Home and Community Care Digest
Background: This study was undertaken by Aukland Hospital in New Zealand to compare the costs, acceptability and health outcomes of homecare versus inpatient care for adults aged 65+. This intensive homecare program consisted of a nurse-led multidisciplinary team which coordinated care for the patient at home, under the clinical direction of geriatricians at Auckland Hospital. Elements included seven days a week nursing care, 24 hour geriatrician on-call, daily chart review, a 24 hour live-in home caregiver if necessary, paraprofessional and rehabilitation services.
Methods: Eligible study participants belonged to one of two patient groups: (1) the admission prevention category included those experiencing a health crisis that would normally require hospital admission, but who could be cared for at home with adequate support; and (2) the early discharge category comprised hospital inpatients who could be discharged early through the provision of clinical services at home. Two hundred and eighty-five patients were randomized to receive either homecare or hospital inpatient care. Health outcomes examined included changes in personal and instrumental activities of daily living, cognitive function, self-reported recovery, health status after 90 days, hospital readmission, falls, bladder and bowel problems, long-term care admission, and death. Acceptability of homecare was measured at 90 days using a satisfaction survey. Costs included direct costs of health care and support services in the 30 days following randomization, and included specialty care received, length of stay, attendance at outpatient clinics, and use of paraprofessional services. For both groups, estimates were made for overhead costs. Pharmaceutical costs and costs incurred by patients for all items other than direct care were excluded.
Findings: Most of the patients were elderly women living alone and receiving care for a range of conditions such as fractures, stroke, and cardiac diagnoses. The average duration of care was 8.8 days for homecare patients and 5.7 days for hospital patients. There were no notable differences in health outcomes between the two groups. The number of hospital admissions of homecare patients was higher than inpatients in the first 10 days following randomization (as expected since inpatients were still in hospital), but this difference was negligible after 10 days, when the initial care episode was complete. Acceptability measures found that homecare patients and their relatives or caregivers were more satisfied with their care. Total average patient costs were twice as high for the homecare group (NZ $6524) than the hospital group ($3525) and this difference was largely attributed to the longer duration of care for homecare patients. Nevertheless, cost per patient day remained higher for the homecare group (NZ$570) than the hospital group (NZ $538). No differences were found between the groups for personal expenditures or community care costs incurred post-discharge. Because the homecare program was operating below capacity, a sensitivity analysis was performed to estimate costs at full capacity. It revealed that total average costs per homecare patient would decline to NZ $3696.
Conclusions: An intensive homecare program designed to prevent hospital admission or to facilitate early hospital discharge was found to be as safe and effective as regular inpatient care, and to be more acceptable to patients and their families. However, costs for homecare were almost double those of hospital care, even without taking into account the likely substantial indirect personal costs incurred by homecare patients and their families. Results of the sensitivity analysis suggest that it may have been worthwhile to conduct further evaluations after the homecare program had been in existence for a longer period. Unfortunately this particular homecare program was cancelled as a result of its higher costs and therefore, its long-term cost-effectiveness cannot be assessed. Randomized trials comparing intensive home care to hospital care which also include careful cost assessments are rare; similar studies may be worth pursuing in Canada to better understand the optimum allocation of resources between hospital and home care.
Reference: Harris R, Ashton T, Broad J, Connolly G, Richmond D. "The effectiveness, acceptability and costs of a hospital-at-home service compared with acute hospital care: a randomized controlled trial." Journal of Health Services Research and Policy, 2005 10(3), 158-166.
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