番茄社区

A program for physician assistants (PAs) to visit patients at home after discharge from cardiac surgery was cost-effective at a center that examined the question.

The net was $39 in savings for each $1 spent on PA home visits after cardiac surgery, , of Staten Island University Hospital and North Shore-LIJ Health System in New York City, and colleagues reported at the in Phoenix.

The study included 1,185 consecutive adult cardiac procedure patients discharged to home, not to rehabilitation or skilled nursing facilities, over a 4-year period. That group was further winnowed to 726 propensity matched on 17 pre-, peri-, and post-operative factors.

Readmission rates were 10% in the 2-year study period when patients got home visits at days 2 and 5 after discharge compared with 17% among those in the 2-year period when they did not get the visits -- a 41% relative difference (P=0.0061).

Notably, patients who did return to the hospital after PA home visits had stays that cost a relative 31% more than averaged by controls -- $56,600 versus $39,100 -- though the difference just missed statistical significance in the analysis (P=0.0547). The difference held after excluding outliers.

While the study couldn't determine the cause of the difference, Nabagiez said it's intuitive that physician assistants' reassurance and medication optimization are going to prevent some of the simple problems from escalating to an emergency visit.

"The easy readmissions in the control group are going to cost less because all they needed are antibiotics or all they needed was a little bit of medication and they stayed a day or less and went home, whereas someone who has been visited twice and still winds up coming in has some serious problems," he said. "It makes sense that someone who fails all manner of outpatient optimization will need more services when they finally do get admitted."

He attributed some of that effect to use of physician assistants rather than nurses, as has been the case in some prior home visit studies.

"To have a practitioner -- whether a PA or nurse practitioner -- who knows the patients, is in there in the ICU taking care of them, they know what's a concerning problem and what's not," Nabagiez told 番茄社区.

Some home health visit programs attempted in heart failure have actually increased the cost of care, Nabagiez noted. "Not all are cost neutral or cost saving."

After accounting for PAs' time and travel expenses, the cost of the program was $25,286 over 2 years, but saved an estimated $977,500 in healthcare billing.

Nabagiez acknowledged that billing doesn't translate directly to reimbursement and that centers in a rural setting or with a large geographic capture area might not see the same savings.

But, "there's no math that I can do that makes it not cost-effective," he said.

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