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This meta-analysis of Hospital- in-the-Home (HITH) compared to in-hospital care identified 61 Randomised Controlled Trials from MEDLINE, Embase, Social Sciences Citation Index, CINAHL, EconLit, PsycINFO and the Cochrane Database of Systematic Reviews. HITH care led to reduced mortality (odds ratio [OR] 0.81;95% CI, 0.69 to 0.95;p = 0.008; 42 RCTs; 6992 patients), readmission rates (OR 0.75;95% CI,0.59 to 0.95;p = 0.02; 41 RCTs; 5372 patients) and cost (mean-difference 1567.11; 95% CI, 2069.53 to 1064.69; p < 0.001; 11 RCTs; 1215 patients). The number needed to treat at home to prevent one death was 50. Mortality data was homogenous, but heterogeneity was observed for readmission rates and cost. HITH had higher patient and carer satisfaction (21/ 22; 6/8 studies respectively); carer burden was nonsignificantly lower (8/11 studies). HITH is associated with reductions in mortality, readmission rates and cost, and increases in patient and carer satisfaction, but no change in carer burden.
IIAGG 2017 World Congress
Background: Nursing home (NH) residents with demen-
tia exhibit challenging behaviors or resistiveness to care
(RTC) that increase staff time, stress, and NH costs. RTC
is linked to elderspeak communication. Communication
training (CHAT) was provided to staff to reduce their use
of elderspeak.
Hypothesis: We hypothesized that CHAT would improve
staff communication and subsequently reduce RTC.
Methods: Thirteen NHs were randomized to intervention
and control groups. Dyads (n= 42) including 29 staff and
27 persons with dementia (PWD) were videorecorded dur-
ing care before and/or after the intervention, and at a three
month follow-up. Videos were behaviorally coded for 1)staff
communication (normal, elderspeak, or silence) and 2)resi-
dent behaviors (cooperative or RTC). Linear mixed modeling
was used to evaluate training effects.
Results: On average elderspeak declined from 34.6%
(SD=18.7) at baseline by 13.6 percentage points (SD=20.00)
post-intervention and 12.2 percentage points (SD=22.0) at
3-month follow-up. RTC declined from 35.7% (SD=23.2)
by 15.3 percentage points (SD = 32.4) post-intervention
and 13.4 percentage points (SD=33.7) at 3-months. Linear
mixed modeling determined that change in elderspeak was
predicted by the intervention (b=-12.20, p=.028) and base-
line elderspeak (b=-0.65, p < .001) while RTC change was
predicted by elderspeak change (b=0.43, p < .001); baseline
RTC (b=-0.58, p < .001); and covariates.
Conclusions: Abrief intervention can improve communi-
cation and reduce RTC, providing an effective nonpharma-
cological intervention to manage behavior and improve the
quality of dementia care. No adverse events occurred.
Chair: J.M.Jacobs, Hadassah-Hebrew University Hospital,
Jerusalem, Israel
Co-Chair: G.Caplan, Prince of Wales Hospital
The primary purpose of Hospital at Home (HaH) is to
enable the delivery of complex care at home as an alternative
to in-patient care. Traditional in-patient care for older people
frequently has numerous negative repercussions, and the ris-
ing number of HaH models from different Healthcare systems
bears witness to this developing niche in health care deliv-
ery. Compared to usual hospital care, HaH has proven high
patient satisfaction, quality of care outcomes, and evidence
favors reduced mortality and overall costs. Furthermore,
innovative and available technological advancements are
expanding the range of treatment options available at home,
and facilitating the delivery of care to a wide spectrum of
increasingly more complex patients.
Yet, HaH dissemination has been limited by numerous
barriers, including challenging logistics, bias towards facility-
based care, and lack of payment models. Recent advances in
HaH models seek to ameliorate such barriers, but they still
exist. Moreover, the implementation of HaH on a widespread
basis has not been well described in the research literature.
In addition to a critical review and meta-analysis of cur-
rent literature, this symposium will present innovative models
of HaH providing a wide platform of care for older adults,
and technologies facilitating care for specic patient groups
with acute heart failure, or requiring long term mechanical
ventilation. Challenges facing the implementation of wide-
spread HaH will be addressed.
Understanding the impact of new modes of Hospital at
Home care delivery, and ways at promoting implementation,
is of critical importance to geriatric health service delivery in
the 21st century.
G.Caplan1, N.Sulaiman1, D.Mangin 4, N.Aimonino
Ricauda 2, A.Wilson 3, L.Barclay 1, 1. Department of
Geriatric Medicine, Prince of Wales Hospital, Sydney,
Sydney, New South Wales, Australia, 2. Unit of Geriatrics
and Metabolic Bone Diseases, Molinette Hospital, AOU
Città della Salute e della Scienza” of Torino;, Torino, Italy,
3. Universtiry of Leicester, Leicester, United Kingdom, 4.
University of Otago, Christchurch, New Zealand
This meta-analysis of Hospital- in-the-Home (HITH)
compared to in-hospital care identied 61 Randomised
Controlled Trials from MEDLINE, Embase, Social Sciences
Citation Index, CINAHL, EconLit, PsycINFO and the
Cochrane Database of Systematic Reviews. HITH care led
to reduced mortality (odds ratio [OR] 0.81;95% CI, 0.69
to 0.95;p = 0.008; 42 RCTs; 6992 patients), readmission
rates (OR 0.75;95% CI,0.59 to 0.95;p = 0.02; 41 RCTs;
5372 patients) and cost (mean-difference 1567.11; 95% CI,
2069.53 to 1064.69; p < 0.001; 11 RCTs; 1215 patients).
The number needed to treat at home to prevent one death
was 50. Mortality data was homogenous, but heterogene-
ity was observed for readmission rates and cost. HITH had
higher patient and carer satisfaction (21/ 22; 6/8 studies
respectively); carer burden was nonsignicantly lower (8/11
HITH is associated with reductions in mortality, readmis-
sion rates and cost, and increases in patient and carer satis-
faction, but no change in carer burden.
B.A.Leff1, L.De Cherrie2, A.Wajnberg2, A.Federman2,
T. Soones2, A.Brody3, A.Siu2, 1. Johns Hopkins University
School of Medicine, Baltimore, Maryland, 2. Icahn School
of Medicine, Mount Sinai, New York, New York, 3. New
York University, New York, New York
To date, Hospital at Home (HaH) care has focused on
substitutive admission avoidance or early discharge models.
In the context of a U.S. Federal innovation award program
for the Center for Medicare and Medicaid Services, we have
evolved the HaH model into a care “platform” for older
adults. In addition to providing substitutive admission avoid-
ance care, the platform includes: 1) “observation” stay at
home; 2)acute palliative care at home; 3)acute care for hos-
pital adverse patients (people who refuse hospital admission
under all circumstances) at home; and 4)subacute rehabilita-
tion care at home as a substitute for admission to inpatient
subacute rehabilitation. This platform evolved in recognition
of the evolving health care delivery system, the need to create
greater demand for HaH resources, provide adequate patient
Innovation in Aging, 2 0 1 7, Vol. 1, No. S1
Copyedited by: OUP
... This could indicate that although overall times waiting in the ED or BAM hospital prior to transition to ACH was increasing at both sites over time, the Florida site prevented a significant increase in this time by getting the option of ACH as an alternative to the physical hospital to these patients in a faster timeframe. Nevertheless, we believe that reducing the patients' physical time in the ED or BAM hospital ward is crucial to both provide the best patient experience as well as drive down the cost of care which has been reported in other HaH studies [19,20]. ...
... Fear of prolonged ALOS in HaH and the subsequent costs associated may push some patients or providers to not use this modality. However, previous HaH studies have shown a reduction in comparative costs [19,20]. Our study shows that ALOS does not increase as we added an APP resource. ...
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In July 2020, Mayo Clinic introduced a hospital-at-home program, known as Advanced Care at Home (ACH) as an alternate option for clinically stable medical patients requiring hospital-level care. This retrospective cohort study evaluates the impact of the addition of a dedicated ACH patient acquisition Advanced Practice Provider (APP) on average length of stay (ALOS) and the number of patients admitted into the program between in Florida and Wisconsin between 6 July 2020 and 31 January 2022. Patient volumes and ALOS of 755 patients were analyzed between the two sites both before and after a dedicated acquisition APP was added to the Florida site on 1 June 2021. The addition of a dedicated acquisition APP did not affect the length of time a patient was in the emergency department or hospital ward prior to ACH transition (2.91 days [Florida] vs. 2.59 days [Wisconsin], p = 0.22), the transition time between initiation of the ACH consult to patient transfer home (0.85 days [Florida] vs. 1.16 days [Wisconsin], p = 0.28), or the total ALOS (6.63 days [Florida] vs. 6.34 days [Wisconsin], p = 0.47). The average number of patients acquired monthly was significantly increased in Florida (38.3 patients per month) compared with Wisconsin (21.6 patients per month) (p < 0.01). The addition of a dedicated patient acquisition APP resulted in significantly higher patient volumes but did not affect transition time or ALOS. Other hospital-at-home programs may consider the addition of an acquisition APP to maximize patient volumes.
... For this question, we drew primarily on two Cochrane reviews of step-up and step-down hospital at home care [11,16]. Supporting evidence was drawn from 14 additional Cochrane and non-Cochrane reviews, of which six were in general populations [19][20][21][22][23][24], and eight were conditionspecific populations [17,[25][26][27][29][30][31][32]. One of the reviews identified is a review of reviews [21] and there is additional overlap in the included studies of some of these reviews. ...
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Background Virtual wards are being rapidly developed within the National Health Service in the UK, and frailty is one of the first clinical pathways. Virtual wards for older people and existing hospital at home services are closely related. Methods In March 2022, we searched Medline, CINAHL, the Cochrane Database of Systematic Reviews and medRxiv for evidence syntheses which addressed clinical-effectiveness, cost-effectiveness, barriers and facilitators, or staff, patient or carer experience for virtual wards, hospital at home or remote monitoring alternatives to inpatient care. Results We included 28 evidence syntheses mostly relating to hospital at home. There is low to moderate certainty evidence that clinical outcomes including mortality (example pooled RR 0.77, 95% CI 0.60–0.99) were probably equivalent or better for hospital at home. Subsequent residential care admissions are probably reduced (example pooled RR 0.35, 95% CI 0.22–0.57). Cost-effectiveness evidence demonstrated methodological issues which mean the results are uncertain. Evidence is lacking on cost implications for patients and carers. Barriers and facilitators operate at multiple levels (organisational, clinical and patient). Patient satisfaction may be improved by hospital at home relative to inpatient care. Evidence for carer experience is limited. Conclusions There is substantial evidence for the clinical effectiveness of hospital at home but less evidence for virtual wards. Guidance for virtual wards is lacking on key aspects including team characteristics, outcome selection and data protection. We recommend that research and evaluation is integrated into development of virtual ward models. The issue of carer strain is particularly relevant.
... Back in 2011, the report by the National Research Council (NRC) declared, "Health care is coming home" [4]. However, the literature is confusing because there are different terms of healthcare at home (Hospital in the home, HITH; Home Healthcare; Home Hospitalization; Early Supported Discharge) [5] and different types of services, some of which focus on specialities (surgical and medical specialities, rehabilitation medicine, geriatrics, psychiatry, infectious diseases, respiratory diseases), others on diagnostic groups (e.g. hip fracture or stroke), or a mixture of them [6] [7]. ...
... 4,6,[8][9][10][11][12][13][14][15][16][17] There have been numerous efforts to mitigate ED crowding such as leveraging alternative pathways to avoid hospital admissions, creation of full-capacity protocols to increase inpatient availability of beds, opening of nearby urgent care centers to offload low-acuity volume, and protocols triggering reductions in outside hospital transfers, direct admissions, and elective procedures. [18][19][20][21][22][23][24][25][26][27][28] While ED crowding has multiple negative operational impacts, the impact on patient experience for ED patients who are ultimately discharged has not been well studied. While long waits and throughput times have been shown to negatively impact experience, the aspects of crowding that most directly impact the experience of discharged ED patients are poorly understood. ...
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Introduction: While emergency department (ED) crowding has deleterious effects on patient care outcomes and operational efficiency, impacts on the experience for patients discharged from the ED are unknown. We aimed to study how patient-reported experience is affected by ED crowding to characterize which factors most impact discharged patient experience. Methods: This institutional review board-exempt, retrospective, cohort study included all discharged adult ED patients July 1, 2020-June 30, 2021 with at least some response data to the the National Research Corporation Health survey, sent to most patients discharged from our large, academic medical center ED. Our query yielded 9,401 unique encounters for 9,221 patients. Based on responses to the summary question of whether the patient was likely to recommend our ED, patients were categorized as "detractors" (scores 0-6) or "non-detractors" (scores 7-10). We assessed the relationship between census and patient experience by 1) computing percentage of detractors within each care area and assessing for differences in census and boarder burden between detractors and non-detractors, and 2) multivariable logistic regression assessing the relationship between likelihood of being a detractor in terms of the ED census and the patient's last ED care area. A second logistic regression controlled for additional patient- and encounter-specific covariates. Results: Survey response rate was 24.8%. Overall, 13.9% of responders were detractors. There was a significant difference in the average overall ED census for detractors (average 3.70 more patients physically present at the time of arrival, 95% CI 2.33-5.07). In unadjusted multivariable analyses, three lower acuity ED care areas showed statistically significant differences of detractor likelihood with changes in patient census. The overall area under the curve (AUC) for the unadjusted model was 0.594 (CI 0.577-0.610). The adjusted model had higher AUC (0.673, CI 0.657-0.690]; P<0.001), with the same three care areas having significant differences in detractor likelihood based on patient census changes. Length of stay (OR 1.71, CI 1.50-1.95), leaving against medical advice/without being seen (OR 5.15, CI 3.84-6.89), and the number of ED care areas a patient visited (OR 1.16, CI 1.01-1.33) was associated with an increase in detractor likelihood. Conclusion: Patients arriving to a crowded ED and ultimately discharged are more likely to have negative patient experience. Future studies should characterize which variables most impact patient experience of discharged ED patients.
... This is particularly relevant for patients with multiple comorbidities already at risk for increased healthcare utilization and readmission. Implementing this innovative model mitigates the increasing demand for traditional hospital beds and the negative aspects associated with lengthy and recurrent hospitalizations [9][10][11][12]. Here, we report the acute and postacute care of a severely ill patient suffering from short gut syndrome with a high ileostomy output and severe protein-calorie malnutrition successfully managed at home through the Mayo Clinic's ACH program. ...
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Chronically ill patients with superimposed acute illness requiring hospitalization are more likely to develop an extended length of stay, hospital-acquired infections, and adverse events throughout their hospitalization. An excellent alternative to managing this population of patients in the traditional bricks-and-mortal (BAM) hospital is the hospital-at-home (HaH) model. The Advanced Care at Home (ACH) program is Mayo Clinic’s HaH model that provides acute and postacute care to high-acuity patients in their homes rather than in the traditional hospital and skilled nursing facility. We report a case of postoperative care through the ACH program of a patient suffering from short gut syndrome, high-output ileostomy, and severe protein-calorie malnutrition in the setting of previously diagnosed triple-negative invasive ductal carcinoma (IDC) of the right breast complicated by lung and brain metastasis. The patient had multiple complications that required repeated scare escalations directed by a multidisciplinary virtual care. Despite these complications, the ACH model of care was able to keep the patient in the home setting the majority of the time, limiting BAM hospital days, and eliminating the need to use the emergency department for acute escalation for 3 months. The patient was able to recover during this time period and proceed to successful take-down of the ileostomy. This case highlights the benefits of the ACH program by offering high-acuity hospital-level care to severely ill patients in the comfort of their homes. Highly qualified providers paired with curated technology in the home allowed for prompt identification of patient decompensation and timely initiation of treatment while avoiding institutionalization.
Több mint negyedszázada már, hogy a Magyar Máltai Szeretetszolgálat Egyesülettel, illetve a fenntartásában működő siófoki Gondviselés Háza intézményével kapcsolatba kerültem. Kezdetben gondozóként, majd szakmai vezetőként (támogató szolgáltatás és fogyatékos személyek nappali ellátása), 2008. augusztus 1-jétől pedig a Gondviselés Háza integrált intézmény vezetőjeként tevékenykedem. Segítői hivatásom több évtizedes gyakorlása során szembesültem a folyamatosan változó körülményekkel, melyek a társadalom, a szociális ellátórendszer, az intézményünk, a családok és egyének számára egyaránt nehézségeket, megoldásra váró élethelyzeteket generálnak. Írásom a demenciára fókuszál, a Gondviselés Házában tapasztaltakat alapul véve. A rövid bemutatkozás után a probléma komplex bemutatására, elemzésére törekszem. Bemutatom az intézményünk által alkalmazott terápiákat, beavatkozási módokat, értékelésüket, valamint a megoldási alternatívákat.
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Objective: Hospital-at-home schemes have been widely adopted as an alternative to in-hospital treatment for acutely ill patients. However, their impact on hospital costs remains unclear. Study setting: we calculated the costs during the index admission and 30 days later of 131 randomly selected acutely ill patients attending a tertiary medical center in 2011-2021 who met the inclusion criteria for hospital-at-home care. study design: findings were compared to a simulation of the same cohort based on assumptions of potential costs and outcomes under a hospital-at-home program. principal findings: hospital-at-home care was found to incur higher costs during the index admission (+30%) and 30 days after (+14%). It remained costlier on most subpopulation and sensitivity analyses, except when patients were readmitted within 30 days of the index admission (-27%), owing to 30% lower hospital-at-home labor costs, and if the predicted index admission days were decreased by 10% in the hospital-at-home scheme (-11%). Conclusions: under the assumptions made, there may not be a clear and robust cost reduction to hospitals by the mere application of a hospital-at-home scheme.
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Background: Despite the expansion of home care services (HCS) in several countries, there is still a need to systematically investigate the available evidence on the cost-effectiveness of this type of service compared to hospital care in the world, particularly for the pediatric population. Hence, we aimed to systematically synthesize and critically evaluate the evidence on the cost-effectiveness of HCS versus in-hospital services worldwide. Methods: A systematic review and meta-analysis protocol guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. Ten databases will be searched: MEDLINE/PubMed, Cochrane Library, Excerpta Medica database, cummulative index to nursing and allied health literature (CINAHL), Web of Science, SCOPUS, Science Direct, PsycINFO, Latin American and Caribbean Health Sciences Literature and Chinese national knowledge infrastructure with no restrictions on publication date or languages. A checklist for assessing the quality of reporting of economic evaluation studies will be applied. To assess the methodological quality of evidence from observational research on comparative effectiveness, the Good Research for Comparative Effectiveness Checklist v5.0 will be used. The heterogeneity among the studies will be assessed using the I 2 statistic test. According to the results of this test, we will verify whether a meta-analysis is feasible. If feasibility is confirmed, a random-effect model analysis will be carried out. For data analysis, the calculation of the pooled effect estimates will consider a 95% CI and alpha will be set in 0.05 using the R statistical software, v.4.0.4. In addition, we will rate the certainty of evidence based on Grading of Recommendations Assessment, Development and Evaluation. All methodological steps of this review will be performed independently and paired by 2 reviewers and conducted and managed in the EPPI-Reviewer Software™. Results: The results may have relevance for the basis of public health policies, regarding the forms of organization of HCS, especially in terms of complete economic evaluations through cost-effectiveness analysis in relation to hospital care. Conclusion: To the best of our knowledge this will be the first systematic review and metanalysis to synthesize and critically evaluate the evidence on the cost-effectiveness of HCS versus in-hospital services worldwide. The review will adopt a rigorous approach, adhering to PRISMA Statement 2020, using a comprehensive and systematic search strategy in 10 databases, further the gray literature, pre-prints, with no time period or language restrictions.
Background: The Centers for Medicare & Medicaid Services (CMS) announced the Acute Hospital Care at Home (AHCaH) waiver program in November 2020 to help expand hospital capacity to cope with the COVID-19 pandemic. The AHCaH waived the 24/7 on-site nursing requirement and enabled hospitals to obtain full hospital-level diagnosis-related group (DRG) reimbursement for providing Hospital-at-Home (HaH) care. This study sought to describe AHCaH implementation processes and strategies at the national level and identify challenges and facilitators to launching or adapting a HaH to meet waiver requirements. Methods: We conducted semi-structured interviews to explore barriers and facilitators of HaH implementation. The analysis was informed by the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework. Interviews were audio recorded for transcription and thematic coding. Principal findings: We interviewed a sample of clinical leaders (N = 18; clinical/medical directors, operational and program managers) from 14 new and pre-existing U.S. HaH programs diverse by size, urbanicity, and geography. Participants were enthusiastic about the AHCaH waiver. Participants described barriers and facilitators at planning and implementation stages within three overarching themes influencing waiver program implementation: 1) institutional value and assets; 2) program components, such as electronic health records, vendors, pharmacy, and patient monitoring; and 3) patient enrollment, including eligibility and geographic limits. Conclusions: Implementation of AHCaH waiver is a complex process that requires building components in compliance with the requirements to extend the hospital into the home, in coordination with internal and external partners. The study identified barriers that potential adopters and proponents should consider alongside the strategies that some organizations have found useful. Clarity regarding the waiver's future may expedite HaH model dissemination and ensure longevity of this valuable model of care delivery.
Policy Points • Hospital-at-Home (HaH) is a home-based alternative for acute care that has expanded significantly under COVID-19 regulatory flexibilities. • The post-pandemic policy agenda for HaH will require consideration of multistakeholder perspectives, including patient, caregiver, provider, clinical operations, technology, equity, legal, quality, and payer. • Key policy challenges include reaching a consensus on program standards, clarifying caregivers’ issues, creating sustainable reimbursement mechanisms, and mitigating potential equity concerns. • Key policy prescriptions include creating a national surveillance system for quality and safety, clarifying legal standards for care in the home, and deploying payment reforms through value-based models.
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Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
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An intravenous course of standard (unfractionated) heparin with the dose adjusted to prolong the activated partial-thromboplastin time to a desired length is the standard initial in-hospital treatment for patients with deep-vein thrombosis, but fixed-dose subcutaneous low-molecular-weight heparin appears to be as effective and safe. Because the latter treatment can be given on an outpatient basis, we compared the two treatments in symptomatic outpatients with proximal-vein thrombosis but no signs of pulmonary embolism. We randomly assigned patients to adjusted-dose intravenous standard heparin administered in the hospital (198 patients) or fixed-dose subcutaneous low-molecular-weight heparin administered at home, when feasible (202 patients). We compared the treatments with respect to recurrent venous thromboembolism, major bleeding, quality of life, and costs. Seventeen of the 198 patients who received standard heparin (8.6 percent) and 14 of the 202 patients who received low-molecular-weight heparin (6.9 percent) had recurrent thromboembolism (difference, 1.7 percentage points; 95 percent confidence interval, -3.6 to 6.9). Major bleeding occurred in four patients assigned to standard heparin (2.0 percent) and one patient assigned to low-molecular-weight heparin (0.5 percent; difference, 1.5 percentage points; 95 percent confidence interval, -0.7 to 2.7). Quality of life improved in both groups. Physical activity and social functioning were better in the patients assigned to low-molecular-weight heparin. Among the patients in that group, 35 percent were never admitted to the hospital at all, and 40 percent were discharged early. This treatment was associated with a mean reduction in hospital days of 67 percent, ranging from 29 percent to 86 percent in the various study centers. In patients with proximal-vein thrombosis, treatment with low-molecular-weight heparin at home is feasible, effective, and safe.
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Febrile neutropenia commonly complicates cancer chemotherapy. Outpatient treatment may reduce costs and improve patient comfort but risk progression of undetected medical problems. By using our validated algorithm, we identified medically stable inpatients admitted for febrile neutropenia (neutrophils < 500/μL) after chemotherapy and randomly assigned them to continued inpatient antibiotic therapy or early discharge to receive identical antibiotic treatment at home. Our primary outcome was the occurrence of any serious medical complication, defined as evidence of medical instability requiring urgent medical attention. We enrolled 117 patients with 121 febrile neutropenia episodes before study termination for poor accrual. We excluded five episodes as ineligible and three because of inadequate documentation of the study outcome. Treatment groups were clinically similar, but sociodemographic imbalances occurred because of block randomization. The median presenting absolute neutrophil count was 100/μL. Hematopoietic growth factors were used in 38% of episodes. The median neutropenia duration was 4 days (range, 1 to 15 days). Five outpatients were readmitted to the hospital. Major medical complications occurred in five episodes (8%) in the hospital arm and four (9%) in the home arm (95% CI for the difference, -10% to 13%; P = .56). No study patient died. Patient-reported quality of life was similar on both arms. We found no evidence of adverse medical consequences from home care, despite a protocol designed to detect evidence of clinical deterioration. These results should reassure clinicians who elect to treat rigorously characterized low-risk patients with febrile neutropenia in suitable outpatient settings with appropriate surveillance for unexpected clinical deterioration.
Judging by reports in medical magazines and journals, 'early discharge schemes', better termed 'post acute care', are not popular with doctors. However, government policy encourages earlier discharge from hospital, so that the choice facing clinicians is to discharge patients early with support, or early without support, or deal with the consequences of length of stay overruns. Fortunately, government funding for post acute care is increasing. There is a strong rationale for post acute care based on better patient outcomes and cost-effectiveness, but these desirable results will only be achieved if scrupulous attention is paid to detail, as embodied in the 10 principles of post acute care. To function optimally, post acute care should be coordinated by the hospital which provided the acute care.
Objectives: To compare hospital at home care with inpatient hospital care in terms of patient outcomes. Design: Randomised controlled trial with three month follow up. Setting: District general hospital and catchment area of neighbouring community trust. Subjects: Patients recovering from hip replacement (n = 86), knee replacement (n = 86), and hysterectomy (n = 238); elderly medical patients (n = 96); and patients with chronic obstructive airways disease (n = 32). Interventions: Hospital at home care or inpatient hospital care. Main outcome measures: Dartmouth COOP chart to measure patients' general health status; SF-36 to measure possible limitations in physical functioning of patients with hysterectomy; disease specific measures-chronic respiratory disease questionnaire, Barthel index for elderly medical patients, Oxford hip score, and Bristol knee score; hospital readmission and mortality data; carer strain index to measure burden on carers; patients' and carers' preferred form of care. Results: At follow up, there were no major differences in outcome between hospital at home care and hospital care for any of the patient groups except that those recovering from hip replacement reported a significantly greater improvement in quality of life with hospital at home care (difference in change from baseline value 0.50, 95% confidence interval 0.13 to 0.88). Hospital at home did not seem suitable for patients recovering from a knee replacement, as 14 (30%) of patients allocated to hospital at home remained in hospital. Patients in all groups preferred hospital at home care except chose with chronic obstructive airways disease. No differences were detected for carer burden. Carers of patients recovering from knee replacement preferred hospital at home care, while carers of patients recovering from a hysterectomy preferred hospital care. Conclusions: Few differences in outcome were detected. Thus, the cost of hospital at home compared with hospital care becomes a primary concern.
Length of inpatient stay is decreasing generally. This decreases pressure on acute hospital beds and is believed to reduce the risk of hospital-acquired complications. To bridge the gap between hospital and home, specialist outreach teams are gaining in popularity. However, research evidence supporting outreach schemes, is scant and inconclusive; in particular doubt exists over the safety issues surrounding early discharge. This study compares the rehabilitation of two patient groups (n = 60) following knee replacement. The trial patients were discharged early, supported by an orthopaedic outreach team. The control group remained inpatients for their rehabilitation. Outcomes evaluated were clinical performance of the knee, patient satisfaction and complication rates. The trial group had a significantly better mean function score at 5 days (p = 0.04), but at 6 weeks, 12 weeks and 1 year, movement and function scores between groups showed no significant difference. Both groups continued to improve over the 1-year period. Patients in the trial group expressed greater satisfaction in their care and felt less of a burden to their families than the control group. There was no significant difference in the reported frequency of contact with GPs or in the number of serious complications between the groups.
Delirium is a common problem, mostly affecting older patients in hospital, which results in greater mortality, nursing-home placement and cognitive and functional impairment. Delirium can be triggered by a wide range of conditions, treatments and procedures, as well as by certain environments. Some hospital environments have been causally implicated, but until it was possible to compare treatment in hospital with treatment in other places, the observation remained at the level of an association. However, the development of 'Hospital in the Home' services has allowed clinicians to explore this question scientifically. Recently, a number of studies comparing treatment of acute conditions, both medical and surgical, anq rehabilitation in hospital with treatment at home, have found a lower incidence of delirium with home treatment, as well as lower rates of the sequelae of delirium. Since delirium is an indicator of a wide range of subsequent poor outcomes, this information has broad implications for the delivery of hospital-level services to older patients, and means that health services should seek to provide Hospital in the Home services wherever older patients are treated.
The policy in a number of countries is to provide people with a terminal illness the choice of dying at home. This policy is supported by surveys indicating that the general public and patients with a terminal illness would prefer to receive end of life care at home. To determine if providing home-based end of life care reduces the likelihood of dying in hospital and what effect this has on patients' symptoms, quality of life, health service costs and care givers compared with inpatient hospital or hospice care. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library) to October 2009, Ovid MEDLINE(R) 1950 to March 2011, EMBASE 1980 to October 2009, CINAHL 1982 to October 2009 and EconLit to October 2009. We checked the reference lists of articles identified for potentially relevant articles. Randomised controlled trials, interrupted time series or controlled before and after studies evaluating the effectiveness of home-based end of life care with inpatient hospital or hospice care for people aged 18 years and older. Two authors independently extracted data and assessed study quality. We combined the published data for dichotomous outcomes using fixed-effect Mantel-Haenszel meta-analysis. When combining outcome data was not possible we presented the data in narrative summary tables. We included four trials in this review. Those receiving home-based end of life care were statistically significantly more likely to die at home compared with those receiving usual care (RR 1.33, 95% CI 1.14 to 1.55, P = 0.0002; Chi (2) = 1.72, df = 2, P = 0.42, I(2) = 0% (three trials; N=652)). We detected no statistically significant differences for functional status (measured by the Barthel Index), psychological well-being or cognitive status, between patients receiving home-based end of life care compared with those receiving standard care (which included inpatient care). Admission to hospital while receiving home-based end of life care varied between trials and this was reflected by high levels of statistically significant heterogeneity in this analysis. There was some evidence of increased patient satisfaction with home-based end of life care, and little evidence of the impact this form of care has on care givers. The evidence included in this review supports the use of end of life home-care programmes for increasing the number of patients who will die at home, although the numbers of patients being admitted to hospital while receiving end of life care should be monitored. Future research should also systematically assess the impact of end of life home care on care givers.