The value of admission avoidance: cost-consequence analysis of one-year activity in a consolidated service.

BACKGROUND: Many advantages of hospital at home (HaH), as a modality of acute care, have been highlighted, but controversies exist regarding the cost-benefit trade-offs. The objective is to assess health outcomes and analytical costs of hospital avoidance (HaH-HA) in a consolidated service with over ten years of delivery of HaH in Barcelona (Spain). METHODS: A retrospective cost-consequence analysis of all first episodes of HaH-HA, directly admitted from the emergency room (ER) in 2017-2018, was carried out with a health system perspective. HaH-HA was compared with a propensity-score-matched group of contemporary patients admitted to conventional hospitalization (Controls). Mortality, re-admissions, ER visits, and direct healthcare costs were evaluated. RESULTS: HaH-HA and Controls (n = 441 each) were comparable in terms of age (73 [SD16] vs. 74 [SD16]), gender (male, 57% vs. 59%), multimorbidity, healthcare expenditure during the previous year, case mix index of the acute episode, and main diagnosis at discharge. HaH-HA presented lower mortality during the episode (0 vs. 19 (4.3%); p < 0.001). At 30 days post-discharge, HaH-HA and Controls showed similar re-admission rates; however, ER visits were lower in HaH-HA than in Controls (28 (6.3%) vs. 34 (8.1%); p = 0.044). Average costs per patient during the episode were lower in the HaH-HA group (€ 1,078) than in Controls (€ 2,171). Likewise, healthcare costs within the 30 days post-discharge were also lower in HaH-Ha than in Controls (p < 0.001). CONCLUSIONS: The study showed higher performance and cost reductions of HaH-HA in a real-world setting. The identification of sources of savings facilitates scaling of hospital avoidance. REGISTRATION: ClinicalTrials.gov (26/04/2017; NCT03130283).

Five years of Hospital at Home adoption in Catalonia: impact, challenges, and proposals for quality assurance.

BACKGROUND: Hospital at home (HaH) was increasingly implemented in Catalonia (7.7 M citizens, Spain) achieving regional adoption within the 2011-2015 Health Plan. This study aimed to assess population-wide HaH outcomes over five years (2015-2019) in a consolidated regional program and provide context-independent recommendations for continuous quality improvement of the service. METHODS: A mixed-methods approach was adopted, combining population-based retrospective analyses of registry information with qualitative research. HaH (admission avoidance modality) was compared with a conventional hospitalization group using propensity score matching techniques. We evaluated the 12-month period before the admission, the hospitalization, and use of healthcare resources at 30 days after discharge. A panel of experts discussed the results and provided recommendations for monitoring HaH services. RESULTS: The adoption of HaH steadily increased from 5,185 episodes/year in 2015 to 8,086 episodes/year in 2019 (total episodes 31,901; mean age 73 (SD 17) years; 79% high-risk patients. Mortality rates were similar between HaH and conventional hospitalization within the episode [76 (0.31%) vs. 112 (0.45%)] and at 30-days after discharge [973(3.94%) vs. 1112(3.24%)]. Likewise, the rates of hospital re-admissions at 30 days after discharge were also similar between groups: 2,00 (8.08%) vs. 1,63 (6.58%)] or ER visits [4,11 (16.62%) vs. 3,97 (16.03%). The 27 hospitals assessed showed high variability in patients' age, multimorbidity, severity of episodes, recurrences, and length of stay of HaH episodes. Recommendations aiming at enhancing service delivery were produced. CONCLUSIONS: Besides confirming safety and value generation of HaH for selected patients, we found that this service is delivered in a case-mix of different scenarios, encouraging hospital-profiled monitoring of the service.

Prevention of Unplanned Hospital Admissions in Multimorbid Patients Using Computational Modeling: Observational Retrospective Cohort Study.

BACKGROUND: Enhanced management of multimorbidity constitutes a major clinical challenge. Multimorbidity shows well-established causal relationships with the high use of health care resources and, specifically, with unplanned hospital admissions. Enhanced patient stratification is vital for achieving effectiveness through personalized postdischarge service selection. OBJECTIVE: The study has a 2-fold aim: (1) generation and assessment of predictive models of mortality and readmission at 90 days after discharge; and (2) characterization of patients' profiles for personalized service selection purposes. METHODS: Gradient boosting techniques were used to generate predictive models based on multisource data (registries, clinical/functional and social support) from 761 nonsurgical patients admitted in a tertiary hospital over 12 months (October 2017 to November 2018). K-means clustering was used to characterize patient profiles. RESULTS: Performance (area under the receiver operating characteristic curve, sensitivity, and specificity) of the predictive models was 0.82, 0.78, and 0.70 and 0.72, 0.70, and 0.63 for mortality and readmissions, respectively. A total of 4 patients' profiles were identified. In brief, the reference patients (cluster 1; 281/761, 36.9%), 53.7% (151/281) men and mean age of 71 (SD 16) years, showed 3.6% (10/281) mortality and 15.7% (44/281) readmissions at 90 days following discharge. The unhealthy lifestyle habit profile (cluster 2; 179/761, 23.5%) predominantly comprised males (137/179, 76.5%) with similar age, mean 70 (SD 13) years, but showed slightly higher mortality (10/179, 5.6%) and markedly higher readmission rate (49/179, 27.4%). Patients in the frailty profile (cluster 3; 152/761, 19.9%) were older (mean 81 years, SD 13 years) and predominantly female (63/152, 41.4%, males). They showed medical complexity with a high level of social vulnerability and the highest mortality rate (23/152, 15.1%), but with a similar hospitalization rate (39/152, 25.7%) compared with cluster 2. Finally, the medical complexity profile (cluster 4; 149/761, 19.6%), mean age 83 (SD 9) years, 55.7% (83/149) males, showed the highest clinical complexity resulting in 12.8% (19/149) mortality and the highest readmission rate (56/149, 37.6%). CONCLUSIONS: The results indicated the potential to predict mortality and morbidity-related adverse events leading to unplanned hospital readmissions. The resulting patient profiles fostered recommendations for personalized service selection with the capacity for value generation.

Actionable Factors Fostering Health Value Generation and Scalability of Prehabilitation: A Prospective Cohort Study.

IMPORTANCE: Prehabilitation has potential for improving surgical outcomes as shown in previous randomized controlled trials. However, a marked efficacy-effectiveness gap is limiting its scalability. Comprehensive analyses of deployment of the intervention in real-life scenarios are required. OBJECTIVE: To assess health outcomes and cost of prehabilitation. DESIGN: Prospective cohort study with a control group built using propensity score-matching techniques. SETTING: Prehabilitation Unit in a tertiary-care university hospital. PARTICIPANTS: Candidates for major digestive, cardiac, thoracic, gynecologic, or urologic surgeries. INTERVENTION: Prehabilitation program, including supervised exercise training, promotion of physical activity, nutritional optimization, and psychological support. MAIN OUTCOMES AND MEASURES: The comprehensive complication index, hospital and intensive care unit length of stay, and hospital costs per patient until 30 days after surgery. Patients were classified by the degree of program completion and level of surgical aggression for sensitivity analysis. RESULTS: The analysis of the entire study group did not show differences in study outcomes between prehabilitation and control groups (n=328 each). The per-protocol analysis, including only patients completing the program (n=112, 34%), showed a reduction in mean hospital stay [9.9 (7.2) vs 12.8 (12.4) days; P =0.035]. Completers undergoing highly aggressive surgeries (n=60) additionally showed reduction in mean intensive care unit stay [2.3 (2.7) vs 3.8 (4.2) days; P =0.021] and generated mean cost savings per patient of €3092 (32% cost reduction) ( P =0.007). Five priority areas for action to enhance service efficiencies were identified. CONCLUSIONS AND RELEVANCE: The study indicates a low rate of completion of the intervention and identifies priority areas for re-design of service delivery to enhance the effectiveness of prehabilitation.

Green Tea Catechins Modulate Skeletal Development with Effects Dependent on Dose, Time, and Structure in a down Syndrome Mouse Model.

Altered skeletal development in Down syndrome (DS) results in a brachycephalic skull, flattened face, shorter mandibular ramus, shorter limbs, and reduced bone mineral density (BMD). Our previous study showed that low doses of green tea extract enriched in epigallocatechin-3-gallate (GTE-EGCG), administered continuously from embryonic day 9 to postnatal day 29, reduced facial dysmorphologies in the Ts65Dn (TS) mouse model of DS, but high doses could exacerbate them. Here, we extended the analyses to other skeletal structures and systematically evaluated the effects of high and low doses of GTE-EGCG treatment over postnatal development in wild-type (WT) and TS mice using in vivo µCT and geometric morphometrics. TS mice developed shorter and wider faces, skulls, and mandibles, together with shorter and narrower humerus and scapula, and reduced BMD dynamically over time. Besides facial morphology, GTE-EGCG did not rescue any other skeletal phenotype in TS treated mice. In WT mice, GTE-EGCG significantly altered the shape of the skull and mandible, reduced the length and width of the long bones, and lowered the BMD. The disparate effects of GTE-EGCG depended on the dose, developmental timepoint, and anatomical structure analyzed, emphasizing the complex nature of DS and the need to further investigate the simultaneous effects of GTE-EGCG supplementation.

Prospective cohort study for assessment of integrated care with a triple aim approach: hospital at home as use case.

BACKGROUND: Applicability of comprehensive assessment of integrated care services in real world settings is an unmet need. To this end, a Triple Aim evaluation of Hospital at Home (HaH), as use case, was done. As ancillary aim, we explored use of the approach for monitoring the impact of adoption of integrated care at health system level in Catalonia (Spain). METHODS: Prospective cohort study over one year period, 2017-2018, comparing hospital avoidance (HaH-HA) with conventional hospitalization (UC) using propensity score matching. Participants were after the first episode directly admitted to HaH-HA or the corresponding control group. Triple Aim assessment using multiple criteria decision analysis (MCDA) was done. Moreover, applicability of a Triple Aim approach at health system level was explored using registry data. RESULTS: HaH-HA depicted lower: i) Emergency Room Department (ER) visits (p < .001), ii) Unplanned re-admissions (p = .012); and iii) costs (p < .001) than UC. The weighted aggregation of the standardized values of each of the eight outcomes, weighted by the opinions of the stakeholder groups considered in the MCDA: i) enjoyment of life; ii) resilience; iii) physical functioning; iv) continuity of care; v) psychological wellbeing; (vi) social relationships & participation; (vii) person-centeredness; and (viii) costs, indicated better performance of HaH-HA than UC (p < .05). Actionable factors for Triple Aim assessment of the health system with a population-health approach were identified. CONCLUSIONS: We confirmed health value generation of HaH-HA. The study identified actionable factors to enhance applicability of Triple Aim assessment at health system level for monitoring the impact of adoption of integrated care. REGISTRATION: ClinicalTrials.gov (26/04/2017; NCT03130283).