Summary of findings 1. Admission avoidance hospital at home compared with inpatient admission for older people requiring admission to hospital.

Admission avoidance hospital at home compared with inpatient admission for older people requiring admission to hospital
Patient or population: older people requiring hospital admission Settings: home Intervention: admission avoidance hospital at home Comparison: inpatient care
Outcomes	Illustrative comparative risks* (95% CI)		Relative effect (95% CI)	Number of participants (studies)	Certainty of the evidence (GRADE)
	Assumed risk	Corresponding risk
	Inpatient care	Admission avoidance hospital at home
Mortality (6 months' follow‐up) (using data from trialists and published data)	Study population		RR 0.88 (0.68 to 1.13)	1502 (5 studies)A	⊕⊕⊕⊝a Moderate
	208 per 1000	183 per 1000 (141 to 235)
Admission to hospital (3 to 12 months' follow‐up) (using individual patient data and published data)	Study population		RR 1.14 (0.97 to 1.34	1757 (8 studies)B	⊕⊕⊕⊝b Moderate
	407 per 1000	464 per 1000 (395 to 546)
Living in residential care at follow‐up (6 months' follow‐up)	Study population		RR 0.53 (0.41 to 0.69)	1271 (4 studies)C	⊕⊕⊕⊝b Moderate
	124 per 1000	66 per 1000 (51 to 85)
Patient self‐reported health status	Patient‐reported health status was largely the same for participants treated in hospital at home and hospital, with some reporting higher quality of life or better health status in hospital at home.D		‐	2006 (9 studies)	⊕⊕⊕⊝c Moderate
Patient satisfaction	Patients allocated to hospital at home reported higher levels of satisfaction on average; a small proportion preferred hospital, or satisfaction was equal between groups.E		‐	1812 (8 studies)	⊕⊕⊝⊝d Low
Length of stay in hospital and hospital at home	Hospital at home reduced average length of stay in hospital, which ranged from an average of 4.1 to 18.5 days in the hospital group to 1.2 to 5.1 days in the hospital at home group.F Hospital at home length of stay ranged from an average of 3 to 20.7 days (hospital at home group only).G Length of stay for the acute episode ranged from a mean increase of 0.7 to 9.1 daysF for the hospital at home group compared to the hospital group.		‐	2036 (11 studies)	⊕⊕⊝⊝e Low
Cost and resource use	Hospital at home was generally less costly than hospital care, with a range of estimates for the mean reduction per episode with different levels of certainty, from USD −215 (P = 0.38) to GBP −1981 (95% CI −2551 to −1411).H Estimates for the difference in total health and social care costs for a variety of follow‐up durations also varied, ranging from GBP −1015.7 (95% CI −2735.5 to 644.8) to GBP −2265 (95% CI −4279 to −252).I		‐	2148 (12 studies)	⊕⊕⊕⊝f Moderate
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

^aWe downgraded the certainty of the evidence by one level to moderate due to imprecision of the estimate.
^bWe downgraded the certainty of the evidence by one level to moderate due to indirect comparisons between studies.
^cWe downgraded the certainty of the evidence by one level to moderate due to risk of performance bias since patients cannot be blinded to the intervention.
^dWe downgraded the certainty of the evidence by two levels to low as only 35% of the studies reported this outcome, and there is a risk of detection bias due to subjective reporting of this outcome.
^eWe downgraded the certainty of the evidence by two levels to low due to imprecision and indirect comparisons between studies.
^fWe downgraded the certainty of the evidence by one level to moderate since only three trials reported a full cost analysis.

^ACaplan 1999; Ricauda 2008; Shepperd 2021; Tibaldi 2009; Wilson 1999.
^BCaplan 1999; Davies 2000; Harris 2005; Mendoza 2009; Ricauda 2008; Shepperd 2021; Tibaldi 2009; Wilson 1999.
^CRicauda 2008; Shepperd 2021; Tibaldi 2004; Tibaldi 2009.
^DCorwin 2005; Echevarria 2018; Mendoza 2009; Ricauda 2008; Richards 2005; Shepperd 2021; Talcott 2011; Tibaldi 2009; Wilson 1999.
^ECaplan 1999; Corwin 2005; Levine 2018; Levine 2020; Ricauda 2008; Richards 2005; Shepperd 2021; Wilson 1999.
^FDavies 2000; Echevarria 2018; Shepperd 2021; Wilson 1999.
^GHarris 2005; Levine 2018; Levine 2020; Mendoza 2009; Ricauda 2008; Tibaldi 2009; Wilson 1999.
^HCaplan 1999; Nicholson 2001; Ricauda 2004; Ricauda 2008; Richards 2005; Shepperd 2021; Wilson 1999.
^IEchevarria 2018; Mendoza 2009; Shepperd 2021.