January, 2017 - SUPPORT Summary of a systematic review | print this article |

Does paediatric home care improve health outcomes in children?

Paediatric home care for ill children has been developed for different diseases and with different models as an alternative to care based in hospitals. In this summary we present evidence for home care for children with acute physical conditions, home rehabilitation for children with traumatic brain injury, and home chemotherapy.

Key messages

  • Compared with hospital care, home care may lead to little or no difference in readmissions or the time spent by families caring for children with acute physical conditions. Home care for children with acute physical conditions probably increases healthcare costs but decreases costs incurred by families in the UK.
  • For children with traumatic brain injury, home rehabilitation compared with clinic based rehabilitation may slightly improve mental functioning. The effects on adverse events, family and carers, and costs were not reported.
  • For children with acute lymphoblastic leukaemia, home chemotherapy compared with hospital chemotherapy may slightly improve their quality of life and may lead to little or no difference in adverse events or family costs. The impact on family and carers is uncertain.
  • None of the studies included in the review were conducted in low income countries and none reported effects on mortality.

Background

This review is an update of an earlier review that found “a relatively small and weak evidence base, whether for generic or specialist (condition specific) models of care for children with complex or long term healthcare needs” (Parker 2006). The review authors defined ‘care closer to home’ as “any model of care that acts to prevent immediate inpatient admission and/or enable a reduced length of stay for children (up to the age of 18 years) with acute, chronic, complex or palliative care needs. The model has to involve clinical care that would otherwise be provided in an acute clinical setting and had to be exclusively for children.” Educational or training interventions without a clinical component were excluded, as were longer term strategies to prevent or avoid hospital care for example, interventions to reduce asthma triggers in children’s homes or services that provided care for both children and adults.



About the systematic review underlying this summary

Review objectives: To identify recent evidence on effectiveness and costs of care closer to home (CCTH) for children with long term conditions, including evidence on CCTH for children with short term health needs and those with palliative or end oflife care needs
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials and other comparative studies with health economic data that assess any model of care that brings CCTH by preventing immediate inpatient admission and/or reducing length of stay of children, published since 1990
11 randomised trials and 15 health economic studies were included. The studies include 7 types of CCTH: for very low birthweight babies, for long term conditions, for mental health problems, for acute medical conditions, home chemotherapy, home based alternative to clinic based care and telemedicine support
Participants Children with acute, chronic, complex or palliative care needs
Diverse populations of children included, depending upon the health condition studied
Settings Any home and hospital setting
Studies were from US (3), UK (3) and one each from Canada, Finland, Germany, Australia and Brazil
Outcomes Any measure of effectiveness, cost or cost effectiveness
Depending on the intervention: mortality, morbidity outcomes, costs
Date of most recent search: April 2007
Limitations: This is a well-conducted review with minor limitations. However, the last search was in 2007.
Parker G, Spiers G, Gridley K, et al. Systematic review of international evidence on the effectiveness and costs of paediatric home care for children and young people who are ill. Child: Care, Health and Development 2013; 39:1–19.

Parker G, Spiers G, Gridley K, et al. Systematic review of international evidence on the effectiveness and costs of paediatric home care for children and young people who are ill. Child: Care, Health and Development 2013; 39:1–19.

Summary of findings

This review found 11 new studies that assessed effects of care closer to home and 15 studies including health economic data for the following types of interventions: home care for very low birth weight or medically “fragile” babies (1 study); for chronic or long term conditions (1), for mental health problems (2), for acute physical conditions (3), home chemotherapy (1), home based alternatives to clinic based care (2), and telemedicine support (1). The studies were from the USA (3), the UK (3), and one each from Australia, Canada, Finland, Germany, and Brazil.

Only information for home care for acute physical conditions, home based alternatives to clinic based care, and home chemotherapy is summarised here.

1) Home care for acute physical conditions compared with hospital care

Three studies assessed home care for three different acute conditions: children with fractures of the distal radius, children with breathing difficulties, diarrhoea with or without vomiting, and children with acute bronchiolitis. In the first condition, the intervention was home removal of backslab (a temporary cast) compared with hospital removal. In the other two, it was hospital at home with early discharge from hospital compared with in hospital management.

  • For children with fracture of the radius, home care may lead to little or no difference in clinical outcomes or daily activities compared with hospital care. The certainty of this evidence is low.
  • Compared with hospital care, home care may lead to little or no difference in readmissions or the time spent by families caring for children with acute physical conditions. The certainty of this evidence is low.
  • Home care for children with acute physical conditions probably increases healthcare costs but decreases costs incurred by families in the UK. The certainty of this evidence is moderate.
  • The effects of home care compared with hospital care for children with acute physical conditions was not reported.

Home care for acute physical conditions compared with hospital care

People: Children with fracture of radius, acute bronchiolitis, or diarrhoea.
Settings:  UK and USA.
Intervention
Home care (different models).
Comparison
Hospital care.
Outcomes Impact Certainty of the evidence
(GRADE)
Clinical outcomes
Home care for fracture of the radius may lead to little or no difference in clinical outcomes or daily activities compared with hospital care.
Low
Adverse events and re admissions
Home care may lead to little or no difference in hospital re admissions for children with acute physical conditions compared with hospital care.
Low
Impact on family and carers Home care may lead to little or no difference in time spent by families caring for children with acute physical conditions compared with hospital care. Low
Mortality Not reported  
Costs Home care probably increases healthcare costs compared with hospital care, but decreases costs incurred by families (in the UK). Moderate
GRADE: GRADE Working Group grades of evidence (see above and last page).

2) Home based alternatives to clinic based care

Two trials assessed home care as an alternative to clinic based care, however one of them did not report results comparing both groups under study, but only comparisons before and after for each group. The only study included in the Summary of Findings table was conducted in Brazil in children with traumatic brain injury. It compared home rehabilitation by parents with clinic rehabilitation by health professionals.

  • Home care rehabilitation may slightly improve mental functioning compared with clinical based rehabilitation. The certainty of this evidence is low.
  • Effects of home care on adverse events, family and carers, mortality, and costs were not reported.

Home based compared to clinic based rehabilitation

People: Children with traumatic brain injury in rehabilitation
Settings
:  Brazil
Intervention
Home care rehabilitation
Comparison
Clinic based rehabilitation
Outcomes Impact Certainty of the evidence
(GRADE)
Psychological and mental functioning
Mean intellectual quotient (IQ) in home cared children was 91.4 compared with 85.3 points in children rehabilitated in clinics.
Low
Adverse events and re admissions
Not reported

Impact on family and carers Not reported  
Mortality Not reported  
Direct Costs Direct Costs  
GRADE: GRADE Working Group grades of evidence (see above and last page)

3) Home versus hospital chemotherapy

One trial conducted in Canada compared initial chemotherapy in hospital and the remainder at home with hospital chemotherapy for children 2 to 16 years with high risk acute lymphoblastic leukaemia.

  • Home chemotherapy may slightly improve the quality of life of children with acute lymphoblastic leukaemia compared with hospital chemotherapy. The certainty of this evidence is low.
  • Home chemotherapy may lead to little or no difference in adverse events compared with hospital chemotherapy. The certainty of this evidence is low.
  • The impact of home chemotherapy on family and carers compared with hospital chemotherapy is uncertain. The certainty of this evidence is very low.
  • Home chemotherapy may lead to little or no difference in family costs compared with hospital chemotherapy. The certainty of this evidence is low.
  • The effect of home chemotherapy compared with hospital chemotherapy on mortality was not reported.

Home care for very low birth weight and/or medically fragile babies

People: Children with high risk acute lymphoblastic leukaemia.
Settings
:  Canada.
Intervention
: Home chemotherapy.
Comparison
: Hospital chemotherapy
Outcomes Impact Certainty of the evidence
(GRADE)
Quality of Life of children
Home chemotherapy may slightly improve the quality of life of children with acute lymphoblastic leukaemia compared with hospital chemotherapy
Low
Adverse events and re admissions
Home chemotherapy may lead to little or no difference in adverse events compared with hospital chemotherapy.
Low
Impact on family and carers It is uncertain what the impact of home therapy is on family and carers compared with hospital chemotherapy. Very low
Mortality Not reported  
Family Costs Home chemotherapy may lead to little or no difference in family costs compared with hospital chemotherapy. Low
GRADE: GRADE Working Group grades of evidence (see above and last page)

 


 


 

 

 

 

 

 

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

All studies (except one conducted in a upper middle income country) were conducted in high income countries and most were probably in urban settings.

  • Evidence about effectiveness of different types of paediatric home care on different groups of paediatric patients is limited.
  • Paediatric home care assessed in this review differed in intensity, the healthcare professionals involved, and the types of service provided.
  • “Standard care” used as the comparator in the included studies was heterogeneous.

Family support and home conditions could be very different in low income countries. Basic home support available in most homes in high income countries might not be widely available in low income countries.

  •  Standard care could be very different in high income countries compared with low income countries.
EQUITY
The included studies provided little data regarding differential effects of the interventions for disadvantaged populations

Poor populations might not have the home conditions necessary to provide home care for seriously ill children.

  • The educational level of mothers was not assessed and this might be an important consideration.
  • Home care, if effective, might benefit wealthier families with better home conditions more than poorer families.
ECONOMIC CONSIDERATIONS
Evidence about cost effectiveness of paediatric home care compared with “standard care” comes from studies conducted in high income countries.

Healthcare professionals and resources to assist home care (home visits or remote assistance) might not be available in health systems in low income countries.

  • There is a trade off between demand for additional human resources allocated to home care and potential reductions in demand for hospitalisation.
  • Financial and delivery arrangement constraints of health systems of low income countries could make it difficult to implement home care.
  • Special attention should be given to the burden and financial impacts on families or other informal care givers if paediatric home care is implemented.
  • Costs and cost effectiveness reports should be considered cautiously until studies in low income countries are available.
MONITORING & EVALUATION
Evidence of the effects of different types of paediatric home care is limited and no evidence from low income countries was found.

Because there is important uncertainty about the potential benefits, harms and costs of paediatric home care compared to hospital care, pragmatic randomised trials in low income countries are needed.



*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods

Additional information

Related literature

While AE, Dyson L. Characteristics of paediatric home care provision: the two dominant models in England. Child: Care, Health and Development 2000; 26:263–76.

 

Parker G, Bhakta P, Lovett CA, et al. A systematic review of the costs and effectiveness of different models of paediatric home care. Health Technology Assessment 2002; 6:35.

 

Parker G, Bhakta P, Lovett C. et al. Paediatric home care: a systematic review of randomized trials on costs and effectiveness. Journal of Health Services Research& Policy 2006; 11: 110–19.

 

Parker G, Spiers G, Gridley K, et al. Evaluating models of care closer to home for children and young people who are ill: a systematic review. Final report. NIHR Service Delivery and Organisation programme 2011.

Shepperd S, Doll H, Gowers S, et al. Alternatives to inpatient mental health care for children and young people. Cochrane Database Syst Rev 2009; 2: CD006410.

 

Shepperd S, Iliffe S, Doll HA, et al. Admission avoidance hospital at home. Cochrane Database Syst Rev 2016; 9: CD007491.

 

Shepperd S, Doll H, Broad J, et aø. Hospital at home early discharge. Cochrane Database Syst Rev 2009; 1: CD000356.

 

This summary was prepared by

Blanca Peñaloza, Unit of Health Policy and System Research, Pontificia Universidad Catolica de Chile.

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

Acknowledgements

This summary has been peer reviewed by: Gillian Parker and Harriet Nabudere.

 

This review should be cited as

Parker G, Spiers G, Gridley K, et al. Systematic review of international evidence on the effectiveness and costs of paediatric home care for children and young people who are ill. Child: Care, Health and Development 2013; 39:1–19.

The summary should be cited as

Penaloza B. Does paediatric home care improve health outcomes in children? A SUPPORT Summary of a systematic review. January 2017. www.supportsummaries.org

Keywords

evidence informed health policy, evidence based, systematic review, health systems research, health care,low and middle income countries, developing countries, primary health care, paediatric home care,care closer to home, home chemotherapy, home based treatment

This summary was prepared with additional support from:

  • Pontificia Universidad Catolica de Chile.

 

 

 

 



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