Specialist home-based nursing services for children with acute and chronic illnesses: Cochrane systematic review

Abstract

Assessed as up to date: 2012/08/09

Background

Specialist paediatric home-based nursing services have been proposed as a cost-effective means of reducing distress resulting from hospital admissions, while enhancing primary care and reducing length of hospital stay. This review is an update of our original review, which was published in 2006.

Objectives

To evaluate specialist home-based nursing services for children with acute and chronic illnesses.

Search methods

We searched the following databases in February 2012: the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2012 Issue 2, Ovid MEDLINE, EMBASE, PsycINFO, CINAHL and Sociological Abstracts. We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. No language restrictions were applied.

Selection criteria

Randomised controlled trials (RCTs) of children from birth to age 18 years with acute or chronic illnesses allocated to specialist home-based nursing services compared with conventional health care. Outcomes included utilisation of health care, physical and mental health, satisfaction, adverse health outcomes and costs.

Data collection and analysis

Two review authors extracted data from the studies independently and resolved any discrepancies by recourse to a third author. Meta-analysis was not appropriate because of the clinical diversity of the studies and the lack of common outcome measures.

Main results

We screened 4226 titles to yield seven RCTs with a total of 840 participants. Participants, interventions and outcomes were diverse. No significant differences were reported in health outcomes; two studies reported a reduction in the hospital stay with no difference in the hospital readmission rates. Three studies reported a reduction in parental anxiety and improvement in child behaviours was reported in three studies. Overall increased parental satisfaction was reported in three studies. Also, better parental coping and family functioning was reported in one study. By contrast, one study each reported no impact on parental burden of care or on functional status of children. Home care was reported as more costly for service providers with substantial cost savings for the family in two studies, while one study revealed no significant cost benefits for the family.

Authors' conclusions

Current research does not provide supporting evidence for a reduction in access to hospital services or a reduction in hospital readmission rate for children with acute and chronic illnesses using specialist home-based nursing services; however, the only summary finding across a few studies was that there is a significant decrease in length of hospitalisation. The preliminary results show no adverse impact on physical health outcomes and a number of papers reported improved satisfaction with home-based care. Further trials are required, measuring health, satisfaction, service utilisation and long-term costs.

Author(s)

Parab Chitra S, Cooper Carolyn, Woolfenden Susan, Piper Susan M

Summary

Specialist home-based nursing services for children with acute and chronic illnesses

This review aimed to examine whether specialist paediatric home-based nursing services for children with acute and chronic illnesses reduce the number of hospital admissions and length of stay, enhance health care in the community and reduce stress for families at the time of their child's illness. It is an update of our original review published in 2006. We found seven relevant randomised controlled trials (RCTs) of total of 840 children aged from birth to 18 years with acute and/or chronic illnesses receiving either specialist home-based nursing services or conventional health care. The outcomes included use of health care services, physical and mental health, satisfaction, adverse health outcomes and costs. We decided not to combine the results of these RCTs because of the variety in types of services provided, types of participants and the outcome measures used. The results of individual RCTs show improved satisfaction with home-based care with no adverse impact on physical health outcomes for children. There is some evidence that specialist home-based nursing services reduce the length of hospital stay; however, there is no evidence that it leads to a reduction in use of hospital services. Further trials are required, measuring health, satisfaction, service use and long-term costs.

Reviewer's Conclusions

Implications for practice

This systematic review has demonstrated a limited evidence base for home care programmes, with few randomised controlled trials undertaken, clinical and methodological heterogeneity between trials that have been completed. At present, there is insufficient evidence to support the effectiveness of specialist paediatric nurse home visiting for acute and chronic illnesses in reducing hospital admissions and Emergency Department utilisation. However, there is suggestive evidence that home care programmes may lead to greater parent satisfaction, improved quality of life and a reduction in the length of hospital stay. The cost effectiveness of these programmes is still to be determined.

Implications for research

Additional randomised controlled trials are required to examine home care programmes for children with acute and chronic illnesses across the full age range of birth to 18 years. Adequate sample sizes must be used to generate the statistical power to detect differences between the intervention and control groups. Clinically relevant outcomes need to be defined for utilisation of Emergency Departments and length of hospital stay; physical health determinants; mental health determinants; and satisfaction measures. It would be useful if there were a standardised and consistent method of measuring these clinically relevant outcomes across studies, in particular, a definition of readmission to hospital and a standardised questionnaire for measuring parental satisfaction. While data for disease-specific diagnostic groupings would be the ideal, in reality ambulatory care programmes are usually set up in local populations to address a range of acute and chronic conditions. These include, but are not limited to, ambulatory sensitive conditions such as asthma and gastroenteritis.

Currently there are no data to support comprehensive costings for home care programmes from the perspective of a health organisation and the family. Complete evaluation of home care programmes requires estimation of both direct costs to healthcare providers and indirect costs to the child and their family, as well as to society. While healthcare provider costs may be readily assessable, the indirect costs of time off work, loss of earnings and childcare expenses must also be considered. The recently published systematic review (Parker 2012) on this topic refers to the need for additional high-quality research and collection of good-quality service level data with details about effects on the health economy. It also mentions that the evidence for paediatric home-based services continues to grow slowly.

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