Saving lives by keeping patients out of hospital
Next time you hear a politician or medical lobby group arguing for “more hospital beds”, perhaps you could flick them the link to this recent study suggesting they have the wrong end of the stick.
Instead, they should be calling for more patients to be cared for at home, suggests a meta-analysis of 61 randomised controlled trials that compared the outcomes for patients and the costs of inpatient care with Hospital in the Home care.
The study found death and readmission rates were lower in patients who avoided admission and were diverted to home care or who were discharged early into care at home. The number of patients who needed to be treated at home to prevent one death was 50.
The findings, published recently in The Medical Journal of Australia, clearly present a major challenge to the status quo, as noted in the article below by the lead author, the University of NSW’s Professor Gideon Caplan:
“Hospitals exist to treat patients in a way that is convenient for those who work there, and hospital-based experts largely design the health system around the hospital.”
However, he is optimistic that change is occurring, and says this will be driven by patients and their families asking for the safer treatment of Hospital in the Home.
Encouraging patients and their families to ask for safer care
Gideon Caplan writes:
Until the 1930’s admission to hospital was something to be strongly resisted, as for many patients it was a death sentence. Lack of antisepsis and a paucity of effective therapeutic options led to high mortality rates and meant that most people preferred to be treated at home.
There is no doubt that subsequent improvements have rendered hospitals more attractive. This is certainly clearly illustrated by the large number of hospital-based television dramas where hospitals gleam on the screen.
The staff, usually young, always attractive and wise, sorts out the health, relationship and emotional problems of all and sundry while maintaining a healthy work-life balance.
In reality, we know that there are still many hazards of hospitalisation – delirium, falls, pressure ulcers and cross-infections (as per these articles, here, here, and here). Delirium is a frequent complication of hospitalisation for older people due to a multitude of factors including acute illness, change of environment, disturbance of their sleep-wake cycle and medications.
But the unique concentration of expertise and technology in modern hospitals has rendered equivocation about such details moot. Until now, where we see technological improvement enabling a return to treatment in the home.
Many critical pieces of equipment are now smaller, lighter and more portable, so that the essentials of a hospital ward can fit into the boot of a small car.
Early antibiotics had to be given four times a day, but newer antibiotics can be given once per day, or by a portable infusion system that only needs to be loaded daily. Instead of an infusion to treat clots in the lungs (pulmonary emboli) and legs (deep venous thromboses) that had to be monitored by blood tests and adjusted many times a day, a daily injection can be given.
Such developments have permitted a flowering of Hospital in the Home treatment, treatment in your home that substitutes for treatment in hospital.
This saves the patient from being exposed to all the hazards of hospitalisation listed above, not to mention hospital food, as well as allowing the patient to sleep in their own bed, not having to share a room with a stranger or multiple strangers they’ve never met, who may be calling out all night.
It’s been well known that such treatment is cheaper for the health system. A Deloittes Access Economics report published in 2011 found that Hospital in the Home treatment was on average 32% cheaper for the health system.
This is because the health system saves on the hotel costs of providing a room and meals, as well as having to provide three shifts a day of staff, because Hospital in the Home treatment usually is limited to one or two visits per day.
My colleagues and I have recently published a meta-analysis combining the results of many randomised controlled trials, which found that Hospital in the Home treatment does more than save money. By protecting the patient from the hazards of hospitalisation, it also saves lives.
The meta-analysis showed that mortality was reduced by 19% for patients treated at home. This reduction in mortality was seen in all age groups and in all types of studies, whether they were looking at medical, surgical or rehabilitation patients.
The extent of mortality reduction was so powerful that the study found that the number of patients needed to be treated in hospital in the home to save one life was only 50.
This compares favourably with other life saving interventions, such as drugs used to treat blood pressure, where 69 people need to be treated for 5 years to save one life, or drugs to lower cholesterol where 89 people need to be treated for one year to save one life.
Of course, many surgical procedures and other treatments cannot safely be done on or around the kitchen table, but the day is coming closer when hospitals will only be operating theatres and intensive care units. Many patients will be better off for that.
To enable this shift to occur will require a change in focus, from the health system, the public and the media, to worry about how many Hospital in the Home beds there are, rather than how many hospital beds; to reallocate resources and priorities.
For most people who work in the hospital there is a quiet disbelief that things will ever change, although they are changing all the time, albeit at a slow but regular rate, and no desire for a diversion of resources to the community.
Managers of health systems have a very few levers of limited impact to pull, inadequate carrots and sticks to drive rapid change, and the inertia of the status quo to deal with.
Hospitals exist to treat patients in a way that is convenient for those who work there, and hospital-based experts largely design the health system around the hospital.
But things are changing.
In some areas, Hospital in the Home treatment is 5% of hospital level “inpatient” treatments.
To accelerate this change may require a crisis, or a change in public attitudes: once patients and their families start asking for the safer treatment of Hospital in the Home.