Acute? care at home. The health and cost effects of substituting home care for inpatient acute care: a review of the evidence.

PURPOSE: To review the evidence regarding the health and cost effects of providing acute care at home in lieu of hospital care. BACKGROUND: The acute hospital represents the current paradigm and gold standard of care for acutely and seriously ill patients. However, the hospital environment may not be ideal for older patients. Iatrogenic complications are common and their incidence increases with age. 1 Older persons commonly experience functional decline in the acute hospital environment, increasing the risk of becoming dependent. 2 In addition, hospital care is very expensive. Given the potential adverse effects of hospitalization on older persons, alternatives to usual hospital care have been developed. Hospital-based models such as Acute Care for the Elderly (ACE) units attempt to make the inpatient hospital experience more friendly for older people. 3 Alternatively, models that have substituted acute care at home for usual hospital inpatient care have been developed. These programs have been referred to as hospital in home, hospital at home, hospital in the home, and home hospital (HH). Semantics in the home care literature has always been challenging, and at times the literature has suffered for combining disparate home care models together for the purposes of analysis. The case of HH is no different. The nature of HH programs has varied greatly and has included programs that substitute entirely for an inpatient admissions and, more commonly, those that facilitate early hospital discharge by providing services that many in the United States would consider standard postacute-hospital-discharge home care. Some programs have focused solely on patients following surgeries such as total knee or hip replacement or hernias, others have targeted older patients with certain medical conditions, still others have combined several surgical and medical conditions into a single study. In addition, other programs have focused on pediatric or psychiatric populations or high-technology programs. These studies have come mainly from the United Kingdom and Australia, countries with national health insurance schemes. This mix of program types is important to keep in mind when reviewing the evidence on HH, and especially when reviewing reviews of HH. This being said, a recent review of HH versus inpatient hospital care in 1997 and updated in 1999 found five studies that met methodological selection criteria. 4 No studies testing models that substituted entirely for an inpatient hospital stay were included. Patients discharged early from hospital to hospital-at-home following surgery had higher satisfaction while caregivers had lower levels of satisfaction. The one study that assessed cost differences found none. DATA SOURCES: Trials eligible for inclusion in the current analysis met the following selection criteria: publication between 1975 and 1998, evaluation of an acute home care program for people at least 1 8 years old with a non-psychiatric health condition who were not receiving terminal care, and use of a control group to evaluate the health and cost effects of the trial. DATA EXTRACTION: Of 1,970 articles published on home care between 1975 and 1998, only 22 met the selection criteria. Two articles were excluded because they were early evaluations of home care for conditions for which later research showed day surgery to he more appropriate. The remaining 20 articles reported on evaluations of 14 different programs.