Recommendations from NICE guidelines

The recommendations from the NICE guidelines are shown in table 1⇓, but leave many unanswered questions:

• How, where and by whom should patients be assessed for suitability for HaH?

• Should HaH aim to avoid admission or to implement early supported discharge?

• Should the service be limited to 9:00 to 17:00 hours Monday to Friday or should its hours of operation be more extended?

• What proportion of patients with exacerbations of COPD will be suitable for HaH?

• Should the HaH team be composed of specialist practitioners or could it be generic?

• Does HaH require modification of treatment policy?

• What competencies are necessary to deliver HaH?

• What should comprise home care?

• How many visits will be necessary and for how long?

• Would stable COPD patients benefit from intermediate care?

This guideline will attempt to answer the above questions so that both existing services may be modified and also that new services may be set up in the light of the present evidence base.

Assessment proformas/protocols/integrated care pathways

Several studies have shown that integrated care pathways (ICPs) can improve the delivery of care. This has been demonstrated by RCTs in the areas of inpatient asthma management, pneumonia, stroke rehabilitation, heart failure and orthopaedic surgery.^{8,9,10,11,12,13} Given the stereotyped nature of assessment and treatment in exacerbations of COPD, it is a potential area in which to use an ICP, but there have been no trials of this. Most ESD services use assessment proformas, although some have more detailed protocols (Angus, 2005). Examples of such documents can be viewed on the BTS website (http://www.brit-thoracic.org.uk/). [Level of evidence IV]

Recommendation

• (R1) A hospital should use an assessment proforma, protocol or ICP if setting up an integrated care service in order to deliver uniform care and facilitate audit. [Grade D]

The decision to treat at home

In making this decision, several questions need to be asked:

• During the period of the exacerbation, patients are likely to need increased social or nursing input to enable them to manage their essential activities of daily living. Can this be provided by relatives, social services and respiratory liaison nurses? Can the patients rapidly and easily obtain help should they deteriorate?

• Can additional pharmacological treatment be delivered in the home environment? The major issues are compliance, ability to operate a nebuliser or oxygen cylinder unsupervised and current smoking status if oxygen is required.

• Is it possible to identify patients at high risk of rapid decline or failure to cope such that they should not be offered home treatment?

On the last question, many studies have demonstrated factors which identify group characteristics of patients at an increased risk of relapsing or requiring admission to hospital during an exacerbation of COPD.^14–,²⁵

Such factors include:

• increasing age;

• longer duration of COPD;

• severity of impairment of FEV₁;

• frequency of exacerbations;

• chronic mucus hypersecretion;

• co-morbidity (especially heart disease);

• use of home oxygen or maintenance steroids;

• failure of first-line treatment;

• previous history of relapses;

• generalised debility or malnutrition.

However, the models developed from these risk factors to predict relapse show only moderate sensitivity and specificity^14,26 and are of marginal usefulness when faced with individuals. In a descriptive study of intermediate care for COPD,²⁷ the initial severity of the exacerbation was similar among those treated at home and those who later required admission.

The RCTs looking at HaH for exacerbations of COPD have taken a pragmatic approach in deciding which patients can be managed at home. Since they have repeatedly shown no increase in admission/readmission rates, it is likely that their criteria for managing at home are safe.

The least restrictive set of absolute criteria for admission which were used in three studies^3,6,7 were impaired level of consciousness, acute confusion, pH <7.35, acute changes on the chest radiograph, a concomitant medical problem requiring inpatient stay, insufficient social support, no telephone and residence geographically removed from hospital.

Some of the studies were slightly more prescriptive and required an ECG to be performed,⁴ or excluded subjects with any respiratory failure²⁸ or those with newly diagnosed type 2 respiratory failure.⁵[Level of evidence III]

Recommendations

HaH should not be offered to patients with:

• (R2) Impaired level of consciousness. [Grade C]

• (R3) Acute confusion. [Grade C]

• (R4) pH <7.35, if arterial blood gases have been measured. [Grade C]

• (R5) Acute changes on chest radiograph. [Grade C]

• (R6) Concomitant medical problem requiring inpatient stay. [Grade C]

• (R7) Insufficient social support, no telephone, residence geographically removed from hospital. [Grade C]

• (R8) New hypoxaemia (Spo₂ ⩽90%)–a contraindication if oxygen cannot be provided at home. [Grade D]

Venous blood tests

Venous blood tests may help in some cases to clarify the cause or contributory factors of an exacerbation or help in guiding treatment. The frequency with which such tests affect management in exacerbations of COPD has not been the subject of a study and therefore they are not routinely recommended. [Level of evidence IV]

Recommendation

• (R9) Blood tests need not be routinely performed when considering patients for home management of their exacerbation but should be available if they are indicated after assessment. [Grade D]

Sputum analysis

The use of sputum microbiology to guide treatment of an exacerbation of COPD has not been the subject of a study. It is known that the airways of a proportion of patients with stable COPD are chronically colonised with bacteria and consequently an organism cultured during an exacerbation may not be causal.^29,30 Similarly, the spectrum of antibiotic-responsive organisms commonly causing exacerbations is well known without the need for culture.¹⁸ Consequently, the NICE guideline² recommends routine sputum culture only for patients admitted to hospital and when the sputum is purulent.

Recommendation

• (R10) Routine sputum culture before referral to HaH is not necessary. [Grade D]

ECG

The usefulness of an ECG has not been the specific subject of a study in exacerbations of COPD. In the absence of specific symptoms or signs such as chest pain or arrhythmia, it is unlikely that this test would alter management. [Level of evidence IV]

Recommendation

• (R11) An ECG need not be routinely performed when considering patients for home management of their exacerbation but is indicated if the resting heart rate is <60/min or >110/min. [Grade D]

Arterial blood gases and pulse oximetry

According to the NICE guidelines²:

• supplemental oxygen therapy should be given in exacerbations of COPD to maintain Spo₂ >90% and <94%; and

• patients with hypercapnic respiratory failure with an arterial blood pH <7.35 should be considered for ventilatory support.

Since oxygen therapy can cause decompensation of respiratory failure in COPD, arterial blood gas measurements should be performed before and after 1 hour on the flow rate of oxygen on which it is intended to send the patient home. [Level of evidence NICE]

Recommendation

• (R12) Pulse oximetry should be performed on all subjects being considered for home management. Arterial blood gas measurements should be performed if Spo₂ is ⩽90%. These should be repeated after 1 hour on the intended therapeutic flow rate of oxygen aiming for 90% <Spo₂ <94% and an arterial blood pH >7.35. [Grade NICE]

Chest radiography

In patients presenting to hospital with an exacerbation of COPD, performance of chest radiography leads to a change in management in 7–21% of patients.^31–,³³ In the population of patients considered for HaH, this figure is likely to be lower as these patients are less acutely unwell. However, as the principal differential diagnoses are detectable on a chest radiograph (pneumonia, pneumothorax, pulmonary oedema),³⁴ this test remains important. [Level of evidence IV]

Recommendation

• (R13) A chest radiograph should be performed on all subjects being considered for home management. [Grade D]

Spirometry

Spirometry is important in confirming the diagnosis of COPD and, unless confused or comatose, even the sickest of patients can attempt an FEV₁ manoeuvre. [Level of evidence IV]

Recommendation

• (R14) Baseline spirometry should be carried out to confirm the diagnosis in cases where this is the patient’s first presentation with presumed COPD. [Grade D]

Types of service

Second UK COPD audit (2003)³⁷

In this audit 44% of hospitals had access to ESD and, in these, eligibility for ESD was 31%. The types of service in the hospitals with ESD were:

• Admission avoidance from A&E: 5%

• Early supported discharge (<48 hours): 26%

• Supported discharge (>48 hours): 23%

• Combination of above: 12%

• Unknown: 34%

Recommendations

• (R15) In busy inner city hospitals, if staffing levels permit, the combined approach of admission avoidance and early supported discharge is practicable but might be expensive. Eligibility for HaH varies from 30% to 35% with readmission from home care of 10%. [Grade A]

• (R16) In hospitals with fewer admissions for COPD or limited respiratory staffing levels, early inpatient assessment for supported discharge is the favoured model for HaH. Eligibility for HaH varies from 35% to 40%. [Grade A]

• (R17) Recruitment for HaH following direct GP referral is not recommended because of large numbers of inappropriate referrals. [Grade C]

Hours of operation

Recommendations

• (R18) For inner city hospitals with high COPD admission rates, a 24 h/7 day service should be set up in order to maximise admission avoidance. [Grade C]

• (R19) For hospitals with fewer COPD admissions, hours of operation should correspond to the peak times of COPD referrals and a Monday to Friday service may be most cost effective. [Grade C]

A summary of HaH approaches in COPD is shown in table 3⇓.

Overall responsibility

In general, out-of-hours cover and responsibility for the patient has remained with the hospital-based HaH service although, in one study, patients were advised to contact their GP if problems arose out-of-hours.⁷ The authors did not report how this arrangement impacted on primary care services. All schemes have included assessment by a respiratory physician before recruitment to HaH. Patients are usually discharged from the service by the respiratory practitioner who has been supervising the home care. At that stage clinical responsibility is formally transferred back to primary care either by fax or email. [Level of evidence III]

Recommendations

• (R20) After recruitment to HaH, clinical responsibility and out-of-hours cover should be undertaken by the acute trust. [Grade C]

• (R21) When the patient is discharged from HaH, clinical responsibility should be formally transferred back to primary care either by fax or by email. [Grade C]

Team composition

The medical lead in all teams which have published their results has come from a consultant respiratory physician, backed up by junior respiratory trainees. Respiratory nurse specialists have been members of the HaH team in all published randomised trials. Respiratory physiotherapists also participate in several UK schemes.³⁸

Generic HaH models have been described in which home care is provided by non-specialist district nurses.^28,36,39 Two of these were small RCTs^28,39 and the other an observational study.³⁶ In the latter, the initial assessment was carried out by specialised respiratory staff and the results were broadly similar to the findings in the RCTs where HaH was delivered by specialist respiratory practitioners.^3–,⁷

In the 2nd UK COPD audit,³⁷ 81% of the schemes were run primarily by respiratory nurses, 11% by general nurses, 2% by physiotherapists and 2% by both physiotherapists and nurses. [Level of evidence III]

Recommendations

• (R22) The lead clinician should be a consultant respiratory physician, supported by trainee junior medical staff. [Grade C]

• (R23) The home care team should be lead by a specialist respiratory nurse, physiotherapist or appropriately qualified health professional. [Grade C]

• (R24) Inner city hospitals should aim for specialist teams, but district general hospitals in provincial or rural areas should consider generic teams which may deal with several HaH services. [Grade C]

Home care team competencies

None of the published studies has dealt with the skills which are necessary for the home care nurses and physiotherapists. The following recommendations are based on the consensus view of the Guideline Development Group. [Level of evidence IV]

Recommendations

• (R25) Key skills for members of the HaH teams include:

  • ability to take a comprehensive clinical history;

  • proficiency in assessing clinical condition;

  • familiarity with pharmacological and non-pharmacological approaches;

  • knowledge of current guidelines in COPD management;

  • excellent communication skills;

  • excellent team working skills. [Grade D]

• (R26) Useful but non-essential team member skills include:

  • ability to perform chest auscultation;

  • venous and arterial blood sampling;

  • performance of and basic interpretation of an ECG;

  • interpretation of a chest radiograph;

  • performance of spirometry;

  • understanding of airway clearance techniques. [Grade D]

Assessment at home after recruitment into HaH scheme

None of the published studies has critically evaluated the various aspects of assessment at home during HaH. However, there is general agreement that the first visit should be on the day after recruitment to HaH and subsequent visits arranged as considered necessary by the respiratory practitioner. In one study, visits were carried out twice daily for the first 3 days.⁴ In most studies, dyspnoea, cough, sputum colour/volume and vital signs were recorded. Oxygen saturation was measured by oximetry.

The studies on the role of oral steroids in exacerbations have used changes in FEV₁ as an outcome measure and have shown that this measurement can detect recovery from an exacerbation.⁴⁰ Furthermore, a low FEV₁ value at admission associated with failure to improve over the first few days of an exacerbation in hospital was highly predictive of a poor clinical outcome.⁴¹ In some HaH studies spirometry was carried out using portable electronic spirometers,^7,27 but was not always considered essential.³⁶ It is, however, recommended before discharge.²

Telephone contact via the respiratory practitioner’s mobile phone was encouraged^6,42 and a copy of the clinical notes left with the patient to assist the general practitioner if called in an emergency.²⁷ In two studies there were weekly team meetings with the hospital respiratory physician.^3,6 In an inner city scheme, each nurse visited 5–6 patients daily usually in the mornings with an average of 2–3 assessments carried out in the hospital in the afternoons (Stevenson, 2005). [Level of evidence IV]

Recommendations

• (R27) The first visit should be carried out on the day after recruitment to HaH. [Grade D]

• (R28) Details of level of dyspnoea, cough and sputum volume/colour should be recorded. [Grade D]

• (R29) Vital signs including pulse, BP, respiratory rate and temperature should be measured. [Grade D]

• (R30) Oxygen saturation should be measured by oximetry and the Spo₂ documented alongside the Fio₂. [Grade D]

• (R31) A copy of the clinical notes and observations should be left in the patient’s home. [Grade D]

• (R32) Serial spirometry may be useful as objective confirmation of improvement or worsening during an exacerbation and should always be measured before discharge. [Grade D]

• (R33) Treatment compliance and nebuliser/oxygen usage should be assessed. [Grade D]

• (R34) Telephone contact with respiratory practitioner should be encouraged. [Grade D]

• (R35) Weekly team meetings should be held. [Grade D]

Duration of hospital/home care and number of visits

The duration of home care has varied considerably in the published studies, from 3.56 days⁶ to 24 days,⁷ with a mean value of 11 days. The number of visits varied from 3.8³ to 11.^4,7 In one study the intervention was considered to have failed if more than five visits were required.⁶ These parameters are obviously influenced by the experience and confidence of the practitioners. There is no evidence that the outcomes were affected by the duration of care or by the number of visits.

In the 2nd UK COPD audit³⁷ the median length of stay in hospitals with access to ESD was 4 days compared with 7 days where there was no ESD. The median length of stay in the ESD scheme was 11 days (hospital time + ESD time). [Level of evidence III]

Recommendations

• (R36) Home care should be completed in fewer than 14 days and with fewer than 10 visits. [Grade C]

• (R37) Failure to comply with the above recommendation requires team discussion. [Grade C]

Understanding ESD

Three important points arose from a recent qualitative study which was aimed at evaluating a COPD supported discharge scheme (Clarke et al, unpublished, 2005):

1. Hospital managers and staff should agree precise aims and objectives of the service.

2. Patients should understand why the service was set up, the meaning of supported discharge and the necessity of home visits by respiratory practitioners.

3. The discharge process was often similar to that for ordinary discharges and included long waits for transport and delays in getting drugs from pharmacy, despite HaH patients technically still being within a period of secondary care. [Level of evidence IV]

Recommendations

• (R38) There should be written agreement between management and medical/nursing staff defining the scope and objectives of an ESD service. [Grade D]

• (R39) Patients should be given an information leaflet about the service, as shown in Appendix 2. [Grade D]

• (R40) The process of discharge should be streamlined. [Grade D]

Telemetry

A home telecare system was found to be time consuming for staff as they had to familiarise themselves with the equipment and this was a barrier to its implementation. Procurement and user-friendliness of equipment were problematical.^43–,⁴⁵ A review of cost effectiveness in telemedicine found that the literature was limited and the methodology seriously flawed.⁴⁶ This view was confirmed in a systematic review where only 4% of 600 studies met the criteria for inclusion in a formalised quality review.⁴⁷[Level of evidence III]

Recommendation

• (R41) There is insufficient evidence to justify setting up telemetry in HaH at present. [Grade C]

Economics of service provision

The published HaH studies have largely been performed in inner city teaching hospitals. Two of the randomised trials of HaH have included economic evaluations of the intervention. In the Edinburgh study the estimated average cost to the health service of patients in the HaH group was £877 per exacerbation compared with £1753 in the control group.³ Similar findings were reported in the Barcelona study where the average health care cost of HaH patients was 62% less than that of the control patients.⁶ Difficulty in obtaining funding was the primary reason for inability to set up a HaH scheme for COPD among UK physicians.³⁸ Further more detailed health economic evaluations are required to inform healthcare providers of the cost implications of HaH for COPD exacerbations, but the evidence to date does suggest that a cost benefit is likely. A sample business case is shown in Appendix 3. [Level of evidence III]

Recommendation

• (R42) Plans for new HaH services should include formal health economics evaluation. [Grade C]

When and how to give bronchodilators?

Short-acting bronchodilators (β agonists or anticholinergics) are effective in increasing FEV₁ and reducing breathlessness.² These can be given in combination and have effects that last between 4 and 6 hours and therefore need to be administered regularly at the time of exacerbation.

Bronchodilators can effectively be administered by nebulisers or hand-held inhalers.² Nebulised treatments are more convenient to administer as supervision of up to 20 inhalations of a hand-held inhaler would be necessary to produce a similar effect to one nebuliser.⁴⁸ Nebulised delivery of bronchodilator was the standard treatment for most patients enrolled in controlled trials of HaH.^3–5,7,42[Level of evidence NICE]

Recommendations

• (R43) Regular administration of short-acting broncho-dilators (β agonist/anticholinergic or both) should be administered to all patients during HaH care. [Grade NICE]

• (R44) Nebulised delivery is the mode of choice in HaH. [Grade C]

Who should receive corticosteroids?

Well conducted trials have established a role for corticosteroid therapy in COPD exacerbations.^49–,⁵¹ Rates of treatment failure decrease and duration of hospital stay is reduced by approximately 2 days after corticosteroid administration.

In the randomised trials, a significant number of patients developed glycosuria or required treatment for hyperglycaemia. Employing HaH limits the approaches that can be taken to control hyperglycaemia induced by prednisolone. Particular attention should be paid to diabetics who are prescribed corticosteroids during home care.

The NICE guidelines have proposed the use of prednisolone at 30 mg for 7–14 days in all those hospitalised with an exacerbation and its consideration in outpatients with an exacerbation who can tolerate prednisolone.² Since HaH patients would be hospitalised if the service did not exist, it is reasonable that they should all be prescribed corticosteroids. [Level of evidence NICE]

Recommendation

• (R45) Prednisolone 30 mg/daily should be given for 7–14 days to all patients unless there is a specific contraindication to steroid therapy. [Grade NICE]

Who should be given oxygen?

Oxygenation deteriorates unpredictably during an exacerbation.⁵² Oxygen administration improves arterial oxygenation and relieves symptoms including breathlessness.⁵³ It is considered that oxygen saturations greater than 90% and less than 94% are optimal and that this is usually achievable with 2 or 4 litres by nasal cannula, or by 24% or 28% by Venturi mask.⁵² The target oxygenation (90–93%), not mode of delivery, is prescribed in the NICE and joint ATS/ERS COPD guidelines.^2,54

Arterial blood gas measurement is necessary to assess the initial response to oxygen therapy and to monitor for worsening hypercapnia with repetition after 1 h.² Oxygen saturation monitors can be used to monitor the continuing need for oxygen at home. HaH services which were part of randomised trials have provided concentrator or cylinder oxygen to patients.^3–5,7,42 It may not be possible to withdraw oxygen from all patients, hypoxic during exacerbation, when they have sufficiently recovered to be discharged from HaH back to primary care.⁵⁵[Level of evidence III]

Recommendations

• (R46) Oxygen therapy is a cornerstone of treatment of an exacerbation of COPD and should be made available to patients if they are hypoxaemic. [Grade C]

• (R47) Supplementary oxygen should be administered in a controlled fashion aiming for 90% <Spo₂ <94%. [Grade C]

• (R48) Patients who remain in respiratory failure should be referred for consideration of long term oxygen therapy. [Grade C]

Who should receive antibiotics?

It has been shown that those with two or more symptoms of an exacerbation (purulent sputum, increased sputum and increased breathlessness) benefit from antibiotic therapy.^56,57 The NICE guidelines recommend the use of antibiotics for those with a history of more purulent sputum, but do not stratify patients towards differing antibiotic therapy.²[Level of evidence NICE]

With severe disease, pathogens such as Staphylococcus and Pseudomonas become more likely and beta lactam resistant organisms are more prevalent in those with multiple antibiotic courses.^57,58 Risk factors for treatment failure include increased exacerbation frequency, severe FEV₁ impairment, co-morbidity and increasing age.⁵⁸ It is therefore logical to avoid repeating similar antibiotics in those with recurrent requirements for treatment. [Level of evidence 1b]

Recommendations

• (R49) Antibiotic therapy should be offered to patients with two or more of breathlessness, increased sputum and increased sputum purulence. [Grade A]

• (R50) Patients with a high risk of treatment failure or unusual pathogens benefit from tailored antibiotic therapy. [Grade B]

What other treatments can be offered?

HaH interventions provide the opportunity to offer additional ancillary treatments to the patient. Although components of care such as smoking cessation and pulmonary rehabilitation were not offered as part of the studies forming the evidence base of HaH for COPD, these form part of basic COPD care delivery. Additional support for patients and carers may be provided by home help and occupational therapy services.

Positioning to improve the mechanics of breathing has been shown to improve breathlessness and respiratory muscle strength.⁵⁹ The use of positive expiratory pressure masks led to greater sputum clearance in a randomised trial.⁶⁰ Acute administration of nutritional support has been shown to be feasible during exacerbation, but with no clear benefit proven.⁶¹ Pulmonary rehabilitation begun in the aftermath of an exacerbation results in improvement in exercise capacity and quality of life evident 6 months after an initial hospital-based programme.⁶²[Level of evidence 1b]

Recommendations

• (R51) HaH should not prevent patients gaining access to broader COPD care such as pulmonary rehabilitation or smoking cessation programmes. [Grade D]

• (R52) Selected physiotherapeutic techniques and nutritional support may be beneficial. [Grade D]

Components of the interventions

The components of home care/chronic disease management interventions for stable COPD patients may include:

• An education programme with information on the following topics:

  • the disease and its management;

  • control of symptoms;

  • encouragement and help to stop smoking;

  • plan of action for acute exacerbations;

  • adopting a healthy lifestyle;

  • leisure activities and travelling;

  • long term oxygen therapy if appropriate.

• An exercise programme.

• A contact list for advice on acute emergencies.

• Prescriptions at home to initiate when an exacerbation occurs.

• Follow-up visits at home or hospital or in the community.

• Psychological support.

• Support, advice and education for carers.

The relative importance of each component may vary according to the perspective of the patient, carer and health professional. We present the evidence relevant to the following questions, from the RCTs included in the two systematic reviews (together with RCTs published more recently):

• Do they improve quality of life?

• Do they improve objective measurements of pulmonary function or patient mortality?

• Do they alter the frequency of unscheduled visits to the GP or hospital A&E departments?

• Do they alter the frequency of hospital admissions?

• Do they depend on any particular type of intervention for their success?

Do the schemes improve the quality of life?

Several different types of health related quality of life (HRQoL) questionnaires have been used to measure this important outcome. The commonest measure has been the SGRQ. None of the RCTs of chronic disease management/home care schemes has demonstrated a significant improvement in total SGRQ with the intervention. Some statistically significant differences have been seen in individual components of the SGRQ, but their clinical significance is unclear.

There is currently no evidence to suggest that these interventions improve patients’ HRQoL as measured by total SGRQ score. [Level of evidence 1a]

Recommendation

• (R53) New and established schemes should include a validated tool to assess impact on patients’ HRQoL. [Grade D]

Do the schemes improve objective measurements of pulmonary function or patient mortality?

There is no evidence that the 6 minute walking test was improved in any of the three schemes where this parameter was measured.^65–,⁶⁸ Patients not looked after by a respiratory health worker had a higher chance of dying (relative risk 2.9, confidence limits 0.8 to 10.2) in one study,⁶⁷ but the other studies have found no such effect and a meta-analysis of the effect on mortality found no significant improvement in the intervention patients.⁶⁴

There is no available evidence to suggest that such schemes alter pulmonary function or influence mortality rates. [Level of evidence 1a]

Do the schemes alter the frequency of hospital admissions or unscheduled visits to the GP or A&E departments?

Researchers from Spain and Quebec have demonstrated reductions in the frequency of unscheduled visits to hospital A&E departments at 1 year^66,69 and 2 years follow-up⁷⁰ with their chronic disease management schemes. In the Canadian study there was also a significant reduction in unscheduled visits to the family physician at 12 months in the intervention group.⁶⁶ The Spanish study only included patients receiving long term oxygen therapy,⁶⁹ whereas the other study involved patients with at least one hospital admission for an acute exacerbation of COPD in the 12 months before entry into the scheme.^66,70

These two studies also demonstrated a significant reduction in hospital admissions from all causes in the intervention groups. The Canadian study reported a 40% reduction in admissions for an acute exacerbation, a 57% reduction in admissions for other health problems at 12 months,⁶⁶ and a 27% reduction in all cause admissions at 2 years.⁷⁰

Patients in the Spanish study had a significant reduction in hospital stay (7.43 vs 18.2 days).⁶⁹ Similar findings were reported from the Quebec study (7.2 vs 12.5 days).⁶⁶ However, several other RCTs have failed to detect or report any benefit in terms of unscheduled visits to the GP,⁷¹ visits to A&E departments,^72,73 hospital admissions,^{67,71,72,74,75} or length of hospital stay.⁷³ Overall, the trials defy meta-analysis due to their differing presentation of results.

The available evidence is conflicting and it is not clear whether these interventions reduce hospital admissions, unscheduled visits to the family physician/GP or attendance at A&E departments. [Level of evidence 1a]

Recommendations

• (R54) Further robust studies are required to assess whether chronic disease management interventions improve patient outcomes in terms of hospital re-admission, A&E attendance or unscheduled GP/family physician attendance. [Grade D]

• (R55) The Spanish study of patients on long term oxygen therapy needs to be repeated as it may have identified a subgroup of patients who experience particular benefits from this kind of intervention. [Grade D]