Hospital-at-Home Interventions vs In-Hospital Stay for Patients With Chronic Disease Who Present to the Emergency Department: A Systematic Review and Meta-analysis.

Importance: Hospitalizations are costly and may lead to adverse events; hospital-at-home interventions could be a substitute for in-hospital stays, particularly for patients with chronic diseases who use health services more than other patients. Despite showing promising results, heterogeneity in past systematic reviews remains high. Objective: To systematically review and assess the association between patient outcomes and hospital-at-home interventions as a substitute for in-hospital stay for community-dwelling patients with a chronic disease who present to the emergency department and are offered at least 1 home visit from a nurse and/or physician. Data Sources: Databases were searched from date of inception to March 4, 2019. The databases were Ovid MEDLINE, Ovid Embase, Ovid PsycINFO, CINAHL, Health Technology Assessment, the Cochrane Library, OVID Allied and Complementary Medicine Database, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. Study Selection: Randomized clinical trials in which the experimental group received hospital-at-home interventions and the control group received the usual in-hospital care. Patients were 18 years or older with a chronic disease who presented to the emergency department and received home visits from a nurse or physician. Data Extraction and Synthesis: Risk of bias was assessed, and a meta-analysis was conducted for outcomes that were reported by at least 2 studies using comparable measures. Risk ratios (RRs) were reported for binary outcomes and mean differences for continuous outcomes. Narrative synthesis was performed for other outcomes. Main Outcomes and Measures: Outcomes of interest were patient outcomes, which included mortality, long-term care admission, readmission, length of treatment, out-of-pocket costs, depression and anxiety, quality of life, patient satisfaction, caregiver stress, cognitive status, nutrition, morbidity due to hospitalization, functional status, and neurological deficits. Results: Nine studies were included, providing data on 959 participants (median age, 71.0 years [interquartile range, 70.0-79.9 years]; 613 men [63.9%]; 346 women [36.1%]). Mortality did not differ between the hospital-at-home and the in-hospital care groups (RR, 0.84; 95% CI, 0.61-1.15; I2 = 0%). Risk of readmission was lower (RR, 0.74; 95% CI, 0.57-0.95; I2 = 31%) and length of treatment was longer in the hospital-at-home group than in the in-hospital group (mean difference, 5.45 days; 95% CI, 1.91-8.97 days; I2 = 87%). In addition, the hospital-at-home group had a lower risk of long-term care admission than the in-hospital care group (RR, 0.16; 95% CI, 0.03-0.74; I2 = 0%). Patients who received hospital-at-home interventions had lower depression and anxiety than those who remained in-hospital, but there was no difference in functional status. Other patient outcomes showed mixed results. Conclusions and Relevance: The results of this systematic review and meta-analysis suggest that hospital-at-home interventions represent a viable substitute to an in-hospital stay for patients with chronic diseases who present to the emergency department and who have at least 1 visit from a nurse or physician. Although the heterogeneity of the findings remained high for some outcomes, particularly for length of treatment, the heterogeneity of this study was comparable to that of past reviews and further explored.

Elderly patients with COPD require more health care than elderly heart failure patients do in a hospital-based home care setting.

Background: Elderly patients with advanced stages of COPD or chronic heart failure (CHF) often require hospitalization due to exacerbations. We hypothesized that telemonitoring supported by hospital-based home care (HBHC) would detect exacerbations early, thus, reducing the number of hospitalization. We also speculated that patients with advanced COPD or CHF would present differences regarding exacerbation frequency and the need of HBHC. Methods: The Health Diary system, based on digital pen technology, was employed. Patients aged ≥65 years with ≥2 hospitalizations the previous year were included. Exacerbations were categorized and treated as either COPD or CHF exacerbation by an experienced physician. All HBHC contacts (home visits or telephone consultations) were registered. Results: Ninety-four patients with advanced diseases were enrolled (36 COPD and 58 CHF subjects) of which 53 subjects (19 COPD and 34 CHF subjects) completed the 1-year study period. Death was the major reason for not finalizing the study. Compared to the 1-year prior inclusion, the intervention significantly reduced hospitalization. Although COPD subjects were younger with less comorbidity, exacerbations and HBHC contacts were significantly greater in this group. Conclusions: COPD subjects exhibit exacerbations more frequently, mainly due to disease characteristics, thus, demanding much more HBHC.

Development, implementation, and effects of a cancer center's exercise-oncology program.

BACKGROUND: National and international bodies acknowledge the benefit of exercise for people with cancer, yet limited accessibility to related programing remains. Given their involvement in managing the disease, cancer centers can play a central role in delivering exercise-oncology services. The authors developed and implemented a clinically integrated exercise-oncology program at a major cancer center and evaluated its effectiveness and participant experience. METHODS: A hospital-based program with prescribed at-home exercise was developed and accepted referrals over a 42-month period (3.5 years). Implementation was conducted in 2 phases: a pilot phase for women with breast cancer and men with genitourinary cancer and a roll-out phase for all patients with cancer. Enrolled patients were assessed and received an exercise prescription as well as a program manual, resistance bands, and a stability ball from a kinesiologist. Program participation and effectiveness were evaluated up to 48 weeks after the baseline assessment using intention-to-treat analyses. Participants in the roll-out phase were asked to complete a program experience questionnaire at the completion of the 48-week follow-up. RESULTS: In total, 112 participants enrolled in the pilot, and 150 enrolled in the roll-out phase. Program attrition to 48 weeks was 48% and 65% in the pilot and roll-out phases, respectively. In participants who consented to research evaluation of their performance, objective and patient-reported measures of functional capacity improved significantly from baseline in both phases. Participants were highly satisfied with the program. CONCLUSIONS: Despite significant drop-out to program endpoints, our cancer-exercise program demonstrated clinically relevant improvement in functional outcomes and was highly appreciated by participants.

Publicly-funded homebirth models in Australia.

BACKGROUND: Publicly-funded homebirth programs in Australia have been developed in the past decade mostly in isolation from each other and with limited published evaluations. There is also distinct lack of publicly available information about the development and characteristics of these programs. We instigated the National Publicly-funded Homebirth Consortium and conducted a preliminary survey of publicly-funded homebirth providers. AIM: To outline the development of publicly-funded homebirth models in Australia. METHODS: Providers of publicly-funded homebirth programs in Australia were surveyed using an on-line survey in December 2010. Questions were about their development, use of policy and general operational issues. A descriptive analysis of the quantitative data and content analysis of the qualitative data was undertaken. FINDINGS: In total, 12 programs were identified and 10 contributed data to this paper. The service providers reported extensive multidisciplinary consultation and careful planning during development. There was a lack of consistency in data collection throughout the publicly-funded homebirth programs due to different databases, definitions and the use of different guidelines. DISCUSSION: Publicly-funded homebirth services followed different routes during their development, but essentially had safety and collaboration with stakeholders, including women and obstetricians, as central to their process. CONCLUSION: The National Publicly-funded Homebirth Consortium has facilitated a sharing of resources, processes of development and a linkage of homebirth services around the country. This analysis has provided information to assist future planning and developments in models of midwifery care. It is important that births of women booked to these programs are clearly identified when their data is incorporated into existing perinatal datasets.

Estudio comparativo y aleatorizado de la visita puerperal en el domicilio de la madre y en el centro de salud / Randomized comparative study of the puerperal visits in the mothers house and in the health center

Objetivo: Evaluar la efectividad, en cuanto a evolución clínica y satisfacción materna, de la visita puerperal en el domicilio y compararla con la realizada en el centro de salud. Personas, material y método: Ensayo de intervención, multicéntrico y aleatorizado, donde se comparó un grupo experimental formado por 100 mujeres que recibieron la primera asistencia posparto en el domicilio con un grupo control de 100 mujeres que tuvieron la primera visita posparto en la consulta del centro de salud. Resultados: La visita puerperal domiciliaria se asoció de manera independiente a un alto grado de satisfacción materna con la asistencia recibida (OR 10,1; IC del 95%: 3,5-29,3; p <0,001) y a un menor grado de abandono precoz de la lactancia materna (OR 15,3; IC del 95%: 1,1-205,9; p= 0,039), que fue 6 veces inferior respecto al grupo con visita puerperal en el centro de salud (1,1 frente a 6,7%; p= 0,034). El grupo de la visita puerperal domiciliaria refirió un mayor grado de información sobre sexualidad (67 frente a 33%; p <0,001) y anticoncepción (63 frentea 37%; p <0,001) en el puerperio. No se constataron diferencias en el uso de recursos sanitarios ni en otras variables clínicas. Conclusiones: Comparada con la visita puerperal en el centro de salud,la visita domiciliaria se asoció a un mayor grado de satisfacción y adquisición de conocimientos de la madre; los resultados clínicos de ambos grupos fueron comparables, excepto en el abandono precoz de la lactancia materna, inferior en el grupo que recibió la visita puerperal domiciliaria (AU)

Objective: Evaluate the effectiveness regarding to the clinical evolution and maternal satisfaction of the puerperal visit (PV) in the residence and compare it with the one done in the health center. Persons/material and method: Randomized multicentre intervention study where an experimental group of 100 women who received the first postpartum assistance in their own home, and another control group of 100 women whom received their first postpartum visit at the consultation of the health center. Results: The home PV was associated in an independent manner to a high percentage of maternal satisfaction with the assistance they received (OR 10.1; CI 95%: 3.5-29.3; p <0.001) and in a lesser degree of early abandonment of maternal breast feeding (OR 15.3; CI 95%: 1.1-205.9; p <0.039), which was six times less than the group with PV in the health center (1.1 vs 6.7% p= 0.034). The group with home PV referred a greater degree of information about sexuality (67 vs 33%;p <0.001) and anticonception (63 vs 37%; p <0.001) in the puerperal. No differences where obtained in the use of sanitary resources or in other clinical variables. Conclusions: Compared with the PV in the health center, the home PVis associated with a greater degree of satisfaction and a knowledge acquisitionby the mother, with some clinical results comparable, except for the early abandonment of breast feeding, which was favorable in thegroup with home PV (AU)

Análisis de la actividad en las unidades móviles de rehabilitación-fisioterapia en atención primaria / Analysis of the activity of mobile rehabilitation-physiotherapy units in primary care

ObjetivoDescribir la atención domiciliaria que ofrecen los equipos móviles de rehabilitación-fisioterapia (EMRF) como respuesta a las necesidades de la población dependiente, las características que tiene su aplicación y las consecuencias que produce sobre el paciente y su independencia funcional.DiseñoEstudio descriptivo transversal desde 2004 hasta junio de 2007.EmplazamientoMedio comunitario. Los EMRF de atención primaria en Almería.ParticipantesEn total 1.093 pacientes incluidos en el programa.Mediciones principalesSe recogió sistemáticamente el estado de salud de los pacientes (proceso discapacitante principal, motivos de inclusión en el tratamiento, valoración funcional inicial y final e índice de Barthel), los datos sobre la atención fisioterapéutica y el n.o de sesiones.ResultadosUn 64,2% de la muestra fueron mujeres; la edad media fue de 78 años. El tiempo medio de espera para su valoración fue de 4 días y hubo una gran diversidad de procesos discapacitantes principales que han quedado descritos. Existió un elevado porcentaje de síntomas de grave deterioro motor, dolor y debilidad muscular. El 88,6% de los pacientes realizó tratamiento fisioterapéutico; el 11,1% de los pacientes fisioterapia y tratamiento ocupacional y el 0,3% de los pacientes tratamiento ortésico. El número medio de sesiones fue de 12,85. Se describe la variación en el índice de Barthel final tras la intervención realizada (cinesiterapia [61,9%]; combinada con electroterapia [10,2%]; cinesiterapia y educación al cuidador [14,5%], etc.).ConclusionesSe aporta información valiosa respecto a las características de la población geriátrica y dependiente así como la ayuda fisioterapéutica que viene recibiendo y cómo se lleva a cabo el proceso(AU)

ObjectiveTo describe the home care provided by mobile rehabilitation-physiotherapy teams as a response to the needs of the dependent population, the characteristics of their application, and the results they have on patients and their functional independence.DesignA descriptive, cross-sectional study from 2004 to June 2007.SettingCommunity setting. Mobile rehabilitation-physiotherapy teams from Primary Care in Almeria.ParticipantsA total of 1093 patients were included in the programme.Main measurementsData were collected on, the state of the patients’ health (primary disabling process, reasons for inclusion in the treatment, initial and final functional assessment and Barthel Index); details of physiotherapy treatment, and number of sessions.ResultsOf the total sample, the mean age was 78 years and 64.2% were female. The mean waiting time for their assessment was 4 days and there was a wide variety of primary disabling processes described. There was a high percentage of symptoms of severe motor deterioration, pain and muscle weakness. Physiotherapy treatment was given in 88.6%, physiotherapy and occupational therapy in 11.1%, and orthopaedic treatment in 0.3%, of the patients. The mean number of sessions was 12.85. The variation in the Barthel Index after the final therapy was given was, 61.9% for kinesiotherapy, 10.2% combined with electrotherapy, and 14.5% for kinesiotherapy and carer education.ConclusionsValuable information is provided as regards the characteristics of the geriatric and dependent population, as well as the physiotherapy help they are receiving, and also how the procedure is carried out(AU)

The St. George Homebirth Program: an evaluation of the first 100 booked women.

BACKGROUND: The St. George Homebirth Program was the first publicly funded homebirth model of care set up in New South Wales. This program provides access to selected women at low obstetric risk the option of having their babies at home. There are only four other publicly funded homebirth programs operating in Australia. AIMS: To report the outcomes of the first 100 women booked at the St. George Homebirth Program. METHODS: A prospective descriptive study was undertaken. Data were collected on the first 100 women who gave birth between November 2005 and March 2009. Two databases were accessed and missing data were followed up by review of the relevant charts. RESULTS: Of the first 100 booked women, 63 achieved a homebirth, 30 were transferred to hospital or independent midwifery care in the antenatal period and seven were transferred intrapartum. Two women were transferred to hospital in the early postnatal period, one for a postpartum haemorrhage and one for hypotension. One baby suffered mild respiratory distress, was treated in the emergency department and was discharged home within four hours. CONCLUSION: The St. George Hospital homebirth program has provided reassuring outcomes for the first 100 women it has cared for over the past four years. Wider availability of this service could be achieved provided there is the appropriate close collaboration between providers and effective processes for consultation, referral and transfer. The outcomes of women and babies in publicly funded homebirth programs deserve further study, and the development of a national prospective database of all planned homebirth would contribute to this knowledge.

Hospital at home for chronic obstructive pulmonary disease: an integrated hospital and community based generic intermediate care service for prevention and early discharge.

Recent randomized controlled studies have reported success for hospital at home for prevention and early discharge of chronic obstructive pulmonary disease (COPD) patients using hospital based respiratory nurse specialists. This observational study reports results using an integrated hospital and community based generic intermediate care service. The length of care, readmission within 60 days and death within 60 days in the early discharge (9.37 days, 21.1%, 7%) and the prevention of admission (five to six days, 34.1%, 3.8%) are similar to previous studies. We suggest that this generic community model of service may allow hospital at home services for COPD to be introduced in more areas.

[Organisational diagnosis of a home care-coordinating unit in oncology: which choices for the comprehensive cancer center of Lyon?]. / Diagnostic organisationnel d'un service hospitalier de coordination des soins à domicile en cancérologie. Quels choix stratégiques pour le Centre régional de lutte contre le cancer de Lyon?

Lyon comprehensive cancer center developed a home care-coordinating unit (HCCU) allowing a wide range of cancer care at home. We present the results of an organisational and strategical analysis of the unit, in relation with internal and external contexts. We describe the functioning of the unit, modelled from the daily follow-up of professionnels. Patient discharge is initiated by the oncologist at the inpatient clinic, at the day-hospital or at outpatient visit. After consent of the patient and relatives, the HCCU (nurses and medical oncologists) evaluates patient's needs, organises hospital discharge (contacts with community nurses and general practitioner, supply of medical appliances and drugs), and provides follow-up and counselling to patient and caregivers. The HCCU works in a challenging environment, with both partners and competitors. Within the hospital, it collaborates with all other units. Outside the hospital, partners are, besides patients themselves; general practitioners and community nurses home care agencies and network services, private medical appliance providers, and public health authorities. The unit might evolve towards formal home hospitalisation or community-hospital network. Collaboration of both structure closely associated with hospital could allow to provide continuous and graduated care by the same caregivers even if administrative structures change.

Factors predicting home death for terminally ill cancer patients receiving hospital-based home care: the Lyon comprehensive cancer center experience.

This study aimed to determine factors favoring home death for cancer patients in a context of coordinated home care. A retrospective study was conducted among patients followed up by the home care coordinating unit of the cancer center of Lyon. The main endpoint was place of death. Univariate analysis included general characteristics (age, gender, rural or urban residence, disease), Karnofsky Index (KI), type of care at referral (chemotherapy, palliative care, or other supportive care), and coordinating medical oncologist (MCO) home visits. Significant factors were used in a logistic regression analysis. Of 250 patients, 90 (36%) had home death. Low KI and MCO home visit were correlated with home death (odds ratio, respectively, 2.1 and 3.1). These results indicate that health care support favors home death. A hospital-based home care unit is effective for bridging the gap between community and hospital. MCO home visits offer concrete support to health care professionals, patients, and relatives.

Out-patient and home-parenteral antibiotic therapy (OHPAT): evaluation of the impact of one year's experience in Tayside.

OBJECTIVE: An out-patient and home parenteral antibiotic therapy programme for the treatment of suitable infections was developed over a four year period. This paper describes the impact of one year's experience of its implementation on various measures of outcome. DESIGN: Each patient treatment has a full integrated care pathway (ICP) and patient satisfaction questionnaire completed. The ICP documents the clinical progress of the patient and incorporates various measures of quality of care on the 101 number of patients treated from April 1998 to March 1999 are presented here. SETTING: Dundee Teaching Hospitals NHS Trust (now Tayside University Hospitals NHS Trust). SUBJECTS: Patients with a range of infections requiring intravenous antibiotics. MAIN MEASURES: Number of patients treated with various infections, clinical and microbiological outcome, drug and vascular access complication rates, impact on drug costs and in-patient bed days, and measurement of patient satisfaction/quality of life. RESULTS: Patients were treated over a 12 month period. 51.5 per cent had skin & soft tissue infections and 22.8 per cent bone & joint sepsis. 57 per cent of patients received out-patient and 34 per cent self or carer administered home therapy. Ninety-four per cent of patients were cured or improved following treatment. Only 7.5 per cent of patients required an unscheduled admission to hospital. Twelve per cent of patients had some type of vascular device related adverse event (partly due to a faulty batch of lines) and six per cent of patients had a drug related reaction. The additional daily cost of drugs was minimal (< 12 Pounds/day) and more than 1,461 bed days have been saved across the Directorates. The patient satisfaction level was high.

Understanding hospital referrals to home health agencies.

Using resource dependency theory and transaction-cost economics theory, we examined the simultaneous effects of a vertical integration strategy and environmental complexity on home health agency (HHA) referrals by hospitals. Discharge data for calendar year 1990 from 61 Pennsylvania hospitals were analyzed. Using hospital ownership of home health agencies and urban versus rural location as the primary independent variables, a logistic regression model calculated the probability of HHA referral, after controlling for long-term care beds and patient characteristics. Results showed that HHA ownership was a significant predictor of home health referrals for both rural and urban hospitals, although the effect was greater for urban hospitals. These results suggest that hospitals are actively using referrals to home healthcare in response to environmental pressures. As these pressures increase, hospitals will benefit from tight linkages with home health providers.