in another study
Ricauda 2008	Not reported	PaO2 < 6.7; pH < 7.35 or > 7.55; Suspected PE or MI; MMSS < 14 (severe dementia)	Severe renal impairment; Cancer (not skin); Hepatic failure	No family or social support; Age < 75; no telephone; Living outside catchment area
Utens 2012	10 pack-years of smoking	Impaired LOC or acute confusion; Indication for admission to ICU or NIV; Acute ECG changes; pneumonia on CXR By day 3: no decrease in physical complaints IV therapy or newly prescribed oxygen therapy; BM ≥ 15 mmol/l (and unable to self-regulate)	Major uncontrolled co-morbidity including heart failure and malignancy Mental disability including dementia; Active alcohol and/or drug abuse	Age < 40; Lives outside care region; Inability to understand; Lack of home care By day 3, independent toileting</TB>

Key: AECOPD – Acute exacerbation of chronic obstructive pulmonary disease; FEV₁ – forced expiratory volume in 1 second; MMSS – Mini mental state score; FEV₁/FVC – FEV₁/forced vital capacity; HR – heart rate; SBP – systolic blood pressure; PaO₂ - partial pressure of oxygen in arterial blood; PaCO₂ – partial pressure of carbon dioxide in arterial blood; WCC – white cell count; LOC – level of consciousness; LVF – left ventricular failure; CXR – chest X-ray; MI – myocardial infarction; PE – pulmonary embolus; ICU – intensive care unit; NIV – non-invasive ventilation.

Table 2. Baseline characteristics of patients and risks of bias in trials included in the mortality and readmission analysis

Study	Number of patients	Age	FEV1	PaO2	PaCO2	Risks of bias
Cotton 2000	ESD/HAHUC	4140	65.7 (1.6)*68.0 (1.2)*	0.95(0.08) 41 (3)*%0.94(0.06) 44 (3)*%	8.5 (0.4)*9.2 (0.4)*	6.0 (0.3)*5.5 (0.2)*	Follow-up method varied. Some patients had face-to-face contact, others did not. More withdrawals in ESD/HAH.>
Davies 2000	ESD/HAHUC	10050	70(8)70(8)	0.82(0.37) 36.1(17.2)%0.76(0.28) 35.1(14.7)% post bd	9.7 (2.9)9.0 (1.2)	5.2 (1.0)5.2 (0.8)	Methods of sequence generation and follow-up not reported. Higher rate lost to follow-up in usual care group.
Skwarska 2000	ESD/HAHUC	12262	68.569.9	0.770.66	>7 (91.6%)>7 (90%)	Not reportedNot reported	Allocation concealment unclear. Unequal proportions lost to follow-up.
Oojo 2002	ESD/HAHUC	3030	69.770.1	1.0 (0.38)0.85 (0.34)	Not reportedNot reported	Not reportedNot reported	Random sequence generation method not reported.
Nissen 2007	ESD/HAHUC	2222	69 (10.3)69 (10.1)	1.5 at admission 40.1 (17.7)%1.4 at admission 33.7 (10.0)%	9.2 (1.4)8.9 (1.3)	5.5 (0.7)5.5 (0.81)	Sequence generation not described in article; author confirmed sealed envelopes were used.
Ricauda 2008	ESD/HAHUC	5252	80.1 (3.2)79.2 (3.1)	0.92(0.4)1.04(0.5)	9.2 (2.5)8.7 (1.9)	5.9 (1.6)6.1 (1.6)	Education only provided within the ESD/HAH arm.
Utens 2012	ESD/HAHUC	7069	68.3 (10.3)67.8 (11.3)	Not reportedNot reported	9.0 (1.1)9.4 (1.8)	5.2 (0.7)5.0 (0.8)	Unequal proportions of patients lost to follow-up.

Values are given as means (standard deviations). Key: * – standard error; ^† – 8 weeks post discharge; FEV₁ – forced expiratory volume in 1 second; PaO₂ – partial pressure of oxygen in arterial blood; PaCO₂ – partial pressure of carbon dioxide in arterial blood; ESD/HAH – early supported discharge/ hospital at home; UC – usual care; bd – bronchodilator.

Table 3. Recruitment process and structure of care for ESD/ HAH services in trials

Study	ESD/ HAH recruitment structure			Structure of ESD/ HAH services
	When?	Where from?	Who by?	Intervention	Additional services provided
Cotton 2000	Monday to Friday mornings Discharge next working day after recruitment	Medical Wards	Respiratory specialist nurse, respiratory middle grade doctor	Nurse visited morning after discharge and then as required: median 11 visits over median 24 days. GP out of hours care.	Nebulised bronchodilators, oxygen cylinders. (Additional social support or community physiotherapy not provided).
Davies 2000	Monday to Sunday 08.00 to 18.00	Accident and Emergency	Respiratory specialist nurse; Respiratory Doctor	Nurse escorted home, visited mornings and evenings for first 3 days, then as required: mean (SD) 11 (3) home visits. District nurse cover evenings and overnight.	Social support (cleaning, shopping, W&D, MOW, day and night-sitters). Nebulised bronchodilators, oxygen concentrator.
Skwarska 2000	Monday to Friday 09.00 to 17.00	Accident and Emergency; Medical Admissions Unit	Medical Registrar; Acute Respiratory Assessment Service; Respiratory Consultant	Nurse visited next day and then 2–3-day intervals: mean 3.8 nurse visits. Weekly meeting with consultant. Medical advice available daily from on-call respiratory team	Nebulised bronchodilators, oxygen concentrator.
Ojoo 2002	Monday to Thursday 09.00 to 17.00 Discharge within 48hrs	Medical Chest Unit	Respiratory outreach nurses	Nurses complete daily progress and symptoms score charts. The medical chest unit were available out of hours by phone.	Oxygen therapy and nebulised bronchodilators.
Nissen 2007	Discharged from hospital within 48 hours of admission	Not reported	Project nurses	Chest physiotherapy (assumed provided in hospital). Mean 2.6 (1–6) home visits; mean 1.5 hours nurse visit; mean 2.1 (0–6) phone contacts; mean phone time 15 mins; average time per patient = 4 hours 15 mins.	Oxygen therapy. No additional social support.
Ricauda 2008	Monday to Sunday. Mean time in emergency department =15.5 hrs	Emergency department	Not reported	3 Geriatricians, 13 nurses, 3 physiotherapists, 1 social worker, 1 counsellor. Daily meetings. 7 day service. Physician and nurse visit day after discharge, then daily nurse visit (mean = 14.1) and physician visit every 2–3 days (mean = 9.9).	Oxygen therapy, nebulised bronchodilators, intravenous antibiotics and steroids.
Utens 2012	Screened for inclusion day 1. Randomised day 3 of admission, home on day 4	Not reported	Community nurses; Respiratory Physician	Community nurses visited or contacted patient at least once daily on day of discharge and for 3 consecutive days.	24-hour telephone access to hospital respiratory ward for emergencies.</TB>

Key: GP – General Practitioner; W&D – washing and dressing; MOW – meals on wheels.

Table 4. Readmission and mortality rate in trials.

Study	Readmitted / at-risk patients		Died / at-risk patients		Notes	Further information provided by author?	Lost to follow-up?
	ESD/HAH	UC	ESD/HAH	UC
Cotton 2000	12 / 41 12 / 41	12 / 40	1 / 41	2 / 40	Readmission and mortality data analysis as reported in study.	Clarification on definition of readmission, and exclusions and withdrawals.	Nil reported
Davies 2000	35 / 93 37 / 95	17/ 45	9 / 95	4 / 45	Two patients died within 14 days in ESD/HAH, both developed pneumonia, not visible on admission CXR, and returned to hospital before death. Denominator reduced in ESD/HAH and UC for patients with missing data for readmission and mortality.	Confirmed 14-day period defined as the period of acute care and additional details regarding mortality.	5 in ESD/HAH 5 in UC
Skwarska 2000	27 / 108 39 / 120	21 / 61	4 / 122	7 / 62	In UC one patient died in acute period so removed from denominator for readmission. In ESD/HAH, twelve patients readmitted during hospital at home period, who were not analysed as readmissions so subtracted.	Mortality and readmission data confirmed with author. On review of the data, author confirmed that two patients in ESD/HAH were not included in the readmission analysis (subtracted from denominator).	Nil reported
Ojoo 2002	9 / 27 11 / 29	12 / 27	1 / 27	3 / 27	In UC readmission rate reported as 44.4% (12/27). ESD/HAH readmission rate 33.3%. As 27 followed up, number of events = 9. Of three patients excluded from ESD/HAH analysis, authors report two patients returned to hospital during ESD/HAH.	No.	3 in ESD/HAH 3 in UC
Nissen 2007	4 / 22 6 / 22	8 / 22	1 / 22	0 / 22	No deaths during the acute period. No patients lost to follow-up.	Detailed information provided on readmission and return to hospital data. Two patients who were admitted during ESD/HAH were included in the analysis, and were not readmitted during follow-up, so denominator not adjusted.	Nil reported
Ricauda 2008	17 / 41 20 / 41	34 / 39	9 / 50	12 / 51	Three patients returned to hospital during ESD/HAH, not termed readmissions. Unable to clarify if these 3 patients were readmitted during follow-up period.	No.	2 in ESD/HAH 1 in UC.
Utens 2012	17 / 66 18 / 66	17 / 56	1 / 66	1 / 56	Patients died during the follow-up period, not acute period, so denominator not adjusted.	Detailed information provided on follow-up. UC- of 16 lost to follow-up, 3 known to be readmitted. ESD/HAH- of 6 lost to follow-up, 2 known to be readmitted prior to being “lost”.	4 in ESD/HAH 13 in UC

In some instances, patients who returned to hospital during EDS/HAH were not included in the authors' analysis, so they have been removed from both the numerator and denominator. Patients who died during the acute period are not at risk of readmission and have been removed. The numbers in bold (readmission column) describe readmissions including return to hospital during ESD/HAH. Patients who were lost to follow-up have been removed.

Figure 2. Forest plot comparing ESD/HAH versus UC for mortality.

Figure 3. Forest plot comparing ESD/HAH versus UC for proportion of readmissions with return to hospital not classed as a readmission.

Figure 4. Forest plot comparing ESD/HAH versus UC for proportion of readmissions including return to hospital as a readmission.

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