This document summarizes a study that investigated patient preference and satisfaction with hospital-at-home care versus usual hospital care for COPD exacerbations. The study involved 139 patients who were randomized to either early assisted discharge (hospital-at-home care) or usual hospital care. Results showed that at 4 days, patients receiving early assisted discharge were less satisfied with care at night and ability to resume daily activities, but overall satisfaction did not differ. At 90 days, there were no differences in satisfaction between groups. Preference for home treatment was higher in the early assisted discharge group at 4 days and 90 days. Patients' mental state was associated with their treatment preference. The results support wider implementation of early assisted discharge and offering this option to

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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

3. 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 hospital-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 satisfaction
A B S T R A C T

4. 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

5. 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.
� 2013 Elsevier Ltd. All rights reserved.
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.

6. Corresponding author at: Department of Respiratory Medicine,
arina Hospital, Eindhoven, The Netherlands. Tel.: +31
612796688.
E-mail address: [email protected] (Cecile M.A. Utens).
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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

7. 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

8. (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

9. 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

10. 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
situ
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12. 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

13. 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 1.
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

14. 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

15. 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

16. 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

17. 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

18. 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)

19. 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

20. (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)

21. 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

22. 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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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)

24. 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

25. 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

26. ‘‘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)

27. 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)

28. 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 …