'Hospital-at-home' concept does not save money or improve outcomes, study finds

(2005-07-23)

Although patients generally prefer to be home instead of the hospital to recover from serious illness, a new review of studies finds that "hospital-at-home" programs common in Europe and Australia do not save money and may not affect health outcomes very much.

The review also shows that the higher patient satisfaction may be offset by evidence that the burden on caregivers is greater.

The review, an update of previous studies on the subject, appears in the July of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

Led by Sasha Shepperd, Ph.D, of Oxford University, the review combines results from 22 individual hospital-at-home studies that measure various outcomes including mortality, patient satisfaction, psychological well-being, caregiver satisfaction and readmission rates "Available data does suggest hospital at home services increase patient satisfaction compared with hospital care," the researchers concluded, but "the view of carers was mixed."

The hospital-at-home concept provides treatment by health care professions at a patient's home for an acute condition that would otherwise require at least a short-term hospital stay. The idea is to reduce expenditures by national health systems.

"Despite increasing interest in the potential of hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit," the authors found, as they had in a previous smaller review.

One effect they did find was that while the hospital-at-home reduced how long a patient stayed in a hospital at the outset of an illness, the overall length of care increased for the patients treated at home, possibly negating overall savings.

The tendency to extend care can wipe out the cost savings, Shepperd says. And, she adds, hospital-at-home programs do not reduce the most expensive items on a hospital bill, items like surgery and intensive-care monitoring. "Most of the costs for a hospital stay are at admission and right at the beginning of recovery," she says.

The review also finds no evidence that people treated at home live longer or avoid readmission to a hospital, although it could be because the small size of individual studies reviewed did not offer enough statistical power to detect differences.

For the studies included in the review, the hospital care provided at home was often physical and occupational therapy. These services are generally provided by health workers or nurses who earn less than the surgeons and intensive-care nurses who staff a hospital. The majority of the trials looked at patients older than 65.

Shepperd says hospital administrators considering an early-discharge or hospital-at-home initiative should carefully select the patients who will be eligible to enroll in the program.

Cheryl Peterson, a senior policy fellow with the American Nurses Association, says the views of the family and friends of patients may reveal a need for better education and support for the caregivers, who are essential to any hospital-at-home program.

"A caregiver is taking on a huge burden, especially when the patient is still regaining strength," Peterson says.

Peterson says patients typically admitted to the hospital today are more acutely ill than patients hospitalized 10 or 15 years ago. That fact requires a careful understanding of "the complications that allow for the success and failure of the discharge," she says. In the United States, Peterson says, health care providers are trying to better identify the conditions that can be well-managed at home and lend themselves to early discharge. Diabetes and chronic obstructive pulmonary disease may be two good candidates, she says.

Shepperd says she suspects that when hospital administrators sit down to do cost-benefit analyses and patient volume projections, they overestimate the number of patients who are suitable for hospital-at-home care.

Hospital-at-home may be more efficient with a "mix of dependencies," or levels of patient illnesses, Shepperd suggests.

The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit cochrane.org for more information.

Betina Andersen
cccg@cccg.dk
Center for the Advancement of Health
http://www.cfah.org