Ash Clinical News recently interviewed Dr. Bruce Leff of Johns Hopkins in connection with “hospital-at-home”, one of the major changes occurring in hospital care.
Dr. Leff and his team at Johns Hopkins founded the ”Hospital at Home” program in 1995. The program was developed while observing the negative effects of the hospital environment on the elderly. The team witnessed mental and physical deterioration during long stays and much higher adverse reactions to drugs.
According to Dr. Leff, hospitals of the future will consist primarily of operating and emergency rooms and intensive care units. The rate of doctors making house calls fell from forty percent one hundred years ago to only one percent today. Dr. Leff and many others in the medical world see a dramatic reversal of this trend.
It is safe to say that the trend was given momentum by the development of oral chemotherapy agents. This step helped to improve quality-of-life by allowing patients to receive their treatment at home.
Treatment Administered At Home For Deep Vein Thrombosis (DVT)
A significant shift from hospital to home has occurred in DVT therapy. Results of seven clinical trials involving DVT patients were analyzed comparing at home administration of an anticoagulant (low molecular weight heparin) to the standard type of heparin that is administered in the hospital.
Low molecular weight heparin has proven to be somewhat more predictable than the standard version and therefore does not require the same amount of monitoring for dose adjustment.
Adverse events were similar in the groups studied. However, it was noted that there were fewer recurrences of DVT in patients who received treatment at home.TDVT is usually first diagnosed in the doctor’s office. Unless the patient has severe clotting that is causing pain or there is a need for surgery that would require hospitalization, the patient is prescribed medication. The at-home therapy begins with a follow-up by their physician. The doctors acknowledge that patients are exposed to bacterial infections during their hospital stay.
The Cost Saving Factor
When the researchers tallied the number of clinical services provided for all groups, they found that fewer clinical services were required for the at-home program.
The researchers reviewed the cost related to a full hospital stay against the same amount of time the patients received treatment at home. The cost of at-home services was reduced by about thirty percent when all therapy was carried out at home.
List of Benefits of the At-Home Program
Benefits of the At-Home Program include:
- Higher patient satisfaction
- Fewer serious complications
- Improved mortality
- Improved interaction between caregiver and patient
- Lower cost
Agencies Are Adopting the At-Home Program
Medicare was one of the first agencies to adopt the Hospital-at-Home model. The program offers tools to advance the adoption of the model. Implementation includes guidelines to assess patient’s eligibility, check their home environment, and coordinate future nurse, doctor, at-home or virtual visits.
Atrius Health, an organization of doctors, also adopted the at-home model. Atrius arranges for nurses, under contract with the company, to coordinate home care. The nurses also handle medical supplies and many other aspects of the program which are controlled by a command center.
Johns Hopkins staff collaborated with Clinically Home of Tennessee to design an at-home model. Some of the services it provides include management of intravenous lines and diagnostic testing. In this case, doctors do not visit the homes but rely on video technology to interface with the nurses or nurse practitioners who make the actual house calls.
Other Conditions Under Consideration
Pulmonary embolism (PE) has been accepted in Europe and Canada as one of the conditions managed in at-home settings. However, the U.S. has taken a more conservative approach and has not as yet accepted the management of low-risk PE at home. Practice guidelines presenting criteria for either at home or in hospital treatment of PE are currently being developed in the U.S.
Sickle cell disease (SCD) patients are most often treated for complications of the disease at emergency locations rather than at SCD centers. It has been reported that a large number of SCD patients are not able to travel long distances for treatment at SCD centers. An effort is underway to adopt an adequate home-based model for SCD patients affording them more opportunities for treatment.
Cancer patients have begun to see at-home services available perhaps not for treatment of the disease itself but for common side effects that occur as a result of chemotherapy.
Febrile neutropenia involves fever and or infection that occasionally accompanies neutropenia (low neutrophils). This condition is normally treated at an emergency location then the patient is admitted for a hospital stay. Recent studies indicate that in cases deemed low risk it is safe to simply prescribe an oral antibiotic then discharge the patient.
Day Hospitals for Stem-Cell Transplant Patients
The in-hospital stay for stem-cell transplant (HCT) patients is four weeks or possibly longer. The patients also remain in isolation mode during their hospital stay and after they are discharged.
Doctors are greatly aware of the risk of bacterial infection from long hospital confinement. This has prompted a move to “day hospitals.” The patients are treated at the day hospitals and allowed to be at home each evening. It is believed that avoiding a long hospital stay will prevent many hospital-related complications.
HCT Phase 1 Study
Twenty-two patients who received HCT were involved in a Phase 1 study that gauged the patients’ quality of life and any complications that occurred after the transplant. Eligibility requirements for the study included inspecting the patient’s home to determine suitability (free of pathogens, risk of falls, etc.)
Normal pre-transplant conditioning was performed at either a hospital or at a day hospital. Patients were discharged once they had received the stem cell transplant.
Each morning either a nurse practitioner or a PA, physician assistant, went to the patient’s home to examine the patient and take a blood sample for the lab.
Each afternoon a nurse would visit and provide either IV fluids, antibiotics, administer blood transfusions, or other treatments as needed. To the extent possible, complications from the HCT were managed at home with the exception of febrile neutropenia which required treatment at the hospital.
Another complication that required hospital stay was graft-versus-host disease (GVHD) that is commonly associated with HCT. GVHD is a life-threatening complication that occurs when donor stem cells attack the normal tissue of the transplant patient. As a precaution, the first blood transfusion after the HCT was performed in the day hospital.
Researchers concluded that patients who received treatment in their homes on average had fewer complications from infections. Results showed that four patients developed infections in their bloodstream. The patients’ overall satisfaction and improvement were evident.
The Future of the At-Home Program
The next step is already underway with a Phase II study of HCT patients. The researchers intend to show that by remaining in their normal environment patients’ gut microbiomes are preserved and GVHD occurrences are reduced.
Many clinicians are wary of transfusions administered at home due to the fact that reactions are often severe. They point out that clinics offer vital support in these instances. It will be up to the researchers to address their concerns.
In addition to the concern about at-home transfusions there are other issues that may or may not be resolved:
- At-home services are definitely not feasible for all conditions or in all settings.
- Telemedicine may be used in many at-home programs to connect doctors with their patients but getting paid may be problematic.
- Clinicians are concerned that if there is not sufficient monitoring the patients may not adhere to the program. They point out the necessity for follow-up.
- There is the concern that with the transition to home-based models, organizations may be subject to malpractice lawsuits or at a minimum delayed or non-payment for services.
The hospital-at-home concept represents a major change in healthcare. Each new oral drug that is approved provides another avenue to expand these services.