The effectiveness, acceptability and costs of a hospital-at-home service compared with acute hospital care: a randomized controlled trial

OBJECTIVE: To compare the safety, effectiveness, acceptability and costs of a hospital-at-home programme with usual acute hospital inpatient care. METHOD: Patients aged 55 years or over being treated for an acute medical problem were randomized to receive either standard inpatient hospital care or hospital-at-home care. Follow-up was for 90 days after randomization. Health outcome measures included physical and mental function, self-rated recovery, health status as assessed by the SF-36, adverse events and readmissions to hospital. Acceptability was assessed using satisfaction surveys and the Carer Strain Index. Costs comprised hospital care, care in the home, community services, general practitioner services and personal health care expenses. RESULTS: In all, 285 people were randomized with a mean age of 80 years. There were no significant differences in health outcome measures between the two randomized groups. Significantly more patients receiving care at home reported high levels of satisfaction, as did more of their relatives. Relatives of the care-at-home group also reported significantly lower scores on the Carer Strain Index. However, the mean cost per patient was almost twice for patients treated at home (NZ 6524 dollars) as for standard hospital care (NZ 3525 dollars). A sensitivity analysis indicated that, if the service providing care in the home had been operating at full capacity, the mean cost per patient episode would have been similar for both modes of care. CONCLUSIONS: This hospital-at-home programme was found to be more acceptable and as effective and safe as inpatient care. While caring for patients at home was significantly more costly than standard inpatient care, this was largely due to the hospital-at-home programme not operating at full capacity.     

Does the National Health Service want hospital-at-home?

There has been increasing interest in the development of hospital-at-home within the National Health Service (NHS) as a way of shifting resources from secondary to primary care. We describe the development of hospital-at-home schemes in London and draw on data from an evaluation of five such schemes to discuss support for hospital-at-home within the NHS. The study has identified a small but important group of patients who do not want hospital-at-home, as well as resistance to it from some health care professionals and managers, particularly in hospitals. These organizational issues must be taken into account in any evaluation of hospital-at-home, along with issues of quality, outcome and cost. Feasibility studies are needed to identify possible organizational barriers to hospital-at-home and the development work that is required. This service innovation should not be considered in isolation from other services, but rather within the context of a wider debate about the pattern of acute care.     

Does hospital-at-home make economic sense? Early discharge versus standard care for orthopaedic patients.

Hospital-at-home has been promoted as a potentially effective means of replacing costly inpatient care with cheaper domiciliary care. We studied three hospital-at-home schemes in West London providing intensive home care for early discharge orthopaedic patients, comparing their costs with those of standard inpatient care. Although costs per day of hospital-at-home care were lower than those of inpatient care, the schemes appeared to increase the total duration of orthopaedic episodes, so that the costs of standard care, per episode, were lower than those of hospital-at-home. While hospital-at-home may offer considerable future potential, substitution of home care for inpatient care will not necessarily save resources.     

The cost-effectiveness of rehabilitation in the home: a study of Swedish elderly.

OBJECTIVES. To investigate whether care of elderly and disabled patients could be more cost-effective after a short-term hospital stay, we examined the impact of a primary home care intervention program on functional status, use and costs of care after 6 months. METHODS. When clinically ready for discharge from the hospital, chronically ill patients with dependence in one to five functions in personal activities of daily living were randomized to physician-led primary home care with a 24-hour service, and the controls were offered ordinary care. Physical, cognitive, social, and medical functions were assessed in 110 team subjects and 73 controls. Data regarding inpatient days and outpatient visits were collected and converted to costs. RESULTS. Team patients demonstrated better instrumental activities of daily living and outdoor walking and significantly fewer diagnoses and drugs at 6 months. They used less inpatient and more outpatient care compared with the control patients. Significant cost reductions were found in the team group. CONCLUSIONS. This primary home care intervention program is cost-effective, at least for a selection of patients at risk for long-term hospital care.     

Hospital-managed advanced care of children in their homes

A hospital-managed project for the advanced care of children in their homes (SABH) has been established in Sweden. The aim was to provide an alternative to inpatient paediatric care by providing hospital-at-home care to stable infants and children using mobile units based on advanced information and communication technology. The Karolinska Hospital children's ward and emergency room referred children to SABH care. A medical care plan was drawn up by the physicians and nurses responsible for the patient while in hospital, in conjunction with the parents and the patient. In one year, 350 episodes of care requiring 3000 bed-days were managed by SABH in the children's homes rather than at hospital. Forty-two per cent of the patients were aged less than one year, 41% were between one and six years old, and 17% were older than six years. SABH care was at least 30% cheaper than conventional hospital care and patient satisfaction with the service was high. At the conclusion of the two-year project, the SABH became a permanent unit at the Karolinska Hospital.     

A cost-minimization analysis of orthopaedic consultations using videoconferencing in comparison with conventional consulting

We compared the costs of conventional outpatient visits to the surgical department of the University Hospital of Oulu with those of videoconferencing between the primary care centre in Pyh?j?rvi and the University Hospital (separated by 160 km). The cost data were obtained from a randomized controlled trial that included 145 first-admission and follow-up orthopaedic patients. In the telemedicine group the annual fixed costs were 6074 in the hospital and 3910 in the primary care centre. The additional variable costs were 2 in the hospital and 19 in primary care. At a workload of 100 patients, the total cost, including travel and indirect costs, was 87.8 per patient in the telemedicine group and 114.0 per patient in the conventional group (i.e. a total cost saving from the use of teleconsultation of 2620). A cost-minimization analysis showed that telemedicine was less costly for society than conventional care at a workload of more than 80 patients per year. If the distance to specialist care were reduced from 160 km to 80 km, the break-even point increased to about 200 patients per year. Wider utilization of the videoconferencing equipment for other purposes, or the use of less expensive videoconferencing equipment, would make services cost saving even at relatively short distances. The study showed that orthopaedic outpatient telecare can be cost minimizing.     

An Economic Analysis of Psychotherapy for Borderline Personality Disorder Patients

BACKGROUND: BPD is a serious mental illness in which psychotherapy has been shown to improve patient outcomes and reduce the use of health services. In most studies of psychotherapy, lower use of health services has been taken to imply lower health service costs. However, the costs of psychotherapy can offset any cost savings due to reduced use of other health services. AIMS OF THE STUDY: To estimate the net costs of health service use in a group of BPD patients receiving intensive psychotherapy. METHODS: Data on use of inpatient hospital, emergency hospital, ambulatory care, diagnostic tests and medications were collected for the twelve months before psychotherapy and the twelve months after the completion of treatment. Cost estimates were developed using standardised unit costs. RESULTS: There was a saving of approximately $670,000 in health service use over the thirty patients compared to a cost of $130,000 for psychotherapy, giving a net cost saving of $18,000 per patient. Most of this was due to reduced hospital admissions. Cost saving was higher in those patients who were high users of hospital services. Sensitivity analyses were performed; overall, the findings consistently show a reduction in the cost of health services used. DISCUSSION: The group studied consisted of 30 patients and comprised a before/after design. Therefore it does not overcome criticisms of other work in this area, that is of observational studies and small sample sizes. Nonetheless, the results were based on detailed costing of service use, using conservative assumptions and subject to sensitivity analysis. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The use of intensive psychotherapy in BPD patients who are high users of health services, particularly those who have had multiple hospital admissions, is probably warranted until more evidence is available. IMPLICATIONS FOR HEALTH POLICIES: There is little rigorous evidence on the effectiveness and cost-effectiveness of psychotherapy. BPD patients appear to generate high service costs so it is important to establish effective and cost-effective modes of treatment. IMPLICATIONS FOR FURTHER RESEARCH: Further research is warranted to establish accurate patterns of service use in BPD patients, and to identify those groups who will most benefit from intensive psychotherapy. erans.     

Elderly people with cognitive impairment: costing possible changes in the balance of care

The objective of this paper is to investigate the service needs and support costs of elderly people with cognitive impairment on hospital and community health services, primary health care, social services, and informal carers in England. It examines the resource consequences of major changes in the provision of care, exploring the implications for both cost and effectiveness. The study was designed to provide a secondary analysis of the OPCS disability surveys in order to estimate the balance of care, and current provision of services. It also estimates of costs of present provision and potential policy options. Results show large scale improvements in the provision of care for people living in private households and local authority homes require significant increases in funding, but reductions in the provision of long-stay hospital beds can significantly reduce the cost burden to the public purse. Given the increasing demand pressure on health and social care expenditure, it seems unlikely that large scale improvements in the care supplied to elderly people with cognitive impairment can be achieved without some change in the balance of care. The cost of implementing improvements in care for the 200000 people living in private households and the 45000 people in local authority homes could be offset by reducing the provision of costly long stay hospital provision with alternative institutional care such as NHS nursing homes.     

NHS plan. Exclusive offer?

Little consideration has been given to the proposals for social care in the NHS plan. The emphasis on social services' role in unblocking hospital beds ignores their responsibilities to the whole community. The plan is ambiguous on health improvement. There is a risk of health promotion being sidelined.     

A prospective study of health care resource utilisation and selected costs of schizophrenia in France

ABSTRACT: BACKGROUND: Schizophrenia is among the most burdensome and costly illnesses worldwide. To estimate the cost of schizophrenia in France, a longitudinal study was carried out between 1998 and 2002. The main objective of this study was to describe and update the cost of schizophrenia in a longitudinal, representative sample of French patients. The second objective was to identify cost drivers in the treatment of schizophrenia. METHODS: Based on a cohort of 288 French schizophrenic patients during 2 years of prospective follow-up, this study collected clinical, patient reported outcomes, quality of life, functioning, patient management, care giver involvement and resource utilisation data every 6 months. For each service, information was collected on the type of service, the frequency of attendance and type of intervention provided to the patient. Unit costs were based on available French databases. Mean service use and costs over the five time points were estimated using between-effects regression models. RESULTS: In the total sample of 288 patients aged 18-64 years, the mean total cost ([EURO SIGN] 3 534) was mainly accounted for by the cost of inpatient treatment ([EURO SIGN] 1 390) and day care ([EURO SIGN] 1 331). The estimate of the annual cost for direct medical health care for all French schizophrenic patients was [EURO SIGN] 1 581 million, including [EURO SIGN] 621 million for inpatient treatment and [EURO SIGN] 595 million for day care (77 %). The costs for medication accounted for 16.1 % of total annual costs. The remaining costs (6.9 %) included visits to psychiatrists, general practitioners, other physicians and psychologists. The direct resource allocation showed inpatient treatment as the main direct cost. Unemployment was identified as a major indirect cost of schizophrenia treatment. Positive and depressive schizophrenia symptoms at baseline and relapse occurrence during the follow-up period were associated with a higher cost of treatment. Health satisfaction or negative symptoms of schizophrenia at baseline were associated with lower costs. CONCLUSION: Several cost drivers were identified. Based on the results obtained in France, we suggest further analysis of mechanisms that influence the service-specific costs for schizophrenia in other areas of the world.     

Carrot and sticks? The Community Care Act (2003) and the effect of financial incentives on delays in discharge from hospitals in England

BACKGROUND: The belief that many delays in discharge from hospital were caused by social service departments (SSDs) led to the Community Care Act 2003 giving NHS hospitals in England the power to charge SSDs. METHODS: We surveyed 150 SSDs in England about the implementation of the Act and used routine data to analyse trends in the number of delayed discharge patients; the number and cause of delayed discharge bed days by sector; and the proportion of inpatient bed days that consisted of delayed discharges. FINDINGS: Most hospitals opted not to charge SSDs for delays. Almost two thirds of SSDs (62%) made no payment of any kind to an acute hospital in 2004/05 and 2005/06, preferring to work collaboratively. The fall in number of 'delayed discharge patients' is a long term trend which precedes the implementation of the 2003 Act. Delayed discharge bed days accounted for 1.58% of all inpatient bed days in 2004/05. Contrary to popular opinion, the NHS accounted for two thirds (67%) of bed day delays, lack of suitable alternative NHS provision and services is a key factor. Patients are being discharged in greater numbers and earlier in their post-acute recovery phase. There are however questions about the quality and safety of early discharge. For example, emergency hospital readmissions rates have risen from 5.4% in 2002/03 to 6.7% in 2005/06, and patient dissatisfaction is significant. CONCLUSION: Although delays in discharge from acute hospital beds have fallen, the quality of discharge and the capacity of Primary Care Trusts (PCTs) and SSDs to ensure appropriate and adequate post-discharge care is not as it should be. Contrary to popular perception, social services delays are of less significance than delays attributable to the NHS. There is no evidence to support government policy of charging SSDs for delay. Other factors, including NHS provision, are important, and a comprehensive overview of health and social care is vital.     

Performance of hospital-at-home after a randomised controlled trial

OBJECTIVE: To compare the performance of an admission-avoidance hospital-at-home scheme one year after the end of a randomised trial with its performance during the trial. METHODS: Observational study of patients admitted to the scheme during a period of 12-19 months after the trial ended. In addition to routine data from service records, patients were interviewed at three days, two weeks and three months after admission, using the same instruments as used in the trial. RESULTS: All 78 patients admitted to hospital-at-home during the follow-up period were included, and compared with the 95 patients admitted during the trial. The referral rate to hospital-at-home was the same (11 per month) as during the trial. During the trial, patients were randomised to hospital-at-home or hospital, meaning that hospital-at-home worked at about double the trial volume in the post-trial period. Baseline characteristics showed no statistically significant differences except that post-trial patients were less cognitively impaired. There were no statistically significant differences between the groups in survival at two weeks and three months, or in Barthel index, Sickness Impact Profile 68 and Philadelphia Geriatric Morale Scale. Length of stay in hospital-at-home was significantly shorter in the post-trial period (median of five days versus seven, P < 0.001), and more patients received a visit from their general practitioner during the period of admission (54% versus 38%, P = 0.04); otherwise there were no significant differences in process measures. CONCLUSION: Apart from working at higher volume and achieving a shorter length of stay, performance of the hospital-at-home scheme a year after the trial ended was little different from that reported during the trial. This is an example of an observational study providing evidence to support the generalisability of trial findings.     

Cost-Effectiveness of Early Assisted Discharge for COPD Exacerbations in The Netherlands

ObjectivesHospital admissions for exacerbations of chronic obstructive pulmonary disease are the main cost drivers of the disease. An alternative is to treat suitable patients at home instead of in the hospital. This article reports on the cost-effectiveness and cost-utility of early assisted discharge in The Netherlands.MethodsIn the multicenter randomized controlled Assessment of GOing Home under Early Assisted Discharge trial (n = 139), one group received 7 days of inpatient hospital treatment (HOSP) and one group was discharged after 3 days and treated at home by community nurses for 4 days. Health care resource use, productivity losses, and informal care were recorded in cost questionnaires. Microcosting was performed for inpatient day costs.ResultsSeven days after admission, mean change from baseline Clinical Chronic Obstructive Pulmonary Disease Questionnaire score was better for HOSP, but not statistically significantly: 0.29 (95% confidence interval [CI]−0.04 to 0.61). The difference in the probability of having a clinically relevant improvement was significant in favor of HOSP: 19.0%-point (95% CI 0.5%–36.3%). After 3 months of follow-up, differences in effectiveness had almost disappeared. The difference in quality-adjusted life-years was 0.0054 (95% CI−0.021 to 0.0095). From a health care perspective, early assisted discharge was cost saving:−€244 (treatment phase, 95% CI−€315 to−€168) and−€168 (3 months, 95% CI−€1253 to €922). Societal perspective:−€65 (treatment phase, 95% CI−€152 to €25) and €908 (3 months, 95% CI−€553 to €2296). The savings per quality-adjusted life-year lost were €31,111 from a health care perspective. From a societal perspective, HOSP was dominant.ConclusionsNo clear evidence was found to conclude that either treatment was more effective or less costly.     

Buying time II: an economic evaluation of a joint NHS/Social Services residential rehabilitation unit for older people on discharge from hospital

The study's aim was to investigate the cost-effectiveness of an NHS/Social Services short-term residential rehabilitation unit (a form of intermediate care) for older people on discharge from community hospital compared with 'usual' community services. An economic evaluation was conducted alongside a prospective controlled trial, which explored the effectiveness of a rehabilitation unit in a practice setting. The aim of the unit was to help individuals regain independence. A matched control group went home from hospital with the health/social care services they would ordinarily receive. The research was conducted in two matched geographical areas in Devon: one with a rehabilitation unit, one without. Participants were recruited from January 1999 to October 2000 in 10 community hospitals and their eligibility determined using the unit's strict inclusion/exclusion criteria, including 55 years or older and likely to benefit from a short-term rehabilitation programme: potential to improve, realistic, achievable goals, motivation to participate. Ninety-four people were recruited to the intervention and 112 to the control group. Details were collated of the NHS and Social Services resources participants used over a 12-month follow-up. The cost of the resource use was compared between those who went to the unit and those who went straight home. Overall, costs were very similar between the two groups. Aggregated mean NHS/Social Services costs for the 12 months of follow-up were pound 8542.28 for the intervention group and pound 8510.68 for the control. However, there was a clear 'seesaw' effect between the NHS and Social Services: the cost of the unit option fell more heavily on Social Services (pound 5011.56, whereas pound 3530.72 to the NHS), the community option more so on the NHS (pound 5146.74, whereas pound 3363.94 to Social Services). This suggests that residential rehabilitation for older people is no more cost-effective over a year after discharge from community hospital than usual community services. The variability in cost burden between the NHS and Social Services has implications for 'who pays' and being sure that agencies share both pain and gain.     

Preventive home visits to older people are cost-effective

AIMS: There is ongoing debate over the effectiveness of preventive home visits (PHVs) for the elderly. A municipality in the north of Sweden carried out a controlled trial of such visits. Healthy seniors aged 75 years and over received two PHVs per year over 2 years. The aim of this study was to do a cost utility analysis of the intervention. METHODS: The intervention group (n=196) was compared with a control group (n=346), and a cost utility analysis was performed. The analysis was carried out with three different time perspectives. Data were sourced from official documents and medical and social records. RESULTS: From a societal perspective, using a time period of 4 years, the analysis of PHVs to healthy seniors showed net savings. When including estimated future costs for health and elderly care during gained life years, the result changed from a net saving to a cost of Euro 200,000. A lifetime perspective also resulted in net savings if the costs of future health and elderly care were not included in the analysis. In this case, the total costs rose to approximately Euro 900,000. The cost could also be expressed as Euro 14,200 per quality-adjusted life year gained if future costs for elderly care and healthcare were included. CONCLUSIONS: PHVs represent a cost-effective intervention in this setting. The costs are justified by the outcomes.     

Controlling hospital readmission of elderly persons living at home: a risk factor analysis

A large proportion of hospital stays stem from rapid readmission of elderly patients. These patients represent high cost users of inpatient care. Intervention in the hospital admission-readmission cycle may serve the interests of patients and payors alike. Data collected through comprehensive geriatric assessment can be useful in identifying those patients at high risk of readmission and who might benefit from more intensive in-hospital or post hospital attention. However, risk factors for readmission are largely unknown. We conducted a prospective study of elderly patients admitted to a metropolitan teaching hospital medical service and assessed by a geriatric team, to increase our knowledge of the factors associated with hospital readmissions. The most powerful predictor of hospital readmission within 6 months proved to be prior hospitalization. Attempts to reduce rehospitalizations in elderly patients must focus on those with prior recent hospitalizations.     

临床护理路径在老年腹股沟疝患者围术期护理中的应用研究

目的研究临床护理路径在老年腹股沟疝患者护理中的应用。方法选取老年腹股沟疝无张力修补术患者160例,分为临床路径组组及对照组。临床路径组参照临床护理路径表进行护理,对照组采用常规护理模式进行护理。分别比较两组患者平均住院日、平均住院费用,术后并发症、健康教育掌握情况、患者满意度。结果临床路径组的平均住院日、平均住院费用,术后并发症明显低于对照组(P<0.05);临床路径组的健康教育掌握情况、患者满意度显著高于对照组(P<0.05)。结论对腹股沟疝患者实施临床护理路径,可以缩短患者住院天数,降低患者住院费用;减少术后并发症,增加患者对健康教育知识的掌握,提高患者对护理工作的满意度。     

家庭医生签约服务在老年高血压患者社区护理管理中的应用价值

目的:探讨家庭医生签约服务在老年高血压患者社区护理管理中的应用价值。方法:选取2020年1—12月上海市闵行区颛桥社区卫生服务中心收治的200例老年高血压患者作为签约组,另选取同期该社区医院收治的150例未签约老年高血压患者作为对照组。对照组实施常规护理管理,签约组在对照组常规护理的基础上融入家庭医生签约服务,比较两组患者血压控制、服药依从性以及自护能力情况。结果:干预3个月后,两组Morisky用药依从性问卷评分均存在不同程度增长,但签约组明显高于对照组。两组自我护理能力量表评分均存在不同程度上升,但签约组明显高于对照组。两组患者收缩压和舒张压水平均存在不同程度下降,但签约组明显低于对照组。结论:老年高血压患者社区护理管理过程中融入家庭医生签约服务能够改善其服药依从性和自护能力,进一步稳定患者血压水平。     

家庭医生签约服务在老年高血压患者社区护理管理中的应用价值

目的:探讨家庭医生签约服务在老年高血压患者社区护理管理中的应用价值。方法:选取2020年1—12月上海市闵行区颛桥社区卫生服务中心收治的200例老年高血压患者作为签约组,另选取同期该社区医院收治的150例未签约老年高血压患者作为对照组。对照组实施常规护理管理,签约组在对照组常规护理的基础上融入家庭医生签约服务,比较两组患者血压控制、服药依从性以及自护能力情况。结果:干预3个月后,两组Morisky用药依从性问卷评分均存在不同程度增长,但签约组明显高于对照组。两组自我护理能力量表评分均存在不同程度上升,但签约组明显高于对照组。两组患者收缩压和舒张压水平均存在不同程度下降,但签约组明显低于对照组。结论:老年高血压患者社区护理管理过程中融入家庭医生签约服务能够改善其服药依从性和自护能力,进一步稳定患者血压水平。