Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Hospital-at-home care was at least as effective, safe, and acceptable as hospitalization for older adults

ACP J Club. 1999 July-Aug;131:7. doi:10.7326/ACPJC-1999-131-1-007


Source Citation

Caplan GA, Ward JA, Brennan NJ, et al. Hospital in the home: a randomised controlled trial. Med J Aust. 1999 Feb 15;170:156-60.


Abstract

Question

Is hospital-at-home (HaH) care as effective, safe, and acceptable as hospital care for older adults?

Design

Randomized, unblinded, controlled trial with 6-month follow-up after discharge.

Setting

A tertiary care university hospital and its catchment area in Sydney, New South Wales, Australia.

Patients

100 older adults (mean age 76 y, 55% women) who were considered to need hospitalization. Patients came from home (70%), nursing homes (25%), or hostel (4%). Inclusion criteria were acute infections requiring intravenous antibiotics, deep venous thrombosis, minor cerebrovascular accidents, and cardiac failure. Exclusion criteria were evidence of shock, need for oxygen, being too ill, lack of an available caregiver, residence outside the local area, or an unsuitable home situation. Follow-up was 100%.

Intervention

Patients were randomized within 24 hours of diagnosis. 51 patients were allocated to HaH care, defined as care from the hospital community outreach team and the patient's family physician that could involve once-daily intravenous antibiotics (patients with dementia were cannulated daily), blood transfusions, daily subcutaneous enoxaparin injections (1.5 mg/kg of body weight), or oral warfarin until the international normalized ratio (INR) was ≥ 2.0. 49 patients were hospitalized (usual care).

Main outcome measures

Self-reported satisfaction and geriatric complications (confusion, falls, bowel and urinary complications, phlebitis, and pressure ulcers) and treatment failure (hospitalization) in the HaH group.

Main results

4 patients in the HaH group were hospitalized. Patients and caregivers in the HaH group were more satisfied with their care (P < 0.001). Fewer patients in the HaH group had confusion (P < 0.001), any bowel or urinary complications (P < 0.001), or constipation (P = 0.01) than did patients in the hospital group (Table). The groups did not differ for mortality, falls, incontinence, urine retention, phlebitis, or pressure ulcers.

Conclusion

Hospital-at-home care was at least as effective, safe, and acceptable as hospitalization for older adults who needed acute care.

Source of funding: Commonwealth Department of Health and Family Services.

For correspondence: Dr. G.A. Caplan, Post Acute Care Services, Prince of Wales Hospital, Randwick, New South Wales 2031, Australia. FAX 61-2-9382-2477.


Table. Hospital-at-home (HaH) care vs hospital care for older adults*

Outcomes at 6 mo HaH Hospital RRR (95% CI) NNT (CI)
Confusion 0% 20% 100% (65 to 100) 5 (3 to 9)
Bowel complications 0% 22% 100% (68 to 100) 5 (3 to 8)
Constipation 0% 14% 100% (50 to 100) 8 (4 to 15)
Urinary complications 2% 16% 88% (30 to 98) 7 (4 to 27)

*Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article.


Commentary

Caplan and colleagues discuss the alternative to hospital care for a subset of elderly patients who met criteria for hospitalization but were managed at home or in nursing homes. Demand for cost containment makes this a very important issue; however, this study does not include economic analyses.

Selecting patients for intensive home care requires rather subjective analysis by the treating physician; patients must be appropriate for management at home. A strength of this study is its generalizability: Patients had illnesses that could normally be managed without the technology readily available in a hospital (e.g., patients requiring oxygen were excluded). The home also had to be a suitable facility with adequate care-giver support. The authors concluded that fewer complications occurred among the patients treated at home, especially with respect to confusion and bowel complications. Equally important, the satisfaction of patient and caregiver was higher in the HaH group. Other randomized controlled trials (1, 2) have shown that treatment of deep venous thrombosis in the home was more favorable than that in the hospital.

Physicians who treat elderly persons with similar illnesses of similar degrees of severity may ask how many of such patients could be safely treated in the home. Although patient satisfaction is important and may be greater with home care, it would be difficult to justify if the final outcome meant greater morbidity and mortality. Physicians should anticipate that treatment of patients at home is more likely to need supervision than treatment given in the hospital. Complications and unexpected events do arise, and surveillance is required to handle them properly.

Michael P. Martin, MD
Texas A&M University College of MedicineTemple, Texas, USA


References

1. Levine M, Gent M, Hirsh J, et al. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med. 1996;334:677-81.

2. Koopman MM, Prandoni P, Piovella F, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. The Tasman Study Group. N Engl J Med. 1996;334:682-7.