Hospital at home for acute respiratory patients

doi:10.1016/j.ejim.2006.02.023

European Journal of Internal Medicine

Volume 17, Issue 6, October 2006, Pages 402-407

https://doi.org/10.1016/j.ejim.2006.02.023 Get rights and content

Abstract

Background

The issue of “hospital at home” (HAH) for acute respiratory patients is one that is still being debated, partly because economic, cultural and health service differences between locations imply that HAH schemes need to be tailored to local situations. The aim of the present study was to analyze the feasibility and effectiveness of HAH for patients with acute respiratory disease at our institution.

Methods

Of all the patients admitted to our institution via the emergency department during a 34-day subject enrollment period, 25 with diagnoses of respiratory infection, pneumonia, pulmonary insufficiency or exacerbated chronic obstructive pulmonary disease who were living within 25 km of our center and who were willing to receive HAH care were assigned to HAH. Fifty sex-matched controls with the same diagnoses were given conventional hospital care (CHC) as inpatients. The dependent variables evaluated included time to discharge, readmissions within 3 months and deaths within 3 months.

Results

There were no significant differences between the HAH and CHC groups with regard to age, diagnoses, physical and analytical findings, or co-morbidity, or with regard to deaths (HAH 16%, CHC 10%) or readmissions (HAH 17%, CHC 24%). Time to final discharge was significantly shorter for HAH patients (7 days) than for CHC patients (12 days). Some 95% of the HAH patients were satisfied and would choose HAH again.

Conclusions

HAH seems feasible for appropriately selected acute respiratory disease patients presenting in our emergency department. It frees hospital beds for other patients, its readmission and mortality rates are no higher than for conventional hospitalization, and, in general, it is favorably evaluated by patients.

Introduction

Hospital inpatient costs account for a major part of total public health costs. Recent years have seen a marked trend towards shortening the time patients spend in the hospital, with the concomitant risk that morbidity and mortality rise due to the discharge of unstable patients [1], [2]. One way of countering this risk is to implement hospital at home (HAH) or supported discharge services, a practice that has become increasingly widespread since its initiation by Bluestone at the Montefiori Hospital in New York [3]. In this paper, “HAH” will refer exclusively to the practice of returning patients home, with support by hospital medical staff, immediately after evaluation, while “supported discharge” will refer to the discharge of patients, with home support by hospital medical staff, after an initial period as inpatients; both modalities are increasingly being employed [4], [5], [6], [7], [8], [9].

In spite of their growing popularity, the benefits that HAH and supported discharge are claimed to bring, both for the patient and the health system [4], [5], [8], [10], [11], [12], have been disputed on both economic and patient satisfaction grounds [13], [14]. In the study described here, we assessed the utility of a HAH scheme for acute respiratory patients in our institution; compared it with conventional admission to a hospital ward with regard to time to final discharge, readmissions and mortality within 3 months of discharge, and other parameters, and evaluated the satisfaction of patients assigned to HAH.

Section snippets

The HAH scheme and study

The HAH scheme evaluated works as follows. Patients admitted to hospital care in the emergency department (by physicians not involved in the HAH scheme) are then evaluated by HAH physicians to determine whether they fulfill not only the clinical criteria for HAH but also the residential and social criteria and the willingness criterion (willingness to be attended at home; see Appendix A). Patients who do not meet these criteria are dealt with as inpatients (conventional hospital care, CHC),

Results

Of the 28 patients admitted to the emergency department during the study period who fulfilled the criteria for admission to HAH (other than willingness) in this study, only 3 (11%) refused to be attended at home. However, it was not possible to obtain full data for the totality of either the HAH group or the control group. In particular, spirometric parameters were measured for only 14 HAH patients and for 25 in the CHC group. Of the other 11 patients in the HAH group, the habitual place of

Discussion

The desirability and viability of HAH or supported discharge schemes in a given context depend on the organization and funding of the relevant public health services and on the possibility of the need for family involvement being met, which in turn depends on social, economic and cultural factors. In this study, our first objective was to evaluate the utility of the HAH service we had designed and set up for the care of acute respiratory patients. In this regard, the 25 patients who satisfied

References (34)

S. Bechich et al.
Efecto de la hospitalización a domicilio en la reducción de la hospitalización convencional y frecuentación de urgencias en la insuficiencia cardíaca
Rev Clin Esp
(2000)
J.H. Gravil et al.
Home treatment of exacerbations of chronic obstructive pulmonary disease by an acute respiratory assessment service
Lancet
(1998)
M.E. Charlson et al.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
J Chronic Dis
(1987)
J.M. Antoñana et al.
Programa de altas precoces y asistencia domiciliaria en pacientes con exacerbación de enfermedad pulmonar obstructiva crónica
Arch Bronconeumol
(2001)
D.C. McCrory et al.
Management of acute exacerbations of COPD: a summary and appraisal of published evidence
Chest
(2001)
S. Kim et al.
Prospective multicenter study of relapse following emergency department treatment of COPD exacerbation
Chest
(Feb 2004)
N.A. Dewan et al.
Acute exacerbation of COPD: factors associated with poor outcome
Chest
(2000)
S.G. Adams et al.
Antibiotics are associated with lower relapse rates in outpatients with acute exacerbations of COPD
Chest
(2000)
N.N. Hansel et al.
Hospitalization for tuberculosis in the United States in 2000: predictors of in-hospital mortality
Chest
(2004)
J.E. Nunez et al.
Prognostic value of Charlson comorbidity index at 30 days and 1 year after acute myocardial infarction
Rev Esp Cardiol
(2004)

J. Kosecoff et al.

Prospective payment system and impairment at discharge. The ‘quicker-and-sicker’ story revisited

JAMA

(Oct 17 1990)

E.A. Halm et al.

Instability on hospital discharge and the risk of adverse outcomes in patients with pneumonia

Arch Intern Med

(Jun 10 2002)

E.M. Bluestone

The principles and practices of home care

JAMA

(1954)

M.M. Cotton et al.

Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomised controlled trial

Thorax

(2000)

E. Sala et al.

Supported discharge shortens hospital stay in patients hospitalized because of an exacerbation of COPD

Eur Respir J

(June 1 2001)

S.H. Richards et al.

Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care

BMJ

(1998)

D.S. Postma et al.

Home treatment of COPD exacerbations

Thorax

(1999)

Cited by (17)

Prognostic Usefulness of Basic Analytical Data in Chronic Obstructive Pulmonary Disease Exacerbation
2023, Open Respiratory Archives
COPD causes high morbidity and mortality and high health costs. Thus, identifying and analyzing the distinctive and treatable traits seems useful to optimize the management of AEPOC patients. While various biomarkers have been researched, no solid data for systematic use have been made available.
Assessing the short-term prognostic usefulness of clinical and analytical parameters available in routine clinical practice in COPD exacerbations.
Multicenter prospective observational study conducted between 2016 and 2018. Patients admitted for COPD exacerbation who agreed to participate and signed an informed consent form were included. Prolonged stay, in-hospital mortality or early readmission was considered an unfavorable progression. 30-Day mortality was also analyzed.
615 patients were included. Mean age was 73.9 years (SD 10.6); 86.2% were male. Progression of 357 patients (58%) was considered unfavorable. Mortality at 1 month from discharge was 6.7%. The multivariate analysis shows a relationship between the CRP/Albumin ratio and unfavorable progression (OR 1.008, 95% CI 1.00; 1.01), as well as increased risk of death at 1 month from discharge with elevated urea (OR 1.01, 95% CI 1.005; 1.02) and troponin T (OR 2.21, 95% CI 1.06; 4.62).
Elevated CRP/Albumin, urea and TnT are prognostic indicators of poor short-term outcome in patients admitted for COPD exacerbation. Cardiovascular comorbidity and systemic inflammation could explain these findings.
: La EPOC provoca una elevada morbimortalidad y elevados costes sanitarios. Identificar y analizar los rasgos distintivos y tratables parece útil para optimizar el tratamiento de los pacientes con AEPOC. Se han investigado varios biomarcadores sin que de momento se disponga de datos sólidos para su uso sistemático.
Evaluar la utilidad pronóstica a corto plazo de los parámetros clínicos y analíticos disponibles en la práctica clínica habitual en las exacerbaciones de la EPOC.
Estudio observacional prospectivo multicéntrico realizado entre 2016 y 2018. Se incluyeron pacientes ingresados por exacerbación de EPOC que aceptaron participar y que firmaron consentimiento informado. Se consideró evolución desfavorable la estancia prolongada, la mortalidad hospitalaria o el reingreso precoz. También se analizó la mortalidad a 30 días.
Se incluyeron 615 pacientes. La edad media fue 73,9 años (DE 10,6); El 86,2% eran varones. Se consideró desfavorable la evolución de 357 pacientes (58%). La mortalidad al mes del alta fue del 6,7%. El análisis multivariante muestra una relación entre el ratio PCR/Albúmina y la progresión desfavorable (OR 1,008, IC 95% 1,00; 1,01), así como un mayor riesgo de muerte al mes del alta con urea elevada (OR 1,01, IC 95% 1,005; 1,02) y troponina T (OR 2,21; IC del 95%: 1,06; 4,62).
La elevación de PCR/albúmina, la urea y la TnT son indicadores de mal pronóstico a corto plazo en pacientes ingresados por exacerbación de la EPOC. La comorbilidad cardiovascular y la inflamación sistémica podrían explicar estos hallazgos.
Outpatient Interventions for Managing Acute Complications of Chronic Diseases: A Scoping Review and Implications for Patients With CKD
2020, American Journal of Kidney Diseases
Citation Excerpt :
Home visits were conducted by physicians in 9 interventions and by nurses in all, with involvement of allied health professionals on the care team in 4 programs. Almost half the interventions (n = 7)26,28,33,35,36,38,39 indicated that they were operational 7 days per week, most often during daytime hours, with 4 specifying after-hours nursing or physician telephone support.9-41 All provided standard medical therapies in the home for patients meeting eligibility criteria (eg, clinical stability, proximity to hospital, and access to telephone and home support), but only 4 described the provision of patient education as part of the program.26,27,29,35
Patients with chronic kidney disease (CKD) have high rates of emergency department (ED) use and hospitalization. Outpatient care may provide an alternative to ED and inpatient care in this population. We aimed to explore the scope of outpatient interventions used to manage acute complications of chronic diseases and highlight opportunities to adapt and test interventions in the CKD population.
Scoping review of quantitative and qualitative studies.
Outpatient interventions for adults experiencing acute complications related to 1 of 5 eligible chronic diseases (ie, CKD, chronic respiratory disease, cardiovascular disease, cancer, and diabetes).
MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, grey literature, and conference abstracts were searched to December 2019.
Intervention and study characteristics were extracted using standardized tools.
Quantitative data were summarized descriptively; qualitative data were summarized thematically. Our approach observed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews.
77 studies (25 randomized controlled trials, 29 observational, 12 uncontrolled before-after, 5 quasi-experimental, 4 qualitative, and 2 mixed method) describing 57 unique interventions were included. Of identified intervention types (hospital at home [n = 16], observation unit [n = 9], ED-based specialist service [n = 4], ambulatory program [n = 18], and telemonitoring [n = 10]), most were studied in chronic respiratory and cardiovascular disease populations. None targeted the CKD population. Interventions were delivered in the home, ED, hospital, and ambulatory setting by a variety of health care providers. Cost savings were demonstrated for most interventions, although improvements in other outcome domains were not consistently observed.
Heterogeneity of included studies; lack of data for outpatient interventions for acute complications related to CKD.
Several interventions for outpatient management of acute complications of chronic disease were identified. Although none was specific to the CKD population, features could be adapted and tested to address the complex acute-care needs of patients with CKD.
Home Hospitalization in Pulmonology: Efficient Management and High Patient Satisfaction
2020, Archivos de Bronconeumologia
Self-administered outpatient parenteral antimicrobial therapy (S-OPAT) for infective endocarditis: A safe and effective model
2015, European Journal of Internal Medicine
Citation Excerpt :
Most HIHs have a wide list of services for the patient including intravenous antibiotic treatment (OPAT) which, over recent years, has received considerable attention. Other clinical processes addressed by HIHs include pulmonary embolism, acute renal insufficiency, post-surgery processes as well as decompensation in chronic diseases including chronic obstructive pulmonary disease and congestive heart failure [10–12]. The main difference between OPAT and HIH is that, in the latter, clinical follow-up by the healthcare professionals is very close.
The safety and efficacy of treatment of infectious endocarditis (IE) was evaluated within a program of hospital-in-home (HIH) based on self-administered outpatient parenteral antimicrobial therapy (S-OPAT). IE episodes (n = 48 in 45 patients; 71% middle-aged males) were recruited into the HIH program between 1998 and 2012. Following treatment stabilization at the hospital they returned home for HIH in which a physician and/or a nurse supervised the S-OPAT. Safety and efficacy were evaluated as mortality, re-occurrence, and unexpected re-admission to hospital. Of the episodes of IE, 83.3% had comorbidities with a mean score of 2.3 on the Charlson index and 1.5 on the Profund index; 60.4% had pre-existing valve disease (58.6% having had surgical intervention); 8.3% of patients had suffered a previous IE episode; 62.5% of all episodes affected a native valve; 45.8% being mitral; 70.8% of infection derived from the community. In 75% of the episodes there was micro-organism growth, of which 83.3% were Gram positive. Overall duration of antibiotic treatment was 4.8 weeks; 60.4% of this time corresponding to HIH. Re-admission occurred in 12.5% of episodes of which 33.3% returned to HIH to complete the S-OPAT. No deaths occurred during HIH. One year after discharge, 2 patients had recurrence and 5 patients died, in 2 of whom previous IE as cause-of-death could not be excluded. In conclusion, the S-OPAT schedule of hospital-in-home is safe and efficacious in selected patients with IE.
Patients with uncomplicated diverticulitis and comorbidity can be treated at home
2010, European Journal of Internal Medicine
Citation Excerpt :
Hospital at Home is becoming an alternative to Conventional Hospitalization, because it allows treating patients with conditions requiring hospital admission at their own home. Several studies have shown the efficacy of home treatment of patients with acute diseases and acute exacerbations of chronic diseases [7–11]. The aim of our study was to analyze the efficacy and safety of treating patients with uncomplicated diverticulitis and comorbidity in Hospital at Home.
Patients with uncomplicated diverticulitis and comorbidity are usually hospitalized. We analyze the efficacy and safety of treating these patients in Hospital at Home.
Prospective study since January 2007 to December 2009. Patients were transferred to the Hospital at Home after 12–24 h at Emergency Department Observation Ward. All patients were treated with intravenous antibiotic until clinical condition improved.
176 patients were diagnosed with uncomplicated diverticulitis at the Emergency Department. 18% of them (33) had comorbidity. Twenty four patients were transferred to the Hospital at Home (seventeen patients had cardiopathy, four diabetes mellitus and three chronic renal failure). Mean age was 73.4 years. All patients had abdominal pain and 29.1% fever; 45.8% presented with leucocytosis. 20.8% had a previous history of diverticulitis. Mean stay of patients was 9 days. All patients had a favorable course. The home treatment was successfully completed in 100% of patients. 95% of the patients expressed their satisfaction with this type of treatment.
Treatment of patients with uncomplicated diverticulitis and comorbidity at home after a short period of observation in Hospital is safe and effective.
Home hospitalisation in patients with COPD
2009, Atencion Primaria

View all citing articles on Scopus

View full text

Original articleHospital at home for acute respiratory patients

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

The HAH scheme and study

Results

Discussion

Rev Clin Esp

Lancet

J Chronic Dis

Arch Bronconeumol

Chest

Chest

Chest

Chest

Chest

Rev Esp Cardiol

Prospective payment system and impairment at discharge. The ‘quicker-and-sicker’ story revisited

JAMA

Instability on hospital discharge and the risk of adverse outcomes in patients with pneumonia

Arch Intern Med

The principles and practices of home care

JAMA

Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomised controlled trial

Thorax

Supported discharge shortens hospital stay in patients hospitalized because of an exacerbation of COPD

Eur Respir J

Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care

BMJ

Home treatment of COPD exacerbations

Thorax

Original article
Hospital at home for acute respiratory patients