A systematic review of hospital-at-home care: Cost savings are overestimated

OBJECTIVES: The concept of hospital-at-home means that home treatment is provided to patients who would otherwise have been treated in the hospital. Hospital admissions may be shortened (early assisted discharge, EAD) or avoided. This may lead to lower costs, but there is a risk that savings are overestimated if homecare and other relevant outpatient costs are not taken into account appropriately or if average or generic prices per inpatient day are applied. The objective of this study was to assess the quality of cost analyses of hospital-at-home studies for acute conditions published from 1996 through 2011 and to present an overview of evidence on cost savings. METHODS: The Medline and NHS HEED databases were searched. Methodological quality was assessed using the Quality of Health Economic Studies instrument (QHES). Cost calculations were considered incorrect if they failed to meet four criteria. Unit costs of inpatient hospital days had to be disease-specific. The decreasing intensity of care over the course of an admission had to be reflected in costs of inpatient days. In studies from the societal perspective, informal care costs had to be included. Violating any of these criteria leads to overestimation of savings from hospital-at-home. Finally, follow-up had to be at least one month in order to capture relevant downstream costs, in particular for readmissions. RESULTS: The average QHES score was 65 (out of 100) . Only 5 out of 29 studies met all criteria and had a sufficiently clear explanation of their methodology. The most frequent problem was the use of average costs per inpatient hospital day, which was problematic in at least 11 EAD studies. Follow-up was too short in 13 studies. Informal care costs lacked in one study that stated to adopt a societal perspective. CONCLUSIONS: While most studies found cost savings, these were probably overestimated.