Article Text

Download PDFPDF

What are the positive drivers and potential barriers to implementation of hospital at home selected by low-risk DECAF score in the UK: a qualitative study embedded within a randomised controlled trial
  1. Lorelle Louise Dismore1,2,
  2. Carlos Echevarria3,
  3. Anna van Wersch2,
  4. John Gibson4,
  5. Stephen Bourke3
  1. 1 Department of Research and Development, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
  2. 2 School of Social Sciences, Humanities and Law, Teesside University, Middlesbrough, UK
  3. 3 Respiratory Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
  4. 4 Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
  1. Correspondence to Lorelle Louise Dismore; lorelle_dismore{at}


Objective Hospital at home (HAH) for chronic obstructive pulmonary disease exacerbation selected by low-risk Dyspnoea, Eosinopenia, Consolidation, Acidaemia and atrial Fibrillation (DECAF) score is clinical and cost-effective; DECAF is a prognostic score indicating risk of mortality. Up to 50% of admitted patients are suitable, a much larger proportion than earlier services. Introduction of new models of care is challenging, but may be facilitated by informed engagement with stakeholders. This qualitative study sought to identify facilitators and barriers to implementation of HAH.

Design Semistructured interviews, data were analysed using thematic-construct analysis.

Setting Interviews were conducted within patients’ homes and hospitals in North East England.

Participants 89 participants were interviewees; 44 patients, 15 carers, 15 physicians, 11 specialist nurses and 4 managers.

Results Facilitators include the following: (1) availability of home comforts and maintaining independence (with positive influences on perceived rate of recovery, sleep quality and convenience for friends, family and carers) and (2) confidence in the continuity of HAH care. Barriers include the following: (1) fear of being alone at home; (2) privacy issues and not wanting visitors and (3) resistance to change. Clinician concerns occasionally delayed return home, principally during the early phase of the trial. Nurses cited higher workload and greater responsibility, but with additional resource and training; overall, they viewed HAH positively. Operational concerns included keeping medical records in a patient’s home and inability to capture activity within current payment systems.

Conclusion HAH selected by DECAF was preferred to inpatient care by most patients and their families. Implementation in other hospitals will require education, training and service planning, tailored to overcome the identified barriers.

Trial registration number ISRCTN29082260.

  • qualitative
  • COPD
  • exacerbation
  • service development

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

Statistics from


  • Contributors SB conceived the study and was chief investigator with overall responsibility for the management of the study. SB, AvW and CE were responsible for the original design and protocol, and obtaining funding. JG contributed to the study design methodology. LLD and CE recruited patients to the study. LLD performed all interviews and transcripts. SB, AvW and LLD analysed all transcripts for themes. CE performed statistical analyses. LLD and AvW wrote the first draft of the manuscript. JG provided a critical review for important intellectual content. All authors were involved in the final version of the manuscript and approved the manuscript for publication.

  • Funding NIHR Research for Patient Benefit and Northumbria Healthcare NHS Foundation Trust Teaching and Research Fellowship programmes.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

  • Competing interests SCB reports grants from NIHR: Research for Patient Benefit programme, during the conduct of the study; HTA funding, grants from Philips Respironics, grants from Pzifer Open Air, personal fees from Pzifer and AztraZeneca outside the submitted work. AvW reports grants from NIHR: Research for Patient Benefit programme, during the conduct of the study.

  • Ethics approval Ethics approval was provided by NRES Committee North East Sunderland (3/NE/0275). All participants gave informed consent before taking part in the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The data are anonymised transcripts and are available upon reasonable request by emailing However, additional supporting quotes for the identified themes can be found in the supplementary information.

  • Presented at This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0213-30105).

  • Patient consent for publication Not required.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.