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COVID-19 in Venezuela: Costs and Challenges of Management Severe Cases at Home in a Crisis Setting
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Background
Admission avoidance hospital at home provides active treatment by healthcare professionals in the patient's home for a condition that would otherwise require acute hospital inpatient care, and always for a limited time period. This is the fourth update of this review.
Objectives
To determine the effectiveness and cost of managing patients with admission avoidance hospital at home compared with inpatient hospital care.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL on 24 February 2022, and checked the reference lists of eligible articles. We sought ongoing and unpublished studies by searching ClinicalTrials.gov and WHO ICTRP, and by contacting providers and researchers involved in the field.
Selection criteria
Randomised controlled trials recruiting participants aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital inpatient care.
Data collection and analysis
We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. We performed meta‐analysis for trials that compared similar interventions, reported comparable outcomes with sufficient data, and used individual patient data when available. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes.
Main results
We included 20 randomised controlled trials with a total of 3100 participants; four trials recruited participants with chronic obstructive pulmonary disease; two trials recruited participants recovering from a stroke; seven trials recruited participants with an acute medical condition who were mainly older; and the remaining trials recruited participants with a mix of conditions. We assessed the majority of the included studies as at low risk of selection, detection, and attrition bias, and unclear for selective reporting and performance bias.
For an older population, admission avoidance hospital at home probably makes little or no difference on mortality at six months' follow‐up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.68 to 1.13; P = 0.30; I² = 0%; 5 trials, 1502 participants; moderate‐certainty evidence); little or no difference on the likelihood of being readmitted to hospital after discharge from hospital at home or inpatient care within 3 to 12 months' follow‐up (RR 1.14, 95% CI 0.97 to 1.34; P = 0.11; I² = 41%; 8 trials, 1757 participants; moderate‐certainty evidence); and probably reduces the likelihood of living in residential care at six months' follow‐up (RR 0.53, 95% CI 0.41 to 0.69; P < 0.001; I² = 67%; 4 trials, 1271 participants; moderate‐certainty evidence).
Hospital at home probably results in little to no difference in patient's self‐reported health status (2006 patients; moderate‐certainty evidence). Satisfaction with health care received may be improved with admission avoidance hospital at home (1812 participants; low‐certainty evidence); few studies reported the effect on caregivers. Hospital at home reduced the initial average hospital length of stay (2036 participants; low‐certainty evidence), which ranged from 4.1 to 18.5 days in the hospital group and 1.2 to 5.1 days in the hospital at home group. Hospital at home length of stay ranged from an average of 3 to 20.7 days (hospital at home group only). Admission avoidance hospital at home probably reduces costs to the health service compared with hospital admission (2148 participants; moderate‐certainty evidence), though by a range of different amounts and using different methods to cost resource use, and there is some evidence that it decreases overall societal costs to six months' follow‐up.
Authors' conclusions
Admission avoidance hospital at home, with the option of transfer to hospital, may provide an effective alternative to inpatient care for a select group of older people who have been referred for hospital admission. The intervention probably makes little or no difference to patient health outcomes; may improve satisfaction; probably reduces the likelihood of relocating to residential care; and probably decreases costs.
Background:
Studies conducted during the COVID-19 pandemic have shown that crowding in nursing homes is associated with high incidence of SARS-CoV-2 infections, but this effect has not been shown for other respiratory pathogens. We aimed to measure the association between crowding in nursing homes and outbreak-associated respiratory infection incidence and related mortality before the COVID-19 pandemic.
Methods:
We conducted a retrospective cohort study of nursing homes in Ontario, Canada. We identified, characterised, and selected nursing homes through the Ontario Ministry of Long-Term Care datasets. Nursing homes that were not funded by the Ontario Ministry of Long-Term Care and homes that closed before January, 2020 were excluded. Outcomes consisting of respiratory infection outbreaks were obtained from the Integrated Public Health Information System of Ontario. The crowding index equalled the mean number of residents per bedroom and bathroom. The primary outcomes were the incidence of outbreak-associated infections and mortality per 100 nursing home residents per year. We examined the incidence of infections and deaths as a function of the crowding index by use of negative binomial regression with adjustment for three home characteristics (ie, ownership, number of beds, and region) and nine mean resident characteristics (ie, age, female sex, dementia, diabetes, chronic heart failure, renal failure, cancer, chronic obstructive pulmonary disease, and activities of daily living score).
Findings:
Between Sept 1, 2014, and Aug 31, 2019, 5107 respiratory infection outbreaks in 588 nursing homes were recorded, of which 4921 (96·4%), involving 64 829 cases of respiratory infection and 1969 deaths, were included in this analysis. Nursing homes with a high crowding index had higher incidences of respiratory infection (26·4% vs 13·8%; adjusted rate ratio per one resident per room increase in crowding 1·89 [95% CI 1·64-2·17]) and mortality (0·8% vs 0·4%; 2·34 [1·88-2·92]) than did homes with a low crowding index.
Interpretation:
Respiratory infection and mortality rates were higher in nursing homes with high crowding index than in homes with low crowding index, and the association was consistent across various respiratory pathogens. Decreasing crowding is an important safety target beyond the COVID-19 pandemic to help to promote resident wellbeing and decrease the transmission of prevalent respiratory pathogens.
Funding:
None.
Background:
The COVID-19 pandemic greatly impacted traditional health structures, posing new challenges in an unprecedented health crisis. Telemedicine services were implemented in countries with robust digital platforms to reduce hospital attendance while continuing to provide medical care. This study aims to determine how telemedicine services have been used as a tool to ensure the right to health in Latin America during the pandemic.
Materials and methods:
We conducted a narrative review in which words such as telemedicine, COVID-19, Latin America, access, and right to health, were searched on scientific medical datasets such as PubMed and SciELO. Additionally, we reviewed legislation in the Latin American health domain regarding the administration and transmission of digital data.
Results and conclusions:
Several countries have used telemedicine to reduce the saturation of healthcare systems and increase patient access. Issues such as broadband access for low-income populations and adequate legal regulations for transmitting and storing confidential data must be addressed to improve telemedicine use in Latin America.
Variations across OECD countries in the prices of health care and hospital services can be vast. These price differences mean that comparisons of such services should be adjusted to reflect the ‘real’ volumes consumed. Purchasing power parities (PPPs) can be used to make such comparisons more accurately, going beyond simple GDP-based comparisons, by aggregating the prices of actual individual consumption of health items. These health and hospital PPPs demonstrate that GDP PPPs are a weak substitute, as price structures vary widely. Moreover, there is tentative evidence that higher relative prices for health care tend to bloat health expenditure and are associated with lower life expectancy.
Objectives
COVID-19 has altered health sector capacity in low-income and middle-income countries (LMICs). Cost data to inform evidence-based priority setting are urgently needed. Consequently, in this paper, we calculate the full economic health sector costs of COVID-19 clinical management in 79 LMICs under different epidemiological scenarios.
Methods
We used country-specific epidemiological projections from a dynamic transmission model to determine number of cases, hospitalisations and deaths over 1 year under four mitigation scenarios. We defined the health sector response for three base LMICs through guidelines and expert opinion. We calculated costs through local resource use and price data and extrapolated costs across 79 LMICs. Lastly, we compared cost estimates against gross domestic product (GDP) and total annual health expenditure in 76 LMICs.
Results
COVID-19 clinical management costs vary greatly by country, ranging between <0.1%–12% of GDP and 0.4%–223% of total annual health expenditure (excluding out-of-pocket payments). Without mitigation policies, COVID-19 clinical management costs per capita range from US75.57; in 22 of 76 LMICs, these costs would surpass total annual health expenditure. In a scenario of stringent social distancing, costs per capita fall to US1.10–US1.32.
Conclusions
We present the first dataset of COVID-19 clinical management costs across LMICs. These costs can be used to inform decision-making on priority setting. Our results show that COVID-19 clinical management costs in LMICs are substantial, even in scenarios of moderate social distancing. Low-income countries are particularly vulnerable and some will struggle to cope with almost any epidemiological scenario. The choices facing LMICs are likely to remain stark and emergency financial support will be needed.
The coronavirus disease 2019 (COVID‐19) pandemic has particularly affected countries with weakened health services in Latin America, where proper patient management could be a critical step to address the epidemic. In this study, we aimed to characterize and identify which epidemiological, clinical and paraclinical risk factors defined COVID‐19 infection from the first confirmed cases through the first epidemic wave in Venezuela. A retrospective analysis of consecutive suspected cases of COVID‐19 admitted to a sentinel hospital was carried out, including 576 patient cases subsequently confirmed for severe acute respiratory syndrome coronavirus 2 infection. Of these, 162 (28.1%) patients met definition criteria for severe/critical disease, and 414 (71.2%) were classified as mild/moderate disease. The mean age was 47 (SD 16) years, the majority of which were men (59.5%), and the most frequent comorbidity being arterial hypertension (23.3%). The most common symptoms included fever (88.7%), headache (65.6%), and dry cough (63.9%). Severe/critical disease affected mostly older males with low schooling (p < 0.001). Similarly, higher levels of glycemia, urea, aminotransferases, total bilirubin, lactate dehydrogenase, and erythrocyte sedimentation rate were observed in severe/critical disease patients compared to those with mild/moderate disease. Overall mortality was 7.6% (44/576), with 41.7% (28/68) dying in hospital. We identified risk factors related to COVID‐19 infection which could help healthcare providers take appropriate measures and prevent severe clinical outcomes. Our results suggest that the mortality registered by this disease in Venezuela during the first epidemic wave was underestimated. An increase in fatalities is expected to occur in the coming months unless measures that are more effective are implemented to mitigate the epidemic while the vaccination process is ongoing. This article is protected by copyright. All rights reserved.
Background
As the global strategies to fight the SARS-COV-2 infection (COVID-19) evolved, response strategies impacted the magnitude and distribution of health-related expenditures. Although the economic consequence of the COVID-19 pandemic has been dire, and its true scale is yet to be ascertained, one key component of the response is the management of infected persons which its cost has not been adequately examined, especially in Africa.
Methods
To fill gaps in context-specific cost of treating COVID-19 patients, we adopted a health system’s perspective and a bottom-up, point of care resource use data collection approach to estimate the cost of clinical management of COVID-19 infection in Ghana. The analysis was based on the national protocol for management of COVID-19 patients at the time, whether in public or private settings. No patients were enrolled into the study as it was entirely a protocol-based cost of illness analysis.
Result
We found that resource use and average cost of treatment per COVID-19 case varied significantly by disease severity level and treatment setting. The average cost of treating COVID-19 patient in Ghana was estimated to be US282 (GH¢1629) for patients with mild/asymptomatic disease condition managed at home to about US$23,382 (GH¢135,149) for critically ill patients requiring sophisticated and specialised care in hospitals. The cost of treatment increased by some 20 folds once a patient moved from home management to the treatment centre. Overheard costs accounted for 63–71% of institutionalised care compared to only 6% for home-based care. The main cost drivers in overhead category in the institutionalised care were personal protective equipment (PPEs) and transportation, whilst investigations (COVID-19 testing) and staff time for follow-up were the main cost drivers for home-based care.
Conclusion
Cost savings could be made by early detection and effective treatment of COVID-19 cases, preferably at home, before any chance of deterioration to the next worst form of the disease state, thereby freeing up more resources for other aspects of the fight against the pandemic. Policy makers in Ghana should thus make it a top priority to intensify the early detection and case management of COVID-19 infections.
Human lives and nations’ economies have been adversely affected worldwide by the COVID-19 pandemic. The hyperinflammatory state associated with the disease may be related to mortality. Systemic glucocorticoid is the first-line therapy for cytokine storm. Various immunomodulatory drugs such as tocilizumab and baricitinib have been used in those not responding to glucocorticoid monotherapy. Amid the peak crisis of COVID-19 in India, there was an extreme paucity of medications, oxygen, and hospital beds. We describe three patients with COVID-19 who received low-dose tofacitinib (an oral Janus kinase inhibitor) in addition to moderate-dose glucocorticoid. These patients were treated at their homes, as the hospitals were short of beds. Rapid reduction in hypoxemia along with gradual resolution of other signs of the disease were observed. The results are reassuring regarding the feasibility of managing of severe COVID-19 outside the hospital setting when healthcare resources are overwhelmed by pandemic-related caseload.
The COVID-19 pandemic has necessitated the rise of telehealth modalities to relieve the incredible stress the pandemic has placed on the healthcare system. This rise has seen the emergence of new software, applications, and hardware for home-based physiological monitoring, leading to the promise of innovative predictive and therapeutic practices. This article is a literature-based review of the most promising technologies and advances regarding home-based physiological monitoring of patients with COVID-19. We conclude that the applications currently on the market, while helping stem the flow of patients to the hospital during the pandemic, require additional evidence related to improvement in patient outcomes. However, new devices and technology are a promising and successful venture into home-based monitoring with clinical implications reaching far into the future.
Testing and isolation have been crucial for controlling the COVID-19 pandemic. Venezuela has one of the weakest testing infrastructures in Latin America and the low number of reported cases in the country has been attributed to substantial underreporting. However, the Venezuelan epidemic seems to have lagged behind other countries in the region, with most cases occurring within the capital region and four border states. Here, we describe the spatial epidemiology of COVID-19 in Venezuela and its relation to population mobility, migration patterns, non-pharmaceutical interventions and fuel availability. Using an SEI metapopulation model, we explore how movement patterns could have driven the observed distribution of cases. Low within-country connectivity most likely delayed the epidemic in most states, except for those bordering Colombia and Brazil where high immigration seeded outbreaks. NPIs slowed early epidemic growth and subsequent fuel shortages appeared to be responsible for limiting the spread of COVID-19 across the country.
Introduction
We estimated unit costs for COVID-19 case management for patients with asymptomatic, mild-to-moderate, severe and critical COVID-19 disease in Kenya.
Methods
We estimated per-day unit costs of COVID-19 case management for patients. We used a bottom-up approach to estimate full economic costs and adopted a health system perspective and patient episode of care as our time horizon. We obtained data on inputs and their quantities from data provided by three public COVID-19 treatment hospitals in Kenya and augmented this with guidelines. We obtained input prices from a recent costing survey of 20 hospitals in Kenya and from market prices for Kenya.
Results
Per-day, per-patient unit costs for asymptomatic patients and patients with mild-to-moderate COVID-19 disease under home-based care are 1993.01 Kenyan shilling (KES) (US18.991), respectively. When these patients are managed in an isolation centre or hospital, the same unit costs for asymptomatic patients and patients with mild-to-moderate disease are 6717.74 KES (US63.70), respectively. Per-day unit costs for patients with severe COVID-19 disease managed in general hospital wards and those with critical COVID-19 disease admitted in intensive care units are 13 137.07 KES (US599.51).
Conclusion
COVID-19 case management costs are substantial, ranging between two and four times the average claims value reported by Kenya’s public health insurer. Kenya will need to mobilise substantial resources and explore service delivery adaptations that will reduce unit costs.
This study aimed to estimate both direct medical and indirect costs of treating the Coronavirus disease 2019 (COVID-19) from a societal perspective in the patients at a referral hospital in Fars province as well as the economic burden of COVID-19 in Iran in 2020.
Methods
This study is a partial economic evaluation and a cross-sectional cost-description study conducted based on the data of the COVID-19 patients referred to a referral university hospital in Fars province between March and July 2020. The data were collected by examining the patients’ records and accounting information systems. The subjects included all the inpatients with COVID-19 (477 individuals) who admitted to the medical centre during the 4 months. Bottom-up costing (also called micro-costing approach), incidence-based and income-based human capital approaches were used as the main methodological features of this study.
Results
The direct medical costs were estimated to be 28,240,025,968 Rials ( 3755) per person (SD = 4684 735,510 (M = 24,310,728 Rials or 2168(. The second to which were the costs of medicines and medical consumables (28%). The mean indirect costs, including income loss due to premature death, economic production loss due to hospitalization and job absenteeism during recovery course were estimated to be 129,870,974 Rials ( 1,439,083,784.
Conclusion
The results of this study showed that the severe status of the disease would bring about the extremely high cost of illness in this case. It is estimated that the high prevalence rate of COVID-19 has been imposing a heavy economic burden on the country and health system directly that may result in rationing or painful cost-control approaches.
Background:
Covid-19 is a triphasic disorder characterized by a viral phase lasting 7-10 days from onset of symptoms. In approximately 20% it is followed by a second stage heralded by elevation of pro-inflammatory markers such as ferritin, IL-6, CRP, LDH and D-dimers. We hypothesized that those with few abnormalities would have a low risk for progression to respiratory insufficiency and hence could be monitored at home without treatment.
Methods:
Inclusion criteria included Covid infection, age >21, Oxygen saturation >90%. To be observed without treatment, patients could have no more than 1 of the following: CRP > 10 mg/dL, high LDH, ferritin > 500 ng/ml, D-dimer > 1 mg/L, IL-6 > 10 pg/ml, absolute lymphocyte count <1,000, Oxygen saturation <94%, or CT chest evidence of pneumonia. Primary endpoint was progression to respiratory failure and secondary endpoints was 28-day survival.
Results:
Of 208 entered, 132 were low-risk and hence were monitored without therapy. None progressed to respiratory failure or died.
Conclusions:
We have shown that our approach can identify cases who can safely be observed without treatment, thus avoiding expensive, potentially toxic therapies, and circumventing unnecessary, costly hospitalizations. These results support our hypothesis that applying our criteria, 64% of Covid-19 cases can be monitored as outpatients without therapy.
Introduction: Home-based care (HBC) services associated with COVID-19 pandemic are inevitable due to rising number of cases, the need for patients to self-isolate and curb the spread of infection. We reviewed the practices of HBC for COVID-19, identified possible challenges and suggested solutions for its optimization in Nigeria.
Methods: We adopted the scope review methodology. We conducted an extensive search of published articles on three databases; MedLine, PubMed, and PLOS ONE focusing on home management for COVID-19 and screened them for eligibility.
Results: Our findings revealed HBC decongests health facilities, makes room for health workers to focus on critically ill patients, and enhances recuperation of ill persons at a low cost. However, when self-isolation and infection prevention and control are not strictly adhered to, HBC increases the risk of transmission of COVID-19 among family members and further community transmission. Similarly, the existence of the perception of ‘imprisonment’ and difficulty in adherence to safety measures could be key challenges to optimizing HBC.
Conclusion: Strict infection prevention and control (IPC) measures could reduce the transmission of COVID-19 during HBC. We recommend HBC training sessions, and IPC education for community members regarding home care of COVID-19 patients. Patients who are less likely to adhere to HBC should be isolated in health facilities where available. Organized trainings need to be scheduled for community-based volunteer healthcare workers to undertake visitations to household where COVID-19-infected persons are being isolated. A periodic review of HBC is needed to identify its challenges and proffer prompt solutions.
Background: In many countries, patients with mild coronavirus disease 2019 (COVID-19) are told to self-isolate at home, but imperfect compliance and shared living space with uninfected people limit the effectiveness of home- based isolation. We examine the impact of facility-based isolation compared to self-isolation at home on the continuing epidemic in the USA.
Methods: We developed a compartment model to simulate the dynamic transmission of COVID-19 and calibrated it to key epidemic measures in the USA from March to September 2020. We simulated facility-based isolation strategies with various capacities and starting times under different diagnosis rates. Our primary model outcomes are new infections and deaths over 2 months from October 2020 onwards. In addition to national-level estimations, we explored the effects of facility-based isolation under different epidemic burdens in major US Census Regions. We performed sensitivity analyses by varying key model assumptions and parameters.
Results: We find that facility-based isolation with moderate capacity of 5 beds per 10 000 total population could avert 4.17 (95% credible interval 1.65–7.11) million new infections and 16 000 (8000–23 000) deaths in 2 months compared with home-based isolation. These results are equivalent to relative reductions of 57% (44–61%) in new infections and 37% (27–40%) in deaths. Facility-based isolation with high capacity of 10 beds per 10000 population could achieve reductions of 76% (62–84%) in new infections and 52% (37–64%) in deaths when supported by expanded testing with an additional 20% daily diagnosis rate. Delays in implementation would substantially reduce the impact of facility-based isolation. The effective capacity and the impact of facility-based isolation varied by epidemic stage across regions.
Conclusion: Timely facility-based isolation for mild COVID-19 cases could substantially reduce the number of new infections and effectively curb the continuing epidemic in the USA. Local epidemic burdens should determine the scale of facility-based isolation strategies.
Importance
Home health care workers care for community-dwelling adults and play an important role in supporting patients with confirmed and suspected coronavirus disease 2019 (COVID-19) who remain at home. These workers are mostly middle-aged women and racial/ethnic minorities who typically earn low wages. Despite being integral to patient care, these workers are often neglected by the medical community and society at large; thus, developing a health care system capable of addressing the COVID-19 crisis and future pandemics requires a better understanding of the experiences of home health care workers.
Objective
To understand the experiences of home health care workers caring for patients in New York City during the COVID-19 pandemic.
Design, Setting, and Participants
From March to April 2020, a qualitative study with 1-to-1 semistructured interviews of 33 home health care workers in New York City was conducted in partnership with the 1199SEIU Home Care Industry Education Fund, a benefit fund of the 1199 Service Employees International Union United Healthcare Workers East, the largest health care union in the US. Purposeful sampling was used to identify and recruit home health care workers.
Main Outcomes and Measures
Audio-recorded interviews were professionally transcribed and analyzed using grounded theory. Major themes and subthemes were identified.
Results
In total, 33 home health care workers employed by 24 unique home care agencies across the 5 boroughs of New York City participated. Participants had a mean (SD) age of 47.6 (14.0) years, 32 (97%) were women, 21 (64%) were Black participants, and 6 (18%) were Hispanic participants. Five major themes emerged: home health care workers (1) were on the front lines of the COVID-19 pandemic but felt invisible; (2) reported a heightened risk for virus transmission; (3) received varying amounts of information, supplies, and training from their home care agencies; (4) relied on nonagency alternatives for support, including information and supplies; and (5) were forced to make difficult trade-offs in their work and personal lives.
Conclusions and Relevance
In this qualitative analysis, home health care workers reported providing frontline essential care, often at personal risk, during the COVID-19 pandemic. They experienced challenges that exacerbated the inequities they face as a marginalized workforce. Interventions and policies to better support these frontline health care professionals are urgently needed.
Background:
Coronavirus disease 2019 (COVID-19) is now a global public threat. Given the pandemic of COVID-19, the economic impact of COVID-19 is essential to add value to the policy-making process. We retrospectively conducted a cost and affordability analysis to determine the medical costs of COVID-19 patients in China, and also assess the factors affecting their costs.
Methods:
This analysis was retrospectively conducted in Shandong Provincial Chest Hospital between 24 January and 16 March 2020. The total direct medical expenditures were analyzed by cost factors. We also assessed affordability by comparing the simulated out-of-pocket expenditure of COVID-19 cases relative to the per capita disposable income. Differences between groups were tested by student t test and Mann-Whitney test when appropriate. A multiple logistic regression model was built to determine the risk factors associated with high cost.
Results:
A total of 70 COVID-19 patients were included in the analysis. The overall mean cost was USD 6827 per treated episode. The highest mean cost was observed in drug acquisition, accounting for 45.1% of the overall cost. Total mean cost was significantly higher in patients with pre-existing diseases compared to those without pre-existing diseases. Pre-existing diseases and the advanced disease severity were strongly associated with higher cost. Around USD 0.49 billion were expected for clinical manage of COVID-19 in China. Among rural households, the proportions of health insurance coverage should be increased to 70% for severe cases, and 80% for critically ill cases to avoid catastrophic health expenditure.
Conclusions:
Our data demonstrate that clinical management of COVID-19 patients incurs a great financial burden to national health insurance. The cost for drug acquisition is the major contributor to the medical cost, whereas the risk factors for higher cost are pre-existing diseases and severity of COVID-19. Improvement of insurance coverage will need to address the barriers of rural patients to avoid the occurrence of catastrophic health expenditure.
Background: Substitutive hospital-level care in a patient's home may reduce cost, health care use, and readmissions while improving patient experience, although evidence from randomized controlled trials in the United States is lacking. Objective: To compare outcomes of home hospital versus usual hospital care for patients requiring admission. Design: Randomized controlled trial. (ClinicalTrials.gov: NCT03203759) Setting: Academic medical center and community hospital. Patients: 91 adults (43 home and 48 control) admitted via the emergency department with selected acute conditions. Intervention: Acute care at home, including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing. Measurements: The primary outcome was the total direct cost of the acute care episode (sum of costs for nonphysician labor, supplies, medications, and diagnostic tests). Secondary outcomes included health care use and physical activity during the acute care episode and at 30 days. Results: The adjusted mean cost of the acute care episode was 38% (95% CI, 24% to 49%) lower for home patients than control patients. Compared with usual care patients, home patients had fewer laboratory orders (median per admission, 3 vs. 15), imaging studies (median, 14% vs. 44%), and consultations (median, 2% vs. 31%). Home patients spent a smaller proportion of the day sedentary (median, 12% vs. 23%) or lying down (median, 18% vs. 55%) and were readmitted less frequently within 30 days (7% vs. 23%). Limitation: The study involved 2 sites, a small number of home physicians, and a small sample of highly selected patients (with a 63% refusal rate among potentially eligible patients); these factors may limit generalizability. Conclusion: Substitutive home hospitalization reduced cost, health care use, and readmissions while increasing physical activity compared with usual hospital care.
Objective:
To examine reciprocal relations of loneliness and cognitive function in older adults.
Methods:
Data were analyzed from 8382 men and women, age 65 and older, participating in the US Health and Retirement Study from 1998 to 2010. Participants underwent biennial assessments of loneliness and depression (classified as no, low or high depression) determined by the Center for Epidemiologic Studies Depression scale (8-item version), cognition (a derived memory score based on a word list memory task and proxy-rated memory and global cognitive function), health status and social and demographic characteristics from 1998 to 2010. We used repeated measures analysis to examine the reciprocal relations of loneliness and cognitive function in separate models controlling sequentially and cumulatively for socio-demographic factors, social network, health conditions and depression.
Results:
Loneliness at baseline predicted accelerated cognitive decline over 12 years independent of baseline socio-demographic factors, social network, health conditions and depression (β = -0.2, p = 0.002). After adjustment for depression interacting with time, both low and high depression categories were related to faster cognitive decline and the estimated effect of loneliness became marginally significant. Reciprocally, poorer cognition at baseline was associated with greater odds of loneliness over time in adjusted analyses (OR 1.3, 95% CI (1.1-1.5) p = 0.005), but not when controlling for baseline depression. Furthermore, cognition did not predict change in loneliness over time.
Conclusion:
Examining longitudinal data across a broad range of cognitive abilities, loneliness and depressive symptoms appear to be related risk factors for worsening cognition but low cognitive function does not lead to worsening loneliness over time.
Stroke is a major cause of severe physical disability, leading into a variety of impairments. In general, stroke rehabilitation is a process which requires intensive direct physical therapy and is usually guided by physiotherapists. The long and intensive therapy sessions often results in patients losing the motivation to continue with the therapy, and as a result patients do not recover to their prospective. With increasing occurrence of stroke incidence, therapists are under pressure for time. At present most of the rehabilitation programmes are highly human intensive. Thus an innovative game technology that supports stroke rehabilitation may provide new opportunities. The main objective of this paper is to present a new low cost game framework for stroke rehabilitation programme that would increase patients' motivation for therapy, and also to study the feasibility and effect of a new game based technology to support hand and leg rehabilitation. In this paper, some important new game design principles for hand and leg rehabilitation with a standard angle based representation of the full body motion during exercise, for improving the accuracy of stroke exercise are presented. The design of serious games, with important game design principle frequently linked with worthy user engagement, may offer perceptions into how more effective systems can be developed for stroke rehabilitation. The additional bio-signal and online database will enable evaluation of patient s movement performance.
Home-based rehabilitation is a promising approach to improve access to pulmonary rehabilitation.
To assess whether self-monitored, home-based rehabilitation is as effective as outpatient, hospital-based rehabilitation in patients with chronic obstructive pulmonary disease (COPD).
Randomized, multicenter, noninferiority trial.
10 academic and community medical centers in Canada.
252 patients with moderate to severe COPD.
After a 4-week education program, patients took part in home-based rehabilitation or outpatient, hospital-based rehabilitation for 8 weeks. They were followed for 40 weeks to complete the 1-year study.
The primary outcome was the change in Chronic Respiratory Questionnaire dyspnea subscale score at 1 year. The primary analysis took a modified intention-to-treat approach by using all patients who provided data at the specified follow-up time, regardless of their level of adherence. The analysis used regression modeling that adjusted for the effects of center, sex, and baseline level. All differences were computed as home intervention minus outpatient intervention.
Both interventions produced similar improvements in the Chronic Respiratory Questionnaire dyspnea subscale at 1 year: improvement in dyspnea of 0.62 (95% CI, 0.43 to 0.80) units in the home intervention (n = 107) and 0.46 (CI, 0.28 to 0.64) units in the outpatient intervention (n = 109). The difference between the 2 treatments at 1 year was small and clinically unimportant. The 95% CI of the difference did not exceed the prespecified noninferiority margin of 0.5: difference in dyspnea score of 0.16 (CI, -0.08 to 0.40). Most adverse events were related to COPD exacerbations. No serious adverse event was considered to be related to the study intervention.
The contribution of the educational program to the improvement in health status and exercise tolerance cannot be ascertained.
Home rehabilitation is a useful, equivalent alternative to outpatient rehabilitation in patients with COPD.
We examined the effect of a home-based intervention (HBI) on readmission and death among "high-risk" patients with congestive heart failure discharged home from acute hospital care.
Hospitalized patients with congestive heart failure and impaired systolic function, intolerance to exercise, and a history of 1 or more hospital admissions for acute heart failure were randomized to either usual care (n=48) or HBI at 1 week after discharge (n=49). Home-based intervention comprised a single home visit (by a nurse and pharmacist) to optimize medication management, identify early clinical deterioration, and intensify medical follow-up and caregiver vigilance as appropriate. The primary end point of the study was frequency of unplanned readmissions plus out-of-hospital deaths within 6 months of discharge. Secondary end points included duration of hospital stay and overall mortality.
During follow-up, patients in the HBI group had fewer unplanned readmissions (36 vs 63; P=.03) and fewer out-of-hospital deaths (1 vs 5; P=.11): 0.8+/-0.9 vs 1.4+/-1.8 (mean +/- SD) events per patient assigned to HBI and usual care, respectively (P=.03). Patients in the HBI group also had fewer days of hospitalization (261 vs 452; P=.05) and fewer total deaths (6 vs 12; P=.11). Patients assigned to usual care were more likely to experience 3 or more readmissions for acute heart failure (P=.02). Predictors of unplanned readmission were (1) 14 days or more of unplanned readmission during the 6 months before study entry (odds ratio [OR], 5.2; 95% confidence interval [CI], 1.8-16.2), (2) previous admission for acute myocardial ischemia (OR, 3.3; 95% CI, 1.2-9.1), and (3) an albumin plasma concentration of 38 g/L or less (OR, 2.4; 95% CI, 1.2-6.0). Home-based intervention was also associated with a trend toward reduced risk of unplanned readmission (OR, 0.4; 95% CI, 0.2-1.1).
Among a cohort of high-risk patients with congestive heart failure, HBI was associated with reduced frequency of unplanned readmissions plus out-of-hospital deaths within 6 months of discharge from the hospital.
Acutely ill older persons often experience adverse events when cared for in the acute care hospital.
To assess the clinical feasibility and efficacy of providing acute hospital-level care in a patient's home in a hospital at home.
Prospective quasi-experiment.
3 Medicare-managed care (Medicare + Choice) health systems at 2 sites and a Veterans Administration medical center.
455 community-dwelling elderly patients who required admission to an acute care hospital for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis.
Treatment in a hospital-at-home model of care that substitutes for treatment in an acute care hospital.
Clinical process measures, standards of care, clinical complications, satisfaction with care, functional status, and costs of care.
Hospital-at-home care was feasible and efficacious in delivering hospital-level care to patients at home. In 2 of 3 sites studied, 69% of patients who were offered hospital-at-home care chose it over acute hospital care; in the third site, 29% of patients chose hospital-at-home care. Although less procedurally oriented than acute hospital care, hospital-at-home care met quality standards at rates similar to those of acute hospital care. On an intention-to-treat basis, patients treated in hospital-at-home had a shorter length of stay (3.2 vs. 4.9 days) (P = 0.004), and there was some evidence that they also had fewer complications. The mean cost was lower for hospital-at-home care than for acute hospital care (5081 dollars vs. 7480 dollars) (P < 0.001).
Possible selection bias because of the quasi-experimental design and missing data, modest sample size, and study site differences.
The hospital-at-home care model is feasible, safe, and efficacious for certain older patients with selected acute medical illnesses who require acute hospital-level care.
Home care and hospice are unique and rapidly growing healthcare settings. However, there is a lack of published findings related to evidence-based infection surveillance programs among these settings. Our health system hired a Home Care and Hospice Infection Preventionist to implement an infection surveillance program using evidence-based infection surveillance criteria appropriate for these settings, the Association for Professionals in Infection Control and Epidemiology (APIC) and Healthcare Infection Control Practices Advisory Committee (HICPAC) definitions for home health care and home hospice infections, National Healthcare Safety Network long-term care facility (LTCF) criteria, and McGeer criteria for LTCFs. These surveillance criteria were built into new surveillance databases for Home Care, Home Hospice, and inpatient Hospice House. Infection Prevention reported infections and trends to respective departments monthly and as needed in the event of any significant infections. For most infection types, there were less infections identified during January-April 2021 than for the same period in 2019-2020. Having Infection Prevention coordinate the Home Care and Hospice infection surveillance program will help establish reliable healthcare-associated infection baseline data and help identify the population at risk. Future enhancements to automatically identify infections among this patient population are planned once Home Care and Hospice begin using the health system's electronic medical record.
Despite the increased burden of Covid-19 on older adults, ethical and public health frameworks lack adequate guidance for elderly patients who manage severe, even fatal, illness at home. The U.S. Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) recognize the heightened risks of Covid-19 for older adults; however, both organizations presuppose that most cases of Covid-19 will be mild to moderate and recoverable at home. Yet, older adults are least likely to follow this trajectory. Older patients are more susceptible to experiencing severe illness at home from which they may not recover; and if they do seek medical care, they tend to suffer worse outcomes than younger patients in intensive care settings. Given their likelihood of severe illness, worse outcomes in intensive care settings, and potential difficulty accessing resources, frail, disabled, and otherwise vulnerable older patients may face Covid-19 at home without adequate resources, information, or support for home-based care. This editorial proposes three approaches to prevent needless suffering and ensure that this vulnerable population continues to receive needed care.
La enfermedad por Coronavirus 2019 (COVID-19) continúa siendo un serio problema de salud pública en todo el mundo, sin embargo, hasta la fecha, existe información limitada sobre el comportamiento de esta pandemia en América Latina y en particular en Venezuela. En este trabajo se describe la experiencia del Hospital Universitario de Caracas (HUC) durante la pandemia de la COVID-19. Posterior al reporte del primer caso de infección en el país el 13 de marzo del 2020, el HUC instauró una carpa para la atención y diagnóstico de pacientes sospechosos de la COVID-19; para el 31 de agosto un total de 6 532 pacientes habían sido atendidos en el HUC, y se habían realizado 1 589 pruebas de PCR-RT, confirmándose la infección en 732 (46 %) pacientes, con una edad media de 47 años (12-82), siendo la mayoría hombres (57,7 %). El subregistro de casos ha sido un factor común en el desarrollo de la pandemia COVID-19 en todos los países, Venezuela no es la excepción. Los estudios prospectivos nos advierten de una mayor frecuencia de eventos catastróficos en las próximas décadas, por lo que se hace necesario preparar a las sociedades para anticipar y gestionar los riesgos, esta pandemia puede ser la primera de muchas por venir.
Importance
Nursing home residents have been disproportionately affected by coronavirus disease 2019 (COVID-19). Prevention recommendations emphasize frequent testing of health care personnel and residents, but additional strategies are needed.
Objective
To develop a reproducible index of nursing home crowding and determine whether crowding was associated with COVID-19 cases and mortality in the first months of the COVID-19 epidemic.
Design, Setting, and Participants
This population-based retrospective cohort study included more than 78 000 residents across more than 600 nursing homes in Ontario, Canada, and was conducted from March 29 to May 20, 2020.
Exposures
The nursing home crowding index equaled the mean number of residents per bedroom and bathroom.
Main Outcomes and Measures
The cumulative incidence of COVID-19 cases confirmed by a validated nucleic acid amplification assay and mortality per 100 residents; the introduction of COVID-19 into a home (≥1 resident case) was a negative tracer.
Results
Of 623 homes in Ontario, we obtained complete information on 618 homes (99%) housing 78 607 residents (women, 54 160 [68.9%]; age ≥85 years, 42 919 [54.6%]). A total of 5218 residents (6.6%) developed COVID-19 infection, and 1452 (1.8%) died of COVID-19 infection as of May 20, 2020. COVID-19 infection was distributed unevenly across nursing homes; 4496 infections (86%) occurred in 63 homes (10%). The crowding index ranged across homes from 1.3 (mainly single-occupancy rooms) to 4.0 (exclusively quadruple occupancy rooms); 308 homes (50%) had a high crowding index (≥2). Incidence in high crowding index homes was 9.7% vs 4.5% in low crowding index homes (P < .001), while COVID-19 mortality was 2.7% vs 1.3%, respectively (P < .001). The likelihood of COVID-19 introduction did not differ (high = 31.3% vs low = 30.2%; P = .79). After adjustment for regional, nursing home, and resident covariates, the crowding index remained associated with an increased incidence of infection (relative risk [RR] = 1.73, 95% CI, 1.10-2.72) and mortality (RR, 1.69; 95% CI, 0.99-2.87). A propensity score analysis yielded similar conclusions for infection (RR, 2.09; 95% CI, 1.30-3.38) and mortality (RR, 1.83; 95% CI, 1.09-3.08). Simulations suggested that converting all 4-bed rooms to 2-bed rooms would have averted 998 COVID-19 cases (19.1%) and 263 deaths (18.1%).
Conclusions and Relevance
In this cohort of Canadian nursing homes, crowding was common and crowded homes were more likely to experience larger and deadlier COVID-19 outbreaks.
Background and Objectives
Older adults with multiple comorbidities experience high rates of hospitalization and poor outcomes from Coronavirus Disease 2019 (COVID-19). Changes in care utilization by persons in advanced illness management (AIM) programs during the COVID-19 pandemic are not well known. The purpose of this study was to describe changes in care utilization by homebound AIM patients in an epicenter of the COVID-19 pandemic before and during the pandemic.
Research Design and Methods
Descriptive statistics and tests of differences were used to compare care utilization rates, including emergency department (ED) and inpatient admissions, acute and sub-acute rehabilitation, and AIM program utilization during the pandemic with rates one year prior.
Results
Acute and post-acute utilization for enrollees (n=1,468) decreased March-May 2020 compared to one year prior (n=1,452), while utilization of AIM program resources remained high. Comparing 2019 and 2020, ED visits/1000 enrollees were 109 versus 44 (p<0.001), inpatient admissions 213 versus 113 (p<0.001), and rehabilitation facility admissions 56 versus 31 (p=0.014); AIM program home visits were 1935 versus 276 (p<0.001), remote visits (telehealth/telephonic) 0 versus 1079 (p<0.001), and all other phone touches 3032 versus 5062 (p<0.001). Home hospice admissions/1000 increased: 16 to 31 (p=0.011).
Discussion and Implications
Our results demonstrate decreased acute and post-acute utilization, while maintaining high levels of connectedness to the AIM program, amongst a cohort of homebound older adults during the COVID-19 pandemic compared with one year prior. While further study is needed, our results suggest that AIM programs can provide support to this population in the home setting during a pandemic.
The COVID‐ 19 pandemic is a critical test for the already overburdened and mostly underfunded public healthcare systems of Latin America. In a region that suffers from severe inequalities, public healthcare systems are the only source of medical care for a large sector of the population who work in the informal economy or are unemployed. State‐run hospitals and clinics are already overstressed by continuous demand for treatment of vector‐borne diseases and community‐acquired infections as well as high rates of non‐communicable diseases. Ideological misconceptions and denial among Latin America’s political leaders prevented timely preparations for the pandemic and added to chronic governance problems. As ethical expertise in Latin America focuses on research ethics, few hospitals in the region have functioning clinical ethics committees or clinical ethics policy, forcing healthcare personnel to make excruciating treatment decisions in an environment dominated by material scarcity and public distrust. This essay examines the emergence of COVID‐19 in Latin America and the serious challenge that it poses for Latin America's public healthcare systems.
The economic crisis in Venezuela has eroded the country's health-care infrastructure and threatened the public health of its people. Shortages in medications, health supplies, interruptions of basic utilities at health-care facilities, and the emigration of health-care workers have led to a progressive decline in the operational capacity of health care. The effect of the crisis on public health has been difficult to quantify since the Venezuelan Ministry of Health stopped publishing crucial public health statistics in 2016. We prepared a synthesis of health information, beyond what is available from other sources, and scholarly discussion of engagement strategies for the international community. Data were identified through searches in MEDLINE, PubMed, and the grey literature, through references from relevant articles, and governmental and non-governmental reports, and publicly available databases. Articles published in English and Spanish until Dec 1, 2018, were included. Over the past decade, public health measures in Venezuela have substantially declined. From 2012 to 2016, infant deaths increased by 63% and maternal mortality more than doubled. Since 2016, outbreaks of the vaccine-preventable diseases measles and diphtheria have spread throughout the region. From 2016 to 2017, Venezuela had the largest rate of increase of malaria in the world, and in 2015, tuberculosis rates were the highest in the country in 40 years. Between 2017 and 2018, most patients who were infected with HIV interrupted therapy because of a lack of medications. The Venezuelan economic crisis has shattered the health-care system and resulted in rising morbidity and mortality. Outbreaks and expanding epidemics of infectious diseases associated with declines in basic public health services are threatening the health of the country and the region.
Background:
The "hospital-at-home" model may provide adequate care without an adverse effect on clinical outcome, and is generally well received by users. Our objective was to compare hospital-at-home and in-patient hospital care for neuromuscular disease (NMD) patients with respiratory tract infections.
Methods:
We conducted a prospective randomized controlled trial in a university teaching hospital offering secondary care service to a population of approximately 500,000. We recruited selected NMD patients with respiratory tract infection for whom hospital admission had been recommended after medical assessment. Hospital-at-home was provided as an alternative to in-patient admission. The main outcome measures were need for hospitalization, treatment failure, time to recovery, death during the first 3 months following exacerbation, and cost of patient care.
Results:
Among 59 consecutive NMD patients eligible for the study, 53 met the criteria for hospital-at-home. Twenty-six subjects were randomized to home care and 27 to hospital care. No significant differences were found in treatment failure (8/26 vs 13/27, P = .19), time to recovery (8.9 ± 4.6 vs 9 ± 8.9 d, P = .21), or mortality at 3 months (3/26 vs 4/27 deaths, P = .42) between the groups. Hospital-at-home failure was independently correlated with type of NMD (P = .004) with an odds ratio of failure of 17.3 (95% CI 2.1 to infinity) for subjects with amyotrophic lateral sclerosis. The total and daily direct cost of patient healthcare was significantly lower for the subjects who were successfully treated at home, compared to the hospitalized individuals.
Conclusions:
Hospital-at-home is an effective alternative to hospital admission for selected NMD patients with respiratory tract infections.
In spite of the fact that home care has grown considerably during the last few years and will continue to grow even more in the future, home care as a phenomenon and a concept is not clearly defined.
• The aim of this study was to review the empirical literature for the description of home care as a phenomenon and as a concept, especially with regard to who the care recipients are, what actions and assessments are performed and what effects are achieved for the care recipient in terms of functional health status and quality of life (QoL).
• Twenty‐six relevant studies meeting the inclusion criteria and requirements for methodological quality were identified.
• The phenomenon of home care is described through content, outcome and objectives. The content of home care involved a range of activities from actions preventing decreased functional abilities in old people to palliative care in advanced diseases.
• The outcome had two different underlying foci: (1) for the benefit of the patient based on the assumption that being cared at home increases their QoL, (2) in the interests of the society, to minimize hospital care by moving activities to the home of the patient.
• The objectives were found to be aiming at improving the QoL and/or maintaining independence, by means of actions and assessments, based on the patient's needs, undertaken to preserve and increase functional ability and make it possible for the person to remain at home.
• In conclusion, home care as a phenomenon was the care provided by professionals to people in their own homes with the ultimate goal of not only contributing to their life quality and functional health status, but also to replace hospital care with care in the home for societal reasons; home care covered a wide range of activities, from preventive visits to end‐of‐life care.
To compare the efficacy of home based care with standard hospital care in treating serious mental illness.
Randomised controlled trial.
South Southwark, London.
189 patients aged 18-64 living in catchment area. 92 were randomised to home based care (daily living programme) and 97 to standard hospital care. At three months' follow up 68 home care and 60 hospital patients were evaluated.
Use of hospital beds, psychiatric diagnosis, social functioning, patients' and relatives' satisfaction, and activity of daily living programme staff.
Home care reduced hospital stay by 80% (median stay six days in home care group, 53 days in hospital group) and did not increase the number of admissions compared with hospital care. On clinical and social outcome there was a non-significant trend in favour of home care, but both groups showed big improvements. On the global adjustment scale home care patients improved by 26.8 points and the hospital group by 21.6 points (difference 5.2; 95% confidence interval -1.5 to 12). Other rating scales showed similar trends. Home care patients required a wide range of support in areas such as housing, finance, and work. Only three patients dropped out from the programme.
Home based care may offer some slight advantages over hospital based care for patients with serious mental illness and their relatives. The care is intensive, but the low drop out rate suggests appreciation. Changes to traditional training for mental health workers are required.
Background:
Hospital at home is defined as a service that provides active treatment by health care professionals, in the patient's home, of a condition that otherwise would require acute hospital in-patient care, always for a limited period.
Objectives:
To assess the effects of hospital at home compared with in-patient hospital care.
Search strategy:
We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register, MEDLINE (1966 to 1996), EMBASE (1980 to 1995), Social Science Citation Index (1992 to 1995), Cinahl (1982 to 1996), EconLit (1969 to 1996), PsycLit 1987 to 1996), Sigle (1980 to 1995), and the Medical Care supplement on economic literature (1970 to 1990).
Selection criteria:
Randomised trials of hospital at home care compared with acute hospital in-patient care. The participants were patients aged 18 years and over.
Data collection and analysis:
Two reviewers independently extracted data and assessed study quality.
Main results:
For the update, 11 trials were added to the five included in the original review. Trials evaluating hospital at home for elderly patients with a mix of medical conditions and those recovering from elective surgery failed to detect a difference for patient health outcomes. The data for those recovering from a stroke was conflicting. One trial reported an increase in independence for those allocated to hospital at home, and another decreased communication and psychosocial well being at three months follow-up but not at six months follow-up. Patients allocated to hospital at home expressed greater satisfaction with care than those in hospital. Carers however expressed less satisfaction with hospital at home compared with hospital care. Allocation to hospital at home resulted in a reduction in hospital length of stay, but hospital at home increased overall length of care.
Reviewer's conclusions:
This review does not support the development of hospital at home services as a cheaper alternative to in-patient care. Early discharge schemes for patients recovering from elective surgery and elderly patients with a medical condition may have a place in reducing the pressure on acute hospital beds, providing the views of the carers are taken into account. For these clinical groups hospital length of stay is reduced, although this is offset by the provision of hospital at home. The evidence supporting hospital at home for patients recovering from a stroke is conflicting. There is some evidence that admission avoidance schemes may provide a less costly alternative to hospital care. Future research should focus on admission avoidance schemes, and the effect of early discharge hospital at home schemes for patients recovering from a stroke.
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