Strøm Camilla, Stefansson Jakob S, Fabritius Maria Louise, Rasmussen Lars S, Schmidt Thomas A, Jakobsen Janus C
Department of Emergency Medicine, Holbaek Hospital, University of Copenhagen, Holbaek, Denmark, 4300.
Cochrane Database Syst Rev. 2018 Aug 13;8(8):CD012370. doi: 10.1002/14651858.CD012370.pub2.
Short-stay units are hospital units that provide short-term care for selected patients. Studies have indicated that short-stay units might reduce admission rates, time of hospital stays, hospital readmissions and expenditure without compromising the quality of care. Short-stay units are often defined by a target patient category, a target function, and a target time frame. Hypothetically, short-stay units could be established as part of any department, but this review focuses on short-stay units that provide care for participants with internal medicine diseases and conditions.
To assess beneficial and harmful effects of short-stay unit hospitalisation compared with usual care in people with internal medicine diseases and conditions.
We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to 13 December 2017 together with reference checking, citation searching and contact with study authors to identify additional studies. We also searched several grey literature sources and performed a forward citation search for included studies.
We included randomised trials and cluster-randomised trials, comparing hospitalisation in a short-stay unit with usual care (hospitalisation in a traditional hospital ward or other services). We defined a short-stay unit to be a hospital ward where the targeted length of stay in hospital for patients was five days or less. We included both multipurpose and specialised short-stay units. Participants were adults admitted to hospital with an internal medicine disease or condition. We excluded surgical, obstetric, psychiatric, gynaecological, and ambulatory participants. Trials were included irrespective of publication status, date, and language.
We used standard methodological procedures expected by Cochrane. Two review authors independently extracted data and assessed the risk of bias of each included trial. We measured intervention effect sizes by meta-analyses for two primary outcomes, mortality and serious adverse events, and one secondary outcome, hospital readmission. We narratively reported the following important outcomes: quality of life, activities of daily living, non-serious adverse events, and costs. We used risk ratio differences of 15% for mortality and of 20% for serious adverse events for minimal relevant clinical consideration. We rated the certainty of the evidence and the strength of recommendations of the outcomes using the GRADE approach.
We included 19 records reporting on 14 randomised trials with a total of 2872 participants. One trial was ongoing. Thirteen trials evaluated short-stay unit hospitalisation for six specific conditions (acute decompensated heart failure (one trial), asthma (one trial), atrial fibrillation (one trial), chest pain (seven trials), syncope (two trials), and transient ischaemic attack (one trial)) and one trial investigated participants presenting with miscellaneous internal medicine disease and conditions. The components of the intervention differed among the trials as dictated by the trial participants' condition. All included trials were at high risk of bias.The certainty of the evidence for all outcomes was very low. Consequently, it is uncertain whether hospitalisation in short-stay units compared with usual care reduces mortality (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.47 to 1.15) 5 trials (seven additional trials reporting on 1299 participants reported no deaths in either group)); serious adverse events (RR 0.95, 95% CI 0.59 to 1.54; 7 trials (one additional trial with 108 participants reported no serious adverse events in either group)), and hospital readmission (RR 0.80, 95% CI 0.54 to 1.19, 8 trials (one additional trial with 424 participants did not report results for participants)). There was not enough information to confirm or refute that short-stay unit hospitalisation had relevant effects on quality of life, activities of daily living, non-serious adverse events, and costs.
AUTHORS' CONCLUSIONS: Overall, the quantity and the certainty of the evidence was very low. Consequently, it is uncertain whether there are any beneficial or harmful effects of short-stay unit hospitalisation for adults with internal medicine diseases and conditions - more trials comparing the effects of short-stay units with usual care are needed. Such trials ought to be conducted with low risk of bias and low risks of random errors to improve the overall confidence in the evidence.
短期住院单元是为特定患者提供短期护理的医院单元。研究表明，短期住院单元可能会降低住院率、缩短住院时间、减少再次入院率和费用，同时不影响护理质量。短期住院单元通常由目标患者类别、目标功能和目标时间框架来定义。理论上，短期住院单元可以作为任何科室的一部分设立，但本综述重点关注为内科疾病患者提供护理的短期住院单元。
评估与常规护理相比，短期住院单元住院对内科疾病患者的有益和有害影响。
我们检索了截至2017年12月13日的Cochrane中心对照试验注册库（CENTRAL）、医学期刊数据库（MEDLINE）、荷兰医学文摘数据库（Embase）以及其他三个数据库和两个试验注册库，并进行参考文献核对、引文检索以及与研究作者联系以识别其他研究。我们还检索了多个灰色文献来源，并对纳入研究进行了向前引文检索。
我们纳入了随机对照试验和整群随机对照试验，比较短期住院单元住院与常规护理（传统医院病房住院或其他服务）。我们将短期住院单元定义为患者住院目标时长为五天或更短的医院病房。我们纳入了多功能和专科短期住院单元。参与者为因内科疾病入院的成年人。我们排除了外科、产科、精神科、妇科和门诊参与者。试验纳入不考虑发表状态、日期和语言。
我们采用Cochrane期望的标准方法程序。两位综述作者独立提取数据并评估每个纳入试验的偏倚风险。我们通过荟萃分析测量两个主要结局（死亡率和严重不良事件）以及一个次要结局（再次入院）的干预效应大小。我们以叙述方式报告以下重要结局：生活质量、日常生活活动、非严重不良事件和费用。对于死亡率，我们使用15%的风险比差异，对于严重不良事件，使用20%的风险比差异进行最小相关临床考量。我们使用GRADE方法对证据的确定性和结局推荐的强度进行评级。
我们纳入了19条记录，报告了14项随机对照试验，共2872名参与者。一项试验正在进行中。13项试验评估了短期住院单元住院用于六种特定病症（急性失代偿性心力衰竭（一项试验）、哮喘（一项试验）、心房颤动（一项试验）、胸痛（七项试验）、晕厥（两项试验）和短暂性脑缺血发作（一项试验）），一项试验调查了患有各种内科疾病的参与者。干预的组成部分因试验参与者的病情而异。所有纳入试验均存在高偏倚风险。所有结局的证据确定性都非常低。因此，与常规护理相比，短期住院单元住院是否能降低死亡率（风险比（RR）0.73，95%置信区间（CI）0.47至1.15）尚不确定（5项试验（另外七项试验报告了1299名参与者，两组均未报告死亡））；严重不良事件（RR 0.95，95% CI 0.59至1.54；7项试验（另外一项试验有108名参与者，两组均未报告严重不良事件）），以及再次入院（RR 0.80，95% CI 0.54至1.19，8项试验（另外一项试验有424名参与者未报告参与者的结果））。没有足够信息证实或反驳短期住院单元住院对生活质量、日常生活活动、非严重不良事件和费用有相关影响。
总体而言，证据的数量和确定性非常低。因此，对于患有内科疾病的成年人，短期住院单元住院是否有任何有益或有害影响尚不确定——需要更多比较短期住院单元与常规护理效果的试验。此类试验应以低偏倚风险和低随机误差风险进行，以提高对证据的总体信心。
