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 Researchers analyzed past studies on four alternatives to hospital
admission for serious situations like chest pain, heart failure or
cancer diagnosis and treatment. The alternatives included emergency
room or clinic workup with close outpatient follow-up, specialty
quick diagnostic units, “hospital-at-home” care and short stays in
dedicated observation units with subsequent outpatient follow-up.
“Importantly, initial work-up in an emergency room or clinic is
necessary for risk stratification and initial treatment, but
subsequent clinical management can occur in an observation unit, an
outpatient clinic or the home,” said lead author Dr. Jared Conley of
Massachusetts General Hospital and Harvard Medical School in Boston.
The team studied 25 existing research reviews which included a total
of 123 prior studies of outpatient management strategies for acute
conditions. Not all of the papers included data on death rates
compared to hospitalized patients with the same condition.
But for common serious conditions like pulmonary embolism,
community-acquired pneumonia and chemotherapy-induced febrile
neutropenia (fever and low blood counts associated with cancer
treatment) mortality risk was the same for inpatient and outpatient
management.
In general, there was low mortality and high patient satisfaction
for quick diagnostic units, and one study found costs were $2,000 to
$3,000 lower per patient for quick diagnostic units compared to
inpatient care.
For heart failure, chronic obstructive pulmonary disease (COPD)
flare-ups, stroke and other conditions, four reviews found no
mortality difference between inpatient treatment and
hospital-at-home treatment while two reviews found mortality lower
at home.
For asthma, chest pain and atrial fibrillation, mortality was the
same for observation units and for inpatient management, but patient
satisfaction was higher and costs were lower with observation units,
the study team reports in JAMA Internal Medicine.
“It should be noted, however, that not all patients within each
condition would qualify - only those deemed low-risk (for rapid
clinical deterioration) based on inclusion/exclusion criteria and/or
clinical scoring systems,” Conley told Reuters Health by email.
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Patients often prefer care at home rather than a hospital, he said.
“The added benefit of making care more affordable through the use of
these alternative management strategies further promotes such care
redesign,” Conley said.
“When an acute medical episode arises and care is sought in the
clinic or the ER, patients can now better engage in shared-decisionmaking
discussions with their doctor regarding disposition, having more
options than simply hospital admission or home for qualifying
conditions and clinical risk categories,” he said.
For example, with flare ups of COPD patients feel short of breath
and need oxygen for a few days, which increasingly can be done in
people’s homes with some community support, said Dr. James Chalmers
of Ninewells Hospital and Medical School in Dundee, U.K., who was
not part of the new study.
“Another good example is for antibiotic treatment - patients needing
injection antibiotics used to have to stay in hospital for seven or
14 days - now I have patients every week where we train them to give
themselves injections of antibiotics so they can do it at home,” he
told Reuters Health by email.
“We need to do more of this and many places including the United
States and the U.K. have been moving more and more in this direction
for several years. It is really the only way that healthcare will
remain sustainable over the next 20-30 years in my opinion,”
Chalmers said.
SOURCE: http://bit.ly/2cO9ysu JAMA Internal Medicine, online October
3, 2016.
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