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
January, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Paediatric home care for ill children has been developed for different diseases and with different models as an alternative to care based in hospitals. In this summary we present evidence for home care for children with acute physical conditions, home rehabilitation for children with traumatic brain injury, and home chemotherapy.
Key messages
People making decisions concerning organisation of home care services for children.
Parker G, Spiers G, Gridley K, et al. Systematic review of international evidence on the effectiveness and costs of paediatric home care for children and young people who are ill. Child: Care, Health and Development 2013; 39:1–19.
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.
This review is an update of an earlier review that found “a relatively small and weak evidence base, whether for generic or specialist (condition specific) models of care for children with complex or long term healthcare needs” (Parker 2006). The review authors defined ‘care closer to home’ as “any model of care that acts to prevent immediate inpatient admission and/or enable a reduced length of stay for children (up to the age of 18 years) with acute, chronic, complex or palliative care needs. The model has to involve clinical care that would otherwise be provided in an acute clinical setting and had to be exclusively for children.” Educational or training interventions without a clinical component were excluded, as were longer term strategies to prevent or avoid hospital care for example, interventions to reduce asthma triggers in children’s homes or services that provided care for both children and adults.
| Review objectives: To identify recent evidence on effectiveness and costs of care closer to home (CCTH) for children with long term conditions, including evidence on CCTH for children with short term health needs and those with palliative or end oflife care needs | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials and other comparative studies with health economic data that assess any model of care that brings CCTH by preventing immediate inpatient admission and/or reducing length of stay of children, published since 1990 |
11 randomised trials and 15 health economic studies were included. The studies include 7 types of CCTH: for very low birthweight babies, for long term conditions, for mental health problems, for acute medical conditions, home chemotherapy, home based alternative to clinic based care and telemedicine support |
| Participants | Children with acute, chronic, complex or palliative care needs |
Diverse populations of children included, depending upon the health condition studied |
| Settings | Any home and hospital setting |
Studies were from US (3), UK (3) and one each from Canada, Finland, Germany, Australia and Brazil |
| Outcomes | Any measure of effectiveness, cost or cost effectiveness |
Depending on the intervention: mortality, morbidity outcomes, costs |
| Date of most recent search: April 2007 | ||
| Limitations: This is a well-conducted review with minor limitations. However, the last search was in 2007. | ||
Parker G, Spiers G, Gridley K, et al. Systematic review of international evidence on the effectiveness and costs of paediatric home care for children and young people who are ill. Child: Care, Health and Development 2013; 39:1–19.
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.
This review found 11 new studies that assessed effects of care closer to home and 15 studies including health economic data for the following types of interventions: home care for very low birth weight or medically “fragile” babies (1 study); for chronic or long term conditions (1), for mental health problems (2), for acute physical conditions (3), home chemotherapy (1), home based alternatives to clinic based care (2), and telemedicine support (1). The studies were from the USA (3), the UK (3), and one each from Australia, Canada, Finland, Germany, and Brazil.
Only information for home care for acute physical conditions, home based alternatives to clinic based care, and home chemotherapy is summarised here.
1) Home care for acute physical conditions compared with hospital care
Three studies assessed home care for three different acute conditions: children with fractures of the distal radius, children with breathing difficulties, diarrhoea with or without vomiting, and children with acute bronchiolitis. In the first condition, the intervention was home removal of backslab (a temporary cast) compared with hospital removal. In the other two, it was hospital at home with early discharge from hospital compared with in hospital management.
Home care for acute physical conditions compared with hospital care |
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| People: Children with fracture of radius, acute bronchiolitis, or diarrhoea. Settings: UK and USA. Intervention: Home care (different models). Comparison: Hospital care. |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
|
| Clinical outcomes |
Home care for fracture of the radius may lead to little or no difference in clinical outcomes or daily activities compared with hospital care. |
Low |
|
| Adverse events and re admissions |
Home care may lead to little or no difference in hospital re admissions for children with acute physical conditions compared with hospital care. |
Low |
|
| Impact on family and carers | Home care may lead to little or no difference in time spent by families caring for children with acute physical conditions compared with hospital care. |
Low |
|
| Mortality | Not reported | ||
| Costs | Home care probably increases healthcare costs compared with hospital care, but decreases costs incurred by families (in the UK). |
Moderate |
|
| GRADE: GRADE Working Group grades of evidence (see above and last page). | |||
Two trials assessed home care as an alternative to clinic based care, however one of them did not report results comparing both groups under study, but only comparisons before and after for each group. The only study included in the Summary of Findings table was conducted in Brazil in children with traumatic brain injury. It compared home rehabilitation by parents with clinic rehabilitation by health professionals.
Home based compared to clinic based rehabilitation |
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| People: Children with traumatic brain injury in rehabilitation Settings: Brazil Intervention: Home care rehabilitation Comparison: Clinic based rehabilitation |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
|
| Psychological and mental functioning |
Mean intellectual quotient (IQ) in home cared children was 91.4 compared with 85.3 points in children rehabilitated in clinics. |
Low |
|
| Adverse events and re admissions |
Not reported |
||
| Impact on family and carers | Not reported | ||
| Mortality | Not reported | ||
| Direct Costs | Direct Costs | ||
| GRADE: GRADE Working Group grades of evidence (see above and last page) | |||
One trial conducted in Canada compared initial chemotherapy in hospital and the remainder at home with hospital chemotherapy for children 2 to 16 years with high risk acute lymphoblastic leukaemia.
Home care for very low birth weight and/or medically fragile babies |
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| People: Children with high risk acute lymphoblastic leukaemia. Settings: Canada. Intervention: Home chemotherapy. Comparison: Hospital chemotherapy |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
|
| Quality of Life of children |
Home chemotherapy may slightly improve the quality of life of children with acute lymphoblastic leukaemia compared with hospital chemotherapy |
Low |
|
| Adverse events and re admissions |
Home chemotherapy may lead to little or no difference in adverse events compared with hospital chemotherapy. |
Low |
|
| Impact on family and carers | It is uncertain what the impact of home therapy is on family and carers compared with hospital chemotherapy. | Very low | |
| Mortality | Not reported | ||
| Family Costs | Home chemotherapy may lead to little or no difference in family costs compared with hospital chemotherapy. |
Low |
|
| GRADE: GRADE Working Group grades of evidence (see above and last page) | |||
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
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All studies (except one conducted in a upper middle income country) were conducted in high income countries and most were probably in urban settings.
|
Family support and home conditions could be very different in low income countries. Basic home support available in most homes in high income countries might not be widely available in low income countries.
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| EQUITY | |
| The included studies provided little data regarding differential effects of the interventions for disadvantaged populations |
Poor populations might not have the home conditions necessary to provide home care for seriously ill children.
|
| ECONOMIC CONSIDERATIONS | |
| Evidence about cost effectiveness of paediatric home care compared with “standard care” comes from studies conducted in high income countries. |
Healthcare professionals and resources to assist home care (home visits or remote assistance) might not be available in health systems in low income countries.
|
| MONITORING & EVALUATION | |
| Evidence of the effects of different types of paediatric home care is limited and no evidence from low income countries was found. |
Because there is important uncertainty about the potential benefits, harms and costs of paediatric home care compared to hospital care, pragmatic randomised trials in low income countries are needed. |
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*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-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods
While AE, Dyson L. Characteristics of paediatric home care provision: the two dominant models in England. Child: Care, Health and Development 2000; 26:263–76.
Parker G, Bhakta P, Lovett CA, et al. A systematic review of the costs and effectiveness of different models of paediatric home care. Health Technology Assessment 2002; 6:35.
Parker G, Bhakta P, Lovett C. et al. Paediatric home care: a systematic review of randomized trials on costs and effectiveness. Journal of Health Services Research& Policy 2006; 11: 110–19.
Parker G, Spiers G, Gridley K, et al. Evaluating models of care closer to home for children and young people who are ill: a systematic review. Final report. NIHR Service Delivery and Organisation programme 2011.
Shepperd S, Doll H, Gowers S, et al. Alternatives to inpatient mental health care for children and young people. Cochrane Database Syst Rev 2009; 2: CD006410.
Shepperd S, Iliffe S, Doll HA, et al. Admission avoidance hospital at home. Cochrane Database Syst Rev 2016; 9: CD007491.
Shepperd S, Doll H, Broad J, et aø. Hospital at home early discharge. Cochrane Database Syst Rev 2009; 1: CD000356.
Blanca Peñaloza, Unit of Health Policy and System Research, Pontificia Universidad Catolica de Chile.
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Gillian Parker and Harriet Nabudere.
Parker G, Spiers G, Gridley K, et al. Systematic review of international evidence on the effectiveness and costs of paediatric home care for children and young people who are ill. Child: Care, Health and Development 2013; 39:1–19.
Penaloza B. Does paediatric home care improve health outcomes in children? A SUPPORT Summary of a systematic review. January 2017. www.supportsummaries.org
evidence informed health policy, evidence based, systematic review, health systems research, health care,low and middle income countries, developing countries, primary health care, paediatric home care,care closer to home, home chemotherapy, home based treatment
