Older persons’ preferences for site of treatment in acute illness

OBJECTIVE: To explore how older persons form preferences for site of medical care by examining their perceptions of home care and hospital care. DESIGN: Qualitative analysis of in-depth interviews using the constant comparative method. SETTING: Respondents’ homes. PARTICIPANTS: Twenty-nine persons age 65 to 89 years who had been hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia and were receiving home care services. MAIN RESULTS: Respondents, who thought of home care only as a means to provide low-intensity and low-frequency services, were initially skeptical about expanded home care services to treat acute illness. Regardless of their opinions about home and hospital, all respondents preferred the site associated with the greatest chance of survival. If the sites offered equal survival, 52% of the respondents preferred treatment at home because of freedom from the constraints of the hospital and the comfort of familiar surroundings. For respondents who preferred the hospital, the home represented a frightening and lonely place to be sick. Respondents’ views of the home and hospital were shaped by their social supports, self-reliance, religious beliefs, and past illness experiences. CONCLUSIONS: Because survival appears to be the most important determinant of preference, home treatment of acute illness is a viable alternative only if it provides outcomes equivalent to those of hospitalization. Strongly held perceptions that home care can only be a low-intensity service may limit preferences for home treatment. When expected outcomes at the two sites are similar, the challenge to the health care system will be incorporating patient preference about the process of care into decisions about the appropriate site of care. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, DC, May 1997. This research was supported by the Picker/Commonwealth Scholars Program.