SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
September, 2009 - SUPPORT Summary of a systematic review | print this article |
Two forms of paediatric home care have been described: community-based services that support children with a range of long term conditions and hospital-based services that provide specialist input to children with specific conditions at their homes.
People making decisions concerning the use of paediatric health care for different diseases.
Parker G, Bhakta P, Lovett CA, Olsen R, Palsley S Turner D et al. Paediatric home care: a systematic review of randomized trials on costs and effectiveness. J Health Serv Res Policy, 11 (2) : 110-119 ; 2006 See in JHSRP
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Technological developments in care, the negative impact of hospital admission on children and their families and the costs of health care have all encouraged the development of paediatric home care. Two types of paediatric home care have been described: community-based services that support children with a range of long term conditions, and predominantly hospital-based services that provide specialist input to children with specific conditions.
Children who may potentially benefit from paediatric home care are those with complex problems who need a coordinated, multidisciplinary approach, those whose conditions have not been stabilized in hospital, and those who are at risk in a hospital environment (i.e. immunocompromised).
The main functions of paediatric home care can be summarized as:
• direct services such as drug administration, general nursing care and counseling;
• education of the family and the patient;
• coordination of services between the hospital, primary care and the community; patient advocacy.
|
Review Objectives: To establish the range and types of home-based models of paediatric care for children with acute or chronic illness; to evaluate the effectiveness and costs of different models for the health care system and for children, their families and carers and to explore how cost-effectiveness differed between children with different needs and between children with similar needs but from different populations. |
||
| / | What the review authors searched for | What the review authors found |
|---|---|---|
| Interventions |
Randomized or pseudo-randomized trials and studies with a health economic element of paediatric home care as an alternative to acute hospital care, published since 1985. |
24 papers from 10 RCTs covering 4 types of paediatric home care: home care for very low birth weight, home-based care for asthma or diabetes, outreach services in mental health and paediatric home care. |
| Participants |
Children under 18 years of age with serious acute or chronic illness |
Diverse populations of children included, depending upon the health condition studied |
| Settings |
Any home and hospital setting |
Home and hospital settings. Studies were from the US (5), Canada (3), UK (1) and New Zealand (1) |
| Outcomes |
Any measure of effectiveness, cost or cost-effectiveness |
Mortality; service use; clinical, physical and psychological outcomes; costs; impact on family, social life and education; knowledge of the condition |
|
Date of most recent search: July 2001 |
||
|
Limitations: This is a systematic review with important limitations: publication bias was not assessed. Heterogeneity was not assessed when appropriate. |
||
Parker G, Bhakta P, Lovett CA, Olsen R, Palsley S Turner D et al. Paediatric home care: a systematic review of randomized trials on costs and effectiveness. J Health Serv Res Policy, 11 (2) : 110-119 ; 2006 See in JHSRP
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
The review found 10 randomised trials evaluating 4 types of paediatric home care: home care for very low birth weight or medically “fragile” babies; home-based care for asthma and diabetes; outreach services in mental health; and “paediatric home care”, described as a complex intervention conducted by an interdisciplinary team for chronically ill children and their families. Studies were done in US (5), Canada (3) UK (1) and New Zealand (1). The authors considered that studies included in the review were heterogeneous in their focus, outcome reporting and quality, although they did not assess it formally.
Two trials were included in this section. Both compared home-based treatment for mental health emergencies with “routine” care, whether hospital or community based. Interventions and comparators were heterogeneous, in one study the intervention group received a “family-based, intensive and multifaceted” intervention delivered in their own homes, while the control group received care in an inpatient unit. In the other study, the intervention was a “brief home-based family intervention conducted by child psychiatric social workers” in addition to routine care that received both control and intervened groups.
Children included in these studies were adolescents with diagnosis of deliberate self-poisoning or severe emotional disturbances.
Outreach services for children with mental health |
|||
|
Patient or population: Adolescents with diagnosis of deliberate self-poisoning or severe emotional disturbances |
|||
| Outcomes | Impact | No of Participants (studies) |
Quality of the evidence (GRADE) |
|
Length of hospital stay and readmission |
One study reported no statistical significance between intervention and comparison groups. |
275 patients |
|
|
Suicidal ideation, major depression and episodes of self harm |
There was not a statistical significant improvement for the intervened group for any of these outcomes. |
162 patients |
|
|
Global Severity In-dex, Child behavior checklist: internalizing and externalizing symptoms |
The intervention group improved compared with the control group, for externalizing symptoms. There were no statistically significant differences between groups for the other outcomes. |
113 patients |
|
|
p: p-value GRADE: GRADE Working Group grades of evidence (see above and last page) |
|||
Four trials were included in this section. Three included low birth weight babies and one trial included medically fragile infants, defined as those with moderate to severe bronchopulmonary dysplasia or those with moderate to severe neurological dysfunction. Models of intervention were diverse including early discharge but different strategies of home follow-up such as home visiting or educational and counselling interventions. Comparators were routine discharge procedures. Most relevant outcomes were mortality, use of health services, clinical outcomes (neurological status, physical and mental functions of babies) and costs of care.
Three trials that assessed paediatric home care for asthma or diabetes were found. Home care models assessed were heterogeneous but all offered some element of care (e.g., drug compliance checking) with or without education and training, one study was done in patients with diabetes and two in patients with asthma.
Outcomes assessed were length of hospital stay and readmission, clinical outcomes and impact on education, between six to 12 months.
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
|
|
| EQUITY | |
|
|
| ECONOMIC CONSIDERATIONS | |
|
|
| MONITORING & EVALUATION | |
|
|
|
|
*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 and middle-income countries. For additional details about how these judgements were made see: http://supportsummaries.org/support-summaries/how-support-summaries-are-prepared/ |
|
Related literature
Stein RE, Jessop DJ. Does paediatric home care make a difference for children with chronic illness? Finding from the paediatric ambulatory care treatment study. Paediatrics 1984; 73: 845-53
Shin JY, Nhan NV, Lee SB, Crittenden KS, Flory M, Hong HT, The effects of a home-based intervention for young children with intellectual disabilities in Vietnam. J Intellect Disabil Res. 2009 Apr;53(4):339-52.
Clar C, Waugh N, Thomas S. Routine hospital admission versus out-patient or home care in children at diagnosis of type 1 diabetes mellitus. Cochrane Data-base of Systematic Reviews 2007, Issue 2.
This summary was prepared by
Blanca Peñaloza and Gabriel Rada, Faculty of Medicine, Pontificia Universidad Católica de Chile, Chile
Conflict of interest
None. For details, see: Conflicts of Interest
Acknowledgements
This summary has been peer reviewed by: Gillian Parker, UK; Meenu Singh, India; Mike English, Kenya; Godfrey Woelk, Zimbabwe
This summary should be cited as
Penaloza B, Rada G. Does Paediatric Home Care improve children health out-comes? A SUPPORT Summary of a systematic review. September 2009.
