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Home treatment of COPD exacerbation selected by DECAF score: a non-inferiority, randomised controlled trial and
Carlos Echevarria1,2, Joanne Gray3, Tom Hartley1,2
1Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK.
Insights
Hospital at Home (HAH) for COPD exacerbation is safe and cost-effective when patients are selected using the DECAF score. This approach makes HAH suitable for twice as many patients, improving care and reducing costs.
Area of Science:
- Pulmonary Medicine
- Health Economics
- Clinical Trials
Background:
- Previous Hospital at Home (HAH) models for COPD exacerbation (ECOPD) lacked a reliable prognostic score for patient selection.
- The DECAF score identifies approximately 50% of hospitalized ECOPD patients as low-risk and potentially suitable for HAH.
Purpose of the Study:
- To evaluate the non-inferiority of HAH compared to usual care (UC) for low-risk ECOPD patients.
- To assess the health and social costs, clinical effectiveness, and patient preference for HAH.
Main Methods:
- A non-inferiority randomized controlled trial involving 118 low-risk ECOPD patients (DECAF score 0 or 1).
- Patients were allocated to either HAH or UC, with primary outcome being health and social costs at 90 days.
Main Results:
- Mean 90-day costs were £1016 lower in the HAH group, though the non-inferiority margin was narrowly missed.
- HAH significantly reduced hospital bed days (1 vs 5 days, P=0.001).
- 90% probability of HAH being cost-effective, similar readmission rates, and 90% patient preference for HAH.
Conclusions:
- HAH, selected using the low-risk DECAF score, is safe, clinically effective, and cost-effective for ECOPD.
- This selection method is simpler and doubles patient eligibility for HAH compared to previous models.
- The DECAF score can guide early discharge, as evidenced by a reduced length of stay in the UC group without adverse outcomes.
Background:
Previous models of Hospital at Home (HAH) for COPD exacerbation (ECOPD) were limited by the lack of a reliable prognostic score to guide patient selection. Approximately 50% of hospitalised patients have a low mortality risk by DECAF, thus are potentially suitable.
Methods:
In a non-inferiority randomised controlled trial, 118 patients admitted with a low-risk ECOPD (DECAF 0 or 1) were recruited to HAH or usual care (UC). The primary outcome was health and social costs at 90 days.
Results:
Mean 90-day costs were £1016 lower in HAH, but the one-sided 95% CI crossed the non-inferiority limit of £150 (CI -2343 to 312). Savings were primarily due to reduced hospital bed days: HAH=1 (IQR 1-7), UC=5 (IQR 2-12) (P=0.001). Length of stay during the index admission in UC was only 3 days, which was 2 days shorter than expected. Based on quality-adjusted life years, the probability of HAH being cost-effective was 90%. There was one death within 90 days in each arm, readmission rates were similar and 90% of patients preferred HAH for subsequent ECOPD.
Conclusion:
HAH selected by low-risk DECAF score was safe, clinically effective, cost-effective, and preferred by most patients. Compared with earlier models, selection is simpler and approximately twice as many patients are eligible. The introduction of DECAF was associated with a fall in UC length of stay without adverse outcome, supporting use of DECAF to direct early discharge.
Trial Registration Number:
Registered prospectively ISRCTN29082260.
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