Hospital in the Home A Good Alternative To Traditional Hospital Care
Australia and New Zealand are leading the world in the provision of hospital-in-the-home services. These services, which can be a cheaper alternative to hospital-based care, have expanded in the past decade, successfully treating more complex and acute conditions, with high patient satisfaction.
This issue of the Medical Journal of Australia features two studies, which examine the suitability of community-based care to treat pulmonary embolism and pneumonia.
Dr Dee Richards, Senior Lecturer at the Christchurch School of Medicine and Health Sciences at Otago University in Christchurch, New Zealand, and colleagues, say home treatment of mild to moderately severe pneumonia is an effective alternative to hospital treatment. They say patients with community-acquired pneumonia (CAP) prefer community-based care, which costs around 75 per cent of hospital care.
In the first of its kind, a randomised controlled trial examined 55 emergency department patients from the Christchurch Hospital from July 2002 to October 2003. Researchers found that mild to moderately severe pneumonia can be managed at home by primary care teams provided there are suitable funding structures.
"Although the median number of days to discharge was higher in the home care group (4 days) than in the hospital groups (2 days), there was no difference in the number of days on intravenous antibiotics or on subsequent oral antibiotics," Dr Richards says.
Pegasus Health is an Independent Practitioners Association of about 230 or seventy per cent of general practitioners in Christchurch. The organisation set up an 'Extended Care @Home' service, providing extended medical and nursing care to patients in their homes.
"This is the first model where the full clinical responsibility for patients with CAP is taken by primary care teams. This not only allows patients to remain at home, but also increases the skills and experience of the GP workforce in managing acutely unwell patients in the home environment," Dr Richards says.
Another study in the same issue of the Journal examined 130 patients with pulmonary embolism (PE) who were treated as outpatients in an ambulatory care program attached to the Bankstown-Lidcombe Hospital during 2003.
Dr Bin Ong, Director of the Department of Ambulatory Care, and colleagues, say appropriately selected patients with sub-massive PE can be treated as outpatients and in the home.
Of the 130 patients, 46 per cent were treated totally as outpatients and 54 per cent as early discharge patients. The mean age was 66.4 years. The program was successfully completed for 89 per cent of patients. Fourteen patients (11 per cent) did not complete the program and had to be readmitted to hospital for further treatment.
"Although the outcome is good in most patients, a significant proportion will require admission, emphasising the need for a well defined protocol and close medical supervision. Appropriate selection is one of the key components of success in an ambulatory care program," Dr Ong says.
Despite the positive outcomes, Dr Ong says further research is needed to confirm the results.
Also in the Journal, Dr Andrew Wilson, Reader in General Practice at the University of Leicester, and Pr Stuart Parker, Director of the Sheffield Institute for Studies on Ageing at the University of Sheffield in the UK, confirmed that patients and carers prefer treatment at home, saying there is a growing list of well-defined conditions that can be managed in the home. They say the care can be provided either as a complete alternative to hospital admission, or to support early discharge.
They say that, while there is less consensus about whether treatment at home saves money, a Victorian study showed home care is cheaper, especially if hospital admission was completely avoided, in which case costs were 38 per cent less. The study suggests the Victorian scheme provides the equivalent of more than 400 beds, effectively providing care that would otherwise require the building and maintenance of a large metropolitan hospital.
The authors say the scale of services provided in Australia and New Zealand offers a real alternative to inpatient care, and the evidence should now focus on issues of roll-out and quality control.
The Medical Journal of Australia is a publication of the Australian Medical Association.
CONTACT Dr Dee RICHARDS (NZ) 0011 64 21 419 841 / 0011 64 33 643 613
Dr Bin ONG 0411 127 169 / 02 9722 8637
Dr Andrew WILSON (UK) 0011 44 116 210 9461(h) / 0011 44 116 258 4367 (w)
Judith TOKLEY, AMA Public Affairs, 0408 824 306 / 02 6270 5471