Randomised controlled trial comparing hospital at home care with inpatient hospital care. II: cost minimisation analysis

COPD exacerbations.5: management

A review of the most relevant evidence based therapeutic options currently available for the management of exacerbations of COPD.

Evaluation of the ambulatory and home care record: Agreement between self-reports and administrative data

OBJECTIVES

Although measuring the utilization of ambulatory and home-based healthcare resources is an essential component of economic analyses, very little methodological attention has been devoted to the development and evaluation of resource costing tools. This study evaluated a newly developed tool, the Ambulatory and Home Care Record (AHCR), which comprehensively evaluates costs incurred by the health system and care recipients and their unpaid caregivers.

METHODS

The level of agreement between self-reports from 110 cystic fibrosis care recipients and administrative data was assessed for four categories of health services: home-based visits with healthcare professionals, ambulatory visits with healthcare professionals, laboratory and diagnostic tests, and prescription medications.

RESULTS

Agreement between care recipients' reports on the AHCR and administrative data ranged from moderate (kappa = 0.41; 95 percent confidence interval, 0.16-0.61) for physician specialist visits to perfect (kappa = 1.0) for physiotherapy visits.

CONCLUSIONS

By evaluating and standardizing a resource and costing tool, such as the AHCR, economic evaluations may be improved and comparisons of the resource implications for different services and for diverse populations are possible.

A mixed method study to compare use and experience of hospital care and a nurse-led acute respiratory assessment service offering home care to people with an acute exacerbation of Chronic Obstructive Pulmonary Disease

BACKGROUND

Over the past 10 years hospital at home schemes for the treatment of an acute exacerbation of Chronic Obstructive Pulmonary Disease have proliferated throughout developed countries. For selected patients treatment at home is no less advantageous in terms of readmission rates and length of stay than treatment in hospital. Although care at home might seem to be a more desirable option than admission to hospital, little is known about care preferences and how people exercise service choice.

OBJECTIVES

1. to determine patients' recent use of and satisfaction with health care services during exacerbations of Chronic Obstructive Pulmonary Disease. 2. To determine and compare patients' and families' perceived future care preferences. 3. To complete an in-depth exploration of care experiences and preferences with a subset of respondents and their families.

DESIGN

A mixed method design was used consisting of a postal survey and in-depth qualitative interviews with a subset of questionnaire respondents.

SETTING

An outreach service provided by a large university hospital within Scotland, UK.

PARTICIPANTS

One hundred and four out-patients registered with the Acute Respiratory Assessment Service and who had experienced hospital inpatient care during the past year, and their families. A subset of respondents was invited to take part in qualitative interviews.

RESULTS

The majority of respondents indicated a preference for the home care service, and this was positively associated with high coping skills. There was a strong relationship between personal and family preferences. There was no linear relationship between a clinical measure of severity of lung disease and service use or care preferences. Results from the qualitative interviews endorsed and explained these findings.

CONCLUSIONS

A range of factors combined to influence service use at a particular point in time, implying a need for increased self-management support from nurses and increased service provision.

Does home treatment affect delirium? A randomised controlled trial of rehabilitation of elderly and care at home or usual treatment (The REACH-OUT trial)

BACKGROUND

delirium is a frequent adverse consequence of hospitalisation for older patients, but there has been little research into its prevention. A recent study of Hospital in the Home (admission substitution) noted less delirium in the home-treated group.

SETTING

a tertiary referral teaching hospital in Sydney, Australia.

METHODS

we randomised 104 consecutive patients referred for geriatric rehabilitation to be treated in one of two ways, either in Hospital in the Home (early discharge) or in hospital, in a rehabilitation ward. We compared the occurrence of delirium measured by the confusion assessment method. Secondary outcome measures were length of stay, hospital bed days, cost of acute care and rehabilitation, functional independence measure (FIM), Mini-Mental State Examination (MMSE) and geriatric depression score (GDS) assessed on discharge and at 1- and 6-month follow-up and patient satisfaction.

RESULTS

the home group had lower odds of developing delirium during rehabilitation [odds ratio (OR) = 0.17; 95% confidence interval 0.03-0.65], shorter duration of rehabilitation (15.97 versus 23.09 days; P = 0.0164) and used less hospital bed days (20.31 versus 40.09, P < or = 0.0001). The cost was lower for the acute plus rehabilitation phases (7,680 pounds versus 10,598 pounds; P = 0.0109) and the rehabilitation phase alone (2,523 pounds versus 6,100 pounds; P < or = 0.0001). There was no difference in FIM, MMSE or GDS scores. the home group was more satisfied (P = 0.0057).

CONCLUSIONS

home rehabilitation for frail elderly after acute hospitalisation is a viable option for selected patients and is associated with a lower risk of delirium, greater patient satisfaction, lower cost and more efficient hospital bed use.

Pharmacological treatment of chronic obstructive pulmonary disease

None of the drugs currently available for chronic obstructive pulmonary disease (COPD) are able to reduce the progressive decline in lung function which is the hallmark of this disease. Smoking cessation is the only intervention that has proved effective. The current pharmacological treatment of COPD is symptomatic and is mainly based on bronchodilators, such as selective beta2-adrenergic agonists (short- and long-acting), anticholinergics, theophylline, or a combination of these drugs. Glucocorticoids are not generally recommended for patients with stable mild to moderate COPD due to their lack of efficacy, side effects, and high costs. However, glucocorticoids are recommended for severe COPD and frequent exacerbations of COPD. New pharmacological strategies for COPD need to be developed because the current treatment is inadequate.

Telemedicine-assisted home support for patients with advanced chronic obstructive pulmonary disease: preliminary results after nine-month follow-up

Eighteen well motivated patients with advanced chronic obstructive pulmonary disease, who had had at least four hospitalizations during the previous two years, were included in a home-based telemedicine study. A visiting nurse was equipped with a case containing a laptop computer and a number of medical devices, including an electrocardiogram recorder, spirometer, oximeter and blood pressure monitor. It also contained a videoconference camera, for realtime audiovisual connection with the hospital using the patient's TV set. A single ISDN line (128 kbit/s) was installed in each house before the study began. After nine months, there was a decrease in hospitalizations, emergency department visits and use of health services. The patient's disease knowledge and self-management also improved. It seems likely that adopting telemedicine in everyday clinical practice could substantially improve the care of chronically ill patients.

Rules for rehabilitation: an agenda for research

Rehabilitation services have grown tremendously in the United States over the past 2 decades. Rules originally designed to guide Medicare reimbursement policies have had substantial effects in shaping the design of clinical services. This article traces the development of the most significant federal rules regarding rehabilitation, outlines the existing empirical evidence to support these rules, and discusses an agenda for research to improve the evidence for future policy development.

Hospital at home versus in-patient hospital care

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 (November 2004), 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

Twenty two trials are included in this update of the review. Among trials evaluating early discharge hospital at home schemes we found an odds ratio (OR) for mortality of 1.79 95% CI 0.85 to 3.76 for elderly medical patients (age 65 years and over) (n = 3 trials); OR 0.58; 95% CI 0.29 to 1.17 for patients with chronic obstructive pulmonary disease (COPD) (n = 5 trials); and OR 0.78; 95%CI 0.52 to 1.19 for patients recovering from a stroke (n = 4 trials). Two trials evaluating the early discharge of patients recovering from surgery reported an OR 0.43 (95% CI 0.02 to 10.89) for patients recovering from a hip replacement and an OR 1.01 (95% CI 0.37 to 2.81) for patients with a mix of conditions at three months follow-up. For readmission to hospital we found an OR 1.76; 95% CI 0.78 to 3.99 at 3 months follow-up for elderly medical patients (n = 2 trials); OR 0.81; 95% CI 0.55 to 1.19 for patients with COPD (n = 5 trials); and OR 0.96; 95% CI 0.63 to 1.45 for patients recovering from a stroke (n = 3 trials). No significant heterogeneity was observed. One trial recruiting patients following surgery for hernia or varicose veins reported 0/117 versus 2/121 patients were re admitted (Ruckley 1978); another that 2/37 (5%) versus 1/49 (2%) (difference 3%, 95% CI -5% to 12%) of patients recovering from a hip replacement, 4/47 (9%) versus 1/39 (3%) (difference 6%, 95% CI -3% to 15%) of patients recovering from a knee replacement, and 7/114 (6%) versus 13/124 (10%) (difference -4% 95% CI -11% to 3%) of patients recovering from a hysterectomy were readmitted. A third trial analysing surgical and medical patients together reported that 42/159 versus 17/81 patients were readmitted at 3 months (OR 1.34 95% CI 0.66 to 2.20). Allocation to hospital at home resulted in a small reduction in hospital length of stay, but hospital at home increased overall length of care. Patients allocated to hospital at home expressed greater satisfaction with care than those in hospital, while the view of carers was mixed.

AUTHORS' CONCLUSIONS

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. 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. Future primary research should focus on rigorous evaluations of admission avoidance schemes and standards for original research should aim at assisting future meta-analyses of individual patient data from these and future trials.

Physiotherapy rehabilitation after total knee or hip replacement: an evidence-based analysis

OBJECTIVE

The objective of this health technology policy analysis was to determine, where, how, and when physiotherapy services are best delivered to optimize functional outcomes for patients after they undergo primary (first-time) total hip replacement or total knee replacement, and to determine the Ontario-specific economic impact of the best delivery strategy. The objectives of the systematic review were as follows: To determine the effectiveness of inpatient physiotherapy after discharge from an acute care hospital compared with outpatient physiotherapy delivered in either a clinic-based or home-based setting for primary total joint replacement patientsTo determine the effectiveness of outpatient physiotherapy delivered by a physiotherapist in either a clinic-based or home-based setting in addition to a home exercise program compared with a home exercise program alone for primary total joint replacement patientsTo determine the effectiveness of preoperative exercise for people who are scheduled to receive primary total knee or hip replacement surgery

CLINICAL NEED

Total hip replacements and total knee replacements are among the most commonly performed surgical procedures in Ontario. Physiotherapy rehabilitation after first-time total hip or knee replacement surgery is accepted as the standard and essential treatment. The aim is to maximize a person's functionality and independence and minimize complications such as hip dislocation (for hip replacements), wound infection, deep vein thrombosis, and pulmonary embolism. THE THERAPY: The physiotherapy rehabilitation routine has 4 components: therapeutic exercise, transfer training, gait training, and instruction in the activities of daily living. Physiotherapy rehabilitation for people who have had total joint replacement surgery varies in where, how, and when it is delivered. In Ontario, after discharge from an acute care hospital, people who have had a primary total knee or hip replacement may receive inpatient or outpatient physiotherapy. Inpatient physiotherapy is delivered in a rehabilitation hospital or specialized hospital unit. Outpatient physiotherapy is done either in an outpatient clinic (clinic-based) or in the person's home (home-based). Home-based physiotherapy may include practising an exercise program at home with or without supplemental support from a physiotherapist. Finally, physiotherapy rehabilitation may be administered at several points after surgery, including immediately postoperatively (within the first 5 days) and in the early recovery period (within the first 3 months) after discharge. There is a growing interest in whether physiotherapy should start before surgery. A variety of practises exist, and evidence regarding the optimal pre- and post-acute course of rehabilitation to obtain the best outcomes is needed.

REVIEW STRATEGY

The Medical Advisory Secretariat used its standard search strategy, which included searching the databases of Ovid MEDLINE, CINHAL, EMBASE, Cochrane Database of Systematic Reviews, and PEDro from 1995 to 2005. English-language articles including systematic reviews, randomized controlled trials (RCTs), non-RCTs, and studies with a sample size of greater than 10 patients were included. Studies had to include patients undergoing primary total hip or total knee replacement, aged 18 years of age or older, and they had to have investigated one of the following comparisons: inpatient rehabilitation versus outpatient (clinic- or home-based therapy) rehabilitation, land-based post-acute care physiotherapy delivered by a physiotherapist compared with patient self-administered exercise and a land-based exercise program before surgery. The primary outcome was postoperative physical functioning. Secondary outcomes included the patient's assessment of therapeutic effect (overall improvement), perceived pain intensity, health services utilization, treatment side effects, and adverse events The quality of the methods of the included studies was assessed using the criteria outlined in the Cochrane Musculoskeletal Injuries Group Quality Assessment Tool. After this, a summary of the biases threatening study validity was determined. Four methodological biases were considered: selection bias, performance bias, attrition bias, and detection bias. A meta-analysis was conducted when adequate data were available from 2 or more studies and where there was no statistical or clinical heterogeneity among studies. The GRADE system was used to summarize the overall quality of evidence.

SUMMARY OF FINDINGS

The search yielded 422 citations; of these, 12 were included in the review including 10 primary studies (9 RCTs, 1 non-RCT) and 2 systematic reviews. The Medical Advisory Secretariat review included 2 primary studies (N = 334) that examined the effectiveness of an inpatient physiotherapy rehabilitation program compared with an outpatient home-based physiotherapy program on functional outcomes after total knee or hip replacement surgery. One study, available only as an abstract, found no difference in functional outcome at 1 year after surgery (TKR or THR) between the treatments. The other study was an observational study that found that patients who are younger than 71 years of age on average, who do not live alone, and who do not have comorbid illnesses recover adequate function with outpatient home-based physiotherapy. However results were only measured up to 3 months after surgery, and the outcome measure they used is not considered the best one for physical functioning. Three primary studies (N = 360) were reviewed that tested the effectiveness of outpatient home-based or clinic-based physiotherapy in addition to a self-administered home exercise program, compared with a self-administered exercise program only or in addition to using another therapy (phone calls or continuous passive movement), on postoperative physical functioning after primary TKR surgery. Two of the studies reported no difference in change from baseline in flexion range of motion between those patients receiving outpatient or home-based physiotherapy and doing a home exercise program compared with patients who did a home exercise program only with or without continuous passive movement. The other study reported no difference in the Western Ontario and McMaster Osteoarthritis Index (WOMAC) scores between patients receiving clinic-based physiotherapy and practising a home exercise program and those who received monitoring phone calls and did a home exercise program after TKR surgery. The Medical Advisory Secretariat reviewed two systematic reviews evaluating the effects of preoperative exercise on postoperative physical functioning. One concluded that preoperative exercise is not effective in improving functional recovery or pain after TKR and any effects after THR could not be adequately determined. The other concluded that there was inconclusive evidence to determine the benefits of preoperative exercise on functional recovery after TKR. Because 2 primary studies were added to the published literature since the publication of these systematic reviews the Medical Advisory Secretariat revisited the question of effectiveness of a preoperative exercise program for patients scheduled for TKR ad THR surgery. The Medical Advisory Secretariat also reviewed 3 primary studies (N = 184) that tested the effectiveness of preoperative exercise beginning 4-6 weeks before surgery on postoperative outcomes after primary TKR surgery. All 3 studies reported negative findings with regard to the effectiveness of preoperative exercise to improve physical functioning after TKR surgery. However, 2 failed to show an effect of the preoperative exercise program before surgery in those patients receiving preoperative exercise. The third study did not measure functional outcome immediately before surgery in the preoperative exercise treatment group; therefore the study's authors could not document an effect of the preoperative exercise program before surgery. Regarding health services utilization, 2 of the studies did not find significant differences in either the length of the acute care hospital stay or the inpatient rehabilitation care setting between patients treated with a preoperative exercise program and those not treated. The third study did not measure health services utilization. These results must be interpreted within the limitations and the biases of each study. Negative results do not necessarily support a lack of treatment effect but may be attributed to a type II statistical error. Finally, the Medical Advisory Secretariat reviewed 2 primary studies (N = 136) that examined the effectiveness of preoperative exercise on postoperative functional outcomes after primary THR surgery. One study did not support the effectiveness of an exercise program beginning 8 weeks before surgery. However, results from the other did support the effectiveness of an exercise program 8 weeks before primary THR surgery on pain and functional outcomes 1 week before and 3 weeks after surgery.

CONCLUSIONS

Based on the evidence, the Medical Advisory Secretariat reached the following conclusions with respect to physiotherapy rehabilitation and physical functioning 1 year after primary TKR or THR surgery: There is high-quality evidence from 1 large RCT to support the use of home-based physiotherapy instead of inpatient physiotherapy after primary THR or TKR surgery.There is low-to-moderate quality evidence from 1 large RCT to support the conclusion that receiving a monitoring phone call from a physiotherapist and practising home exercises is comparable to receiving clinic-based physiotherapy and practising home exercises for people who have had primary TKR surgery. However, results may not be generalizable to those who have had THR surgery.There is moderate evidence to suggest that an exercise program beginning 4 to 6 weeks before primary TKR surgery is not effective. (ABSTRACT TRUNCATED)

Services for reducing duration of hospital care for acute stroke patients

BACKGROUND

Stroke patients conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed which offer patients in hospital an early discharge with rehabilitation at home (early supported discharge (ESD)).

OBJECTIVES

To establish the effects and costs of ESD services compared with conventional services.

SEARCH STRATEGY

We searched the Cochrane Stroke Group's trials register (last searched August 2004) and obtained further information from individual trialists.

SELECTION CRITERIA

Randomised controlled trials recruiting stroke patients in hospital to receive either conventional care or any service intervention which has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care.

DATA COLLECTION AND ANALYSIS

Two reviewers scrutinised trials and categorised them on their eligibility. Standardised individual patient data was then sought from the primary trialists. Results were analysed for all trials and for subgroups of patients and services; in particular whether the intervention was provided by a co-ordinated multidisciplinary team (co-ordinated ESD team) or not.

MAIN RESULTS

Outcome data are currently available for 11 trials (1597 patients). Patients tended to be a selected elderly group with moderate disability. The ESD group showed significant reductions (P < 0.0001) in the length of hospital stay equivalent to approximately 8 days. Overall, the odds ratios (OR) (95% confidence interval (CI)) for death, death or institutionalisation, death or dependency at the end of scheduled follow up were OR 0.90, 95% CI 0.64 to 1.27, P = 0.56, OR 0.74, 95% CI 0.56 to 0.96, P = 0.02 and OR 0.79, 95% CI 0.64 to 0.97, P = 0.02, respectively. The greatest benefits were seen in the trials evaluating a co-ordinated ESD team and in stroke patients with mild-moderate disability. Improvements were also seen in patients' extended activities of daily living scores (standardised mean difference 0.12, 95% CI 0.00 to 0.25, P = 0.05) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, P = 0.02) but no statistically significant differences were seen in carers' subjective health status, mood or satisfaction with services.

AUTHORS' CONCLUSIONS

Appropriately resourced ESD services provided for a selected group of stroke patients can reduce long term dependency and admission to institutional care as well as reducing the length of hospital stay. No adverse impact was observed on the mood or subjective health status of patients or carers.

Critical appraisal of published economic evaluations of home care for the elderly

The goal of the study was to appraise the economic evaluations published between 1980 and 2004 of "home care" for the elderly, focusing on the methodological aspects. MEDLINE was searched to identify and assess economic evaluations (defined as an analysis comparing two or more strategies, involving the assessment of both costs and consequences) related to "home care" exclusively for the elderly (65 years or more) and to critically appraise the methodology using five accepted principles used worldwide for conducting economic evaluations. Twenty-four economic evaluations of "home care" for the elderly were identified and the articles were assessed. All five principles were satisfactorily addressed in two studies (8.3%), four principles in four studies (16.7%), three principles in five studies (20.8%), two principles in eight studies (33.3%) and only one principle in five studies (20.8%). A disparity in the methodology of writing economic evaluations compromises the comparisons among outcomes and lately jeopardizes decisions on the choice of the most appropriate healthcare interventions. The methodological principles represent important guidelines but the discussion of the context of the economic evaluation and the special characteristics of some services and populations should be considered for the appropriate use of economic evaluations.

A cost study of a general practitioner hospital in the Netherlands

OBJECTIVE

To perform a cost study of the first general practitioner (GP) hospital in the Netherlands.

METHODS

We conducted a cost study in a GP hospital in the Netherlands. Data on healthcare utilisation from 218 patients were collected for a period of one year. The costs of admission to the GP hospital were compared with the expected costs of the alternative mode of care. In the GP hospital three types of bed categories were distinguished: GP beds (admission and discharge by GPs, n=131), rehabilitation beds (recovery from hospital surgery, n=62) and nursing home beds (hospital patients awaiting a vacancy in a nursing home, n=25). GPs were interviewed to indicate the best alternative form of healthcare for the GP bed patients in the absence of a GP hospital (dichotomised for this study into "hospital" or "home care"). For the "rehabilitation" and "nursing home" patients the alternative care mode was admission to a hospital.

RESULTS

The mean length of stay was 15 days for the GP beds, 31 days for the rehabilitation beds and 90 days for the nursing home beds. For the GP bed patients the costs were 2533 euros per admission compared with 3792 euros for hospital stay. For the group of GP bed patients for whom "home care" was the best alternative, the costs were 2494 euros for GP hospital days compared with 2814euros , the average cost for home care of patients of 65 years and older. For rehabilitation patients the costs per patient were 4744 euros compared with 8041 euros in a hospital. For patients waiting for admission to a nursing home, these costs were 13,143 euros and 22,670 euros respectively.

CONCLUSION

The GP hospital might be a cost-saving alternative for elderly patients in need of intermediate medical and nursing care between hospital and home care. Further research on the cost-effectiveness of the GP hospital compared with home care and nursing home care is needed.

Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: systematic review of evidence

OBJECTIVES

To evaluate the efficacy of hospital at home schemes compared with inpatient care in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD).

DESIGN

A systematic review of randomised controlled trials.

MAIN OUTCOME MEASURE

Mortality and readmission to hospital.

RESULTS

Seven trials with 754 patients were included in the review. Hospital readmission and mortality were not significantly different when hospital at home schemes were compared with inpatient care (relative risk 0.89, 95% confidence interval 0.72 to 1.12, and 0.61, 0.36 to 1.05, respectively). However, compared with inpatient care, hospital at home schemes were associated with substantial cost savings as well as freeing up hospital inpatient beds.

CONCLUSIONS

Hospital at home schemes can be safely used to care for patients with acute exacerbations of COPD who would otherwise be admitted to hospital. Clinicians should consider this form of management, especially as there is increasing pressure for inpatient beds in the United Kingdom.

A high-volume specialist palliative care unit and team may reduce in-hospital end-of-life care costs

BACKGROUND

Current end-of-life hospital care can be of poor quality and high cost. High volume and/or specialist care, and standardized care with clinical practice guidelines, has improved outcomes and costs in other areas of cancer care.

METHODS

The objective of this study was to measure the impact of the palliative care unit (PCU) on the cost of care. The PCU is a dedicated 11-bed inpatient (PCU) staffed by a high-volume specialist team using standardized care. We compared daily charges and costs of the days prior to PCU transfer to the stay in the PCU, for patients who died in the first 6 months after the PCU opened May 2000. We performed a case-control study by matching 38 PCU patients by diagnosis and age to contemporary patients who died outside the PCU cared for by other medical or surgical teams, to adjust for potential differences in the patients or goals of care.

RESULTS

The unit admitted 237 patients from May to December 2000. Fifty-two percent had cancer followed by vascular events, immunodeficiency, or organ failure. For the 123 patients with both non-PCU and PCU days, daily charges and costs were reduced by 66% overall and 74% in "other" (medications, diagnostics, etc.) after transfer to the PCU (p < 0.0001 for all). Comparing the 38 contemporary control patients who died outside the PCU to similar patients who died in the PCU, daily charges were 59% lower (US dollars 5304 +/- 5850 to US dollars 2172 +/- 2250, p = 0.005), direct costs 56% lower (US dollars 1441 +/- 1438 to US dollars 632 +/- 690, p = 0.004), and total costs 57% lower (US dollars 2538 +/- 2918 to US dollars 1095 +/- 1153, p = 0.009).

CONCLUSIONS

Appropriate standardized care of medically complex terminally ill patients in a high-volume, specialized unit may significantly lower cost. These results should be confirmed in a randomized study but such studies are difficult to perform.

Economic evaluation of integrated care: an introduction

BACKGROUND

Integrated care has emerged in a variety of forms in industrialised countries during the past decade. It is generally assumed that these new arrangements result in increased effectiveness and quality of care, while being cost-effective or even cost-saving at the same time. However, systematic evaluation, including an evaluation of the relative costs and benefits of these arrangements, has largely been lacking.

OBJECTIVES

To stimulate fruitful dialogue and debate about the need for economic evaluation in integrated care, and to outline possibilities for undertaking economic appraisal studies in this relatively new field.

THEORY

Key concepts, including e.g. scarcity and opportunity costs, are introduced, followed by a brief overview of the most common methods used in economic evaluation of health care programmes. Then a number of issues that seem particularly relevant for economic evaluation of integrated care arrangements are addressed in more detail, illustrated with examples from the literature.

CONCLUSION AND DISCUSSION

There is a need for well-designed economic evaluation studies of integrated care arrangements, in particular in order to support decision making on the long-term financing of these programmes. Although relatively few studies have been done to date, the field is challenging from a methodological point of view, offering analysts a wealth of opportunities. Guidance to realise these opportunities is provided by the general principles for economic evaluation, which can be tailored to the requirements of this particular field.

Are Home Care Programs Cost-Effective? A Systematic Review of the Literature

The cost-effectiveness of home care programs and services is an important area of health care research given the recent growth and continuing trend in home health care, the current state of health care reform in Canada, and changing demographics in Canada. Home care programs often proceed with little evidence-based decision-making. Increased demand for evidence-based decision-making is apparent in not only clinical settings, but also in policy environments thus creating a need for more research in this area. There are presently very few rigorous studies on the cost-effectiveness of home care programs. This systematic literature review addresses the research question, “What is the relationship between cost-consequence evidence and policy implications within the home care context?” The findings are not surprising. They include mixed results and indicate that cost-effectiveness of home care programs is an important area to study in spite of the many challenges. The challenges presented must be acknowledged and addressed in order to produce better research designs in future studies.

Hospital in the home: constructions of the nursing role - a literature review

Acute medical and nursing treatment in the home is increasingly seen as an alternative to hospitalization. Models such as hospital in the home (HITH) or acute home care are said to provide a safe, comfortable environment for patients that is conducive to healing. A review of the literature reveals the embryonic nature of the research and discussion related to this alternative care delivery model. In general, the benefits of hospital in the home programmes are presented in an uncritical manner. Medical practitioners have embraced the move to home care as a means of expanding the use of advanced technologies and improved drug regimes beyond the hospital walls. The nursing response has been mechanistic and recipe-like while advancing the HITH nursing role as an opportunity for specialty practice by virtue of the increased autonomy and independence required. This review demonstrates the influence of a professional mandate for specialization, and the ideological and scientific interests that have influenced the role of the nurse.

Hospital at home for acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Hospital at home schemes are a recently adopted method of service delivery for the management of acute exacerbations of chronic obstructive pulmonary disease aimed at reducing demand for acute hospital in-patient beds and promoting a patient centered approach through admission avoidance. However, evidence in support of such a service is contradictory.

OBJECTIVES

To evaluate the efficacy of "hospital at home" compared to hospital inpatient care in acute exacerbations of chronic obstructive pulmonary disease.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials; electronically available databases e.g. MEDLINE (1966-current), EMBASE (1980-current), PubMed, ClincalTrials, Science Citation Index and on-line individual respiratory journals; bibliographies of included trials were all searched and contact with authors was made to obtain studies. The most recent searches were carried out in August 2003.

SELECTION CRITERIA

Only randomised controlled trials were considered where patients presented to the emergency department with an exacerbation of their chronic obstructive pulmonary disease. Studies must not have recruited patients that are usually deemed obligatory admissions.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected articles for inclusion, evaluated methodological quality of the studies and abstracted data.

MAIN RESULTS

Seven studies with 754 patients were included in the review. Studies provided data on hospital readmission and mortality both of which were not significantly different when the two study groups were compared (RR 0.89; 95%CI 0.72 to 1.12 & RR 0.61; 95%CI 0.36 to 1.05, respectively). Both the patients and the carers preferred hospital at home schemes to inpatient care (RR 1.53; 95%CI 1.23 to 1.90). Other reported outcomes included few studies.

REVIEWER'S CONCLUSIONS

This review has shown that one in four carefully selected patients presenting to hospital emergency departments with acute exacerbations of chronic obstructive pulmonary disease can be safely and successfully treated at home with support from respiratory nurses. This review found no evidence of significant differences between "hospital at home" patients and hospital inpatients for readmission rates and mortality at two to three months after the initial exacerbation. Both the patients and carers preferred "hospital at home" schemes to inpatient care.

Adverse events and complications among patients admitted to hospital in the home directly from the emergency department

INTRODUCTION

The nature and incidence of adverse events and complications among patients admitted from the emergency department to hospital in the home has not been investigated. This study aimed to investigate this problem and make recommendations for prevention strategies.

METHODS

This was an explicit retrospective chart review of patients admitted from the emergency department directly to hospital in the home between 22 February 1995 and 1 September 2000. A data extraction document was designed specifically for the study and used to extract data relating to patient demographics, diagnosis, past medical history and outcome. The outcomes of interest include adverse events, complications and death. An adverse effect is defined as an unintended injury or complication that results in disability, death or prolonged hospital stay and is caused by health care management. These adverse events may occur prior to or during the index admission and may be noted during or after the index admission. A complication is defined as an undesirable outcome that occurs during the management but not causing disability, death or prolonged hospital stay.

RESULTS

Three hundred and fifty-seven patients were enrolled (51.3% male; median age 52 years, range 16-96 years). Fifty-five adverse events were identified: 49 adverse events (89%) were due to management prior to hospital in the home admission and six adverse events (10.9%) were directly attributable to hospital in the home management. This represents a rate of 1.7 adverse events per 100 hospital in the home admissions directly attributable to hospital in the home management. One hundred and eighteen complications were identified. Most complications were easily managed. Thirty-one patients had unplanned re-admissions and two patients died within 28 days of hospital in the home admission.

CONCLUSION

Most patients admitted to hospital in the home from the emergency department were managed successfully. Few adverse events arose from hospital in the home treatment. Complications were common but minor in nature. Strategies for the prevention of phlebitis and constipation are recommended.

Economic evaluation of an acute paediatric hospital at home clinical trial

AIMS

To compare the privately borne and NHS costs of hospital at home (HAH) and conventional inpatient care for children with selected acute conditions.

METHODS

Prospective economic evaluation using cost minimisation analysis within a randomised controlled trial, in paediatric wards of a district general hospital, and private homes in the local catchment area in Wirral, Merseyside. Subjects were children who fulfilled the criteria for admission to HAH, suffering from breathing difficulties (n = 202), diarrhoea and vomiting (n = 125), or fever (n = 72).

RESULTS

Direct costs borne by families are reduced by 41% for HAH patients ( pound 23.31 v pound 13.76, p = 0.001). There is no evidence that HAH transfers the burden of care to parents, and there is no difference in absence rates from paid employment. Patients and their careers expressed a strong preference for HAH. Comparison of NHS costs is equivocal, depending on how HAH is implemented alongside the conventional hospital service.

CONCLUSION

Paediatric HAH schemes are unlikely to reduce NHS costs and do not increase privately borne costs. They will, however, significantly increase patient and career satisfaction with care provision for sick children with appropriate conditions.

Hospital in the home is cost saving for appropriately selected patients: a comparison with in-hospital care

BACKGROUND

As the cost of acute care in hospitals increases, there is an increasing need to find alternative means of providing acute care. Hospital in the home (HITH) has developed in response to this challenge. Current evidence is conflicting as to whether HITH provides cost savings compared with in-hospital care (IHC). The heterogeneous nature of HITH and the clinical complexity of patients is the greatest obstacle to making valid comparisons between the two modes of care.

OBJECTIVE

To compare costs and outcomes of HITH to IHC in hospitals in Victoria, Australia.

DATA SOURCES/STUDY SETTING

Hospital morbidity data and medical records from Victoria, Australia.

STUDY DESIGN

A costing study of 924 randomly selected episodes of HITH care, individually matched to 924 comparable IHC episodes.

METHODS

Unadjusted total episode costs (TEC) and averaged daily costs for HITH and IHC were calculated. Mortality and length of stay (LOS) were compared for HITH and IHC episodes. Simple linear and multiple regression were used to analyse costing data, while logistic regression was used to compare in-hospital mortality and LOS in HITH versus IHC episodes.

PRINCIPAL FINDINGS

The 1848 episodes of care in the sample represented a heterogeneous range of acute conditions in 31 Victoria hospitals. HITH consisted of two distinct subgroups: pure-HITH (total episode substitution) and mixed-HITH (partial episode substitution). The cost of episodes of acute care containing a HITH component were overall 9% less expensive than IHC (P = 0.04), while pure-HITH was 38% cheaper than matched IHC (P < 0.001). The variable HITH, along with LOS and chemotherapy, explained the 60% variation in TEC. The mean cost of pure-HITH episodes was 22% lower compared to mixed-HITH (P = 0.004). The in-hospital mortality rate in HITH (3.8%) and IHC (5.2%) was not significantly different. Pure-HITH was associated with shorter LOS, while mixed HITH was strongly associated with longer LOS.

CONCLUSION

In our study the adjusted cost of HITH was significantly cheaper than IHC, particularly as total episode substitution. The cost needs to be adjusted because many factors other than HITH or IHC can influence crude costs. There may be potential for wider use of HITH for appropriately selected patients.

Parents and partners: lay carers' perceptions of their role in the treatment and care of adults with cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) is the most common autosomal recessive genetic disease in Caucasian people, traditionally conceptualized as a condition whereby sufferers died in childhood. However, the current median survival age of 30 and a predicted median survival age of 40 for those born with the disease over the last decade ensure that families members will assist hospital staff with treatment and care well into most patients' adulthood.

AIMS

This study explores the perceptions and experiences of lay care-giving amongst parents and partners of adults with CF who were being treated at a specialist CF centre in England.

METHODS

Thirty-one relatives of adults with CF were interviewed in their own homes using an interview topic guide. All interviews were audiotape recorded and transcribed verbatim. Analysis of data was assisted by ATLAS-ti, a software package for qualitative research.

FINDINGS

Two main themes surrounding lay carers' role in treatment and care were identified. Firstly, the notion of lay carers giving 'expert' care, both in hospital and at home was recognized. Parents' expertise was greater than that of partners until the patient required intensive hospital interventions, when partner expertise increased. Secondly, the degree of lay carers' felt inclusion in the hospital consultation appeared to depend on the nature of their relationship with the patient and the patients' health state.

CONCLUSION

Lay carers are routinely performing tasks for adults with CF that were once the remit of trained nurses. Families need higher levels of nursing and social support when certain treatments are used at home. Attention needs to be directed to how lay carers of adult patients can be included in hospital consultations.

Clinical audit indicators of outcome following admission to hospital with acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND

The 1997 BTS/RCP national audit of acute chronic obstructive pulmonary disease (COPD) in terms of process of care has previously been reported. This paper describes from the same cases the outcomes of death, readmission rates within 3 months of initial admission, and length of stay. Identification of the main pre-admission predictors of outcome may be used to control for confounding factors in population characteristics when comparing performance between units.

METHODS

Data on 74 variables were collected retrospectively using an audit proforma from patients admitted to UK hospitals with acute COPD. Important prognostic variables for the three outcome measures were identified by relative risk and logistic regression was used to place these in order of predictive value.

RESULTS

1400 admissions from 38 acute hospitals were collated. 14% of cases died within 3 months of admission with variation between hospitals of 0-50%. Poor performance status, acidosis, and the presence of leg oedema were the best significant independent predictors of death. Age above 65, poor performance status, and lowest forced expiratory volume in 1 second (FEV(1)) tertile were the best predictors of length of stay (median 8 days). 34% of patients were readmitted (range 5-65%); lowest FEV(1) tertile, previous admission, and readmission with five or more medications were the best predictors for readmission.

CONCLUSIONS

Important predictors of outcome have been identified and formal recording of these may assist in accounting for confounding patient characteristics when making comparisons between hospitals. There is still wide variation in outcome between hospitals that remains unexplained by these factors. While some of this variance may be explained by incomplete recording of data or patient factors as yet unidentified, it seems likely that deficiencies in the process of care previously identified are responsible for poor outcomes in some units.

Services for reducing duration of hospital care for acute stroke patients

BACKGROUND

Stroke patients conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed which offer patients in hospital an early discharge with rehabilitation at home (early supported discharge, ESD).

OBJECTIVES

To establish the costs and effects of ESD services compared with conventional services.

SEARCH STRATEGY

The Stroke Group Specialist Register of Controlled Trials was searched and supplemented with information from individual trialists. Searching was completed in December 2000.

SELECTION CRITERIA

Randomised controlled trials recruiting stroke patients in hospital to receive either conventional care or any service intervention which has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care.

DATA COLLECTION AND ANALYSIS

Two reviewers scrutinised trials and categorised them on their eligibility. Standardised information was then obtained from the primary trialists. Results were analysed for all trials and for subgroups depending on whether the intervention was provided by a coordinated multidisciplinary team (coordinated ESD team) or not.

MAIN RESULTS

Outcome data are currently available for four trials. Patients tended to be a selected elderly group with disability. Overall, the odds ratios (95% confidence interval) for death, death or institutionalisation, death or dependency at the end of scheduled follow up were 0.87 (0.39-1.93), 0.69 (0.36-1.31) and 0.88 (0.49-1.57) respectively. Apparent benefits were more evident in the three trials evaluating a coordinated ESD team. The ESD group showed significant reductions (P<0.001) in the length of hospital stay equivalent to approximately nine days.

REVIEWER'S CONCLUSIONS

ESD services provided for a selected group of stroke patients can reduce the length of hospital stay. However, the relative risks and benefits and overall costs of such services remain unclear.

Work in progress. Integrating physicians' services in the home

OBJECTIVE

While increasing acuity levels and the concomitant complexity of service demand that physicians be involved in in-home care, conflicting evidence and opinions do not show how this can best be achieved.

DESIGN

A phenomenologic research design was used to obtain insights into the challenges and opportunities of integrating physicians' services into the usual in-home services in London, Ont.

SETTING

Home care in London, Ont.

PARTICIPANTS

Twelve participants included three patients, two family caregivers, two family physicians, the program's nurse practitioner, two case managers, and two community nurses.

METHOD

In-depth interviews with a maximally varied purposeful sample of patients, caregivers, and providers were analyzed using immersion and crystallization techniques.

MAIN FINDINGS

Findings revealed the potential for enhanced continuity of care and interdisciplinary team functioning. Having a nurse practitioner, interdisciplinary team-building exercises and meetings, regular face-to-face contact among all providers, support for family caregivers, and 24-hour coverage for physicians were found to be essential for success.

CONCLUSION

Integration of services takes time, money, and sustained commitment, particularly when undertaken in geographically isolated communities. Informed choice and a fair remuneration system remain important considerations for family physicians.

Admission avoidance and early discharge of acute hospital admissions: an accident and emergency based scheme

OBJECTIVES

To validate an accident and emergency (A&E) based approach to assisting early discharge or avoiding admission to acute hospital beds by means of two separate teams, one in hospital and the other in the community, working closely together at the interface between primary and secondary health care.

DESIGN

A purpose designed admission avoidance (AA) team was established in the A&E department, and a target group of patients identified whose admissions might be avoided or curtailed. A rapid response community team (RRCT) based in Cambridge was also established to provide basic health care to patients in their homes after discharge from hospital. The key elements of the project were rapid assessment, careful selection of patients, early decision making at senior level, and close liaison with the community team.

RESULTS

During the first year (1999) of the project the AA team assessed 785 patients and 257 patients were eventually discharged home to the care of the RRCT. Of these, 149 patients (58%) were comparable to a historical control group (from 1997/98), with regard to their demographic and clinical characteristics and care needs, and had an average length of hospital stay of 1.7 days compared with 6.3 days for the control group. The remaining 108 patients were not directly comparable but were supported by the teams because the benefits were clear and exclusion would have been unethical. These patients had an average length of stay of seven days. The readmission rate was 3 of 257(1.2%) for the intervention group and 8 of 531(1.5%) for the control group. A limited patient satisfaction survey among patients cared for at home revealed that 97% of patients were "satisfied to very satisfied" with the care provided. The RRCT had also looked after an additional 194 patients from other sources (total = 451), including postoperative orthopaedic early discharges from an adjacent hospital. The average length of care at home by the RRCT for all 451 patients was 6.6 days. The annual cost of the two teams was pound 113,900.

CONCLUSIONS

These results indicate that an A&E based approach to the identification of patients suitable for short-term domiciliary support that aims rapidly to restore previous levels of independence, can reduce the burden of acute admissions to hospital without reducing quality of care or patient satisfaction. The scheme has now been established on a permanent basis and extension of this strategy to other patient groups is under evaluation.

Evaluation of patients' satisfaction with hospital-at-home care

On July 1, 1997, in the Canton of Vaud, Switzerland, a pilot experiment of Hospital-at-Home Care (H-Hcare) was set up for a 2-year period at four sites to measure patients' satisfaction with this type of health care. Out of 174 patients referred to the H-Hcare program for a wide range of treatments, 107 were medical patients admitted for heart failure, community acquired pneumonia, or for an infectious disease requiring i.v.-antibiotherapy; 95 of these agreed to express H-Hcare satisfaction and dissatisfactions during a semistructured interview conducted 6 weeks after admission. H-Hcare was considered a viable alternative to hospitalization when the illness is not too serious, and for patients who are still independent and need little care. When patients are more severely ill, they prefer to go to hospital to avoid overburdening their caregivers and to feel more secure.

Hospital at home: What is its place in the health system?

Given the expansion of hospital at home in Western countries, policymakers, providers and financial managers are exploring the causes for this and examining whether hospital at home is an alternative to hospitalization for reasons of cost containment and quality of care. The purpose of this paper is to describe hospital at home, discuss its development and examine its role in the health system. A variety of models of hospital at home exist, serving a varied patient case-mix. This article claims that the reasons for the expansion of medical home care are not solely economic. Although a number of studies have examined the cost effectiveness of this service, no consensus has been reached. In fact, the growth of this service seems to be related to a number of other factors: the increase in the number of elderly and chronically ill people, the lack of availability and accessibility of acute and sub-acute inpatient services, technological innovation, improvements in the standard of living and the preference of some patients to be treated at home. Therefore, hospital at home must be examined, not as an independent service, but as part of a continuum of services, with the hospital system at one end and community services at the other end. Further research will help determine its optimal place along this continuum.

An economic overview of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity. Relatively few pharmacoeconomic studies have been conducted on this disease. This article reviews available information about the utilisation of healthcare resources and cost of care, and the cost or cost effectiveness of therapeutic interventions reported for this disease. Burden-of-illness data indicate that hospital care, medications and oxygen therapy were the major cost drivers in these studies. Mean annual Medicare expenditures in the US were $US11,841 (2000 values) for patients with COPD compared with $US4,901 for all covered patients. Utilisation was skewed; the most expensive 10% of the Medicare beneficiaries accounted for nearly 50% of total expenditures for this disease. Costs are associated with health status, age, physician specialty, geographic location and type of insurance coverage. Six types of interventions were assessed in the literature--pharmacotherapy, oxygen therapy, home care, surgery, exercise and rehabilitation and health education. The studies used different analytic strategies (e.g. cost-minimisation and cost-effectiveness analyses) and even within the realm of cost-effectiveness analyses, no uniformity existed as to how outcome was measured. Patient severity was not always delineated, and the length of the follow-up period, while quite short, varied. Only 11 of the 34 evaluations were based on randomised controlled trials. Cost-minimisation studies generally found no significant difference in the cost of antimicrobial treatment for first-line, second-line and third-line agents. Studies of bronchodilators indicated that ipratropium bromide alone or in combination with salbutamol (albuterol) was the preferred medication. The major area for achieving cost savings is by reducing hospital utilisation. As the annual rate of hospitalisation is relatively low, large patient samples will be required to demonstrate an economic advantage for a new therapy. The major challenges will be financing such a study, and selecting an outcome measure that satisfies both clinical and economic conventions.

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

BACKGROUND

We have previously reported the use of a hospital based respiratory nurse service (Acute Respiratory Assessment Service, ARAS) to support home treatment of patients with exacerbations of chronic obstructive pulmonary disease (COPD). A controlled trial was undertaken to compare early discharge with home treatment supported by respiratory nurses with conventional hospital management of patients admitted with exacerbations of COPD.

METHODS

Patients with COPD admitted as emergencies were identified the next working day. They were eligible for inclusion in the study if the differential diagnosis included an exacerbation of COPD, but were excluded if other medical conditions or acidotic respiratory failure required inpatient investigation or management. Of 360 patients reviewed, 209 were being assessed for other active medical problems and were excluded, 33 potential participants were already involved in research studies and so were ineligible, and 37 did not wish to participate in the study. Eighty one patients were randomised to receive conventional inpatient care (n=40) or to planned early discharge the next working day (n=41). Those discharged early continued treatment at home under the supervision of specialist respiratory nurses. Outcome measures were readmission, additional hospital days, and deaths within 60 days of initial admission. Process measures included number of visits, duration of follow up by the respiratory nurse, and additional treatment provided to support early discharge.

RESULTS

On an intention to treat basis, a policy of early discharge reduced inpatient stay from a mean of 6.1 (range 1-13) days with conventional management to 3.2 (1-16) days with an early discharge policy. Twelve patients (30% conventional management, 29.3% early discharge) were readmitted in each group giving a mean difference in readmission of 0.7% (95% CI of the difference -19.2 to 20.6). In the conventional management group readmitted patients spent a mean of 8.75 additional days in hospital compared with 7.83 days in the early discharge group, giving a mean difference of 0.92 days (95% CI of the difference -6.5 to 8.3). There were two deaths (5%) in the conventional management group and one (2.4%) in the early discharge group, a mean difference of 2.6% (95% CI of the difference -5.7 to 10.8).

CONCLUSIONS

Patients with acute exacerbations of COPD uncomplicated by acidotic respiratory failure or other medical problems can be discharged home earlier than is current practice with support by visiting respiratory nurses. No difference was found in the subsequent need for readmission.

A randomized controlled trial of a hospital at home service for the terminally ill

This study evaluated the impact of a Cambridge hospital at home service (CHAH) on patients' quality of care, likelihood of remaining at home in their final 2 weeks of life and general practitioner (GP) visits. The design was a randomized controlled trial, comparing CHAH with standard care. The patient's district nurse, GP and informal carer were surveyed within 6 weeks of patient's death, and 225 district nurses, 194 GPs and 144 informal carers of 229 patients responded. There was no clear evidence that CHAH increased likelihood of remaining at home during the final 2 weeks of life. However, the service was associated with fewer GP out of hours visits. All respondent groups rated CHAH favourably compared to standard care but emphasized different aspects. District nurses rated CHAH as better than standard care in terms of adequacy of night care and support for the carer, GPs in terms of anxiety and depression, and informal carers in terms of control of pain and nausea. Thus whilst CHAH was not found to increase the likelihood of remaining at home, at appeared to be associated with better quality home care.

Characteristics of paediatric home care provision: the two dominant models in England

AIM

To describe characteristics of paediatric home care teams

BACKGROUND

Home care provision is increasing and recent government initiatives such as support for Princess Diana Memorial Fund nursing teams will provide additional impetus to universal provision. However, little is known about the characteristics of paediatric home care teams.

METHOD

A postal survey of all services in England (n = 137) listed in the 13th edition of RCN 1996 Directory of Community Children's Nursing Services was undertaken. A response rate of 85.5% was achieved.

FINDINGS

More than half (54.6%) of the teams had been founded after 1990. Most (72.2%) were managed through paediatric or child health directorates and most (77.8%) were based in hospitals. The size of teams varied enormously (range 1-22; median 3). Only a small (5.6%) minority of teams provided care at night although over a third (37%) reported making special arrangements for terminally ill children.

CONCLUSION

The survey revealed two dominant models of paediatric home care: the community model with strong links to primary health care and other local provisions and the hospital outreach model with strong links to the hospital service. A number of weaknesses in current provision are identified: variability in geographical coverage; undesirably low core staffing numbers; poor 24-h coverage; and potentially compromised staff skills and knowledge. The need for research to clarify the strengths of the different models and their effectiveness is highlighted.

Future strategies needed for palliative care

Too many cancer patients have less than optimal care at the end of life, as measured by unrelieved pain, death in a setting other than home, and uncoordinated care. Solutions will require at least the following: (1) new models of care and better coordination of care; (2) new drugs or techniques; (3) better professional knowledge and dissemination of that knowledge; (4) facing the issue of death; and (5) acknowledgment of cost constraints. Cost constraints will lead to more gaps between the haves and have nots in the United States in the next 5 years.

Innovations in the nursing care of the chronically ill: a literature review from an international perspective

This literature review focuses on substitution-related innovations in the nursing care of chronic patients in six western industrialized countries. Differences between primary and secondary care-orientated countries in the kind of innovations implemented are discussed. Health care systems are increasingly being confronted with chronic patients who need complex interventions tailored to their individual needs. However, it seems that today's health care professionals, organizations and budgets are not sufficiently prepared to provide this kind of care. As a result, health care policy in many countries targets innovations which reduce health care costs and, at the same time, improve the quality of care. Frequently, these innovations are related directly to the 'substitution of care' phenomenon, in which care is provided by the most appropriate professional at the lowest cost level, and encompass advanced nursing practice, hospital-at-home care and integrated care. The main conclusion of this paper is that integrated care innovations are implemented in both primary care as well as in secondary care-orientated countries. However, innovations in hospital-at-home care and advanced nursing practice are primarily implemented in primary care-orientated countries. Whether these innovations positively influence the quality of care, costs of care or patients' use of health care facilities remains rather unclear.

A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients

OBJECTIVE

To test the cost effectiveness of Hospital in the Home compared to hospital admission for acute medical conditions.

METHOD

Randomised controlled trial at the Prince of Wales Hospital, Sydney, from October 1995 to February, 1997; 100 patients with acute medical conditions admitted through the Emergency Department.

RESULTS

The Hospital in the Home (HITH) group costs per separation ($1,764, CI 95% $1,416-$2,111, n = 50) were significantly lower (p < 0.0001, Mann-Whitney U-Wilcoxon Rank Sum) than the control group hospital separation ($3,614, CI 95% $2,881.37-$4,347.27, n = 47) with no significant difference in clinical outcomes, and comparable or better user satisfaction.

CONCLUSION

Given the favourable clinical outcomes the HITH model produces at a lower cost, the cost-effectiveness of the care mode is high, and the allocative efficiency favourable.

IMPLICATIONS

As a care model and critical pathway, HITH offers hospitals real bed day savings that can either be used to rationalise resource usage for a given level of activity, or increase throughput.

[Effect of home hospitalization in the reduction of traditional hospitalization and frequency of emergencies in heart failure]

OBJECTIVE

Medical care to patients with heart failure (HF) entails high needs in health care and social resources. Hospital at home (HH) is a potentially useful care alternative for these patients.

MATERIALS AND METHODS

Observational study with 110 elderly patients with non complicated HF admitted to an HH unit. Patients were treated with educational support (clinical, dietetic and pharmacologic) and intensive home follow-up. Conventional hospital admissions and visits to the Emergency Department were analyzed during the 90 days before and after HH.

RESULTS

After HH, conventional hospital admissions decreased by 86% and visits to the Emergency Department by 91%. The mean Barthel Index changed from 74 to 77 (p < 0.05, in all cases). Ninety-six percent of patients were satisfied or very satisfied with HH.

CONCLUSIONS

In elderly patients with non complicated HF, the intervention of an HH unit reduces conventional hospital admissions and the number of visits to the Emergency Department, the personal satisfaction degree is high and the functional capacity does not worsen.