Los factores psicosociales determinan la aceptación de la hospitalización a domicilio directamente desde el servicio de urgencias

Cost of home hospitalization versus inpatient hospitalization inclusive of a 30-day post-acute period

BACKGROUND

Previous studies have demonstrated that hospital at home (HaH) care is associated with lower costs than traditional hospital care. Most prior studies were small, not U.S.-focused, or did not include post-acute costs in their analyses. Our objective was to determine if combined acute and 30-day post-acute costs of care were lower for HaH patients compared to inpatient comparisons in a Center for Medicare and Medicaid Innovation Center demonstration of HaH.

METHODS

A single-center New York City retrospective observational cohort study of patients admitted to either HaH or inpatient care from September 1, 2014 through August 31, 2017. Eligible patients were 18 years or older, required inpatient admission, lived in Manhattan, and met home safety requirements. Comparison individuals met the same criteria and were included if they refused HaH care or were admitted when HaH was not available. HaH care was substitutive hospital-level care and 30-days of post-acute transitional care. Main outcomes were costs of care of the acute and post-acute 30-day episodes. We matched subjects on age, sex, and insurance and conducted regression analyses using an unadjusted model and one adjusted for several patient characteristics.

RESULTS

Of 523 Medicare admission episodes, data were available for 201 episodes in the HaH arm and 101 episodes of usual care. HaH patients were older (81.6 [SD = 12.3] years vs. 74.6 [SD = 14.0], p < 0.0001) and more likely to have activities of daily living (ADL) impairments (75.4% vs. 46.5%, p < 0.0001). Unadjusted mean costs were $5054 lower for HaH episodes compared to inpatient episodes. Regression analysis with matching showed HaH costs were $5116 (95% CI -$10,262 to $30, p = 0.05) lower, and when adjusted for age, sex, insurance, diagnosis, and ADL impairments, $5977 (95% CI -$10,758 to -$1196, p = 0.01) lower.

CONCLUSIONS

HaH combined with 30-day post-acute transition care was less costly than inpatient care.

Frequency, profile and results of patients with acute heart failure transferred directly to home hospitalisation from emergency departments

OBJECTIVE

To describe the frequency, clinical characteristics and outcomes of patients with acute heart failure (AHF) transferred directly from emergency departments to home hospitalisation (HH) and to compare them with those hospitalised in internal medicine (IM) or short-stay units (SSU).

METHOD

We included patients with AHF transferred to HH by hospitals that considered this option during the Epidemiology of Acute Heart Failure in Spanish Emergency Departments (EAHFE) 4-5-6 Registries and compared them with patients admitted to IM or SSU in these centres. We compared the adjusted all-cause mortality at 1 year and adverse events 30 days after discharge.

RESULTS

The study included 1473 patients (HH/IM/SSU: 68/979/384). The HH rate was 4.7% (95% CI, 3.8-6.0%). The patients in HH had few differences compared with those hospitalised in IM and SSUs. The HH mortality was 1.5%, and the HH median stay was 7.5 days (IQR, 4.5-12), similar to that of IM (median stay, 8 days; IQR, 5-13; p=.106) and longer than that of SSU (median stay, 4 days; IQR, 3-7; p<.001). The all-cause mortality at 1 year for HH did not differ from that of IM (HR, 0.91; 95% CI, 0.73-1.14) or SSU (HR, 0.77; 95% CI, 0.46-1.27); however, the emergency department readmission rate during the 30 days postdischarge was lower than that of IM (HR, 0.50; 95% CI, 0.25-0.97) and SSU (HR, 0.37; 95% CI, 0.19-0.74). There were no differences in the need for new hospitalisations or in the 30-day mortality rate.

CONCLUSIONS

Direct transfer from the emergency department to HH is infrequent despite being a safe option for a certain patient profile with AHF.

Frequency, profile, and outcomes of patients with acute heart failure transferred directly to home hospitalization from emergency departments

OBJECTIVE

To describe the frequency, clinical characteristics and outcomes of patients with acute heart failure (AHF) transferred directly from emergency departments to home hospitalisation (HH) and to compare them with those hospitalised in internal medicine (IM) or short-stay units (SSU).

METHOD

We included patients with AHF transferred to HH by hospitals that considered this option during the Epidemiology of Acute Heart Failure in Spanish Emergency Departments (EAHFE) 4-5-6 Registries and compared them with patients admitted to IM or SSU in these centres. We compared the adjusted all-cause mortality at 1 year and adverse events 30 days after discharge.

RESULTS

The study included 1473 patients (HH/IM/SSU:68/979/384). The HH rate was 4.7% (95% CI 3.8-6.0%). The patients in HH had few differences compared with those hospitalised in IM and SSUs. The HH mortality was 1.5%, and the HH median stay was 7.5 days (IQR, 4.5-12), similar to that of IM (median stay, 8 days; IQR, 5-13; p = .106) and longer than that of SSU (median stay, 4 days; IQR, 3-7; p < .001). The all-cause mortality at 1 year for HH did not differ from that of IM (HR, 0.91; 95% CI 0.73-1.14) or SSU (HR, 0.77; 95% CI 0.46-1.27); however, the emergency department readmission rate during the 30 days postdischarge was lower than that of IM (HR, 0.50; 95% CI 0.25-0.97) and SSU (HR, 0.37; 95% CI 0.19-0.74). There were no differences in the need for new hospitalisations or in the 30-day mortality rate.

CONCLUSIONS

Direct transfer from the emergency department to HH is infrequent despite being a safe option for a certain patient profile with AHF.

Choosing Inpatient vs Home Treatment: Why Patients Accept or Decline Hospital at Home

BACKGROUND/OBJECTIVES

Hospital at home (HaH) provides interdisciplinary acute care in the home as a substitute for inpatient hospitalization. Studies have demonstrated that HaH care is associated with better quality care, fewer complications, and better patient and caregiver experience. Still, some patients decline HaH. The objective of the study was to characterize patients who accept vs decline HaH care and describe reasons for their decisions in the context of a Center for Medicare and Medicaid Innovation demonstration of HaH.

DESIGN/SETTING/PARTICIPANTS

A total of 442 patients with Medicare or other eligible insurance, 18 years or older, who met study eligibility criteria were offered HaH at Mount Sinai Hospitals in New York, NY, between September 1, 2014, and August 31, 2017.

MEASUREMENTS

Reasons for accepting or declining HaH were recorded. Age, sex, insurance type, and admission diagnoses of HaH acceptors and refusers were compared in univariate analyses.

RESULTS

Of the 442 patients offered HaH, 66.7% accepted. Main reasons for enrolling in HaH included being more comfortable at home (78.2%) and being near family (40.7%). Specific reasons given for refusing HaH included preferring in-hospital care (15.0%) and concern that HaH would not meet care needs (12.9%).

CONCLUSION

Two-thirds of patients offered HaH care opted to receive it. The reasons for declining HaH provided by those who chose not to participate should be considered for quality improvement, and reasons for acceptance may be helpful in marketing and other efforts to promote HaH participation. J Am Geriatr Soc 68:1579-1583, 2020.

Changes in the etiology, incidence and prognosis of acute lower respiratory track infections in human immunodeficiency virus patients

AIM

To describe the incidence, the changes in the etiology and the prognosis of lower respiratory tract infection (LRTI) in HIV infected patients, presenting by the first time to the Emergency Department (ED), during years 2000-2010.

STUDY DESIGN

Prospective collection of data.

METHODS

Data were collected on the first visit of HIV-infected patients at our ED due to a LRTI, (defined according to the criteria of the European Respiratory Society), between 1/1/2000 and 31/12/2010. A series of epidemiological and laboratory variables as well as the need for admission to the intensive care unit (ICU). LRTI etiology were also collected. The influence ofthe mentioned variables on 30-day mortality were analyzed.

RESULTS

One hundred thirty one patients were included. LRTI represented 27% of visits to the ED by HIV-infected patients. Mean age was 39±9 years. 72% of patients were males. 18% required admission to the ICU. The most frequent LRTI was pneumonia by P. jiroveci in 35 cases, bacterial penumonia in 27 and pulmonary tuberculosis in 20. LRTI incidence gradually reduced significantly over time from 6.13 × 1000 patients/year in year 2000 to 0.23 × 1000 patients/year in 2010 (p<0.05). Overall mortality was 14%. Logistic regression analysis showed that admission to ICU (p<0.004) and viral load (p<0.029) were independent variables predicting mortality.

CONCLUSION

LRTI is a pathology with a decreasing incidence, probably related to the widespread utilization increased of HAART regimens. lts etiology has also been changing, but with a non negligible mortality, mostly when ICU admission was required.