番茄社区

A hospital-at-home model for cancer care led to significantly fewer unplanned hospitalizations and almost a 50% reduction in cost as compared with usual care for patients recently discharged from hospital, a comparative-cohort study showed.

Unplanned hospitalizations occurred 55% less often and healthcare costs were 47% lower among patients who received hospital-level care at home. Total hospital days and emergency department (ED) visits also were lower in the hospital-at-home group. Frequency of ICU admissions did not differ between the two cohorts, reported Kathi Mooney, PhD, RN, of the Huntsman Cancer Institute and University of Utah in Salt Lake City, and colleagues in the .

"Oncology hospital at home shows promise for provision of acute-level care to patients at home while simultaneously improving value and reserving inpatient beds and ED services for critically ill patients," the authors said. "Significant improvements in healthcare utilization may be achievable through oncology hospital-at-home programs. These benefits will only be realized if new payment models recognize the value of providing cancer care at home."

Background

As the name suggests, hospital at home models bring hospital-level care to patient homes, the authors noted. Over the past 10-15 years, multiple studies have demonstrated the feasibility and efficacy of the model of care in nononcology patient populations. Prior studies focused primarily on care for pneumonia, cellulitis, urinary tract infections, and exacerbations of chronic diseases. Interest in has increased in recent years.

The hospital-at-home model is found more often in single-payer healthcare systems. Early efforts to integrate the approach into the U.S. healthcare system focused on geriatric populations, the authors continued. To date, the programs have gained little traction in the U.S., primarily because current reimbursement models do not adequately compensate the type of intensive home-based care that would normally require hospitalization.

The hospital-at-home model has potential to improve outcomes and add value for oncology patients, they stated.

"Such programs could keep patients at home, provide services that would otherwise require hospitalization, and better control symptom fluctuations, while protecting immunosuppressed and frail patients with cancer from exposure to hospital-acquired bacterial and viral infections," Mooney's group explained. "Such programs also have the potential to reduce costs."

In a limited number of clinical trials involving variable care models, nononcology hospital-at-home programs demonstrated safety, reduced hospitalization rates, ED use, and costs, they added.

Study Design, Findings

Mooney and colleagues conducted a prospective study to evaluable the potential for a novel cancer hospital-at-home strategy to reduce unplanned hospitalizations and costs within the first 30 days after a patient's hospital discharge. The study included patients who required continued acute-level medical care after hospital discharge or who had ongoing unstable symptoms that would otherwise require hospitalization.

Depending on a patient's condition, at-home services included acute symptom management, monitoring of cardiovascular or laboratory parameters, oxygen therapy, medication titration, and administration of IV medications (excluding anticancer drugs). Home visits by nurse practitioners and registered nurses varied by patient need. Because insurers did not adequately reimburse such services, Huntsman Cancer Institute covered unreimbursed costs to allow for a full evaluation of the program, the authors noted.

The study included 367 patients, randomized to oncology hospital-at-home care or usual care. The primary outcome was the number of unplanned hospitalizations and healthcare costs during the first 30 days after hospital discharge. Investigators performed propensity-weighted analyses to account for imbalances between the two groups.

The results showed that 19.5% of patients in the oncology hospital-at-home group had at least one unplanned hospitalization as compared with 35.4% of the usual-care group (P=0.001). Mean cost of care decreased from $9,180 for the usual care group to $4,399 for the experimental group (P<0.001). Secondary outcomes generally favored the hospital-at-home group, including:

• Cumulative hospitalization days: 1.4 vs 2.6 (P=0.010)
• Patients with one or more ED visits: 14.2% vs 23.2% (P=0.039)
• One or more ICU stays: 7.1% vs 9.1% (P=0.615)

The data might have underestimated the difference in hospitalization days and length of stay in favor of the hospital at home because of the limitations of a nonrandomized trial, the authors noted.

'Great Thing for Patients'

The oncology hospital-at-home model "seems like a great thing for patients with advanced cancers, who you want to try and have them spend as little time in the hospital as possible," said 番茄社区 contributor Fred Pelzman, MD, of Weill Cornell Medical Associates in New York City.

"You can stay at home where you're less at risk from germs and you have the right people coming to check on you, both in person and virtually, and giving you treatment at home, when that's safe and the patient is stable," said Pelzman, who has written extensively about patient-centered medical homes.

The hospital-at-home has great cost-savings potential, but the savings can be a two-edged sword in some cases, he added.

"The sad truth is that hospitals want money from admissions," said Pelzman. "A program that prevents admissions sometimes bumps up against what's good for the hospital's bottom line."

Services provided through an oncology hospital at home might also overlap with existing hospice and home care services. The overlap could provide opportunities for business collaboration. A hospital-at-home program might contract with hospice and home health services in ways that could benefit both parties, said Pelzman.

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