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A META-ANALYSIS OF HOSPITAL IN THE HOME

Authors:

Abstract

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.
SESSION 4625 (SYMPOSIUM)
HOSPITAL AT HOME-A DELIVERY MODEL FOR 21ST
CENTURY GERIATRICS CARE
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.
A META-ANALYSIS OF HOSPITAL IN THE HOME
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
studies).
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.
THE HOSPITAL AT HOME/MACT ‘PLATFORM’
MODEL—A SPECTRUM OF FACILITY-LEVEL CARE
PROVIDED AT HOME
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
1246
Copyedited by: OUP
... 2, 3 Caplan et al conducted a meta-analysis which included 61 randomized controlled trials of HBH models, indicating significant reductions in mortality and readmission rates, better patient and caregiver satisfaction, and decreased costs. 4 The central goals of such schemes are cutting costs by avoiding hospital admission and reducing hospital length of stay (LOS). 3 Delivering acute HBH has been shown to be a safe, effective, and cost-effective alternative to conventional hospitalization (CH). ...
... 11 The impact and efficiency of HBH have been widely researched in previous studies for distinct conditions: cancer, 2 chronic obstructive pulmonary disease, [12][13][14][15][16][17] 3,8 stroke, 18,19 neuromuscular diseases, 20 heart failure, 17,[21][22][23][24][25] diabetes, 26 among others. 7,27,28 The impact and efficiency of HBH were also analyzed in different groups (e.g., geriatric, 5,[28][29][30] , adult 17 and pediatric 31 populations) and various countries (e.g., Italy, 25 Spain, 21,32 Sweden, 23 Singapore, 33 United Kingdom, 30,34 the United States 3,6,17 ), with a focus on specific clinical issues (e.g., ulcer area, 26 changes in forced expiratory volume in one second 13 ) and diverse outcomes (e.g., mortality, 4,24,35 LOS 5,7,30 ), as well as costs. 4,17,29,34 Although HBH has been associated with saving costs and improved health outcomes, this model does not seem to represent the change in care burden. ...
... 7,27,28 The impact and efficiency of HBH were also analyzed in different groups (e.g., geriatric, 5,[28][29][30] , adult 17 and pediatric 31 populations) and various countries (e.g., Italy, 25 Spain, 21,32 Sweden, 23 Singapore, 33 United Kingdom, 30,34 the United States 3,6,17 ), with a focus on specific clinical issues (e.g., ulcer area, 26 changes in forced expiratory volume in one second 13 ) and diverse outcomes (e.g., mortality, 4,24,35 LOS 5,7,30 ), as well as costs. 4,17,29,34 Although HBH has been associated with saving costs and improved health outcomes, this model does not seem to represent the change in care burden. 4 A recent metaanalysis suggests that patients with chronic conditions who presented to the emergency department and were treated with HBH interventions had a reduced risk of hospital readmission and long-term care admission compared to those who received CH. ...
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Introduction: In Portugal, evidence of clinical outcomes within home-based hospitalization programs remains limited. Despite the adoption of home-based hospitalization services, it is still unclear whether these services represent an effective way to manage patients compared with inpatient hospital care. Therefore, the aim of this study was to evaluate the outcomes of home-based hospitalization compared with conventional hospitalization in a group of patients with a primary diagnosis of infectious, cardiovascular, oncological, or ‘other’ diseases. Methods: An observational retrospective study using anonymized administrative data to investigate the outcomes of home-based hospitalization (n = 209) and conventional hospitalization (n = 192) for 401 Portuguese patients admitted to CUF hospitals (Tejo, Cascais, Sintra, Descobertas, and the Unidade de Hospitalização Domiciliária CUF Lisboa). Data on demographics and clinical outcomes, including Barthel index, Braden scale, Morse scale, mortality, and length of hospital stay, were collected. The statistical analysis included comparison tests and logistic regression. Results: The study found no statistically significant differences between patients’ admission and discharge for the Barthel index, Braden scale, and Morse scale scores, for both conventional and home-based hospitalizations. In addition, no statistically significant differences were found in the length of stay between conventional and home-based hospitalization, although patients diagnosed with infectious diseases had a longer stay than patients with other conditions. Although the mortality rate was higher in home-based hospitalization compared to conventional hospitalization, the mortality risk index (higher in home-based hospitalization) assessed at admission was a more important predictor of death than the type of hospitalization. Conclusion: The study found that there were no significant differences in outcomes between conventional and home-based hospitalization. Home-based hospitalization was found to be a valuable aspect of patient- and family-centered care. However, it is noteworthy that patients with infectious diseases experienced longer hospital stays.
... Health professionals should be encouraged to view the older person in the context of their daily lives, as part of a family and a community [16,24,25]. Therefore, locating health services closer to a person's home is especially important. ...
... Therefore, locating health services closer to a person's home is especially important. When patient care is integrated into the person's community, higher patient and family/whānau satisfaction, reduced deaths and reduced readmission rates can be seen when compared with a traditional inpatient admission [16,24,25]. Patterson [26] suggests that the majority of rehabilitation services can be safely delivered outside acute hospital settings, either in the community or at home. ...
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Objectives This study aims to explore the opinions of key health leaders in Aotearoa New Zealand (Waikato Region) regarding a proposed facility-based rehabilitation initiative for older people. The initiative involves a team of health professionals providing intensive rehabilitation up to four times a day, seven days a week, to patients transferred to aged care facilities within the Waikato region. Method Structured interviews were conducted across one tertiary hospital, two community facilities, and two aged care facilities in the Waikato region of New Zealand. These were audio recorded and transcribed verbatim to allow for thematic analyses of the transcripts using a (1) general inductive method of inquiry. Results Interview transcripts from participants were analysed utilising a general inductive method of enquiry to develop key themes from the transcripts. This followed grounded theory in that themes emerged from the qualitative data collected from participants (2). The three central themes revealed were: "Person-Centered Care: What Matters Most?", "Rehabilitation: Beyond Monday to Friday, Eight to Five," and the importance of a multidisciplinary team working as "integrated partners in care." All participants supported the implementation of a facility-based rehabilitation initiative and identified key aspects for successful patient outcomes. However, safety was highlighted as a crucial consideration, with participants emphasizing the need for medical support and oversight when implementing such a significant change in the care model. Conclusion The study examines Aotearoa New Zealand health leaders' views on implementing a facility-based rehabilitation initiative for older people. It enables readers to consider key factors for successful implementation, addressing acute hospital bed pressures and bridging the gap between acute care, aged care, and home settings.
... The inception of HaH is particularly poignant against the backdrop of a burgeoning aging population, heralding a paradigm that fosters the efficient allocation of healthcare resources while accentuating the centrality of patient welfare [2]. It has garnered notable attention and application, particularly in the care of older adult patients grappling with a spectrum of conditions such as orthopedic anomalies [3] and chronic obstructive pulmonary disease (COPD) [4]. ...
... A synthesis of empirical explorations into HaH underscores its potential to recalibrate the cost-effectiveness landscape of healthcare delivery. The model, through its emphasis on early hospital discharge, appears to nurture an ecosystem that not only preserves but potentially enhances the quality of clinical outcomes [3,5]. For example, a randomized controlled trial demonstrated that a short hospital stay followed by a well-managed home care program is as effective as a traditional 10-day hospitalization course. ...
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Background The global population of adults aged 60 and above surpassed 1 billion in 2020, constituting 13.5% of the global populace. Projections indicate a rise to 2.1 billion by 2050. While Hospital-at-Home (HaH) programs have emerged as a promising alternative to traditional routine hospital care, showing initial benefits in metrics such as lower mortality rates, reduced readmission rates, shorter treatment durations, and improved mental and functional status among older individuals, the robustness and magnitude of these effects relative to conventional hospital settings call for further validation through a comprehensive meta-analysis. Methods A comprehensive literature search was executed during April–June 2023, across PubMed, MEDLINE, Embase, Web of Science, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) to include both RCT and non-RCT HaH studies. Statistical analyses were conducted using Review Manager (version 5.4), with Forest plots and I² statistics employed to detect inter-study heterogeneity. For I² > 50%, indicative of substantial heterogeneity among the included studies, we employed the random-effects model to account for the variability. For I² ≤ 50%, we used the fixed effects model. Subgroup analyses were conducted in patients with different health conditions, including cancer, acute medical conditions, chronic medical conditions, orthopedic issues, and medically complex conditions. Results Fifteen trials were included in this systematic review, including 7 RCTs and 8 non-RCTs. Outcome measures include mortality, readmission rates, treatment duration, functional status (measured by the Barthel index), and mental status (measured by MMSE). Results suggest that early discharge HaH is linked to decreased mortality, albeit supported by low-certainty evidence across 13 studies. It also shortens the length of treatment, corroborated by seven trials. However, its impact on readmission rates and mental status remains inconclusive, supported by nine and two trials respectively. Functional status, gauged by the Barthel index, indicated potential decline with early discharge HaH, according to four trials. Subgroup analyses reveal similar trends. Conclusions While early discharge HaH shows promise in specific metrics like mortality and treatment duration, its utility is ambiguous in the contexts of readmission, mental status, and functional status, necessitating cautious interpretation of findings.
... Interventions in the hospital-at-home service usually include adjusting medications, intravenous treatment, care for complex sores, pain control, the use of various feeding methods, home rehabilitation, and end of life support therapy as in terminal cancer or dementia. The most investigated indications for the hospital-athome service are specific conditions such as exacerbation of Chronic Obstructive Pulmonary Disease (COPD) or heart failure, acute skin infection, or pneumonia [7][8][9][10][11][12]. The treatment of these conditions through the hospitalat-home service leads to a reduction in the rate of emergency room visits and repeated hospitalizations and reduction of costs [13][14][15]. ...
... The findings of the current study are consistent with those of previous studies that showed the benefits of a home care unit as an alternative to hospitalization, especially relating to care for medical conditions such as heart failure, COPD, infections, pneumonia, following acute stroke [4-6, 8, 9, 11], and in a mixed geriatric population with a high burden of disease [17]. The characteristics of the current model that were like the characteristics of other successful models of hospital-at-home services included a multidisciplinary team, continuous contact with patients, and unlimited treatment time [5,7,[31][32][33]. The unique elements of the current model are a geriatric team that includes a geriatrician and a nurse with experience in geriatrics, the substantial involvement of other health professionals (physiotherapist and occupational therapist, dietitian, and social worker), the determination of very specific treatment goals, and periodic team meetings to discuss continuation or termination of treatment. ...
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Background A model of hospital-at-home services called the Home Care Unit (“the unit”) has been implemented in the southern region of the Clalit Healthcare Services in Israel. The aim of the present study was to characterize this service model. Methods A retrospective cross-over study. included homebound patients 65 years of age and above who were treated for at least one month in the framework of the unit, between 2013 and 2020. We compared the hospitalization rate, the number of hospital days, the number of emergency room visits, and the cost of hospitalization for the six-month period prior to admission to the unit, the period of treatment in the unit, and the six-month period following discharge from the unit. Results The study included 623 patients with a mean age of 83.7 ± 9.2 years with a mean Mini-mental State Examination (MMSE) score of 12.0 ± 10.2, a mean Charlson Comorbidity Index (CCI) of 3.7 ± 2.2 and a Barthel Index score of 23.9 ± 25.1. The main indications for admission to the unit were various geriatric syndromes (56.7%), acute functional decline (21.2%), and heart failure (12%). 22.8% died during the treatment period and 63.4% were discharged to ongoing treatment by their family doctor after their condition stabilized. Compared to the six months prior to admission to the unit there was a significant decrease (per patient per month) in the treatment period in the number of days of hospitalization (2.84 ± 4.35 vs. 1.7 ± 3.8 days, p < 0.001) and in the cost of hospitalization (1606 ± 2170 vs. 1066 ± 2082 USD, p < 0.001). Conclusions Treatment of homebound adults with a high disease burden in the setting of a hospital-at-home unit can significantly reduce the number of hospital days and the cost of hospitalization. This model of service for homebound patients with multiple medical problems maintained a high level of care while reducing costs. The results support the widespread adoption of this service in the community to enable the healthcare system to respond to the growing population of elderly patients with medical complexity.
... of health service resources and costs while providing comparable clinical outcomes [12][13][14][15][16][17][18][19]. These findings, coupled with the increasing strain on hospitals globally have led to the expansion of this service [20]. ...
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Background With the proliferation of Hospital at Home (HaH) programmes globally, there is a need to equip junior doctors with the skills necessary for provision of HaH care. The ideal training structure and clinical requirements for junior doctors to be considered competent in providing HaH care is still poorly understood. This study examines the perceptions of junior doctors towards HaH, and aims to determine the learning needs that might be helpful for future curriculum planning. Methods We conducted a cross-sectional study of residents at the National University Health System (NUHS) Singapore. Using a 45-item questionnaire, we explored the knowledge, attitudes and perceptions of residents towards HaH, and their interest in participating in HaH as part of residency training. Results One hundred six residents responded. Overall knowledge and attitudes were mostly average. Perceptions were neutral but comparatively lower in the domains of safety, efficiency and equity. 69% of residents showed a positive attitude and interest to participate in HaH as part of residency rotations. 80% of respondents were keen to have a 2–4 week rotation incorporated into routine training. Demographic factors that influenced higher scores in various domains included type of residency programme and years of work experience. Conclusion Our findings suggest that residents are interested in participating in HaH. Incorporation of HaH rotations in residency training will allow juniors doctors to receive greater exposure and training in the skills specific to provision of HaH care. Further studies on the introduction of a HaH curriculum and Entrustable Professional Activities (EPAs) specific for HaH in residency training may be useful to to ensure that we have a competent HaH workforce that can support and keep up with the growth of HaH globally.
... To our knowledge, there are few descriptive studies that have directly compared these 2 models. 9,16 Such comparisons are challenging because of inherent selection biases, where higher acuity patients are preferentially selected for hospital-first models. To inform this gap and overcome limitations of prior studies, this study uses propensity score weighting to compare clinical outcomes and resource utilization of a home-first to hospital-first approach, doing so in the context of treating patients with COVID-19 at an HaH unit in Singapore. ...
... While previous reviews of HITH have been completed, 9,12,14,38 these reviews have utilized only Randomized Control Trials, and compared international HITH models. This systematic review narratively synthesizes the barriers, benefits, and enablers of HITH care for older people within the Australian context. ...
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To determine the barriers, benefits, and enablers of acute home-based care in Australia for older people (aged 65 and over). A systematic review for people aged 65 and over receiving acute home-based care in Australia was conducted using various databases (CINAHL, Medline, PsycINFO, SCOPUS, Web of Science, PubMed, Informit) and citation searching in September 2023. The Critical Appraisal Skills Program (CASP) was used to assess the quality of the evidence and a thematic analysis approach was utilized to narratively synthesize results. Ten studies were included, consisting mostly of cohort studies in metropolitan areas. Barriers included inefficacy, patient demographics, and carers. Benefits included efficacy, high satisfaction, and medical management. Enablers included education, holistic assessments, and support interventions. Within the literature there was a significant research gap regarding HITH for older people in rural areas of Australia. Patient outcomes were closely aligned with admission pathways.
... The benefits of safely administering OPAT in settings such as hospital in the home (HITH), outpatient clinics, or patient self-administration models include reducing hospital costs, increasing hospital capacity, and providing treatment at home, a location most patients prefer. 3,4 Portable ambulatory infusion devices such as electronic intravenous infusion devices and disposable restrictive flow devices 5,6 can administer intravenous antibiotics as continuous intravenous infusions over prolonged periods, such as 24 h. This allows a more practical once-a-day (approximately every 24 h) home or clinic visit by the nurse or patient. ...
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... Hospital at home (HaH) programs are rapidly emerging with support from the Centers for Medicare and Medicaid Services waiver, Acute Hospital Care at Home. 1 Compared with traditional hospitalization, HaH has demonstrated improved patient outcomes and decreased cost with superior patient experiences. [2][3][4][5][6] The virtual hybrid HaH model pairs virtual patient interactions with inperson care provided in the patient's home. 7,8 Hospital at home programs serving patients in multiple geographic zones may use a command center to centralize operations and colocate team members for optimal efficiency. ...
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The use of hospital at home (HaH) programs are rapidly increasing due to virtual capabilities, hospital capacities, and patient preferences. In 2020, a large hospital system instituted a multistate HaH program with a single command center. It is not known whether decentralizing command centers to local hospital sites increases patient enrollment in HaH programs. This article outlines how the Agile Implementation Process was applied to rapidly decentralize patient enrollment to a local hospital site and reports pre–post data on the number of patient enrollments per month, staff satisfaction, and qualitative quotes describing how the Agile Implementation process supported interprofessional staff engagement. In brief, 235 patients were included from the local site (pre: n = 105, post: n = 130) with a mean age of 70 years (SD 2.73), 55% male, and primarily Caucasian (99%). Postdecentralization, staff satisfaction increased by 63% (4.4–7.2) and the mean number of patients enrolled per month significantly increased from 15 to 22 ( p = .01). An approximate 10% decrease in patient satisfaction was observed preintervention to postintervention (98.2–88.2%). In summary, the Agile Implementation quality improvement approach successfully decentralized patient enrollment to local hospital sites, increased patient enrollment, and staff satisfaction through staff engagement. Level of Evidence 4, Descriptive quality improvement project.
... Increasing the safety belt for HAH patients is a worldwide challenge and demand. Future tasks for the HAH world would include maintaining patients in their home environment without jeopardizing their health [30][31][32][33] bearing in mind that novel infrastructures and technologies, such as IoT (Internet of Things) must be evaluated and adopted [34,35] for this purpose. Nevertheless, current HAH practices still do not include reliable, validated means for patients' deterioration detection and prediction [36]. ...
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Background: The Hospital-at-home (HAH) model is a viable alternative for conven-tional in-hospital stays worldwide. Serum electrolyte abnormalities are common in acute pa-tients, especially in those with many comorbidities. Pathologic changes in cardiac electrophysi-ology pose a potential risk during HAH stay. Periodical Electrocardiogram (ECG) tracing is therefore advised, but few studies evaluated the accuracy and efficiency of compact, self-activated ECG devices in the HAH settings. This study aimed to evaluate the reliability of such a device in comparison to a standard 12-lead ECG. Methods: We prospectively recruited consecu-tive patients admitted to the Sheba Beyond, virtual hospital, in the HAH department, during a 3-month duration. Each patient underwent a 12-lead ECG recording using the legacy device, and a consecutive recording by a compact 6-lead device. Baseline patients’ characteristics during hospi-talization were collected. Level of agreement between devices was measured by Cohen’s Kappa coefficient for inter-rater reliability (Ϗ). Results: Fifty patients were included in the study. 26 (52%) had electrolyte disturbances. Abnormal D-dimer values were observed in 33 (66%) pa-tients, and 12 (24%) patients had elevated troponin values. We found a level of 94.5% raw agreement between devices with regards to nine of the options included in the automatic read-out of the legacy device. The calculated Ϗ was 0.72, classified as substantial consensus. The rate of raw consensus regarding ECG intervals’ measurement (PR, RR, QT) was 78.5% and the calculated Ϗ was 0.42, corresponding to a moderate level of agreement. Conclusion: This is the first report to our knowledge regarding the feasibility of using a compact, 6-Lead ECG device in the setting of HAH to be safe and bearing satisfying agreement level with a legacy, 12-lead ECG device, en-abling quick, accessible arrythmia detection in this setting. Our findings bear a promise to the future development of telemedicine-based hospital at home methodology.
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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.
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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.
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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.
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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.
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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.