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'Hospital-at-home' care for elderly deemed OK

Providing hospital-level care in an elderly patient’s home appears to be feasible and safe, and may reduce costs, according to a new report.

“The need for hospital-at-home care arises from the fact that for older people, the acute hospital is not always the ideal care environment,” Dr. Bruce Leff told Reuters Health. “They’re exposed to germs they otherwise would not be exposed to, and it’s easy for them to develop acute confusion. The consequences can be enormous.”

In their two-stage study, Leff, a geriatrician at John Hopkins Bayview Medical Center in Baltimore, and colleagues compared outcomes for patients age 65 or older who were treated in-hospital with those of patients who consented to hospital-at-home care during two 11-month intervals.

The patients were being treated for pneumonia, chronic heart failure, chronic obstructive pulmonary disease, or soft tissue inflammation (cellulitis). According to Leff, patients who required ICU care, ventilation, or were having a heart attack or other acute illnesses were strictly excluded.

During the first phase, 289 patients were treated within hospitals at Medicare-managed care sites or a Veterans Administration medical center.

During the second phase, at-home care, accepted by 60 percent of those approached (for a total of 84 patients) was delivered by physicians during visits conducted at least daily and by direct one-on-one nursing supervision.

According to the team’s report in the Annals of Internal Medicine, patients treated at home were no less likely than those treated in the hospital to receive oxygen therapy, intravenous antibiotics, or bronchodilators.

However, in further analyses, patients in the hospital-at-home group were 74 percent less likely to develop delirium and 51 percent less likely to require sedative medication to keep them calm.

Also, fewer patients in the home group than the hospital group experienced critical complications (0 percent versus 6 percent), and fewer died (0 percent versus 3 percent). Costs averaged $5081 and $7480, respectively.

During the 8 weeks after patients were discharged, there were no differences in the number of emergency department visits, inpatient hospital readmissions, and admissions to skilled nursing facilities or home health visits.

“Older people are the chief occupiers of hospital beds,” Leff noted. “Over the next 25 years the number of people per acute hospital bed will double, and we don’t think hospitals will have that capacity. Hospital-at-home is one way to provide that care without having to put up buildings.”

The other thing about this approach “is that patients love it,” he added. “They told us it was comfortable, it was easy, it felt safe, and it was easier on their family members and care givers.”

In a related editorial, Dr. Sasha Shepperd, from the University of Oxford in the UK, writes: “Despite increasing interest in the potential of hospital-at-home services, the message remains that the objective evidence is insufficient to gauge the health or economic benefits of this type of care.”

In response, Leff said: “This is not a definitive study by any stretch; there were technical limitations. But I think Dr. Shepperd was focusing too much on the technical difficulties and not enough on what we accomplished.”