When the home is better than any hospital
Photo: Theo Heimann/Getty Images
Hospitals can be dangerous places. Hospitalized patients are exposed to communicable diseases, they spend excessive time in bed where they may develop blood clots and become deconditioned, and they receive treatments that can have adverse consequences, such as blood thinners and sleeping pills. In addition, with the incessant beeps and continuous interruptions from hospital staff throughout the night, hospitals are difficult places to try to sleep..
For these reasons, the Slow Medicine philosophy teaches us to avoid hospitalizing our patients except when absolutely necessary.
But perhaps even we have been too liberal in admitting patients.
According to a recent review in JAMA Internal Medicine and a perspective piece in the New England Journal of Medicine (NEJM), many patients who meet standard criteria for hospitalization may be safely managed in their home — the so-called “hospital-at-home” approach. Indeed, the NEJM authors reports that “intensive home health care services as an alternative to hospitalization are becoming a standard option in many health systems around the world, perhaps most notably the United Kingdom, France, New Zealand, and Australia.”
Hospital-at-home programs offer many of the same services available in a hospital setting, including nursing care, infusions, medication administration, laboratory draws, home health aids, and physician oversight. According to the NEJM piece, “clinical conditions that appear amenable to these services as a substitute for hospitalization include exacerbations of heart failure or chronic obstructive pulmonary disease, stable pulmonary embolism or deep-vein thrombosis, pneumonia, and skin or soft-tissue infections such as cellulitis.”
The immediate question that arises about hospital-at-home programs is whether they are safe. This question is addressed, in part, by the JAMA Internal Medicine review, a systematic overview of alternatives to hospital admission. The authors found that, with respect to “mortality rates, disease-specific outcomes, and patient and caregiver satisfaction,” hospital-at-home programs so far appear as good or better than standard hospitalization, though more high quality research is needed to confirm these findings. Fortunately, several [randomized controlled trials] of hospital-at-home programs are underway. (It will also be important to evaluate outcomes among low income populations for whom the home environment may be less conducive to healing.)
As we have argued many times in the past, when a health care innovation is first reported, we should wait for high quality evidence to confirm the findings before systematically adopting the new practice. But we are perhaps a bit more bullish in this instance. Why? Because there is virtually no high quality data defining situations in which hospitalization is necessary — i.e. where the benefits of hospitalization clearly outweigh the risks.
It’s not clear that admitting patients for relatively stable conditions like the ones noted above should have ever become the standard of practice. In fact, it is likely that hospitalization in these circumstances came about mainly as a convenience for clinicians or for billing reasons. So, until there is high quality evidence one way or the other, we feel comfortable supporting hospital-at-home programs that deliver the evidence-based services patients acutely ill patients require.
And on that note, check out Liz Kowalczyk’s report in The Boston Globe last month describing what hospital-at-home programs are like for patients.
