The health and cost effects of substituting home care for inpatient acute care: a review of the evidence

Background: There is much interest in reducing hospital stays by providing some health care services in patients' homes. The authors review the eviden ce regarding the effects of this acute care at home (acute home care) on th e health of patients and caregivers and on the social costs (public and pri vate costs) of managing the patients' health conditions. Methods: MEDLINE and HEALTHSTAR databases were searched for articles using the key term "home care." Bibliographies of articles read were checked for additional references. Fourteen studies met the selection criteria (publica tion between 1975 and early 1998, evaluation of an acute home care program for adults, and use of a control group to evaluate the program). Of the 14, only 4 also satisfied 6 internal validity criteria (patients were eligible for home care, comparable patients in home care group and hospital care gr oup, adequate patient sample size, appropriate analytical techniques, appro priate health measures and appropriate costing methods). Results: The 4 studies with internal validity evaluated home care for 5 spe cific health conditions (hip fracture, hip replacement, chronic obstructive pulmonary disease [COPD], hysterectomy and knee replacement); 2 of the stu dies also evaluated home care for various medical and surgical conditions c ombined. Compared with hospital care, home care had no notable effects on p atients' or caregivers' health. Social costs were not reported for hip frac ture. They were unaffected for hip and knee replacement, and higher for COP D and hysterectomy; in the 2 studies of various conditions combined, social costs were higher in one and lower in the other. Effects on health system costs were mixed, with overall cost savings for hip fracture and higher cos ts for hip and knee replacement. Interpretation: The limited existing evidence indicates that, compared with hospital care, acute home care produces no notable difference in health ou tcomes. The effects on social and health system costs appear to vary with c ondition. More well-designed evaluations are needed to determine the approp riate use of acute home care.