X1. Home management

Multidisciplinary care may assist home management (Lorig et al., 1999),(Shepperd et al., 1998),(Skwarska et al., 2000),(Kong et al., 1997) [evidence level II]

The shortage of hospital beds, especially in winter, has prompted interest in home care for management of COPD exacerbations, with involvement of multidisciplinary teams assisting GPs. Economic studies of such programs have shown mixed results. (Lorig et al., 1999),(Shepperd et al., 1998),(Skwarska et al., 2000),(Kong et al., 1997) Up to a quarter of carefully selected patients presenting to hospital emergency departments with acute exacerbations of COPD can be safely and successfully treated at home with support from respiratory nurses. A systematic review of 7 RCTs found no significant differences in readmission rates or mortality, but ‘Hospital at Home’ schemes were preferred by patients and carers (Ram et al., 2003) [evidence level I]. However, further research is needed because the studies reviewed were small and trialed different interventions.

A recent randomised controlled trial from Italy assigned 104 elderly patients with acute exacerbations of COPD to a general medical ward or hospital in the home. (Aimonino Ricauda et al., 2008) Patients managed at home had a longer mean length of stay, but there was a significantly reduced risk of readmission over the following 6 months. Only those managed at home demonstrated improvements in depression and quality of life [evidence level II]. It is not clear whether this system could be successfully applied in Australia, as the lengths of stay were longer and readmission rates were higher than observed here.