- Email: [email protected]
Effectiveness of a Hospital-at-Home Integrated Care Program as Alternative Resource for Medical Crises Care in Older Adults With Complex Chronic Conditions
JAMDA 19 (2018) 860e863
JAMDA journal homepage: www.jamda.com
Original Study
Effectiveness of a Hospital-at-Home Integrated Care Program as Alternative Resource for Medical Crises Care in Older Adults With Complex Chronic Conditions Miquel À. Mas MD a, b, c, *, Sebastià J. Santaeugènia MD, PhD d, Francisco J. Tarazona-Santabalbina MD, PhD e, f, Sara Gámez RN a, Marco Inzitari MD, PhD b, g a
Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Catalonia RE-FiT bcn Research Group, Vall d’Hebrón Institute of Research (VHIR), Barcelona, Catalonia d Chronic Care Program, Ministry of Health, Barcelona, Catalonia e Department of Geriatric Medicine, Hospital Universitario de la Ribera, Valencia, Spain f Universidad Católica de Valencia San Vicente Martir, Valencia, Spain g Parc Sanitari Pere Virgili, Barcelona, Catalonia b c
a b s t r a c t Keywords: Hospital-at-home integrated care medical crises multimorbidity
Objectives: To compare clinical outcomes in older patients with acute medical crises attended by a geriatrician-led home hospitalization unit (HHU) vs an inpatient intermediate-care geriatric unit (ICGU) in a post-acute care setting. Design: Quasi-experimental longitudinal study, with 30-day follow-up. Participants: Older patients with chronic conditions attended at the emergency department or day hospital for an acute medical crisis. Interventions: Patients were referred to geriatrician-led HHU or ICGU wards. Setting: An acute care hospital, an intermediate care hospital, and the community of an urban area in the North of Barcelona, in Southern Europe. Measurements: We compared health crisis outcomes (recovery from the acute health crisis, referral to an acute hospital, or death), length of stay, relative functional gain (RFG) at discharge, readmission to an acute care unit within 30 days of discharge, and mortality within 30 days of discharge. Results: We included 171 older adults (57 in the HHU and 114 in the ICGU) with complex conditions at risk of negative outcomes. At baseline, HHU patients were significantly younger and less likely to be cognitively impaired and referred from an emergency department. Most patients in both groups recovered from their health crises (91.2% in the HHU group vs 88.6% in the ICGU group, P ¼ .79). No differences were found between the 2 groups in 30-day mortality (8.6% vs 9.6%, P ¼ >.99). There was a trend toward lower 30-day readmission to an acute care unit in the HHU group (10.5% vs 19.3% in the ICGU group, P ¼ .19). HHU patients had higher RFG (mean 0.75 days vs 0.51 in the ICGU group, P ¼ .01), and a longer stay in the unit (9.7 vs 8.2 days in the ICGU group, P < .01). Conclusions: These preliminary results suggest that the geriatrician-led HHU seems effective in resolving acute medical crises in older patients with chronic disease. Patients attended by the HHU obtained better functional outcomes compared to those from the ICGU, although the groups did have some baseline differences. Ó 2018 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
The development and analysis of this home-based program forms the core of the PhD project of Dr M.À. Mas (supervised by Drs M. Inzitari and R. Miralles) at the Universitat Autònoma de Barcelona. The authors declare no conflicts of interest.
https://doi.org/10.1016/j.jamda.2018.06.013 1525-8610/Ó 2018 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
* Address correspondence to Miquel À. Mas, MD, Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, El Carme Intermediate Care Hospital, Camí Sant Jeroni de la Murtra 60, 08917, Badalona, Catalonia, Spain. E-mail address: [email protected] (M.À. Mas).
M.À. Mas et al. / JAMDA 19 (2018) 860e863
The aging of the population has led to a high prevalence of older people with complex chronic conditions worldwide, leading to the development of several successful models of comprehensive care.1 In recent decades, different home-based and hospital-based resources have been adapted to high-risk patients by tailoring interventions not only to chronic conditions2 but also to medical crises.3,4 In Catalonia, intermediate care geriatric units (ICGUs) are low-tech geriatric wards located in post-acute care settings. ICGUs are used as alternatives to acute hospitalization for select older patients with acute medical crises.5e7 Moreover, a Comprehensive Geriatric Assessmentebased hospital-at-home model, provided by a geriatrician-led home hospitalization unit (HHU), was developed to deal with disabling health crises,8 based on previous evidence.9,10 Outcomes of orthopedic crises treated by the HHU were at least as good as those treated by conventional hospitalization; furthermore, HHU reduced hospital stays and overall costs.11,12 The current study aimed to compare the effectiveness of the HHU vs the ICGU in older patients with chronic conditions and acute medical crises. Methods This quasi-experimental longitudinal study compared clinical outcomes in older patients with chronic conditions and acute medical crises at 2 units belonging to an integrated care institution in the urban area of Badalona, north of Barcelona, in Catalonia: the ICGU (postacute care setting), which has been providing acute care to frail older patients in selected crises with good prognoses since 2010;6 and the HHU, which has been providing acute medical care to the same profile of patients since 2015. The university’s ethics committee approved the study (Universitat Autònoma de Barcelona, reference number 3438). We included older patients with chronic conditions who had an acute medical crisis between December 1, 2015, and June 30, 2016, whom emergency department or day hospital physicians classified as having a good prognosis and not needing further complex diagnostic tests or management by other specialized units of the acute hospital. Assignment to the HHU or ICGU was based on the availability of resources, on caregiver availability, and on patient acceptance (it was not randomized). To be admitted to the HHU, patients needed to have another person in their home (24/7) who was physically and cognitively able to act as a caregiver, and both patients and caregivers needed to provide informed consent acceptance. All patients in both groups received an initial assessment and treatment visit from a nurse specialized in geriatrics within 12 hours of referral and an initial visit from a geriatrician within 24 hours of referral. The same Comprehensive Geriatric Assessmentebased protocol was applied in all patients, involving geriatricians, nurses, and physical and occupational therapists when necessary, with the support of social workers. Available diagnostic procedures included electrocardiography, laboratory tests, and imaging studies. Available medical procedures included intravenous antibiotics, corticosteroids, diuretics and fluids, and nebulizers for bronchodilator therapies, among others. Patients in the HHU group received 1 to 3 individualized home visits from staff between 8 AM and 9 PM daily; outside this time frame, on-call physicians could be reached by phone. As a rule, patients were visited by a physician daily or every other day, and by a nurse twice a day or daily. In the ICGU, physicians and nurses were available 24 hours/d. Patients in both groups were discharged for primary care follow-up when therapeutic goals were met (ie, when the acute crisis was resolved). Patients whose condition failed to improve or worsened were referred to an acute hospital based on predefined protocols. In calculating the sample size, we assumed 30% of patients would die or be referred to an acute hospital, 20% relative risk reduction, and a ratio of 2 ICGU patients per HHU patient (power of 90%; 5% alphaerror and 10% beta-error).13 We recorded the following variables at
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admission: age, sex, principal diagnosis (respiratory infection, acute heart failure, urinary tract infection, or other), referring medical team (emergency department or day hospital), place of residence (at home or nursing home), and length of emergency department stay (for patients referred from the emergency department). We recorded baseline functional status before the health crisis (Barthel Index score reported by patients or caregivers, considering functional status before the health crisis started), functional status at admission to the HHU or ICGU (Barthel Index score measured by unit professionals of the multidisciplinary team between 1 and 2 days after the health crisis started), presence of functional loss14 (positive difference between baseline Barthel Index score and Barthel Index score at admission to the unit), morbidity (measured by Adjusted Morbidity Groups [AMG]),15 and the presence of cognitive impairment and/or delirium. We recorded the following variables at discharge: functional status (Barthel Index), functional gain (Barthel Index at discharge minus Barthel Index at admission to the unit), relative functional gain (functional gain divided by functional loss),14 length of stay in the unit, and destination (home, nursing home, acute hospital). We classified outcomes as recovery from the acute health crisis (discharged to primary care follow-up), referral to an acute care unit, or death. We also recorded readmission to an acute unit or death during the 30 days after discharge from the HHU or ICGU. Categorical data are reported as frequencies and percentages; continuous data are reported as means and standard deviations. To compare the HHU and ICGU groups at baseline, we used chi-square tests or Fisher exact test, as appropriate, for categorical variables and independent sample t tests for quantitative variables, after verifying normality using the Kolmogorov-Smirnov test. To compare the outcome of relative functional gain, we used an analysis of covariance of repeated measures to quantify the magnitude of the effect. We used linear and binary logistic regression to identify explanatory variables associated with outcomes and intervention unit. In the bivariate analysis, we included statistically significant variables and those considered clinically relevant. Adjustment variables were age, diagnostic group, cognitive impairment, baseline Barthel Index, referral unit, and place of residence. We used a backward stepwise technique to avoid overfitting. All comparisons were 2-tailed, and P < .05 was considered significant. We used SPSS, version 21 (IBM Corp, Armonk, NY), for all analyses.
Results We included 171 patients, 57 in the HHU group and in 114 the ICGU group [mean age 86.1 (6.8) years, 59% women, 34% residing in nursing homes]; 83.6% were referred from the emergency department (mean emergency department stay 19.1 hours). The most common acute diagnoses were respiratory infection (n ¼ 90; 52.6%), urinary tract infection (n ¼ 39; 22.8%), and acute heart failure (n ¼ 30; 17.5%); 12 (7%) patients had other acute conditions. At admission, 86 (50.3%) had cognitive impairment, 29 (17%) delirium, and 92 (53.8%) functional loss due to the acute crisis; 119 (69.6%) patients had an AMG score of 4 (high risk of readmission). Table 1 reports the baseline characteristics of the HHU and ICGU groups. Patients in both groups had high risk of readmission due to morbidity (measured by AMG score) and to acute geriatric syndromes. In the HHU group, the age of the sample was significantly lower, and the proportion of patients referred from day hospital was significantly higher. In the ICGU group, the proportion of respiratory infections as the main diagnosis, the living residence nursing home, and the presence of cognitive impairment as a baseline diagnosis was significantly higher. Among patients referred from the emergency department, the mean length of the emergency department stay was shorter in the HHU group (12.6 vs 22 hours, P ¼ .02).
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M.À. Mas et al. / JAMDA 19 (2018) 860e863
Table 1 Baseline Characteristics of Patients Attended by the HHU and Those Attended by the ICGU
Age (y), mean (SD) Sex (female), n (%) Main diagnosis, n (%) Respiratory infection Heart failure UTI Other Referring unit, n (%) ED Day hospital Place of residence, n (%) Own home Nursing home Length of ED stay,* h, mean (SD) Adjusted Morbidity Group score of 4, n (%) Functional loss due to acute illness, n (%) Cognitive impairment, n (%) Delirium, n (%)
HHU (n ¼ 57)
ICGU (n ¼ 114)
P Value
84.3 (7.6) 28 (49.1)
86.9 (6.3) 73 (64)
.02 .07
24 16 11 6
(42.1) (28.1) (19.3) (10.5)
66 14 28 6
(57.9) (12.3) (24.6) (5.3)
.03
<.01 32 (56.1) 25 (43.9)
111 (97.4) 3 (2.6) <.01
48 9 12.6 34
(84.2) (15.8) (6.4) (59.6)
65 49 22 85
(57) (43) (13.9) (74.6)
.02 .12
32 (56.1)
60 (52.6)
.75
22 (38.6) 10 (17.5)
64 (56.1) 19 (16.7)
.04 >.99
ED, emergency department; HHU, home hospitalization unit; ICGU, intermediatecare geriatric unit; SD, standard deviation; UTI, urinary tract infection. *Patients referred from ED.
Outcome was classified as recovery from the acute health crisis in 153 (89.5%) patients, referral to an acute care hospital within 30 days in 28 (16.4%), and death within 30 days in 16 (9.4%). Destination at discharge was home or nursing home, with primary care follow-up for 152 (89%) patients and an acute care unit for 12 (7%); 6 (3.5%) patients died before discharge. Outcomes are reported in Table 2. After adjustment for age, diagnostic group, presence of cognitive impairment, baseline Barthel Index, referring unit, place of residence, and length of stay in the Emergency Department, the multivariate analysis found the relative functional gain, mean (standard deviation), to be higher in the HHU group 0.75 (0.34), vs 0.51 (0.67) in the ICGU group, P ¼ .01; the mean length of stay also was higher in the HHU group (9.7 vs 8.2 days, P < .01). No significant differences were found between the 2 groups in recovery from the acute health crisis, readmission to an acute care unit within 30 days, or mortality within 30 days. Discussion This study found that patients with selected medical crises at risk for admission to acute hospitals who were attended in a hospital-athome program based on Comprehensive Geriatric Assessment had similar outcomes to those attended in an established inpatient geriatric care program. Moreover, patients in the HHU had better functional outcomes at discharge. These findings, which need to be cautiously analyzed because of some differences at baseline between
the groups, suggest that this program, previously validated as a means to facilitate early hospital discharge in disabling orthopedic and medical crises,8,11,12 may also be a valid alternative to admission to an acute hospital for patients with acute medical crises. For more than a decade, studies have shown that hospital care in patients’ homes is an efficient approach to the management of acute medical crises in older patients with comorbidities.16e23 The present study also corroborates recent results on improved functional recovery20,21 (relative functional gain was 0.75 in patients discharged from the HHU vs 0.51 in patients discharged from the ICGU). For older patients who are frail and/or have multimorbidity, most of whom live in nursing homes, it is imperative to develop alternatives to hospital admission for acute crises. In the present study, 15.8% of the HHU sample and 43% of the ICGU sample were nursing home residents. This group of patients is especially likely to undergo acute hospitalization, and receiving acute medical care in their usual place of residence may help lower the risks of developing problems such as nosocomial infections, cognitive decline, or functional deterioration. Various authors have found that intensive home-based programs can also help lower costs for the health system.24e26 A recent review found that hospital-at-home care yields not only noninferior medical results but, excluding the costs of informal care, also may be less expensive than admission to an acute hospital ward.27 Integrated care strategies designed to treat acute crises in the community can be key if there is a strong policy of financial support for alternatives to conventional hospitalization, as outpatient management resources or hospital-at-home.28 In the present study, 44% of HHU candidates were referred from a day hospital. By contrast, most patients in the ICGU were referred from the emergency department. Including the referring unit as a possible confounding factor did not change the results of our multivariate analysis. Thus, both the emergency and day hospitals seem capable of applying comprehensive assessment protocols to determine whether patients might benefit from HHU as an alternative to conventional hospitalization. The lack of randomization in our study is a limitation. Some baseline characteristics such as less severe cognitive impairment or less morbidity could suggest that HHU patients were slightly less complex (we included cognitive status and morbidity variables in the adjustment). Although we adjusted our analyses for several confounding factors, we did not address other factors that might have influenced our results, such as the severity of acute illness, socioeconomic status, or caregiver resilience. The main strength of the current study is our pragmatic approach, which allowed us to include “realworld” interventions tailored to older patients with complex chronic conditions at risk of readmission. Future research including larger, randomized studies carried out in multiple centers are necessary to confirm our results.29 It would also be interesting to analyze the cost-effectiveness of this admission avoidance program in medical patients. The results of our study suggest that home-based programs to manage acute medical crises in older patients with multiple geriatric
Table 2 Comparison of Outcome Measures Between Patients Attended by the HHU and Those Attended by the ICGU Unadjusted Results
Recovered from acute health crisis, n (%) Died during stay, n (%) Readmitted to an acute care unit within 30 d, n (%) Died within 30 d of discharge, n (%) Relative functional gain, mean (SD) Length of stay, mean (SD), d
Adjusted Results*
HHU (n ¼ 57)
ICGU (n ¼ 114)
P Value
OR (95% CI)
HHU
ICGU
P Value
52 1 6 5 0.77 9.6
101 5 22 11 0.49 8.3
.79 .67 .19 >.99 .01 .01
1.64 2.03 0.83 0.51 e e
e e e e 0.75 (0.34) 9.7 (3.9)
e e e e 0.51 (0.67) 8.2 (2.9)
.58 .71 .77 .53 .01 <.01
(91.2) (1.8) (10.5) (8.6) (0.39) (3.9)
(88.6) (4.4) (19.3) (9.6) (0.32) (2.9)
(0.27-9.83) (0.04-93.5) (0.23-2.95) (0.05-4.45)
CI, confidence interval; HHU, home hospitalization unit; ICGU, intermediate-care geriatric unit; OR, odds ratio; SD, standard deviation. *HHU vs ICGU after adjustment for variables: age, diagnostic group, cognitive impairment, baseline Barthel Index, referral unit, place of residence and length of stay in the emergency department.
M.À. Mas et al. / JAMDA 19 (2018) 860e863
conditions who are at risk of negative outcomes may be a feasible alternative to admission to a hospital ward. If further studies confirm these results, programs like ours may be considered an alternative to acute hospital medical units in health systems like ours. References 1. Boult C, Green AF, Boult LB, et al. Successful models of comprehensive care for older adults with chronic conditions: Evidence for the Institute of Medicine’s “Retooling for an Aging America” report. J Am Geriatr Soc 2009; 57:2328e2337. 2. Stall N, Nowaczynski M, Sinha SK. Systematic review of outcomes from homebased primary care programs for homebound older adults. J Am Geriatr Soc 2014;62:2243e2251. 3. Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev 2017;(9):CD006211. 4. Shepperd S, Gonçalves-Bradley DC, Straus SE, et al. Hospital at home: Home-based end-of-life care. Cochrane Database Syst Rev 2016;(2):CD009231. 5. Colprim D, Martin R, Parer M, et al. Direct admission to intermediate care for older adults with reactivated chronic diseases as an alternative to conventional hospitalization. J Am Med Dir Assoc 2013;14:300e302. 6. Santaeugènia SJ, Tomás S, Alvaro M, et al. Direct admission to intermediate care for older adults with reactivated chronic diseases: Avoiding both conventional hospitalization and emergency department use. J Am Med Dir Assoc 2013;14: 444e445. 7. Inzitari M, Gual N, Roig T, et al. Geriatric screening tools to select older adults susceptible for direct transfer from the emergency department to subacute intermediate care hospitalization. J Am Med Dir Assoc 2015;16: 837e841. 8. Mas MÀ, Inzitari M, Sabaté S, et al. Hospital-at-home Integrated Care Programme for the management of disabling health crises in older patients: Comparison with bed-based Intermediate Care. Age Ageing 2017;46:925e931. 9. Caplan GA, Sulaiman NS, Mangin DA, et al. A meta-analysis of “hospital-in-thehome”. Med J Aust 2012;197:512e519. 10. Mas MÀ, Santaeugènia S. Hospital-at-home in older patients: A scoping review on opportunities of developing comprehensive geriatric assessment based services [in Spanish]. Rev Esp Geriatr Gerontol 2015;50:26e34. 11. Mas MÀ, Closa C, Santaeugènia SJ, et al. Hospital-at-home integrated care programme for older patients with orthopaedic conditions: Early community reintegration maximising physical function. Maturitas 2016;88: 65e69. 12. Closa C, Mas MÀ, Santaeugènia SJ, et al. Hospital-at-home integrated care program for older patients with orthopedic processes: An efficient alternative to usual hospital-based care. J Am Dir Assoc 2017;18:780e784.
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13. Cucinotta D, Savorani G, Piscaglia F, et al. The chronically ill elderly patients discharged from the hospital: Interim report from a controlled study of home care attendance. Arch Gerontol Geriatr Suppl; 2004:103e108. 14. Sánchez-Rodríguez D, Miralles R, Muniesa JM, et al. Three measures of physical rehabilitation effectiveness in elderly patients: A prospective, longitudinal, comparative analysis. BMC Geriatr 2015;15:142. 15. Monterde D, Vela E, Clèries M, et al. Adjusted morbidity groups: A new multiple morbidity measurement of use in primary care [in Spanish]. Aten Primaria 2016;48:674e682. 16. Tibaldi V, Aimonino N, Ponzetto M, et al. A randomized controlled trial of a home hospital intervention for frail elderly demented patients: Behavioural disturbances and caregiver’s stress. Arch Gerontol Geriatr Suppl; 2004:431e436. 17. Caplan GA, Ward JA, Brennan NJ, et al. Hospital in the home: A randomized controlled trial. Med J Aust 1999;170:156e160. 18. Jacobs JM, Hammerman-Rozenberg R, Stessman J. Home hospitalization: 15 years of experience. Ann Intern Med 2006;144:456. 19. Leff B, Burton L, Mader SL, et al. Hospital at home: Feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med 2005;143:798e808. 20. Caplan GA, Coconis J, Woods J. Effect of hospital in the home treatment on physical and cognitive function: A randomized controlled trial. J Gerontol A Biol Sci Med 2005;60:1035e1038. 21. Leff B, Burton L, Mader SL, et al. Comparison of functional outcomes associated with hospital at home care and traditional acute hospital care. J Am Geriatr Soc 2009;57:273e278. 22. Tibaldi V, Isaia G, Scarafiotti C, et al. Hospital-at-home for elderly patients with acute decompensation of chronic heart failure: A prospective randomized controlled trial. Arch Intern Med 2009;169:1569e1575. 23. Aimonino Ricauda N, Tibaldi V, Leff B, et al. Substitutive “hospital at home” versus inpatient care for elderly patients with exacerbations of chronic obstructive pulmonary disease: A prospective randomized, controlled trial. J Am Geriatr Soc 2008;56:493e500. 24. Cryer L, Shannon SB, Van Amsterdam M, et al. Costs for “hospital at home” patients were 19 percent lower, with equal or better outcomes compared to similar inpatients. Health Aff (Millwood) 2012;31:1237e1243. 25. Jacobs JM, Cohen A, Rozengarten O, et al. Closure of a home hospital program: Impact on hospitalization rates. Arch Gerontol Geriatr 2007;45:179e189. 26. Vilà A, Villegas E, Cruanyes J, et al. Cost-effectiveness of a Barcelona home care program for individuals with multimorbidity. J Am Geriatr Soc 2015;63:1017e1024. 27. Shepperd S, Iliffe S, Doll HA, et al. Admission avoidance hospital at home. Cochrane Database Syst Rev 2016;(9):CD007491. 28. Conley J, O’Brien CW, Leff BA, et al. Alternative strategies to inpatient hospitalization for acute medical conditions: A systematic review. JAMA Intern Med 2016;176:1693e1702. 29. Shepperd S, Cradduck-Bamford A, Butler C, et al. A multi-centre randomised trial to compare the effectiveness of geriatrician-led admission avoidance hospital at home versus inpatient admission. Trials 2017;18:491.
JAMDA journal homepage: www.jamda.com
Original Study
Effectiveness of a Hospital-at-Home Integrated Care Program as Alternative Resource for Medical Crises Care in Older Adults With Complex Chronic Conditions Miquel À. Mas MD a, b, c, *, Sebastià J. Santaeugènia MD, PhD d, Francisco J. Tarazona-Santabalbina MD, PhD e, f, Sara Gámez RN a, Marco Inzitari MD, PhD b, g a
Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Catalonia RE-FiT bcn Research Group, Vall d’Hebrón Institute of Research (VHIR), Barcelona, Catalonia d Chronic Care Program, Ministry of Health, Barcelona, Catalonia e Department of Geriatric Medicine, Hospital Universitario de la Ribera, Valencia, Spain f Universidad Católica de Valencia San Vicente Martir, Valencia, Spain g Parc Sanitari Pere Virgili, Barcelona, Catalonia b c
a b s t r a c t Keywords: Hospital-at-home integrated care medical crises multimorbidity
Objectives: To compare clinical outcomes in older patients with acute medical crises attended by a geriatrician-led home hospitalization unit (HHU) vs an inpatient intermediate-care geriatric unit (ICGU) in a post-acute care setting. Design: Quasi-experimental longitudinal study, with 30-day follow-up. Participants: Older patients with chronic conditions attended at the emergency department or day hospital for an acute medical crisis. Interventions: Patients were referred to geriatrician-led HHU or ICGU wards. Setting: An acute care hospital, an intermediate care hospital, and the community of an urban area in the North of Barcelona, in Southern Europe. Measurements: We compared health crisis outcomes (recovery from the acute health crisis, referral to an acute hospital, or death), length of stay, relative functional gain (RFG) at discharge, readmission to an acute care unit within 30 days of discharge, and mortality within 30 days of discharge. Results: We included 171 older adults (57 in the HHU and 114 in the ICGU) with complex conditions at risk of negative outcomes. At baseline, HHU patients were significantly younger and less likely to be cognitively impaired and referred from an emergency department. Most patients in both groups recovered from their health crises (91.2% in the HHU group vs 88.6% in the ICGU group, P ¼ .79). No differences were found between the 2 groups in 30-day mortality (8.6% vs 9.6%, P ¼ >.99). There was a trend toward lower 30-day readmission to an acute care unit in the HHU group (10.5% vs 19.3% in the ICGU group, P ¼ .19). HHU patients had higher RFG (mean 0.75 days vs 0.51 in the ICGU group, P ¼ .01), and a longer stay in the unit (9.7 vs 8.2 days in the ICGU group, P < .01). Conclusions: These preliminary results suggest that the geriatrician-led HHU seems effective in resolving acute medical crises in older patients with chronic disease. Patients attended by the HHU obtained better functional outcomes compared to those from the ICGU, although the groups did have some baseline differences. Ó 2018 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
The development and analysis of this home-based program forms the core of the PhD project of Dr M.À. Mas (supervised by Drs M. Inzitari and R. Miralles) at the Universitat Autònoma de Barcelona. The authors declare no conflicts of interest.
https://doi.org/10.1016/j.jamda.2018.06.013 1525-8610/Ó 2018 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
* Address correspondence to Miquel À. Mas, MD, Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, El Carme Intermediate Care Hospital, Camí Sant Jeroni de la Murtra 60, 08917, Badalona, Catalonia, Spain. E-mail address: [email protected] (M.À. Mas).
M.À. Mas et al. / JAMDA 19 (2018) 860e863
The aging of the population has led to a high prevalence of older people with complex chronic conditions worldwide, leading to the development of several successful models of comprehensive care.1 In recent decades, different home-based and hospital-based resources have been adapted to high-risk patients by tailoring interventions not only to chronic conditions2 but also to medical crises.3,4 In Catalonia, intermediate care geriatric units (ICGUs) are low-tech geriatric wards located in post-acute care settings. ICGUs are used as alternatives to acute hospitalization for select older patients with acute medical crises.5e7 Moreover, a Comprehensive Geriatric Assessmentebased hospital-at-home model, provided by a geriatrician-led home hospitalization unit (HHU), was developed to deal with disabling health crises,8 based on previous evidence.9,10 Outcomes of orthopedic crises treated by the HHU were at least as good as those treated by conventional hospitalization; furthermore, HHU reduced hospital stays and overall costs.11,12 The current study aimed to compare the effectiveness of the HHU vs the ICGU in older patients with chronic conditions and acute medical crises. Methods This quasi-experimental longitudinal study compared clinical outcomes in older patients with chronic conditions and acute medical crises at 2 units belonging to an integrated care institution in the urban area of Badalona, north of Barcelona, in Catalonia: the ICGU (postacute care setting), which has been providing acute care to frail older patients in selected crises with good prognoses since 2010;6 and the HHU, which has been providing acute medical care to the same profile of patients since 2015. The university’s ethics committee approved the study (Universitat Autònoma de Barcelona, reference number 3438). We included older patients with chronic conditions who had an acute medical crisis between December 1, 2015, and June 30, 2016, whom emergency department or day hospital physicians classified as having a good prognosis and not needing further complex diagnostic tests or management by other specialized units of the acute hospital. Assignment to the HHU or ICGU was based on the availability of resources, on caregiver availability, and on patient acceptance (it was not randomized). To be admitted to the HHU, patients needed to have another person in their home (24/7) who was physically and cognitively able to act as a caregiver, and both patients and caregivers needed to provide informed consent acceptance. All patients in both groups received an initial assessment and treatment visit from a nurse specialized in geriatrics within 12 hours of referral and an initial visit from a geriatrician within 24 hours of referral. The same Comprehensive Geriatric Assessmentebased protocol was applied in all patients, involving geriatricians, nurses, and physical and occupational therapists when necessary, with the support of social workers. Available diagnostic procedures included electrocardiography, laboratory tests, and imaging studies. Available medical procedures included intravenous antibiotics, corticosteroids, diuretics and fluids, and nebulizers for bronchodilator therapies, among others. Patients in the HHU group received 1 to 3 individualized home visits from staff between 8 AM and 9 PM daily; outside this time frame, on-call physicians could be reached by phone. As a rule, patients were visited by a physician daily or every other day, and by a nurse twice a day or daily. In the ICGU, physicians and nurses were available 24 hours/d. Patients in both groups were discharged for primary care follow-up when therapeutic goals were met (ie, when the acute crisis was resolved). Patients whose condition failed to improve or worsened were referred to an acute hospital based on predefined protocols. In calculating the sample size, we assumed 30% of patients would die or be referred to an acute hospital, 20% relative risk reduction, and a ratio of 2 ICGU patients per HHU patient (power of 90%; 5% alphaerror and 10% beta-error).13 We recorded the following variables at
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admission: age, sex, principal diagnosis (respiratory infection, acute heart failure, urinary tract infection, or other), referring medical team (emergency department or day hospital), place of residence (at home or nursing home), and length of emergency department stay (for patients referred from the emergency department). We recorded baseline functional status before the health crisis (Barthel Index score reported by patients or caregivers, considering functional status before the health crisis started), functional status at admission to the HHU or ICGU (Barthel Index score measured by unit professionals of the multidisciplinary team between 1 and 2 days after the health crisis started), presence of functional loss14 (positive difference between baseline Barthel Index score and Barthel Index score at admission to the unit), morbidity (measured by Adjusted Morbidity Groups [AMG]),15 and the presence of cognitive impairment and/or delirium. We recorded the following variables at discharge: functional status (Barthel Index), functional gain (Barthel Index at discharge minus Barthel Index at admission to the unit), relative functional gain (functional gain divided by functional loss),14 length of stay in the unit, and destination (home, nursing home, acute hospital). We classified outcomes as recovery from the acute health crisis (discharged to primary care follow-up), referral to an acute care unit, or death. We also recorded readmission to an acute unit or death during the 30 days after discharge from the HHU or ICGU. Categorical data are reported as frequencies and percentages; continuous data are reported as means and standard deviations. To compare the HHU and ICGU groups at baseline, we used chi-square tests or Fisher exact test, as appropriate, for categorical variables and independent sample t tests for quantitative variables, after verifying normality using the Kolmogorov-Smirnov test. To compare the outcome of relative functional gain, we used an analysis of covariance of repeated measures to quantify the magnitude of the effect. We used linear and binary logistic regression to identify explanatory variables associated with outcomes and intervention unit. In the bivariate analysis, we included statistically significant variables and those considered clinically relevant. Adjustment variables were age, diagnostic group, cognitive impairment, baseline Barthel Index, referral unit, and place of residence. We used a backward stepwise technique to avoid overfitting. All comparisons were 2-tailed, and P < .05 was considered significant. We used SPSS, version 21 (IBM Corp, Armonk, NY), for all analyses.
Results We included 171 patients, 57 in the HHU group and in 114 the ICGU group [mean age 86.1 (6.8) years, 59% women, 34% residing in nursing homes]; 83.6% were referred from the emergency department (mean emergency department stay 19.1 hours). The most common acute diagnoses were respiratory infection (n ¼ 90; 52.6%), urinary tract infection (n ¼ 39; 22.8%), and acute heart failure (n ¼ 30; 17.5%); 12 (7%) patients had other acute conditions. At admission, 86 (50.3%) had cognitive impairment, 29 (17%) delirium, and 92 (53.8%) functional loss due to the acute crisis; 119 (69.6%) patients had an AMG score of 4 (high risk of readmission). Table 1 reports the baseline characteristics of the HHU and ICGU groups. Patients in both groups had high risk of readmission due to morbidity (measured by AMG score) and to acute geriatric syndromes. In the HHU group, the age of the sample was significantly lower, and the proportion of patients referred from day hospital was significantly higher. In the ICGU group, the proportion of respiratory infections as the main diagnosis, the living residence nursing home, and the presence of cognitive impairment as a baseline diagnosis was significantly higher. Among patients referred from the emergency department, the mean length of the emergency department stay was shorter in the HHU group (12.6 vs 22 hours, P ¼ .02).
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Table 1 Baseline Characteristics of Patients Attended by the HHU and Those Attended by the ICGU
Age (y), mean (SD) Sex (female), n (%) Main diagnosis, n (%) Respiratory infection Heart failure UTI Other Referring unit, n (%) ED Day hospital Place of residence, n (%) Own home Nursing home Length of ED stay,* h, mean (SD) Adjusted Morbidity Group score of 4, n (%) Functional loss due to acute illness, n (%) Cognitive impairment, n (%) Delirium, n (%)
HHU (n ¼ 57)
ICGU (n ¼ 114)
P Value
84.3 (7.6) 28 (49.1)
86.9 (6.3) 73 (64)
.02 .07
24 16 11 6
(42.1) (28.1) (19.3) (10.5)
66 14 28 6
(57.9) (12.3) (24.6) (5.3)
.03
<.01 32 (56.1) 25 (43.9)
111 (97.4) 3 (2.6) <.01
48 9 12.6 34
(84.2) (15.8) (6.4) (59.6)
65 49 22 85
(57) (43) (13.9) (74.6)
.02 .12
32 (56.1)
60 (52.6)
.75
22 (38.6) 10 (17.5)
64 (56.1) 19 (16.7)
.04 >.99
ED, emergency department; HHU, home hospitalization unit; ICGU, intermediatecare geriatric unit; SD, standard deviation; UTI, urinary tract infection. *Patients referred from ED.
Outcome was classified as recovery from the acute health crisis in 153 (89.5%) patients, referral to an acute care hospital within 30 days in 28 (16.4%), and death within 30 days in 16 (9.4%). Destination at discharge was home or nursing home, with primary care follow-up for 152 (89%) patients and an acute care unit for 12 (7%); 6 (3.5%) patients died before discharge. Outcomes are reported in Table 2. After adjustment for age, diagnostic group, presence of cognitive impairment, baseline Barthel Index, referring unit, place of residence, and length of stay in the Emergency Department, the multivariate analysis found the relative functional gain, mean (standard deviation), to be higher in the HHU group 0.75 (0.34), vs 0.51 (0.67) in the ICGU group, P ¼ .01; the mean length of stay also was higher in the HHU group (9.7 vs 8.2 days, P < .01). No significant differences were found between the 2 groups in recovery from the acute health crisis, readmission to an acute care unit within 30 days, or mortality within 30 days. Discussion This study found that patients with selected medical crises at risk for admission to acute hospitals who were attended in a hospital-athome program based on Comprehensive Geriatric Assessment had similar outcomes to those attended in an established inpatient geriatric care program. Moreover, patients in the HHU had better functional outcomes at discharge. These findings, which need to be cautiously analyzed because of some differences at baseline between
the groups, suggest that this program, previously validated as a means to facilitate early hospital discharge in disabling orthopedic and medical crises,8,11,12 may also be a valid alternative to admission to an acute hospital for patients with acute medical crises. For more than a decade, studies have shown that hospital care in patients’ homes is an efficient approach to the management of acute medical crises in older patients with comorbidities.16e23 The present study also corroborates recent results on improved functional recovery20,21 (relative functional gain was 0.75 in patients discharged from the HHU vs 0.51 in patients discharged from the ICGU). For older patients who are frail and/or have multimorbidity, most of whom live in nursing homes, it is imperative to develop alternatives to hospital admission for acute crises. In the present study, 15.8% of the HHU sample and 43% of the ICGU sample were nursing home residents. This group of patients is especially likely to undergo acute hospitalization, and receiving acute medical care in their usual place of residence may help lower the risks of developing problems such as nosocomial infections, cognitive decline, or functional deterioration. Various authors have found that intensive home-based programs can also help lower costs for the health system.24e26 A recent review found that hospital-at-home care yields not only noninferior medical results but, excluding the costs of informal care, also may be less expensive than admission to an acute hospital ward.27 Integrated care strategies designed to treat acute crises in the community can be key if there is a strong policy of financial support for alternatives to conventional hospitalization, as outpatient management resources or hospital-at-home.28 In the present study, 44% of HHU candidates were referred from a day hospital. By contrast, most patients in the ICGU were referred from the emergency department. Including the referring unit as a possible confounding factor did not change the results of our multivariate analysis. Thus, both the emergency and day hospitals seem capable of applying comprehensive assessment protocols to determine whether patients might benefit from HHU as an alternative to conventional hospitalization. The lack of randomization in our study is a limitation. Some baseline characteristics such as less severe cognitive impairment or less morbidity could suggest that HHU patients were slightly less complex (we included cognitive status and morbidity variables in the adjustment). Although we adjusted our analyses for several confounding factors, we did not address other factors that might have influenced our results, such as the severity of acute illness, socioeconomic status, or caregiver resilience. The main strength of the current study is our pragmatic approach, which allowed us to include “realworld” interventions tailored to older patients with complex chronic conditions at risk of readmission. Future research including larger, randomized studies carried out in multiple centers are necessary to confirm our results.29 It would also be interesting to analyze the cost-effectiveness of this admission avoidance program in medical patients. The results of our study suggest that home-based programs to manage acute medical crises in older patients with multiple geriatric
Table 2 Comparison of Outcome Measures Between Patients Attended by the HHU and Those Attended by the ICGU Unadjusted Results
Recovered from acute health crisis, n (%) Died during stay, n (%) Readmitted to an acute care unit within 30 d, n (%) Died within 30 d of discharge, n (%) Relative functional gain, mean (SD) Length of stay, mean (SD), d
Adjusted Results*
HHU (n ¼ 57)
ICGU (n ¼ 114)
P Value
OR (95% CI)
HHU
ICGU
P Value
52 1 6 5 0.77 9.6
101 5 22 11 0.49 8.3
.79 .67 .19 >.99 .01 .01
1.64 2.03 0.83 0.51 e e
e e e e 0.75 (0.34) 9.7 (3.9)
e e e e 0.51 (0.67) 8.2 (2.9)
.58 .71 .77 .53 .01 <.01
(91.2) (1.8) (10.5) (8.6) (0.39) (3.9)
(88.6) (4.4) (19.3) (9.6) (0.32) (2.9)
(0.27-9.83) (0.04-93.5) (0.23-2.95) (0.05-4.45)
CI, confidence interval; HHU, home hospitalization unit; ICGU, intermediate-care geriatric unit; OR, odds ratio; SD, standard deviation. *HHU vs ICGU after adjustment for variables: age, diagnostic group, cognitive impairment, baseline Barthel Index, referral unit, place of residence and length of stay in the emergency department.
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