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International Journal of Nursing Studies 50 (2013) 1537–1549

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tient preference and satisfaction in hospital-at-home

and

ual hospital care for COPD exacerbations: Results of a
ndomised controlled trial§,§§

cile M.A. Utens a,b,*, Lucas M.A. Goossens c, Onno C.P. van Schayck b,
ureen P.M.H. Rutten-van Mölken c, Walter van Litsenburg a, Annet Janssen a,
ouschka van der Pouw d, Frank W.J.M. Smeenk a

partment of Respiratory Medicine, Catharina Hospital, Eindhoven, The Netherlands

partment of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands

titute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands

partment of Respiratory Medicine, Rijnstate Hospital, Arnhem, The Netherlands

What is already known about the topic?

� Patient satisfaction with hospital-at-home schemes is
high, but most schemes admit patients with various
conditions.
� Effectiveness and cost-effectiveness of hos

pital-at-home

and usual hospital care for COPD patients are not

T I C L E I N F O

le history:

ived 27 September 2012

ived in revised form 15 March 2013

pted 15 March 2013

ords:

pital-at-home

y assisted

discharge

nic Obstructive Pulmonary Disease

ent preference

ent satisfac

tion

A B S T R A C T

Background: In the absence of clear differences in effectiveness and cost-effectiveness

between hospital-at-home schemes and usual hospital care, patient preference plays an

important role. This study investigates patient preference for treatment place, associated

factors and patient satisfaction with a community-based hospital-at-home scheme for

COPD exacerbations.

Methods: The study is part of a larger randomised controlled trial. Patients were

randomised to usual hospital care or early assisted discharge which incorporated

discharge at day 4 and visits by a home care nurse until day 7 of treatment (T + 4 days). The

hospital care group received care as usual and was discharged from hospital at day 7.

Patients were followed for 90 days (T + 90 days). Patient preference for treatment place

and patient satisfaction (overall and per item) were assessed quantitatively and

qualitatively using questionnaires at T + 4 days and T + 90 days. Factors associated with

patient preference were analysed in the early assisted discharge group.

Results: 139 patients were randomised. No difference was found in overall satisfaction. At

T + 4 days, patients in the early assisted discharge group were less satisfied with care at

night and were less able to resume normal daily activities. At T + 90 days there were no

differences for the separate items. Patient preference for home treatment at T + 4 days was

42% in the hospital care group and 86% in the early assisted discharge group and 35% and

59% at T + 90 days. Patients’ mental state was associated with preference.

Conclusion: Results support the wider implementation of early assisted discharge for

COPD exacerbations and this treatment option should be offered to selected patients that

prefer home treatment.

We thank Kitty van der Meer, research assistant, for her work in

the

ribution and management of the questionnaires and data.

Trial registration: NetherlandsTrialRegister NTR 1129.
Corresponding author at: Department of Respiratory Medicine,

arina Hospital, Eindhoven, The Netherlands. Tel.: +31 612796688.

E-mail address: cecileutens@gmail.com (Cecile M.A. Utens).

Contents lists available at SciVerse ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

0-7489/$ – see front matter � 2013 Elsevier Ltd. All rights reserved.
://dx.doi.org/10.1016/j.ijnurstu.2013.03.006

http://crossmark.crossref.org/dialog/?doi=10.1016/j.ijnurstu.2013.03.006&domain=pdf

http://dx.doi.org/10.1016/j.ijnurstu.2013.03.006

mailto:cecileutens@gmail.

com

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http://dx.doi.org/10.1016/j.ijnurstu.2013.03.006

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491538

different, therefore the choice between the two should
be based on patient preference.

What this paper adds

� This paper is the first to demonstrate patient

satisfaction

with hospital-at-home and usual hospital care and
preference for treatment place in only patients with a
COPD exacerbation.
� This paper demonstrates that patients are satisfied with

hospital-at-home.
� The majority of patients prefers home treatment if they

could choose.

1. Introduction

Internationally, there are trends to deliver care in the
community and more closely to the patients’ home.
Combined with a pressure on hospital beds and a
continuous need to constrain health care costs, this has
led to the development of alternatives for hospital care.
Schemes aimed at avoiding hospital admission or reduce
length of stay by treating and supervising patients at home,
instead of the hospital, are called hospital-at-home
schemes (Shepperd et al., 2008, 2009). Studies have proved
that these schemes are safe and have no negative effects on
patient outcomes (Shepperd et al., 2008, 2009; Ram et al.,
2003). Chronic Obstructive Pulmonary Disease (COPD)
exacerbations are responsible for a great number of annual
hospital admissions, and accompanying health care costs
(Toy et al., 2010). To reduce the pressure on hospital beds
hospital-at-home schemes have been designed. Forty-four
percent of British hospitals runs a hospital-at-home
scheme for COPD exacerbations (Quantrill et al., 2007).
Patient satisfaction with hospital-at-home schemes is
high, but results are mainly derived from studies evaluat-
ing general, non-specialised schemes, meaning that they
admit patients with various conditions and treatments
(Montalto, 1996; Dubois and Santos-Eggimann, 2001;
Wilson et al., 2002; Leff et al., 2006). Three British studies
evaluated patient satisfaction with hospital-at-home
schemes admitting only patients with COPD exacerbations
(Ojoo et al., 2002; Schofield et al., 2006; Clarke et al., 2010).
All studies reported high patient satisfaction. However, the
schemes were hospital-based outreach schemes, with
specialised respiratory nurses performing visits at home.
Recently we have reported the results of a randomised
controlled trial studying the effectiveness of community-
based early assisted discharge for patients admitted to the
hospital with a COPD exacerbation (Utens et al., 2012). The
community-based hospital-at-home scheme for COPD
exacerbations, with community nurses performing home
visits, had similar patient outcomes as usual hospital care
(Utens et al., 2012). The economic evaluation, that was
performed as part of this clinical trial, also did not show a
large cost difference between the two treatments. From
the health care perspective savings of early assisted
discharge were s244 and from a societal perspective,
incorporating costs of informal caregiving and productivity
loss in addition to health care costs, savings of early
assisted discharge were s65 (Goosens et al., 2013).

Therefore, the choice between the two treatments should
be largely based on patient preference. Preference is the
desirability of a treatment, process or treatment choice
(Krahn and Naglie, 2008). Little is known about the
preference for treatment place and which factors influence
this preference. Therefore, in this study we investigate
patient preference for treatment place and associated
factors. Preference for treatment and satisfaction with
treatment are associated. Satisfaction reflects the degree to
which a patients’ perceived experience matches prefer-
ences regarding this experience (Brennan, 1995). In this
study we compared satisfaction with the community-
based hospital-at-home scheme and usual hospital care.
Satisfaction is determined by the ratio between patients’
expectations of care and their perceptions of the actual
care received, influenced by previous experiences and
personal values (Carr-Hill, 1992).

2. Methods

2.1. Design and patients

The current study was part of a randomised controlled
trial, investigating the effectiveness of community-based
early assisted discharge for patients admitted to the
hospital with a COPD exacerbation (Utens et al., 2010). The
study was conducted between November 2007 and March
2011 in five hospitals and three home care organisations.
Patients that were considered eligible according to the
inclusion and exclusion criteria at admission (Table 1), and
those meeting the criteria of clinical stability (see Table 1)
on day three of admission, were randomised to usual
hospital care or early assisted discharge. Clinical stability
was assessed by the reviewing physician of the hospital
ward. Randomisation was performed on a 1:1 scale using a
computer-generated allocation list that was placed in
sealed envelopes. Randomisation was performed per
participating hospital location and a block-size of 6. Due
to the nature of the intervention, patients and health care
staff involved could not be blinded to treatment allocation.
Those randomised to early assisted discharge, were
discharged home on the fourth day of admission and
visited at home by community nurses that same day and
the next 3 days. In addition, during the 4 days of home
treatment a 24-h telephone access with the hospital ward
was installed. After a total of 7 days of hospital followed by
home treatment, patients were discharged from the
scheme. Patients randomised to usual hospital care
continued the hospital treatment for another 4 days,
making the total length of hospital treatment 7 days, and
were then discharged home. Patients were followed-up for
three months. A detailed description of the trial and the
early assisted discharge intervention has been published
elsewhere (Utens et al., 2010). The trial was approved by
the Medical Ethics Committee of the Catharina Hospital
Eindhoven, the Netherlands.

2.2. Measurements

Baseline characteristics were collected at admission.
Characteristics that were obtained are age, gender, living

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C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–1549 1539

ation, presence of informal care, care at home prior to
ission, number of years diagnosed with COPD,

ome, education, coping style with the Utrecht Coping
(Schreurs et al., 1993), health status with the Clinical

PD Questionnaire (van der Molen et al., 2003),
asuring 3 domains: symptoms, functional state and
ntal state, and comorbidity with the Charlson comor-
ity index (Charlson et al., 1987). Patients’ satisfaction

preference for treatment place was measured with a,
this study translated, questionnaire by Ojoo et al.

02). The questionnaire for both treatment groups
sisted of three parts. The first qualitative part was two
n-end questions asking for three things of the

eived treatment that patients were most satisfied
most dissatisfied about. The second part consisted of
quantitative questions, with five response options
ying from a very positive to a very negative response.

questions discuss topics of medication, concerns
ing treatment and nursing care among others. Each of

answer options of the second part of the satisfaction
stionnaire was assigned as score between 1

mpletely negative answer) and 5 (completely positive
wer) and an overall score was calculated by dividing

total sum score by the total number of valid
stions. Six missing values were allowed. The final
t was a quantitative, dichotomous, hypothetical
stion on where patients would want to be treated
ey could choose: in the hospital and partly at home or

irely in the hospital. The questionnaire was completed
two moments; at the end of the home or hospital
tment (T + 4 days) and after three months follow-up

90 days). At the end of the home treatment, the early
isted discharge group received an additional, separate,
stionnaire with six quantitative questions for the
luation of the home care. This questionnaire covered
rall satisfaction, satisfaction with the total number of

days that home care was provided, the number of visits
each day and the duration of the daily visits. A from
Dutch to English translated version of the questionnaires
can be found in Appendix

The sample size calculation for the randomised
controlled trial was performed for the primary outcome
measure, which was effectiveness expressed in change in
the clinical COPD questionnaire. Patient preference and
satisfaction were secondary outcomes in the randomised
controlled trial. The required sample size for the primary
outcome was 165 patients.

2.3. Analysis

Patient satisfaction with the care they receive has been
the subject of many quantitative and qualitative studies. In
order to be more specific in the evaluation of hospital-at-
home in comparison to usual hospital care we used
deductive content analysis for the responses to the first
part of the questionnaire which contained the two open-end
questions (Graneheim and Lundman, 2004; Elo and Kyngas,
2008). Deductive content analysis is based on previous
theories or models and therefore allows to go beyond general
findings which would have been the focus of an inductive
analysis. Sofaer and Firminger (2005) have identified seven
categories on which patients base the definition of quality of
health care on. These categories are namely patient-centred
care; access; communication and information; courtesy and
emotional support; technical quality; efficiency of care/
organisation; and structure and facilities. Responses to the
two open-end questions were reviewed and then coded
according to these seven categories. CU performed the first
coding and CPvS checked these codings. Discrepancies were
discussed between the two coders. For each of the categories
the most named aspects are described and illustrated with
authentic citations.

le 1

usion and exclusion criteria (applied at admission) and randomisation criteria (applied at day 3 of admission).

clusion criteria (checked on day 1 Exclusion criteria (checked on day 1)

e �40 years Major uncontrolled comorbidity, including pneumonia that
is prominent, heart failure that is prominent, acute changes on

ECG and (suspected) underlying malignancy

mpetent to give written informed consent Mental disability, including dementia, impaired level of consciousness and

acute confusion

agnosed with COPD. COPD was defined

as at least GOLD stage I and 10 pack

years of smoking

Living outside care region of the home care organisation

spitalisation for COPD exacerbation Inability to understand the program

Indication for admission to intensive care unit of for non invasive ventilation

Insufficient availability of informal care at home

ndomisation criteria (checked on day 3)

mpleted informed consent of day 3 of admission

ceptable general health:

– Decrease of physical complaints

– Non-dependency of therapies that cannot be

given at home (intravenous therapy and

newly prescribed oxygen treatment)

– Being able to visit toilet independently,

or as

prior to admission

rmal or moderately increased blood sugar levels, defined as �15 mmol/L of �15 mmol/L but capable to regulate independently
spiratory complaints of dyspnoea, wheezing and rhonchi must have been decreased in comparison with day of admission

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491540

For the second part of the questionnaire differences in
the overall satisfaction score and differences on the
different items were tested using Mann–Whitney tests.

The third part of the questionnaire – the preference of
treatment place – was analysed in two steps. First, the
comparison of the percentage of patients in both groups
preferring home treatment in the hypothetical situation
that they could choose between treatments, was analysed
using Chi-square test. Second, we wanted to study which
factors are associated with treatment place. Therefore, for
early assisted discharge group (N = 70), that experienced
both hospital treatment and home treatment, a two-step
logistic regression was performed. First, bivariate logistic
regression analysis was conducted to determine the factors
associated with patients’ preference for treatment place.
The following factors were investigated for their associa-
tion with preference for treatment place: age, gender,
living situation (alone vs. with someone), presence of
informal caregiver, presence of home care prior to
admission, long term oxygen treatment (yes vs. no), oral
corticosteroid maintenance treatment (yes vs. no) coping
styles (active, avoidant and passive style), income, educa-
tion, number of years diagnosed with COPD, clinical COPD
questionnaire scores (symptoms, functional state and
mental state) at randomisation, and comorbidity (COPD
vs. COPD and one/multiple comorbidities). Next, factors
with p � 0.1 in the bivariate analyses were included in a
multivariate logistic regression. Four factors (long-term
oxygen treatment, income, living situation and clinical
COPD questionnaire – mental state) were included in the
multivariate regression. This requires a sample size of at
least 40 cases, a requirement that was met (Rothman et al.,
2008). Dependent variable in the logistic regressions was
either preference at T + 4 days or T + 90 days.

The additional six questions for the evaluation of the
home care from the early assisted discharge group are
reported as percentage of total responses.

3. Findings

In total 139 patients were randomised, 69 to usual
hospital care and 70 to early assisted discharge care. Table
2 provides an overview of the patient characteristics. Both
groups appeared to be comparable on baseline character-
istics. Immediately after randomisation seven patients in
the usual hospital care group and three patients in the
early assisted discharge group withdrew consent, because
they were not satisfied with the allocated place of
treatment. These seven patients were not different from
the other patients in the usual hospital care group, but the
three patients in the early assisted discharge group that
withdrew consent immediately after randomisation had a
worse comorbidity score than other patients in this
treatment group.

3.1. Findings – first part: qualitative questions on satisfaction

In total, 105 patients (49 of the usual hospital care group
and 56 of the early assisted discharge group) provided 200
comments on aspects they were most satisfied about and 87

Table 2

Patient characteristics. Scores represent number (%), unless stated

otherwise.

Characteristic Usual hospital

care (N = 69)

Early assisted

discharge (N = 70)

Age (years), mean (SD) 67.8 (11.30) 68.31 (10.34)

Sex: male 38 (55.1) 48 (68.6)

Charlson comorbidity scorea

Patients with score = 1 42 (60.0) 38 (54.0)

Patients with score > 1 27 (39.0) 32 (46.0)

Clinical COPD Questionnaireb

Symptoms (range 0–6),

mean (SD)

2.25 (1.05) 2.50 (1.05)

Fnctional state

(range 0–6), mean (SD)

2.61 (1.33) 3.33 (1.42)

Mental state

(range 0–6), mean (SD)

1.38 (1.28) 1.49 (1.45)

Long term oxygen treatment

prior to admission

Yes 4 (5.8) 5 (7.1)

No 65 (94.2) 65 (92.2)

Oral corticosteroid maintenance treatment prior to admission

Yes 5 (7.2) 10 (14.3)

No 64 (92.8) 60 (85.7)

Coping Utrecht coping list�
Active coping style

(range 7–28), mean (SD)

16.72 (3.26) 17.98 (4.14)

Passive coping style

(range 7–28), mean (SD)

12.30 (3.04) 12.25 (3.99)

Avoidant coping style

(range 8–32), mean (SD)

17.24 (3.94) 17.67 (3.62)

Living situation

Living alone 21 (30.4) 22 (31.4)

Living with partner 44 (63.8) 42 (60.0)

Living with child(ren) 1 (1.4) 2 (2.8)

Living with partner

and child(ren)

3 (4.3) 4 (5.7)

Presence of informal care

Yes 62 (89.9) 62 (88.6)

No 7 (10.1) 8 (11.4)

Care at home before admission

None 54 (78.3) 53 (75.7)

Nursing care or help with

activities of daily living

2 (2.9) 7 (10.0)

Domestic help 10 (14.5) 7 (10.0)

Both 3 (4.3) 3 (4.3)

Number of years

diagnosed with

COPD, mean (SD)

8.32 (7.69) 8.16 (7.96)

Incomec

Low 17 (40.5) 18 (40.9)

Medium 12 (28.6) 11 (25.0)

High 13 (31.0) 15 (34.1)

Education leveld

Low 20 (33.9) 21 (35.0)

Medium 26 (44.1) 27 (45.0)

High 15 (22.0) 12 (20.0)
a Score of 1 means COPD only, score >1 means COPD and other

comorbidities.
b 0 represents best possible score and 6 worst possible score; �higher

scores mean higher level of trait.
c Low refers to monthly family income � s1249, medium refers to

monthly family income between s1250 and s1749, high refers to
monthly family income � s1750. Data are missing or patient did not want
to specify in 27 cases.

d Low refers to (parts) of primary school only, medium refers to lower

vocational education or intermediate general education, high refers to

intermediate vocational education or higher general education or higher

vocational training or university.

aspects they were most dissatisfied about.

3.1.

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C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–1549 1541

1. Patient-centred care

Most responses in this category were on satisfying
ects. Only 5 comments were on dissatisfying aspects.
ients in both groups were satisfied with the (nursing)
e and counselling they received, which is illustrated by

following comments:

‘‘The care I received, problems were solved and the
assistance of the staff.’’ (Patient in usual hospital care
group)
‘‘The care was personal.’’ (Patient in early assisted
discharge group)

Patients in the early assisted discharge group were
sfied with how they were received at home and the
e at home by the home care nurses.
At the end of the follow-up period, patients from
h groups commented that they were dissatisfied
ut the fact that they saw different nurses and doctors
ry time, or that they did not see their own
monologist.

‘‘I was not treated and seen by my own pulmonologist.’’
(Patient in usual hospital care group)
‘‘I saw different specialists’’ and ‘‘I had to tell the same
story over and over again.’’ (Patient in early assisted
discharge group)
‘‘At home there were different nurses every time.’’
(Patient in early assisted discharge group)

2. Access

The aspect which was satisfying and most mentioned
patients in the early assisted discharge group was

possibility to go home by early assisted discharge
receive follow-up care from nurses of the home

e organisation. The regular check-ups, receiving
nursing care and medication at home were very
ch appreciated. One patient described the advantages

disadvantages of early assisted discharge very
rly:

Advantages were: ‘‘Privacy’’ and ‘‘able to follow own
daily rhythm’’ while disadvantages were: ‘‘being alone
at night when I am breathless’’ and ‘‘it is easier to cross
my own limits [in physical context].’’ (Patient in early
assisted discharge group)

Patients in the usual hospital care group appreciated
hospital care that they received.
Due to bed shortages, several patients in both groups
re not treated at the respiratory nursing ward but the
sing ward of another specialty. This was subject of
atisfying comments:

‘‘The first days I stayed not on the respiratory ward.’’
(Patient in usual hospital care group)
‘‘I was not admitted to the respiratory ward, where
I belong.’’ (Patient in early assisted discharge
group)

3. Communication and information

Patients in both groups were satisfied on the informa-
and clear explanation they received of staff which

focussed on the disease COPD, the treatment and the
project, illustrated by the following comments:

‘‘The good explanation on the project.’’ (Patient in early
assisted discharge group)
‘‘The clear explanation about what they [staff] are going
to do.’’ (Patient in usual hospital care group)

However, some patients, especially in the early assisted
discharge group, experienced that they received little
information on medication, the disease and what the
upcoming days would happen. This is illustrated by the
following comments:

‘‘I am surprised that after 12 years having a lung
disease I get breathing exercises for the first time’’ and
‘‘I am surprised to have learned the diagnosis COPD
now and not earlier.’’ (Patient in early assisted
discharge group)
‘‘They [hospital staff] promised more in the hospital.’’
(Patient in early assisted discharge group)
‘‘Insufficient preparation for going home. I expected
more care at home with regard to medication and
making coffee.’’ (Patient in early assisted discharge
group)

3.1.4. Courtesy and emotional support

Patients from both groups were satisfied with the
contact they had with the medical and nursing staff.
Patients were satisfied with the kindness of the staff, the
attention staff had for them and the understanding. The
following comments illustrate this:

‘‘Kindness, which makes me feel calm.’’ (Patient in usual
hospital care group)
‘‘I really appreciated the attention of the student nurse.’’
(Patient early assisted discharge group)
‘‘The guidance at home gave me confidence.’’ (Patient
early assisted discharge group)

At the end of the follow-up period, several patients in
both groups provided satisfying comments on the respira-
tory nurses in the hospital and at home.

Only 2 patients provided comments on where they
were dissatisfied about. Both comments concerned the
attention staff had for them. For example:

‘‘They [staff] have little time and therefore little
attention.’’ (Patient in usual hospital care)

3.1.5. Efficiency of care and organisation

Patients in both groups commented that treatment
(medication, examination and help) took place on time
and/or fast. However, others commented that they had
to wait long for help, medication and examinations.
Patients also commented on the busy hospital staff.

‘‘There is a shortage for staff. There is no time for the
patient.’’ (Patient in usual hospital care group)
‘‘when you press the nursing alarm, you sometimes
have to wait long for a response.’’ (Patient in usual
hospital care group’’

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491542

Patients in both groups had comments on aspects of
coordination of care and transfer of information, which are
illustrated by the following comments:

‘‘The mutual coordination was lacking. This bothers
me.’’ (Patient in the usual hospital care group)
‘‘On the ward it was unstructured and disorganised.’’
(Patient in the usual hospital care group)

‘‘The nurse of the home care organisation did not come.
This should be better organised, especially during
weekends’’ and ‘‘care should be tuned because of the
medication and inhalations.’’ (Patient in early assisted
discharge group)
‘‘There was no clear information transfer to the
respiratory nurse.’’ (Patient in early assisted dischar-
gegroup)

3.1.6. Technical quality

Patients from both groups reported to be satisfied with
the treatment and observation they received in the
hospital and at home that was performed by medical
and nursing staff. Patients were satisfied with the recovery
of their condition.

‘‘Treatment in the hospital was good and the treatment
at home was good as well.’’ (Patient in early assisted
discharge group)

However, many comments on what patients from both
groups were most dissatisfied about concerned medica-
tion in the hospital: the type of medication, errors that
were made with prescribing, distribution and adminis-
tration of medication. The following comments illustrate
this:

‘‘The distribution of medicines was better last time
[previous admission].’’ (Patient in usual hospital care
group)
‘‘There was indistinctness concerning the medicines.’’
(Patient in usual hospital care group)
‘‘In the hospital the mouth piece of my inhaler was not
cleaned.’’ (Patient in early assisted discharge group)
‘‘Mistakes were made with the medicines.’’ (Patient in
early assisted discharge group)

3.1.7. Structure and facilities

Patients in both groups were most satisfied about
the quality of the food in the hospital. On the other
hand, patients in both groups were most dissatisfied
about the busy, crowded rooms in the hospital that
provided little privacy. In addition, one patient com-
mented that the rooms and toilets were dirty. Two
patients in the early assisted discharge group commen-
ted that at home they appreciated the quiet environment
with privacy.

3.2. Findings – second part: quantitative questions on

satisfaction

Table 3 shows the results on the second, quantitative
part of the questionnaire on patient satisfaction. For 34
(49%) patients in the usual hospital care group and 29

(41%) patients in the early assisted discharge group, an
overall satisfaction score could be calculated. Overall
satisfaction was 70% in the usual hospital care group and
71% in the early assisted discharge group (Table 3). Two
differences in satisfaction items between groups were
found (Table 3). During nights, patients in the early
assisted discharge group felt significantly more unsafe in
comparison to patients that received usual hospital care.
Significantly more patients in the early assisted discharge
group felt unable to resume normal daily activities.

More than 60% of patients in both groups were very or
completely satisfied with the received intravenous and
oral medication treatment, inhaled medication treatment
and oxygen treatment. The majority of patients was (very)
satisfied with the medical and nursing treatment, and care
they received in the hospital and/or at home.

At T + 90 days, overall satisfaction was 72% and 70% for
usual hospital care patients (29 valid scores) and early
assisted discharge patients (33 valid scores), respectively.
No differences between groups were found for the separate
questions (data not shown).

3.3. Findings – third part: preference for place of treatment

Fig. 1a shows that at T + 4 days, 42% (N = 25) of patients
allocated to hospital treatment and 86% (N = 56) of patients
allocated to home treatment preferred to be treated at
home, if they could choose. Table 4 shows the results of the
multivariate logistic regression analysis on associated
factors for preference in the early assisted discharge group.
Only clinical COPD questionnaire – mental state was
significantly associated with preference for home treat-
ment. Patients with worse scores were less likely to choose
home treatment. The trend for income was inconsistent. At
T + 90 days the percentage of patients preferring home
treatment had decreased to 35% (N = 17) and 59% (N = 33)
in the hospital treatment and home treatment group,
respectively (Fig. 1b). At T + 90 days, none of the
investigated variables were associated with preference
in the multivariate logistic regression analysis.

3.4. Findings – additional part: evaluation of early assisted

discharge

Results from the additional questionnaire for patients
that received home care showed that 85% (N = 34) of
patients that received home care was (very) satisfied. The
average number of home visits per day was one. The total
number of days that patients received home visits and the
number of visits per day was valued as sufficient by 83%
(N = 29) and 97% (N = 34) of patients. The far majority
valued the duration of the home visits as sufficient.

4. Discussion

The quantitative and qualitative evaluation among
patients in this study showed that patients are satisfied
with the hospital and home care they received. The overall
satisfaction scores in both groups were 70%. Evaluation on
separate items of the satisfaction questionnaire showed
only differences in feelings of safety at night and ability to

Table 3

Patient satisfaction. Numbers represent number of respondents and percentage, unless stated otherwise.

HC N = 34 EAD N = 29

p-Valuea

Overall satisfaction score,

range 0–100, mean (SD)

70 (12.7) 71 (12.5) 0.863

Completely/very satisfied Satisfied (Very) unsatisfied p-Valuea

Satisfaction with HC EAD HC EAD HC EAD

Administration of intravenous therapy

and tablets

44 (72.1) 37 (56.1) 14 (23) 23 (34.8) 3 (4.9) 6 (9.1) 0.068

Administration of nebulised/metered

dose inhalations

41 (69.5) 39 (60.9) 17 (28.8) 19 (29.7) 1 (1.7) 6 (9.4) 0.133

Oxygen treatmentb 30 (73.2) 34 (73.9) 10 (24.4) 12 (26.1) 1 (2.4) 0 (0) 0.755

Improvement of symptoms 37 (60.7) 30 (49.2) 20 (32.8) 21 (34.4) 4 (6.6) 10 (16.4) 0.089

Nursing care during daytime 44 (72.1) 38 (57.6) 15 (24.6) 24 (36.4) 2 (3.3) 4 (6.1) 0.093

Nursing care at night 40 (65.6) 31 (59.6) 17 (27.9) 18 (34.6) 4 (6.6) 3 (5.8) 0.654

Involvement in treatment 33 (55.0) 33 (50.8) 22 (36.7) 28 (43.1) 5 (8.3) 4 (6.2) 0.855

Amount of time spent by

nurses with patient

31 (52.5) 34 (51.5) 25 (42.4) 25 (37.9) 3 (5.1) 7 (10.6) 0.568

Information received on illness 32 (54.2) 32 (49.2) 18 (30.5) 29 (44.6) 9 (15.3) 4 (6.2) 0.736

Length of treatment 28 (46.7) 31 (47.7) 32 (53.3) 29 (44.6) 0 (0) 5 (7.7) 0.516

Extremely/very worried Worried Little or not worried p-Valuea

How worried were you

during treatment?

13 (21.7) 13 (19.7) 18 (30.0) 13 (19.7) 29 (48.3) 40 (60.6) 0.319

Complete/very well

addressed

Adequately addressed Poorly/not at all

addressed
p-Valuea

How was the attention

for worries?

24 (43.6) 28 (45.9) 21 (38.2) 27 (44.3) 10 (18.2) 6 (9.8) 0.417

Extremely/very safe Safe (Most) unsafe p-Valuea

Feeling safe during daytime 42 (68.9) 35 (53.0) 17 (27.9) 30 (45.5) 2 (3.3) 1 (1.5) 0.143

Feeling safe during nights 35 (58.3) 24 (37.5) 20 (33.3) 31 (48.4) 5 (8.3) 9 (14) 0.029

Completely/

very capable

Capable (Very) incapable p-Value*

At end of hospital or home treatment capable to resume normal daily activities 5 (8.5) 4 (6.3) 36 (61) 25 (39.1) 18 (30.5) 35 (54.7) 0.018

HC, usual hospital care; EAD, early assisted discharge; n.a., not applicable.
a Linear-by-linear association.
b Only for those who had oxygen.

Fig. 1. Number of patients preferring hospital and home treatment (A) T + 4 days and (B) T + 90 days.

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–1549 1543

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491544

resume activities. Safety at night and ability to resume
activities was valued significantly worse by patients in the
early assisted discharge group. The separate evaluation in
patients that received home care showed that 85% of
patients was satisfied with early assisted discharge. The
number and duration of home visits was sufficient. Forty-
two percent hospital-treated patients and 86% of home-
treated patients preferred home treatment if they could
have chosen. In home-treated patients, this preference was
influenced by their mental state.

Home-treated patients did not, like hospital-treated
patients, have access to nursing care during nights. This
may have caused them feeling unsafe during nights.
Previous studies showed that help at night is important
and an advantage of hospital treatment (Fried et al., 1998).
When designing and implementing hospital-at-home
schemes, nights should be appropriately addressed. Only
1 study reported to have nursing night cover by district
nurses (Davies et al., 2000). In accordance with Ojoo et al.
(2002) and Diaz et al. (2005) a 24-h telephone access to the
hospital was installed in our study. However, no patient
used this possibility during the nights. Nonetheless, we
believe that patients should be instructed on what
problems they might experience at home at night, how
to avoid these problems and how to act upon.

At the end of the 7-day treatment, patients that
experienced hospital-at-home reported significantly more
often not being capable to resume their normal daily
activities in comparison to patients from the usual hospital
care group. Median time to symptomatic recovery of
exacerbations is 7 days (Seemungal et al., 2000). However,
complete recovery of health status may take up to 90 days
(Seemungal et al., 1998, 2000) and many patients
experience difficulties with their daily activities after
hospital admission (Clarke et al., 2010). At the end of the 7-
day treatment patients from the usual hospital care group
had not been confronted yet with possible difficulties at
home when they completed the questionnaire, whereas
patients in the early assisted discharge group had been
confronted with daily activities since day four of the
treatment. Possibly, at the end of the 7-day treatment,
patients from the usual hospital care group have over-
estimated their capabilities to resume normal daily

activities. At the end of the 90 days follow up, the
difference between the groups regarding this item had
disappeared, supporting this explanation.

Despite feeling unsafe during nights and being less able
to resume activities, most patients in the early assisted
discharge still prefer to be treated at home. It is likely that
the benefits and advantages patients experience from
being treated at home outweigh these disadvantages.

Overall satisfaction with hospital and home care was
high, and not different between groups. Many negative
responses in both groups were related to medication. Most
of these comments could be linked to the hospital, as most
comments concerned the distribution and administration
of medicines which in the hospital is the under the
hospitals’ responsibility (prescribing doctors, hospital
pharmacy, distributing nurses) but at home under the
patients’ own responsibility. The comments did not
concern aspects that were the result of the introduction
of early assisted discharge and most likely have been
present before.

Overall, patients were very satisfied with the early
assisted discharge care. Advantages that patients experi-
enced from being treated at home were that the
environment at home was familiar, quiet, clean and
provided privacy. Furthermore, being at home made
patients able to stick to their own daily routines and
rules. However, patients’ comments revealed aspects that
could be improved. Coordination of the logistics of the
community nursing hampered in several cases. Within the
home care organisation separate teams are responsible for
defined geographic areas. Teams should be timely in-
formed about the patients’ discharge, and visiting arrange-
ments should be confirmed before the patient is
discharged. While some patients commented that care
at home was not necessary and nurses only came to check
upon them, others experienced difficulties at home alone
and expected more care, especially in the domestic field.
This wide difference in opinion was also found in the study
by Taylor et al. (2007). Patients should be explicitly
informed about the purpose and objectives of early
assisted discharge and home treatment and which care
can be expected at home. If this is insufficient, the patient
should not be early assisted discharged or additional

Table 4

Odds ratios and 95% confidence intervals for factors associated with preferred place of treatment at day 7 of treatment.

Preference at day 7a N OR 95% CI p-Value

Long term oxygen treatment

Nob 37 1

Yes 3 0.030 0.001–1.302 0.068

Income

Lowb 17 1

Medium 9 0.032 0.001–0.785 0.035
High 14 3.737 0.057–244.181 0.536

Living situation

With somebodyb 23 1

Alone 17 0.348 0.022–5.411 0.451

Clinical COPD Questionniare – mental state 40 0.349 0.135–0.904 0.030
a Results from multivariate logistic regression performed in early assisted discharge group. Variables from the bivariate logistic regression with p < 0.1

were included in the multivariate logistic regression.
b Reference category.

ser
com
hos
sho
sec
et a
prim
ma

no
pat
the
of O
wh
com
ofte
sim
199
exp

pat
the
hom
pat
Sch
tow
skil
an
pas
tho
abl
are
disc
in t
diffi

and
pre
pre
num
hav

we
200
lon
San
alo
the
pre
net
sup
to m
cho

eva
Pat
disc
pat
pos
the
effe

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–1549 1545

vices should be arranged. Patients from both groups
mented on the hampering information transfer from

pital to home or between hospital staff. It has been
wn that this is an important issue in transfers from
ondary to primary care (Berendsen et al., 2009; Preston
l., 1999). Health care professionals from secondary and

ary care should pay attention to this topic, in order to
ke flawless transitions from hospital to home possible.
Although patients that were treated in the hospital had
experience with home treatment, over half of all

ients preferred home treatment, if they would have had
opportunity to choose. This confirms previous results
joo et al. (2002) and Schofield et al. (2006). Patients

o were treated at home, and were able to make a true
parison, preferred home treatment significantly more
n. Patients find it difficult to imagine that at home
ilar treatment is possible as in the hospital (Fried et al.,
8), but often adjust their opinion once they have
erienced home treatment (Schofield et al., 2006).
In the group of home-treated patients we found that
ients with worse scores on the mental state domain of
clinical COPD questionnaire were less likely to prefer

e treatment. Home treatment appeals on the ability of
ients to manage with the disease more independently.
ofield et al. (2006) found a correlation between attitude
ards home care and emotional functioning and coping
ls. We found no such association. However, we did find
association between worse emotional functioning and
sive coping style. Patients with more negative or anxious
ughts and feelings are less confident that they will be
e to manage at home when problems occur. Patients who

better able to ration the purpose of early assisted
harge in relation to hospital care and have better insight

heir own role in the scheme, are better able to cope with
culties at home (Schofield et al., 2006).

We found an inconsistent association between income
preference. Medium income was associated with
ference for home treatment, high and low income and
ference were not associated. However, the patient

bers in the three groups were unequal which may
e caused inconsistent association.
Previous studies revealed that patients living alone
re treated more often in the hospital (Schofield et al.,
6) and that patients choose to be treated at home as

g as informal care giving was present (Dubois and
tos-Eggimann, 2001). In our study 30% of patients lived

ne, which did not withhold them from participation to
trial. Fried et al. (1998) stated that in patients that
fer home treatment and live alone, without support
work, strong self-reliance is an important factor. This
ports the conclusion that patients who are better able
anage their symptoms and difficulties will more often

ose home treatment.
This study has some limitations. Firstly, the current
luation was part of a randomised controlled trial.
ients with strong resistance against early assisted
harge and home treatment did not consent to partici-

e, which may have caused selection of patient with
itive attitudes towards home treatment. Furthermore,

design of the study was for the comparison of the
ctiveness, and therefore not optimal for the comparison

of preference. Therefore, the analysis of factors influencing
preference was only performed in patients that experienced
both treatments. Secondly, the number of patients in which
the preference analysis was performed was small, which
might have influenced results. However, this was a
pragmatic study reflecting the real situation enhancing
validity of results. Thirdly, because a validated question-
naire for measuring satisfaction with hospital-at-home was
not available, we had to develop one ourselves. The
questionnaire we developed contained questions on specific
items of the hospital care and hospital-at-home care
patients received, and therefore provided a clear view on
how patients value specific aspects of usual hospital care
hospital-at-home care. However, like in many patient
satisfaction evaluations, we found high satisfaction scores
among patients, which may mask real opinions on certain
subjects (Fitzpatrick, 1991). Finally, the satisfaction and
preference measures were performed at the end of the 7-day
treatment and the end of the 90-day follow-up period. In the
time frame between these time points events and challenges
may have occurred that have not been captured in the study
measurements, but may have influenced patient satisfac-
tion and/or preference. Further research is needed to
evaluate hospital-at-home on specific items and to gain
more insight in what and how patient satisfaction and
preference are influenced.

In conclusion, we found no large differences between
patients’ evaluation of home- and hospital care, but
attention should be paid to ensure patients feel safe at
night whilst receiving home treatment. Forty-two percent
of hospital-treated patients over 86% of home-treated
patients preferred home treatment, suggesting an overall
preference for home treatment. Mental state is associated
with preference for home treatment which is most likely to
be associated with being better able to manage the disease
independently. In the absence of clear differences in
outcomes between hospital-at-home and usual hospital
care, patient preference plays an important role in the
decision to implement hospital-at-home. Results from this
study support the wider implementation of hospital-at-
home for COPD exacerbations and this treatment option
should be offered to selected patients that prefer home
treatment over hospital treatment.

Conflict of interest: No conflict of interest.
Funding: The study was funded by the Netherlands

Organisation for Health Research and Development
(ZonMw), grant application number 945-50-7730. The
funder had no role in the design of the study; the collection
analysis and interpretation of the data; or the writing of the
article and the decision to submit the article for publication.
All researchers were independent from the funder.

Ethical approval: The trial was approved by the Medical
Ethics Committee of the Catharina Hospital Eindhoven, the
Netherlands.

Appendix 1. Patient satisfaction questionnaire

Day 7 of treatment
The questions in this questionnaire apply to the treatment

you received for your lung disease in the past 7 days in the
hospital or partly in the hospital and partly at home.

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491546

For each question we ask you to mark the answer that
applies most to your situation. Some questions require a
written reply from you.

Where would you have preferred to be treated?
& Hospital

& Home

2. What 3 things were you most satisfied with the care
you received?
2.1 ___________________________________________
2.2 ___________________________________________
2.3 ___________________________________________

3. What 3 things were you most dissatisfied with in the
care you received?
3.1 ______________________________________
3.2 ______________________________________
3.3 ______________________________________

4. How satisfied were you with the administration of
your infusion and tablets?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

5. How satisfied were you with your inhalations and
nebulised inhalations?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

6. How satisfied were you with the oxygen treatment?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

7. How satisfied were you with the improvement of your
symptoms?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

8. How worried were you during the treatment period?
& Extremely worried
& Very worried
& Worried
& A little bit worried
& Not at all worried

9. How much attention was there for your worries
addressed by the health care staff?
& Fully attention
& Very good attention
& Adequate attention
& Little attention
& No attention at all

10. How safe did you feel during the days in the treatment
period?
& Extremely safe

& Very safe

& Safe
& Unsafe
& Very unsafe

11. How safe did you feel during the nights in the
treatment period?
& Extremely safe

& Very safe
& Safe
& Unsafe
& Very unsafe

12. How satisfied were you with the nursing care during
the day?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

13. How satisfied were you with the nursing care during
the nights?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

14. How satisfied are you with the amount of time spent to
you by health care staff?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

15. How satisfied were you with the way you were
involved in the treatment?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

16. How satisfied were you with the information you
received concerning your illness?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

17. How satisfied were you with the length of the
treatment period?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

18. To what extent did you feel capable to resume your
usual daily activities?
& Completely capable
& Very capable
& Adequately capable
& Incapable
& Very incapable

Add
For

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and

Tot

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v

&
&
&

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h

2. H
c
a
b
c
d

3. T
o
&
&
&

Len
4. T

&
&
&

5. T
w
&
&
&
&

Pat
End

you
ago
hom

app
wri

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–1549 1547

This is the end of the questionnaire.
Thank you for completing the questionnaire.

itional questions
early discharge patients only!
The following questions apply to the home visits by the
munity nurses you received.

With these questions we try to optimise the frequency
duration of the home visits.

al number of days with home care

he total number of days of home treatment with home
isits (4 days) is:

Sufficient number of days
Too many days
Too few days

mber of home visits per day

During the home treatment, 3 home visits per day
ere possible. It is possible that you have not used all 3

ome visits.
ow many home visits did you receive each day? Please

ircle the correct number
. Day 1 (day of discharge): 1/2/3 home visits
. Day 2: 1/2/3 home visits
. Day 3: 1/2/3 home visits
. Day 4: 1/2/3 home visits
he number of days that the nurse of the home care
rganisation performed was:

Sufficient number of visits per days
Too many visits per days
Too few visits per days

gth of home visits
he length of the first home visit each day was:

Sufficiently long
Too long
Too short

he length of the second and third home visit each day
as:

Sufficiently long
Too long
Too short
not applicable, I only received 1 home visit per day

ient satisfaction questionnaire
of follow-up

The questions in this questionnaire apply to the treatment
received for your lung disease approximately 3 months

in the hospital or partly in the hospital and partly at
e.

For each question we ask you to mark the answer that
lies most to your situation. Some questions require a
tten reply from you.

Where would you have preferred to be treated?
& Hospital

2. What 3 things were you most satisfied with the care
you received?
2.1 ______________________________________
2.2 ______________________________________
2.3 ______________________________________

3. What 3 things were you most dissatisfied with in the
care you received?
3.1 __________________________________
3.2 __________________________________
3.3 __________________________________

4. How satisfied were you with the administration of
your infusion and tablets?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
5. How satisfied were you with your inhalations and
nebulised inhalations?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
6. How satisfied were you with the oxygen treatment?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
7. How satisfied were you with the improvement of your
symptoms?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
8. How worried were you during the treatment period?
& Extremely worried
& Very worried
& Worried
& A little bit worried
& Not at all worried
9. How much attention was there for your worries
addressed by the health care staff?
& Fully attention
& Very good attention
& Adequate attention
& Little attention
& No attention at all

10. How safe did you feel during the days in the treatment
period?
& Extremely safe
& Very safe
& Safe
& Unsafe
& Very unsafe

11. How safe did you feel during the nights in the
treatment period?
& Extremely safe
& Home
& Very safe

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491548

& Safe
& Unsafe
& Very unsafe

12. How satisfied were you with the nursing care during
the day?
? Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

13. How satisfied were you with the nursing care during
the nights?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
14. How satisfied are you with the amount of time spent to
you by health care staff?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
15. How satisfied were you with the way you were
involved in the treatment?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
16. How satisfied were you with the information you
received concerning your illness?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
17. How satisfied were you with the length of the
treatment period?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

18. To what extent did you feel capable to resume your
usual daily activities?
& Completely capable
& Very capable
& Adequately capable
& Incapable
& Very incapable

This is the end of the questionnaire.
Thank you for completing the questionnaire.

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Patient preference and satisfaction in hospital-at-home and usual hospital care for COPD exacerbations: Results of a randomised controlled trial

Introduction
Methods
Design and patients
Measurements
Analysis
Findings
Findings – first part: qualitative questions on satisfaction
Patient-centred care
Access
Communication and information
Courtesy and emotional support
Efficiency of care and organisation
Technical quality
Structure and facilities
Findings – second part: quantitative questions on satisfaction
Findings – third part: preference for place of treatment
Findings – additional part: evaluation of early assisted discharge
Discussion
Patient satisfaction questionnaire
References

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