Community rehabilitation

National Guideline Centre (UK)

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National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.)

Emergency and acute medical care in over 16s: service delivery and organisation.

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Chapter 13Community rehabilitation

13. Community rehabilitation

13.1. Introduction

Acute medical illness can be associated with a temporary reduction in our ability to carry out the normal activities of daily living. This can be due to the effect of the illness itself, side effects of treatment or becoming deconditioned from reduced activity whilst in hospital. Therefore rehabilitation is often needed during recovery from an acute medical illness so that patients can return to the same level of functioning and independence.

Whilst rehabilitation should start as soon as possible, there is some uncertainty over the clinical and cost effectiveness of the location of rehabilitation, as certain equipment and expert healthcare professionals (for example, physiotherapists or occupational therapists) may be needed to deliver the optimal rehabilitation therapy.

13.2. Review question: Does the provision of community-based rehabilitation services following acute medical illness improve patient outcomes?

For full details see review protocol in Appendix A.

Table 1

PICO characteristics of review question.

13.3. Clinical evidence

Twenty- nine studies (all RCTs) were included in the review;⁶^,¹³^,¹⁴^,¹⁹^,³⁸^,⁵⁶^,⁶⁴^,⁶⁵^,⁷⁶^,⁸⁸^,⁹⁰^,⁹¹^,⁹³^,⁹⁶^,¹¹³^,¹²²^,¹²⁶^,¹³¹^,¹³⁴^,¹⁵⁵^,¹⁶⁴^,¹⁷⁷^,¹⁹¹^,¹⁹²^,¹⁹⁸^,¹⁹⁹^,²⁰²^,²⁰⁸^,²¹¹^,²⁴³^,²⁴⁴^,²⁵¹ these are summarised in Table 2 and Table 3 below. Evidence from these studies is summarised in the GRADE clinical evidence summary below (Table 4).

Table 2

Summary of studies included in the review: Admission avoidance.

Table 3

Summary of studies included in the review: Early discharge.

Table 4

Clinical evidence summary: Community rehabilitation versus hospital rehabilitation after acute medical emergencies.

See also the study selection flow chart in Appendix B, study evidence tables in Appendix D, forest plots in Appendix C, GRADE tables in Appendix F and excluded studies list in Appendix G.

The studies were also divided by the aim of the intervention: a) avoiding hospital admission (n=3 studies) and b) facilitating early discharge from hospital after admission (n=26 studies).

Interventions in category A: admission avoidance is a service that provides active treatment by health care professionals outside hospital for a condition that otherwise would require acute hospital in-patient admission.

Interventions in category B: early discharge is a service that provides active treatment by health care professionals outside hospital for a condition that otherwise would require continued acute hospital in-patient care.

13.3.1. Admissions avoidance

Outcomes as reported in study (not analysable)

Activities of daily living (number of functions lost, score 0 to 6) (Ricauda 2004): Median (IQR): community rehab group =4 (2-5); hospital group = 4 (2-6), p=0.57.

Functional impairment (range 28 to 126; high score =greater independence) (Ricauda 2004). At 6 months: Median IQR: community rehab group =106 (67.5-121.5); hospital group = 96.5 (56.5-116.5), p=0.26.

National Institute of Health Stroke Scale Score (range 0-36; low score = improvement) (Ricauda 2004): At 6 months: Median IQR: community rehab group=8 (4-26); hospital group =8 (6-24), p=0.37.

Geriatric Depression Scale score (range 0-30) higher scores indicate depression (Ricauda 2004). At 6 months: Median IQR: community rehab group=10 (5-15); hospital group=17 (13-20), p<0.001.

Canadian Neurological Scale Score (range 0-10; higher score= improvement): At 6 months: Median IQR: community rehab group =10 (8.5-10.0); hospital group=9.5 (7.0-10.0), p=0.39.

13.3.2. Early discharge

Table 5

Clinical evidence summary: Community rehabilitation versus hospital rehabilitation after acute medical emergencies.

Outcomes as reported in study (not analysable)

One study (Cunliffe 2004) used Euroqol (Quality of life score): Euroqol (−0.59 to 1); at 3 months: mean difference 0.07 (95% CI −0.01 to 0.14); at 12 months: mean difference 0.02 (95% CI −0.06 to 0.09); Cunliffe 2004: GHQ - carer (36 to 0); at 3 months: mean difference −2.0 (95% CI −3.8 to −0.1); at 12 months, mean difference −1.1 (95% CI −3.7 to 1.5); mean GP visits over 12 months: community rehabilitation: 6 compared to the hospital group: 6.7, p=0.16.

One study (Roderick 2001) included quality of life data: quality of life median (IQR): physical health at 6 months; community rehabilitation group: 35.2 (26.5, 43.7) (n=49), hospital group: 32.7 (26.8, 39.2) (n=50); mental health at 6 months; community rehabilitation group: 57.4 (49.9, 62.9) (n=49), hospital group: 57.1 (50.6, 63.0) (n=50).

One study (Rodgers 1997) included quality of life data: quality of life median, (IQR): community rehabilitation group: 2 (1-5) compared to the hospital group: 3 (1-5); hospital length of stay median (IQR): Community rehabilitation group: 13 days (IQR 8-25) compared to the hospital group: 22 days (IQR 10-57), p<0.02; General health questionnaire for carers (30) median (range): community rehabilitation group: 5 (0-21) (n=22) compared to the hospital group: 5 (1-27) (n=19).

One study (Anderson 2000) included total hospital bed days: median (IQR): community rehabilitation group: 15 (8.0, 22.0) compared to the hospital group: 30 (17.3, 48.5), median difference -15, 95% CI −22.0 to −6.0; Readmission stay (days) median (IQR): community rehabilitation group: 6.0 (3.0 to 39.0) compared to hospital group: 4.0 (1.0 to 29.0), median difference 2.0, 95% CI −7.0 to 18.0, p=0.26.

One study (Bautz-Holter 2002) included length of stay: median: community rehabilitation group: 22 days compared to the hospital group: 31 days, p=0.09.

One study (Donnelly 2004) included length of stay: mean/median: community rehabilitation group: mean 42 days, median 31 days compared to the hospital group: mean 50 days, median 32 days.

One study (Indredavik 2000) included mean stroke unit length of stay: community rehabilitation group: 11 days compared to the hospital group: 11 days; mean hospital length of stay (stroke unit plus rehabilitation): community rehabilitation group: 18.6 days compared to the hospital group: 31.1 days; mean (range) number of GP visits at 1 year; community rehabilitation group: 7.5 (0-58) days compared to hospital group: 6.4 (0-35).

One study (Fleming 2004) included median (IQR) GP visits at 12 months: community rehabilitation group: 3 (1-6) compared to the hospital group: 4 (0-6); median (IQR) length of stay at discharge from index admission; community rehabilitation group: 8 (7-15), hospital group: 18 (8-34); median (IQR) hospital bed days from randomisation to 12 months; community rehabilitation group: 16 (8-35), hospital group: 34.5 (18-60); median (IQR) days either in hospital or in CHRS facility from randomisation to 12 months; community rehabilitation group: 60 (34-87), hospital group: 34.5 (18-63).

One study (Thorsen 2006) included Length of stay at index admission: community rehabilitation group: 14 days, hospital group: 30 days.

13.4. Economic evidence

Published literature

Six economic evaluations in 7 papers were identified with the relevant comparison and have been included in this review.³⁸^,⁵⁵^,⁹¹^,¹³⁰^,¹³¹^,¹⁷⁰^,²³⁸ These are summarised in the economic evidence profiles below (Table 6, Table 7 and Table 9) and the economic evidence tables in Appendix E.

Table 6

Economic evidence profile: Community based stroke rehabilitation versus inpatient rehabilitation.

Table 7

Economic evidence profile: Community based geriatric rehabilitation versus inpatient rehabilitation.

Four economic evaluations relating to this review question were identified but were excluded due to combination of limited applicability and methodological limitations.¹⁴⁷^,¹⁶⁸^,¹⁹³^,²¹⁰ These are listed in Appendix H, with reasons for exclusion given.

The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B.

Table 8

Economic evidence profile: Community based cardiac rehabilitation versus outpatient rehabilitation.

13.5. Evidence statements

Clinical

Admission avoidance

Three studies comprising 453 participants evaluated the role of community rehabilitation for improving outcomes in secondary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that community rehabilitation may provide a benefit in reduced mortality (2 studies, moderate quality). The evidence suggested that there was no difference between the groups for quality of life - physical component summary (1 study, low quality) and quality of life score – mental component summary (1 study, moderate quality). However, there was a possible increase in length of treatment (1 study, low quality) in the community rehabilitation group.

Early discharge

Twenty six studies comprising 3852 participants evaluated the role of community rehabilitation for improving outcomes in secondary care in adults and young people at risk of an AME, or with a suspected or confirmed AME. The evidence suggested that community rehabilitation may provide a benefit in reduced GP presentations (2 studies, moderate quality), admissions to hospital at 6 months (5 studies, very low quality) and at 6 years (1 study, very low quality) and length of stay in hospital (8 studies, moderate quality) and length of stay in hospital and programme (3 studies, moderate quality). However, there was no effect on admissions at 12 months (7 studies, moderate quality) and mortality, although the trend was more deaths at 6 months (8 studies, very low quality) but fewer at 12 months (6 studies, very low quality) and no difference at 2-6 years (6 studies, moderate quality). However, there was a possible increase in adverse events (5 studies, very low quality). The evidence for quality of life with different scores suggested no effect or an improvement (9 studies, moderate quality). The evidence suggested that community rehabilitation may provide a benefit in terms of patient satisfaction (6 studies, very low to low quality). The evidence for carer satisfaction suggested no difference (6 studies, moderate quality) or an improvement (1 study, low quality) when reported using different scores and/or methodologies.

Economic

A UK cost–utility model found community-based rehabilitation following early supported discharge for stroke patients to be cost-effective (ICER: £6184) compared to usual care. This study was assessed as directly applicable with potentially serious limitations.
One cost-consequences analysis found that community-based rehabilitation following early supported discharge was less costly than inpatient rehabilitation for stroke patients (cost saving: £1491 per patient) and improved functionality (1.7 higher Barthel index score), lower mortality and higher care giver strain (0.24 higher care giver strain index score). This study was assessed as directly applicable with potentially serious limitations.
One cost-consequences analysis found that community-based rehabilitation was less costly (cost saving: £3238 per patient) and had better outcomes (less delirium, better quality of life, lower length of stay in hospital and in treatment, higher patient satisfaction, higher carer satisfaction and higher GP satisfaction) compared with inpatient rehabilitation for frail older people. This study was assessed as directly applicable with potentially serious limitations.
Three economic evaluations found that home-based cardiac rehabilitation was dominated by hospital-based outpatient rehabilitation for MI patients (cost: £480 more per patient). These studies were assessed as directly applicable with potentially serious to minor limitations.

13.6. Recommendations and link to evidence

Recommendations	7. Provide a multidisciplinary community-based rehabilitation service for people who have had a medical emergency.
Research recommendation	-
Relative values of different outcomes	Quality of life, mortality, avoidable adverse events, patient and/or carer satisfaction and number of admissions to hospital were considered by the guideline committee to be critical outcomes. Number of GP presentations, readmission, length of hospital stay and number of presentations to the Emergency Department were considered by the committee to be important outcomes.
Trade-off between benefits and harms	A total of 29 studies were identified that assessed community rehabilitation compared to hospital rehabilitation. These studies were separated into admission avoidance or early discharge studies. Stratum - Admissions avoidance: Three studies suggested that community rehabilitation may provide benefits in reduced mortality.. The evidence suggested that there was no difference between the groups for quality of life (physical component and mental component). There was no evidence for the following outcomes: avoidable adverse events, quality of life, patient and/or carer satisfaction, number of presentation to the ED, number of admissions to hospital or number of GP presentations. Stratum - Early discharge: Evidence from 26 studies suggested that community rehabilitation provides a benefit in fewer GP presentations, admissions to hospital at 6 months and at 6 years and reduced length of stay in hospital and in programme. However, there was no effect on admissions at 12 months; mortality trends suggested more deaths at 6 months, fewer at 12 months and no difference at 2-6 years. However, there was a possible increase in adverse events. The evidence for quality of life with different scores suggested no effect or an improvement. There was potential benefit in terms of patient satisfaction. The evidence for carer satisfaction suggested no difference or an improvement when reported using different scores and/or methodologies. There was no evidence for the outcome relating to number of presentations to the ED. The committee considered that the data were consistent with a benefit for rehabilitation in the community, which also has high patient acceptability. The committee agreed that rehabilitation in the community should be offered to patients as an alternative to routine hospital inpatient rehabilitation, depending on their clinical condition and after discussion of risks and benefits. Community rehabilitation is a viable alternative to hospital inpatient treatment for selected patients, and would be the preferred option to maintain patients’ independence.
Trade-off between net effects and costs	Two included studies assessed the cost effectiveness of early supported discharge and rehabilitation following acute admissions for stroke. The studies showed that early supported discharge with rehabilitation in the community is cost effective (either dominant - or has an incremental cost effectiveness ratio (ICER) less than £20,000 per QALY gained). Three economic evaluations found home-based cardiac rehabilitation to be more costly and less effective than hospital outpatient based rehabilitation. One study assessed the cost effectiveness of community-based geriatric rehabilitation compared to inpatient rehabilitation. This study showed that geriatric rehabilitation in the community was dominant (more effective and less costly) compared to inpatient rehabilitation. The committee considered the clinical evidence which showed improvement in patient-centred outcomes, including patient and/or carer satisfaction. However, there was lack of evidence regarding improved functional outcomes and independence for elderly patients which the committee believed, based on their clinical experience, would be improved. The committee were of the view that patients’ quality of life could be enhanced by improved independence and satisfaction. Overall, the committee considered the possible improvements in health outcomes and cost savings to outweigh the costs of providing community based rehabilitation for patients recovering from an AME. Community rehabilitation services are quite common across the country, for example, early supported discharge for suitable patients who have had an acute stroke. But for some parts of the country, providers and commissioners may have to set up or expand the capacity of existing services (including training or hiring of additional staff, including physiotherapists. The rehabilitation services could be integrated within the intermediate care services. The impact of such services should be to free up hospital beds and improved patient outcomes.
Quality of evidence	Admission avoidance: The evidence was graded moderate for mortality and length of stay due to imprecision. Length of treatment data was graded as low due to risk of bias and imprecision. The outcome of quality of life (physical and mental component summary) was graded low to moderate due to imprecision Early discharge: The evidence was graded very low to moderate due to risk of bias, imprecision and inconsistency. Economic evaluations One study of cardiac rehabilitation was assessed as directly applicable with minor limitations. The rest of the evidence was assessed as partially applicable (because of the setting and/or the measure of health outcome) with potentially serious limitations.
Other considerations	As with all forms of rehabilitation, the ‘dose’ of the intervention may be relatively small in terms of the amount of time the practitioner can devote to each patient. The committee noted that rehabilitation would often need to be delivered or reinforced by different disciplines, requiring coordination between those disciplines and the various community and social care agencies to ensure that care was focused on the goals for each patient, involved (and, where necessary, educated) the patient and family or carers, and was integrated between sectors, particularly community nursing. Further discussion on integrated care can be found in Chapter 38. The majority of the evidence was in the stroke population and there was insufficient evidence on other clinical conditions making generalisations more difficult. However, a sub-group analysis by population did not explain heterogeneity within the outcomes. In some specific conditions, such as stroke, the evidence is stronger on outcomes relating to independence (not evaluated specifically in trials on other clinical conditions). The committee agreed that community rehabilitation should be focused on maximising and maintaining independence and thereby reduce the overall burden on the healthcare system.

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Appendices

Appendix A. Review protocol

Table 9Review protocol: community rehabilitation

Review question: Does the provision of community-based rehabilitation services following acute medical illness improve patient outcomes?
Objective	To determine if wider provision of community-based rehabilitation prevents people staying in hospitals longer than necessary while not impacting on patient and carer outcomes.
Rationale	Community-based healthcare services are vital to prevent unnecessary hospital admission and to facilitate early hospital discharge. It is also likely that these resources are less costly than hospital care.
Population	Adults and young people (16 years and over) with a suspected or confirmed AME presenting to an acute medical unit.
Intervention	Community-based rehabilitation services.
Comparison	Hospital-based rehabilitation services.
Outcomes	Mortality during study period (Dichotomous) CRITICAL Avoidable adverse events during study period (Dichotomous) CRITICAL Quality of life during study period (Continuous) CRITICAL Patient and/or carer satisfaction during study period (Dichotomous) CRITICAL Length of stay during study period (Continuous) IMPORTANT Number of presentations to ED during study period (Dichotomous) IMPORTANT Number of admissions to hospital after 28 days of first admission (Dichotomous) CRITICAL Number of GP presentations during study period (Dichotomous) IMPORTANT Readmission up to 30 days (Dichotomous) IMPORTANT
Search criteria	The databases to be searched are: Medline, Embase, the Cochrane Library Date limits for search: None Language: English only
The review strategy	Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.
Analysis	Data synthesis of RCT data. Meta-analysis where appropriate will be conducted. Studies in the following subgroup populations will be included: Frail elderly People with serious mental illness In addition, if studies have pre-specified in their protocols that results for any of these subgroup populations will be analysed separately, then they will be included. The methodological quality of each study will be assessed using the Evibase checklist and GRADE.

Appendix B. Clinical article selection

Figure 1Flow chart of clinical article selection for the review of Community rehabilitation

Appendix C. Forest plots

C.1. Community versus hospital rehabilitation – Admission avoidance

Figure 2Mortality

Figure 3Length of treatment

Figure 4Quality of life –SF 36- Physical component summary

Figure 5Quality of life –SF 36- Mental component summary

C.2. Community versus hospital rehabilitation - Early discharge

Figure 6Mortality

Figure 7Adverse events

Figure 8Quality of life (SF-36)

Table 10Quality of life (St. George’s Respiratory Questionnaire)

Table 11Quality of life (Life Satisfaction)

Figure 9Quality of life (SF-12)- PCS

Figure 10Quality of life (SF-12)- MCS

Figure 11Patient satisfaction

Figure 12Patient Satisfaction

Table 12Carer Satisfaction

Figure 13Carer Satisfaction

Figure 14Carer Satisfaction (Caregiver Strain Index)

Figure 15Length of stay (in-hospital)

Figure 16Length of stay in hospital and programme

Figure 17Admissions

Figure 18GP presentations

Figure 19Quality of life (MacNew-Global)

Appendix D. Clinical evidence tables

Cochrane reviews

Download PDF (360K)

Randomised controlled trials

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Appendix E. Economic evidence tables

Appendix F. GRADE tables

Table 13Clinical evidence profile: Community versus hospital for after acute medical emergencies (admission avoidance)

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Community (admission avoidance) versus hospital	Control	Relative (95% CI)	Absolute	Quality	Importance
Mortality 6-12 months
2	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	42/204 (20.6%)	31.4%	RR 0.74 (0.52 to 1.04)	82 fewer per 1000 (from 151 fewer to 13 more)	⨁⨁◯◯ LOW	CRITICAL
Length of treatment (Better indicated by lower values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious²	none	60	60	-	MD 15.9 higher (8.1 to 23.7 higher)	⨁⨁◯◯ LOW	CRITICAL
Quality of life-SF 36 physical component summary (follow-up 8 weeks; Better indicated by higher values)
1	randomised trials	no serious risk of bias	no serious inconsistency	no serious indirectness	very serious²	None	20	20	-	MD 0.18 higher (6.35 lower to 6.71 higher)	⨁⨁◯◯ LOW	CRITICAL
Quality of life-SF 36 mental component summary (follow-up 8 weeks; Better indicated by higher values)
1	randomised trials	no serious risk of bias	no serious inconsistency	no serious indirectness	serious²	None	20	20	-	MD 3.81 lower (11.08 lower to 3.46 higher)	⨁⨁⨁◯ MODERATE	CRITICAL

1: Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias
2: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

Table 14Clinical evidence profile: Early Supported Discharge for after acute medical emergencies versus continued hospital treatment

Quality assessment							No of patients		Effect		Quality	Importance
No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Community Rehabilitation	Hospital Rehabilitation	Relative (95% CI)	Absolute	Quality	Importance
Mortality (follow-up 3 months - 6 years)
20	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	229/1768 (13%)	9.1%	RR 1.013 (0.84 to 1.25)	1 more per 1000 (from 15 fewer to 23 more)	⨁⨁⨁◯ MODERATE	CRITICAL
Mortality (follow-up median 6 months)
8	randomised trials	serious¹	serious²	no serious indirectness	very serious³	None	64/628 (10.2%)	9.1%	RR 1.26 (0.79 to 2.03)	24 more per 1000 (from 19 fewer to 94 more)	⨁◯◯◯ VERY LOW	CRITICAL
Mortality (follow-up 1 years)
6	randomised trials	serious¹	serious²	no serious indirectness	serious³	None	61/518 (11.8%)	16.3%	RR 0.86 (0.63 to 1.18)	23 fewer per 1000 (from 60 fewer to 29 more)	⨁◯◯◯ VERY LOW	CRITICAL
Mortality (follow-up 2-6 years)
6	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	104/622 (16.7%)	1.61%	RR 0.97 (0.78 to 1.20)	3 fewer per 1000 (from 26 fewer to 23 more)	⨁⨁⨁◯ MODERATE	CRITICAL
Adverse events (follow-up 9 weeks - 6 years)
5	randomised trials	serious¹	serious²	no serious indirectness	serious³	None	100/258 (38.8%)	32.5%	RR 1.20 (0.85 to 1.68)	73 more per 1000 (from 55 fewer to 250 more)	⨁◯◯◯ VERY LOW	CRITICAL
Quality of life (follow-up median 7 months; measured with: SF-36 Physical component summary score; Better indicated by lower values)
5	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	311	312	-	MD 1.04 higher (0.99 lower to 3.07 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Quality of life (follow-up median 7 months; measured with: SF-36 Mental component summary scores; Better indicated by lower values)
5	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	311	312	-	MD 0.86 higher (1.04 lower to 2.77 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Quality of life (follow-up 12 months; measured with: St. George’s Respiratory Questionnaire; Better indicated by higher values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	89	95	-	MD 1 lower (4.14 lower to 2.14 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Quality of life (follow-up 12 months; measured with: Life Satisfaction; Better indicated by higher values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	42	43	-	MD 0.3 higher (4.06 lower to 4.66 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Quality of life (follow-up 8 weeks; measured with MacNew-Global; Better indicated by higher values))
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	60	44	-	MD 0.07 lower (0.51 lower to 0.37 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Patient satisfaction (follow-up median 6 months; Better indicated by higher values)
4	randomised trials	very serious¹	serious²	no serious indirectness	serious³	None	268	146	-	MD 0.32 higher (0.18 lower to 0.82 higher)	⨁◯◯◯ VERY LOW	IMPORTANT
Patient satisfaction (follow-up 6-12 months)
2	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious³	None	89/178 (50%)	51.2%	RR 1.15 (0.93 to 1.43)	77 more per 1000 (from 36 fewer to 220 more)	⨁⨁◯◯ LOW	IMPORTANT
Carer satisfaction (follow-up 6 months; Better indicated by higher values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	serious³	None	70	34	-	MD 0.39 higher (0.01 lower to 0.79 higher)	⨁⨁◯◯ LOW	IMPORTANT
Carer satisfaction (follow-up 12 months)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	68/82 (82.9%)	82.5%	RR 1 (0.86 to 1.17)	0 fewer per 1000 (from 115 fewer to 140 more)	⨁⨁⨁◯ MODERATE	CRITICAL
Carer satisfaction (follow-up median 12 months; measured with: Caregiver Strain Index; Better indicated by lower values)
5	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	282	250	-	SMD 0.16 higher (0.01 lower to 0.34 higher)	⨁⨁⨁◯ MODERATE	IMPORTANT
Length of stay in hospital (follow-up in-hospital; Better indicated by lower values)
8	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	745	644	-	MD 1.38 lower (2.47 to 0.3 lower)	⨁⨁⨁◯ MODERATE	CRITICAL
Length of stay in hospital and programme (follow-up 6 months - 3 years; Better indicated by lower values)
3	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	261	225	-	MD 7.74 lower (14.2 to 1.28 lower)	⨁⨁⨁◯ MODERATE	CRITICAL
Admissions to hospital (follow-up 3 months - 6 years)
13	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	246/890 (27.6%)	24.3%	RR 0.98 (0.86 to 1.11)	5 fewer per 1000 (from 34 fewer to 27 more)	⨁⨁⨁◯ MODERATE	CRITICAL
Admissions to hospital (follow-up 6 months)
5	randomised trials	serious¹	no serious inconsistency	no serious indirectness	very serious³	None	43/244 (17.6%)	22.4%	RR 0.9 (0.61 to 1.33)	22 fewer per 1000 (from 87 fewer to 74 more)	⨁◯◯◯ VERY LOW	CRITICAL
Admissions to hospital (follow-up 12 months)
7	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	168/576 (29.2%)	25.3%	RR 1.03 (0.88 to 1.20)	8 more per 1000 (from 30 fewer to 51 more)	⨁⨁⨁◯ MODERATE	CRITICAL
Admissions to hospital (follow-up 6 years)
1	randomised trials	very serious¹	no serious inconsistency	no serious indirectness	serious³	None	35/70 (50%)	62.2%	RR 0.8 (0.6 to 1.08)	124 fewer per 1000 (from 249 fewer to 50 more)	⨁◯◯◯ VERY LOW	CRITICAL
GP presentations (follow-up 6 months - 5 years)
2	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	74/84 (88.1%)	93.3%	RR 0.94 (0.86 to 1.04)	56 fewer per 1000 (from 131 fewer to 37 more)	⨁⨁⨁◯ MODERATE	IMPORTANT
Quality of life (follow-up 6 months; measured withSF12 - PCS; Better indicated by higher values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	263	262	-	MD 0.28 lower (2.14 lower to 1.58 higher)	⨁⨁⨁◯ MODERATE	CRITICAL
Quality of life (follow-up 6 months; measured withSF12 - MCS; Better indicated by higher values)
1	randomised trials	serious¹	no serious inconsistency	no serious indirectness	no serious imprecision	None	263	262	-	MD 1.14 lower (2.83 lower to 0.55 higher)	⨁⨁⨁◯ MODERATE	CRITICAL

1: Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias.
2: The point estimate varies widely across studies, unexplained by subgroup analysis.
3: Downgraded by 1 increment if the confidence interval crossed 1 MID or by 2 increments if the confidence interval crossed both MIDs.

Appendix G. Excluded clinical studies

Table 15Studies excluded from the clinical review

Reference	Reason for exclusion
Adler 1978²	Not relevant: patients following elective surgery
Aimonino 2001³	Patients not treated for acute medical emergency (advanced dementia patients) - please note not linked to Tibaldi 2004²⁴⁵
Aimonino 2000⁴	Conference abstract; later published as Ricauda 2004¹⁹²
Allen 1999⁵	Not RCT; description of a website
Anderson 2016¹⁰	Systematic review is not relevant to review question or unclear PICO. Exercise training versus usual care
Anderson 2000A⁶	Conference abstract of protocol only
Anderson 2002A⁹	No clinical outcomes; Costs only
Anderson 2002B⁸	Not RCT; Systematic review
Anonymous 1982B¹	Not relevant comparison
Anon 2000⁸¹	Systematic review: eligible papers ordered
Armstrong 2008B¹¹	Not RCT; Retrospective single arm study
Arrigo 2008¹²	No hospital-based comparison
Askim 2010¹⁴	Incorrect interventions. Hospital and community components
Aujesky 2011¹⁶	RCT but no community care (self- administered injections)
Bakken 2012¹⁷	Not RCT; not relevant
Barnes 2003¹⁸	Not RCT; review
Beech 2004²⁰	Not RCT; service evaluation
Bernhaut 2002²¹	Not RCT, service evaluation
Bethell 1990²²	Not substitute for usual care; control group received no intervention, only advice what exercises they could do by themselves
Beynon 2009²³	Not RCT; literature review
Blackburn 2000²⁴	Not RCT; not relevant; costs only
Blair 2011²⁵	Not RCT; systematic review
Board 2000²⁶	Not relevant; costs only
Booth 2004²⁷	Not relevant; patients following bypass surgery
Boston 2001²⁸	Not RCT; prospective non-randomised comparative study
Bowman 1998²⁹	Not RCT; review
Boxall 2005³⁰	Inappropriate comparison. not hospital-based care
Brooks 2002³¹	Not RCT; retrospective case study
Brooks 2003³²	Not RCT; retrospective documentary analysis
Brunner 2008³³	Not RCT; other experimental design
Bryan 2010³⁴	Not RCT; literature review
Buckingham 2016³⁵	Cochrane review – relevant references ordered
Buus 2013³⁶	Protocol only; no study data
Campbell 2001³⁷	No clinical outcomes; costs only
Caplan 2004⁴¹	Comparison is not hospital-based care
Caplan 2006³⁹	Not RCT; service evaluation
Caplan 2012⁴⁰	Not RCT; systematic review- screened for relevant references
Carroll 2005⁴²	Not RCT; review
Chaiyawat 2010⁴³	Conference abstract
Chaiyawat 2010⁴⁴	Conference abstract
Chang 2015⁴⁵	No hospital-based comparison. Not review population. Psychiatric
Chappell 1993⁴⁶	Not relevant; retrospective cost analysis
Chard 2006⁴⁷	Not RCT; review
Chen 2012A⁴⁸	Not relevant; costs associated with acquired brain injury
Coast ⁴⁹	Not relevant; majority of patients with trauma and elective surgery
Cobelli 1996⁵⁰	Not RCT; review
Coburn 1989⁵¹	Not RCT; quasi-experimental; cost
Cohen 1994⁵²	Not RCT; review
Colprim 2012⁵⁴	Not RCT; quasi-experimental study
Colprim 2014⁵³	Not RCT; prospective cohort study
Cowie 2014⁵⁵	Not RCT; economic analysis
Craig 2014⁵⁷	Not RCT; review
Crawford-Faucher 2010⁵⁸	Not RCT; systematic review - screened for relevant references
Crotty 2000⁶⁰	Not RCT; audit of trauma patients
Crotty 2000A⁵⁹	RCT but not relevant as trauma patients only (hip fracture)
Crotty 2002⁶²	RCT but not relevant as trauma patients only (hip fracture)
Crotty 2003⁶¹	RCT but not relevant as trauma patients only
Cunliffe 2002⁶³	Not RCT; qualitative study; abstract only
Dalal 2003⁶⁶	Not RCT; non-randomised prospective study
Daskapan 2005⁶⁷	No extractable outcomes
Deutsch 2006⁶⁸	Not RCT; retrospective study
Dias 2013 ⁶⁹	RCT but not relevant (does not compare to inpatient rehabilitation)
Dolansky 2010⁷⁰	Not RCT
Dombi 2009⁷¹	Not RCT; commentary on costs
Donaldson 1982⁷²	Not RCT; retrospective study
Donath 2001⁷³	Not RCT; Commentary
Donlevy 1996A⁷⁴	Not relevant; article is on cross-training to provide care at home on discharge
Donnelly 2002⁷⁵	Not RCT; not relevant; questionnaire survey
Dorney-Smith 2011⁷⁷	Not RCT; case study of the cost of nurse-led hostels for the homeless
Dow 2004⁷⁸	Not RCT; case study
Dow 2007⁷⁹	Not RCT; qualitative study
Duffy 2010⁸⁰	RCT but wrong comparison (control group not in hospital)
Early supported discharge trialists 2005⁸²	Systematic review: all eligible papers ordered
Eldar 2000A⁸³	Not RCT; review
Elder 2001⁸⁴	Not RCT; literature review
Emme 2014⁸⁵	RCT; but no relevant outcomes
Emme 2014A⁸⁶	RCT; but no relevant outcomes
Eron 2004⁸⁷	Not RCT; no data
Feltner 2014⁸⁹	Not RCT; systematic review- screened for relevant references
Gaspoz 1994⁹⁴	Not RCT; prospective cohort study
Glasby 2008⁹⁷	Not RCT; qualitative study
Glick 1998⁹⁸	Not relevant – observing outcome of aneurysmal subarachnoid haemorrhage
Gobbi 2004⁹⁹	Not RCT; and not relevant
Gracey 1992¹⁰⁰	Not RCT; case studies
Graham 2013¹⁰¹	Not RCT; description of organisation of rehabilitation services
Grande 2004¹⁰²	RCT on bereavement. Not relevant.
Gregory 2009¹⁰⁴	Not RCT; retrospective study
Gregory 2010¹⁰³	Not RCT; Cross-sectional study
Griffiths 2000¹⁰⁷	Not RCT; exploratory analyses
Griffiths 2000A¹⁰⁸	RCT but not relevant comparison (in-patients only)
Griffiths 2001¹⁰⁶	RCT but not relevant comparison; both arms in-patient care (nurse led versus consultant managed)
Griffiths 2005¹¹¹	Not RCT; systematic review-screened for relevant references
Griffiths 2004¹⁰⁹	Systematic review is not relevant to review question or unclear PICO. hospital-based care
Griffiths 2006¹¹⁰	Not RCT; review
Griffiths 2006A¹⁰⁵	Not RCT; review
Gunnell 2000¹¹²	Not relevant; majority of patients with trauma and elective surgery
Hannan 2003¹¹⁴	Not RCT
Hansen 1992¹¹⁵	Cochrane excluded list: Hospital at home early discharge (study did not evaluate hospital at home, but a model for follow-up visits at home after discharge from hospital)
Hardy 2001¹¹⁶	Not RCT; description of a service; and mainly trauma patients
Hauser 1991¹¹⁷	Not RCT; retrospective study
Heseltine 2001¹¹⁸	Not RCT; review on cost
Higgins 2001¹¹⁹	Inappropriate comparison. No hospital-based comparison
Hill 1978¹²⁰	RCT but not relevant to today’s approach of managing MI as thrombolytic therapy made admission necessary (Cochrane)
Hoenig 2010¹²¹	Conference abstract
Hughes 1990¹²³	RCT but has wrong comparison (not in hospital)
Ince 2014¹²⁴	Incorrect interventions. Hospital at home
Indredavik 1999¹²⁵	Not RCT and compares stroke unit rehabilitation with general medical ward treatment
Indredavik 2008¹²⁷	RCT but no relevant outcomes
Jakobsen 2013¹²⁸	Methodology of RCT only
Jolly 2005¹²⁹	RCT but study aborted prematurely due to language barriers with participants. No data
Jones 1999¹³²	Costs only
Jones 2014¹³³	Not RCT; case study with little data
Karapolat 2008¹³⁵	No outcomes of interest
Kehusmaa 2010¹³⁶	The outpatient group did not include community rehabilitation.
Kenny 2002¹³⁷	Not RCT and not relevant
Knapp 1994¹³⁸	Not review population. psychiatric. comparison to a psychiatric hospital-based care
Konrad 2012¹³⁹	Not RCT; retrospective study
Koopman 1996¹⁴⁰	RCT but excluded as home care was self-administered
Kornowski 1995¹⁴¹	Not RCT; observational study
Kortke 2006¹⁴²	Not RCT; open clinical study (non-randomised)
Korzeniowska-Kubacka 2014¹⁴³	Not RCT; prospective observational study
Langhorne 2000¹⁴⁴	Cochrane systematic review withdrawn from publication and superseded by Shepperd 2008²²³
Langhorne 2005¹⁴⁵	Not RCT; review
Lappegard 2012¹⁴⁶	Not RCT; retrospective study
Last 2000¹⁴⁸	Not RCT, service description
Lewis 2007¹⁴⁹	Not RCT; commentary
Lewis 2011¹⁵⁰	Not RCT; research protocol only
Lewis 2012¹⁵²	Not RCT; commentary/conceptual paper
Lewis 2013¹⁵¹	Not RCT; case studies without data
Lim 2003¹⁵³	RCT but not relevant comparison
Linertova 2011¹⁵⁴	Not RCT; Systematic review
Marks 1994¹⁵⁷	Not review population. admission for serious mental illness
Marchionni 2003¹⁵⁶	No extractable outcomes
Martin 1994¹⁵⁸	RCT but wrong comparison (control group not in hospital)
Mason 2003¹⁵⁹	Not RCT; description of a service
Mather 1976¹⁶⁰	No description of the type of service patients at home received (excluded by Cochrane too)
Matukaitis 2005¹⁶¹	Not RCT. Pilot study and no comparison study
Mayhew 2006¹⁶²	Not RCT; health economics only
Mayo 1998¹⁶³	Conference abstract of study protocol only; duplicate of full paper Mayo 2000¹⁶⁴
McNamee 1998¹⁶⁵	Health economic evaluation
Melin 1992¹⁶⁶	Not relevant: patients with long-term care needs were recruited. Hospital at Home was substitute for long-term care and not necessarily in-hospital
Meyer 2009¹⁶⁷	Not RCT; case studies
Muijen 1992¹⁶⁹	RCT but patients treated for acute, severe mental illness (psychiatric ward versus home); not relevant to AME guideline
Nicholson 2001¹⁷²	Health economics only
Nissen 2007¹⁷³	Not in English (Danish)
Nordly 2014¹⁷⁴	Protocol only; no study data
Nyatanga 2014¹⁷⁵	Not RCT; commentary/conceptual paper
Pace 2014¹⁷⁸	No comparator
Palmer Hill 2000¹⁷⁹	Not relevant: patients recovering from knee replacement
Pandian 2013¹⁸⁰	Trial register only; no data
Pandian 2015¹⁸¹	No extractable outcomes
Patel 2004¹⁸²	Health economic evaluation
Penque 1999¹⁸³	Not RCT; retrospective study
Pittiglio 2011¹⁸⁵	Not RCT; not relevant
Piotrowicz 2010¹⁸⁴	Incorrect comparison- home based- telemonitored cardiac rehab versus home based standard cardiac rehab
Plochg 2005¹⁸⁶	Not RCT; process evaluation
Pozzilli 2002¹⁸⁷	RCT BUT not relevant (Multiple Sclerosis patients)
Pradella 2015¹⁸⁸	No hospital-based comparison
Prior 2012 ¹⁸⁹	Not RCT
Puig-Junoy 2007¹⁹⁰	Health economic evaluation
Richards 1998 ¹⁹⁵	Not relevant; majority of patients with trauma and elective surgery
Richards 1998A¹⁹⁴	Not relevant; correction to excluded trial with majority of patients with trauma and elective surgery
Richardson ¹⁹⁶	Health economic evaluation
Robinson 2009¹⁹⁷	Not RCT; description of new model of acute care
Rodriguez-Cerrillo 2010²⁰¹	Not RCT; Non-randomised prospective study
Rodriguez-Cerrillo 2012A²⁰⁰	Not RCT; no comparison group to home treatment
Rosbotham-Williams 2002²⁰³	Not RCT; review
Round 2004²⁰⁴	Not RCT; prospective cohort study
Rout 2011²⁰⁵	Not RCT; review
Rowley 1984²⁰⁶	Not RCT. No comparison group
Ruckley 1978²⁰⁷	Not relevant: patients following elective surgery
Rudkin 1997²⁰⁹	No service provided in community
Sartain 2002²¹²	Paediatric patient population
Saysell 2004²¹³	Not RCT; pilot study of intermediate palliative care in care home
Schachter 2014²¹⁴	Not RCT; study protocol only
Scheinberg 1986²¹⁵	RCT but does not state what the control group intervention is
Schneller 2012²¹⁶	Not RCT; case study
Schou 2014²¹⁷	RCT; but no relevant outcomes
Scott 2010²¹⁸	Not RCT; literature review
Senaratne 1999²¹⁹	Cost evaluation
Shepperd 2016²²⁶	Cochrane review- already included in the hospital at home evidence review
Shepperd 1998²²²	Not RCT; systematic review
Shepperd 1998A²²¹	Costs only; no clinical outcomes
Shepperd 2005A²²⁰	Not RCT; editorial
Shepperd 2009A²²⁴	Not RCT; systematic review
Sindhwani 2011²²⁷	Incorrect study design. cohort study
Standen 2016²³⁰	Inappropriate intervention –virtual reality system for home based rehabilitation of the arm following stroke
Stephenson 1984²³¹	Not RCT; conceptual paper
Steventon 2012²³²	Not RCT; retrospective analysis
Stewart 1999²³³	RCT but control group not in hospital.
Stromberg 2003²³⁴	RCT but only nurse-led follow up appointments in hospital. No actual community care given
Subirana Serrate 2001²³⁵	Not RCT; health economics evaluation
SUIJKER 2016²³⁶	Study to be considered for inclusion in the community nurse review
Suwanwela 2002²³⁷	RCT but excluded because intervention was managed by Red Cross volunteers and family members.
Taylor 2015²³⁹	Systematic review: all eligible papers ordered
Teasell 2003²⁴⁰	Systematic review: all eligible papers ordered
Teng 2003²⁴¹	Health economic evaluation
Thorne 2001²⁴²	Not RCT; service description
Tibaldi 2004²⁴⁵	RCT but no relevant outcomes (carer stress data incomplete)
Trappes-Lomax 2006²⁴⁶	RCT but comparison group not appropriate; did not receive ‘usual’ hospital care.
Tuntland 2015²⁴⁷	No hospital-based comparison
Upton 2014²⁴⁸	Not RCT; not relevant
Utens 2010²⁴⁹	Study protocol of RCT only
Wakefield 2008²⁵³	RCT but all self-care; wrong comparison
Widen Holmqvist 1995²⁵⁴	Not RCT; observational study
Widen Holmqvist 1996²⁵⁵	Health economic evaluation
Winkel 2008²⁵⁶	Not RCT; systematic review
Wolfe 2000²⁵⁷	RCT but excluded from Cochrane because intervention does not substitute for inpatient care; not valid comparison
Woodend 2008²⁵⁸	RCT but wrong control group; both at home with no actual care provided.
Woodhams 2012²⁵⁹	Not RCT; literature review
Young 2003B²⁶²	Not RCT; audit
Young 2005B²⁶³	Not RCT; quasi-experimental study
Young 2010B²⁶¹	RCT but not relevant outcomes
Ytterberg 2010²⁶⁴	No outcomes of interest
Vester-andersen 2015²⁵⁰	All components were hospital-based
Wu 2008²⁶⁰	No hospital-based comparison
Zhong 2015²⁶⁵	Incorrect study design. retrospective cohort
Zwisler 2016²⁶⁶	Systematic review- checked and ordered relevant references.

Appendix H. Excluded economic studies

Table 16Studies excluded from the economic review

Reference	Reason for exclusion
Larsen 2006¹⁴⁷	This study was assessed as not applicable because the resource use was from non-UK studies pre 2005. The study is primarily a cost minimisation analysis under the assumption that the intervention is more effective. However, the only clinical outcome that is assessed is ‘poor outcomes’. This clinical outcome is not all encompassing and therefore cannot definitively conclude whether total health outcomes are better for the intervention. Likewise the cost analysis only looks at intervention cost, bed day costs and nursing home costs. This doesn’t fully capture total costs and likewise costing nursing home costs can be difficult as not all nursing home costs fall on the NHS. For these reasons the study was selectively excluded.
Saka 2009²¹⁰	This study was assessed as partially applicable with very serious limitations. The reporting in the study is quite unclear and it is not clear how early supported discharge (ESD) is costed and what drives the increased costs with ESD.
Miller 2005¹⁶⁸	This study was assessed as partially applicable with very serious limitations. The study is described as a cost-utility analysis but no QALY data reported.
Aimonino Ricauda 2005¹⁹³	This study was assessed as not applicable as it relies on unit costs from 1995.

Bookshelf ID: NBK564897

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