eMJA: Montalto, Hospital in the home: take the evidence and run

Editorial

Hospital in the home: take the evidence and run

The time for apathy and cynicism towards home-based care is over

MJA 1999; 170: 148-149

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Australians are credited with making global contributions in biomedical research,¹ and the same can now be said for their contribution to developing acute home-based care. Hospital in the home (HIH) units have been established for more than four years in Australia (mainly in Victoria), yet in this short time important work of international standard has shown that HIH is a safe, effective, acceptable and efficient alternative to acute hospitalisation for certain patients and conditions.^2-5 Now, in this issue of the Journal, Caplan and colleagues,⁶ from New South Wales (a virtual HIH desert), report a randomised controlled trial (RCT) of home versus hospital care, something that has hitherto seldom been reported in the medical literature (the only other similar RCT is an Australian study in patients with cystic fibrosis⁷). Caplan et al found that frail elderly patients requiring intravenous therapy or low molecular weight heparin deserve active consideration for HIH care: there were fewer geriatric complications and greater patient and carer satisfaction in the HIH group. Although no differences in the rates of adverse events and death were found, the small numbers of patients involved meant that the study's power to draw these conclusions was limited.

HIH care around the world has varied widely, and so too have the studies it has generated. Thus, for the Cochrane review of HIH care,⁸ a meta-analysis was not possible, and for good reason. In HIH studies so far there have been:

Variations in intervention models;
Non-uniformity of conditions, patients and therapies; and
Relatively small patient numbers, allowing only for large effects to be detected. Other factors impeding meta-analysis have included:
The impact of dedicated and motivated staff self-selected to care for the intervention groups;
The refusal of some patients to consent to remain in hospital when HIH treatment was offered as an option;
The need for units to be well established before any trial; and
The reluctance of established HIH programs to reduce their throughput.

Landmark RCTs of HIH care of patients with deep venous thrombosis have taken four years to complete,⁹ and RCTs of home-based care in the United Kingdom have really examined postdischarge coordination.¹⁰ Americans are educated by their constitution to hold some truths to be self-evident, and the appropriateness of HIH appears to be one of them. They have demonstrated this with an expenditure of 2 billion dollars per annum on HIH programs in the absence of RCT evidence.^11,12

If HIH were, for example, an imaging technology, it would have crossed the threshold from the novel and experimental. But hospitals are insecure -- they have difficulty letting go even when the evidence is there. So, let us assume that this issue of the Journal is a defining moment for HIH in Australia, and NSW in particular. Let us assume that hospital administrators will conclude that the time is now right for a concerted move to HIH care, and that to deny appropriate patients this intervention is no longer sustainable and may even be unethical. Let us even fantasise that private insurers will look favourably at the benefits of HIH care now that they will receive an injection of 1.5 billion dollars of public funds (Private Health Insurance Incentives Bill 1998 (Cwlth)).

How could these interested groups move on with the development of HIH? They might be forgiven for concluding that models for HIH are somewhat ill-defined. In fairness, HIH units have been influenced by the manner in which they were funded, and the background of the staff who volunteered to take on the task. The studies have concentrated on comparisons with inhospital care rather than between HIH models. A more analytical approach is now required, but some principles have emerged.

Firstly, let us get the definition clear. The substitution of acute hospital stay is at the heart of HIH.¹³ Thus, HIH is the delivery of care and services which, without HIH, can only be provided by admission to hospital. At present, the healthcare interventions suited to HIH are intravenous therapy of all types (including antibiotics, antifungals and antivirals, some chemotherapeutic agents, corticosteroids, inotropes, and blood products), and acute anticoagulation. Acute rehabilitation, insulin initiation and some complex wound care are also included in some HIH programs. Although new applications will be found, it is important that HIH should adhere to the demonstrable substitution of hospital inpatient care and not establish intermediate care programs or duplicate current community services.

HIH is probably best established through a stand-alone unit within the hospital, with its own budget and staff. It has its own technologies, such as computerised pumps and peripherally inserted central catheters, and is skilled in the use of pharmaceuticals at home. It has its own body of research. It is expert at assessing people for acute home-based care, with involvement in the actual delivery of that care continually updating its expertise. It accepts patients from all other hospital units, services and disciplines. It is therefore generalist in its approach -- a dangerous attribute in a modern hospital environment -- yet is rapidly accumulating its own core of specialist knowledge. It is able to embrace specialist requirements through direct staffing of nurses with appropriate experience, or through the education of current staff. It is developing specific standards that will allow improvement in quality and benchmarking. Australian Council on Healthcare Standards (ACHS) clinical indicators for HIH care are expected this year.¹⁴

HIH units should offer nurse-administered and medically supervised and attended care. The ability to establish venous access and detect, treat or transfer patients with complications of illness or therapy is required. Twenty-four-hour nursing and medical telephone support, with the ability to visit after hours, is mandatory. There should be clear lines of clinical responsibility and continuity within HIH, and between it and the hospital, with a clear link to the hospital (in Victoria patients retain their inpatient status while in HIH). Community-based healthcare service providers may then be able to deliver HIH services. When patients understand and consent to the service level offered, their acceptance is high, as is their subsequent satisfaction.⁵ Patients who have had nosocomial infections or have chronic or relapsing illnesses best understand the advantages of HIH. There is also a level of community altruism, whereby people understand that, as long as they are cared for appropriately, traditional hospital space should go to those who need it more. To keep this faith, Australian HIHs should reject the notion of these programs being built entirely around self-administration of therapy.

Even with all of these inputs, HIH will still offer care equivalent to traditional hospital care at a lower cost.^11,15 Future studies of hospital and HIH patients examining costs and quality-of-life measures will acknowledge the additional advantages of HIH care. To date, Australian costing studies of HIH have suffered from the problems described earlier for the conduct of trials, together with inconsistent cost-accounting across different hospitals.¹⁶ But, even if HIH offered no cost advantage in direct care, in the context of waiting lists and emergency department backlogs HIH offers capital expansion of the hospital's work at a fraction of the usual cost.

Until recently, hospitals have only seen their future as involving exponential growth. The view that the hospital is an Aladdin's cave, where the rich rewards of medical and nursing skill and biotechnology are gathered and bestowed on those who surrender themselves, might be usefully reassessed.¹⁷ But the real danger is that any such reassessment will merely result in briefer glimpses of the skills and technology where they are genuinely required. This appears to be the current direction of public hospital reform. Hospitals have been accustomed to taking responsibility for only those within their walls. While understandable, this limits the effective use of the technologies and skills held tight within those walls. HIH urges hospitals to adapt their infrastructure to take responsibility for the delivery of appropriate, high quality acute care in and for their community. State and federal health authorities could assist with genuine, targeted medium to long term incentives.

Caplan et al offer the best evidence yet that the time for apathy and cynicism towards HIH should be over. We are at the end of a century of unparalleled advances in medical science and hospital care. Any pause in the speed of advance, or any rationing of access due to the burgeoning costs of acute-care delivery, can allow Western healthcare systems to take stock.¹⁸ In their review, the return to home-based care, so prevalent before the early 20th century, should be seen as maximising the quality use of technology to fulfil the wishes of the patients and their families, reasserting their pre-eminent position within the acute-care system into the 21st century.

Michael Montalto
Director, Frankston Hospital in the Home
Executive Member, Australian Home and Outpatient Intravenous
Therapy Association, Frankston Hospital, Frankston, VIC

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