Proven benefits for chronically ill treated at home
Chronically
ill patients who received home-based intervention experienced
significantly fewer hospital admissions and deaths than those who
received the usual care, with one major exception, according to a unique
study by researchers from the University of South Australia.
Home-based intervention (HBI) specifically targeting seriously ill patients with chronic obstructive pulmonary disease (lung diseases that cause severe breathing difficulties) failed to improve health outcomes. In contrast, previous research showed that patients with congestive heart failure experienced the greatest improvement when receiving HBI as opposed to usual care.
Overall HBI was associated with significantly fewer hospital-based health care costs, a major component of health care expenditure in the chronically ill.
Researchers conducted the randomly controlled study of 528 people suffering from a range of chronic diseases who received either home-based intervention or usual care for a median time of 7.5 years following their initial discharge from a South Australian hospital.
HBI patients received a home visit from the study nurse and pharmacist one week after leaving hospital to assess their physical, clinical and psychosocial status, treatment adherence, understanding of their condition and when to seek medical help, self-care behaviour and to improve liaison with community-based services. Patients with more complex problems were referred to a community pharmacist for regular review. Primary care physicians also received comprehensive reports for long-term follow-up of their patients.
Patients under usual care received discharge information and post-hospitalisation care where required. This included appointments with their primary care and/or hospital physician within two weeks of discharge and regular community nurse visits when required.
The long-term study was a follow-up of an earlier study involving 762 patients including 98 with congestive heart failure (CHF) who responded well to home-based intervention, according to UniSA Post-Doctoral Research Fellow, Dr Sue Pearson, who undertook the study with Chair of Cardiovascular Nursing, Professor Simon Stewart, with UniSA students involved in data collection for the more recent seven year follow-up.
The follow-up study is the first to document such long-term benefits of a disease management program in such a diverse range of chronic conditions.
“We conducted a comprehensive review of 528 patients from the original study using hospital records of in-patient activity and individual case records from both hospital and primary care clinics. It included 260 patients receiving home-based intervention and 268 under usual care, but CHF patients were excluded because they derived the greatest benefits from HBI in the earlier study.
“We examined deaths from all causes; unplanned readmissions; the frequency, duration and cause of repeat hospital stays; and the cost of hospitalisation, which was added to home-based intervention costs,” Dr Pearson said.
Because the original study revealed an increase in readmissions among people with lung diseases but not in other major diagnoses in the HBI group, lung related readmissions were excluded from the follow-up analysis. This resulted in reduced hospital readmissions for HBI patients of 14 per cent relative to UC within two years. When the majority of the patients with lung diseases had died, overall HBI was associated with a 32 per cent reduction in recurrent hospital stay.
The inability of researchers to improve health outcomes in patients with lung diseases supports current evidence from other studies that suggests these patients are generally resistant to the otherwise beneficial effects of this type of intervention. Many patients with advanced respiratory disease, unlike those with CHF, have complex needs that are beyond and even exacerbated by self-care strategies. The researchers believe that programs of care that place greater emphasis on palliative support and treatments will prove to be more successful.
A significant outcome of this study was a reduction in readmissions related to falls for HBI patients, a major health problem for the elderly that commonly results in hospitalisation and death. This is consistent with a major focus to reduce the risk of potentially harmful medications being prescribed to elderly patients, which accounts for up to 15 per cent of hospital admissions related to adverse drug effects.
The total cost of unplanned hospitalisation was $4.8 million for UC and $3.3 million for HBI patients in the study. While the cost of elective admissions was greater in the HBI group than the UC group, total hospital costs remained lower in the HBI group when accounting for the cost of the initial intervention.
The overall benefits of comprehensively assessing patients in their own home and providing tailored intervention based on the same, cannot be understated, according to the researchers.
“This unique study suggests that this form of intervention provides long-term cost benefits via reduced recurrent hospital stay associated with a range of chronic illnesses except lung diseases,” Professor Stewart said.
“If reaffirms the potential for chronic disease management programs to
improve health outcomes in many rather than a few individuals.”