No Place Like Home: House Calls for the 21st Century

Acute hospital care is not always what it’s cracked up to be. Nosocomial infections acquired by hospital inpatients can produce less than satisfactory outcomes. Prolonged bed rest can result in pulmonary emboli. Parenteral medication errors may lead to death.

On a broader scale, a report on the Medicare program by the Dartmouth Atlas Project rendered intriguing results.¹ This project demonstrated that with regard to highimpact, high-technology care, more is definitely not better. A greater supply of specialists and an increase in acute hospital care led to more office visits, increased spending, and poorer outcomes in a Medicare population.

HOSPITAL CARE VERSUS HOME CARE

Ricauda and coworkers² compared hospital treatment of chronic obstructive pulmonary disease (COPD) with home care in a cohort of elderly patients in Italy. In Europe and the United States, COPD is a leading cause of death. In Italy alone, COPD is responsible for 130,000 hospital admissions each year. Furthermore, an admission for COPD is associated with frequent readmissions.

In the Italian study, 104 elderly patients who were to be admitted to the hospital as standard care for an exacerbation of COPD were randomly assigned to hospitalization on a general medical ward (n = 52) or to care at their own home by a geriatric home hospitalization service (n = 52). Care at home was supervised by a physician, and all necessary equipment, drugs, and services were provided, including ECGs, spirometry, and antibiotics. Patients who were treated at home could also receive specialty consultations.

Was there any difference in the 2 populations at 6-month follow-up after these seemingly disparate treatments? The home-care patients experienced fewer readmissions than the hospitalized group (42% vs 87%; P < .001). Only the home-care patients experienced improvements in depression and quality-of-life scores. Costs per day were lower in the home group, but these patients had a longer mean length of “stay,” or requirement for in-home professional services.

WILL “HOUSE CALLS” MAKE A COMEBACK?

As data from the Dartmouth Atlas project are disseminated, there will be a prudent reassessment of the dangers of hospitalization and high-technology interventions, especially in elderly patients. Geriatricians are leading the rest of us to models of care that are safer and more userfriendly, yet still effective. Although house calls have been considered a relic of a bygone era, they may resurface in new ways. There are probably more diseases than COPD that lend themselves to this welcome reinvention.

References:

REFERENCES:

1

. The Dartmouth Institute for Health Policy & Clinical Practice. Tracking the Care of Patients With Severe Chronic Illness: The DartmouthAtlas of Health Care 2008.

http://www.dartmouthatlas.org/atlases/

. Accessed August 7, 2008.

2

. Ricauda NA, Tibaldi V, Leff B, et al. Substitutive “hospital at home” versus inpatient care for elderly patients with exacerbations ofchronic obstructive pulmonary disease: a prospective randomized, controlled trial. J Am Geriatr Soc. 2008;56:493-500.