Scott L. Mader

Hospital at Home: Feasibility and Outcomes of a Program To Provide Hospital-Level Care at Home for Acutely Ill Older Patients

Context Hospital care for older people often means iatrogenic complications and a decline in function. Home hospital care might reduce these adverse outcomes. Content Patients were 65 years of age or older and required hospital care for pneumonia, heart failure, chronic obstructive pulmonary disease, or cellulitis. In phase I, they were hospitalized. In phase II, they could choose home hospital care (continuous nursing care followed by at least daily visits from a nurse and a physician). Sixty percent of patients chose home hospital care. Patients who received this type of care had shorter stays; fewer procedures, consultations, and indwelling devices; less delirium; greater satisfaction; and similar functional outcomes. Cautions The study was nonrandomized, and data were missing. Conclusion Home hospital care may be a good alternative for selected patients. The Editors Although the acute care hospital is the standard venue for providing acute medical care, it is expensive and may be hazardous for older persons, who commonly experience functional decline, iatrogenic illness, and other adverse events during care (1-3). Providing acute hospital-level care in a patients home is an alternative to hospital care (4, 5). Although several hospital-at-home models have been studied, there is controversy regarding the effectiveness of this method. In part, this reflects heterogeneity among hospital-at-home models (6). A recent Cochrane review examined surgical and medical early hospital discharge models, terminal care, and admission avoidance, that is, substitutive models. Overall, no differences were found in health outcomes. Patients, but not caregivers, had increased satisfaction with hospital-at-home care, and there was some evidence that substitutive models may be cost-effective (7). However, with some exceptions (8), most of these models would be difficult to distinguish from augmented skilled nursing services, community-based long-term care, or home-based primary care services in the United States. In addition, most studies have been done in countries with single-payer national health insurance systems (7-14). Previous research in the United States has been limited to a pilot study of a physician-led substitutive hospital-at-home model for older persons with acute medical illness (15). The aim of our study was to evaluate the safety, efficacy, clinical and functional outcomes, patient and caregiver satisfaction, and costs of providing acute hospital-level care in a hospital at home that substituted entirely for admission to an acute care hospital for older persons. Methods Patients The target sample was community-dwelling persons, age 65 years and older, who lived in a catchment area and who, in the opinion of a physician not involved in the study, required admission to an acute care hospital for 1 of 4 target illnesses: community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis. Patients were required to meet validated criteria of medical eligibility for hospital-at-home care (16), which were designed to identify patients who would be medically suitable for this type of treatment. The most common reasons for medical ineligibility were uncorrectable hypoxemia (oxygen saturation <90%), suspected myocardial ischemia, and presence of an acute illness, other than the target illness, for which the patient was required to be hospitalized. Study Design This study was a prospective quasi-experiment conducted in 2 consecutive 11-month phases. During the acute care hospital observation phase (1 November 1990 to 30 September 2001), eligible patients were identified and followed through usual hospital care. Study coordinators verified the patients eligibility for hospital-at-home care using a standard protocol at the time of enrollment. During this observation phase of the study, most patients were identified the morning after admission. These patients made up the acute hospital observation comparison group. During the intervention phase (1 November 2001 to 30 September 2002), eligible patients were identified at the time of admission and were offered the option of receiving their care in hospital at home rather than in the acute care hospital. Patients who chose hospital-at-home treatment were never admitted to the acute care hospital but received treatment, after initial evaluation (usually in the emergency department), in their home. The intervention group comprised all patients eligible for hospital-at-home care, irrespective of where they were treated. Approval The institutional review boards from each study site, the coordinating center, and officials at the Center for Health Plans and Providers at the Centers for Medicare & Medicaid Services (CMS) gave their approval for the study. All participants provided informed written consent. Study Sites The study was conducted in 3 Medicare managed care (Medicare + Choice) plans at 2 sites and at a Veterans Administration medical center. Univera Health and Independent Health, in Buffalo, New York, are Medicare + Choice plans that operate in an independent practice association model. These 2 plans collaborated to provide hospital-at-home care and made up 1 study site (site 1). The Fallon Health Care System (site 2), in Worcester, Massachusetts, operates a not-for-profit Medicare + Choice plan, and the Fallon Clinic, a for-profit multispecialty physician group, provides care on a capitated basis to Medicare + Choice beneficiaries. The Portland, Oregon, Veterans Administration Medical Center (site 3) is a quaternary care and teaching facility. Assessments Age, gender, and primary diagnosis were obtained for all eligible patients. Informed written consent was required for all additional data collection: medical record review, cost data review, and interviews. Staff trained at the coordinating center used standard procedures outlined in a detailed training manual to conduct all interviews, assessments, and medical record reviews. At baseline, interrater reliability was verified among the staff. Quality checks of medical record reviews were done midway through the study. Interrater reliability for ratings on the components of the daily patient interview was confirmed in 13 paired observations ( = 0.91). Interrater reliability among study sites was similar. Medical Record Reviews Medical records were abstracted by using a standardized instrument that captured illness acuity, health status, medication use, results of laboratory tests, treatments, the hospital course and complications, health outcomes, and whether treatment standards were met. Illness acuity was determined by using the Acute Physiology and Chronic Health Evaluation II (APACHE II) score (17). Health status was measured by using clinical indicators appropriate to the diagnoses, a checklist of chronic medical conditions, and the Charlson comorbidity index (18). Medication use was defined as the number of prescribed medications taken on a daily basis at the time of admission. Diagnostic and therapeutic interventions were categorized as potentially difficult or not difficult to do in the home. The patients clinical course was characterized according to whether emergency situations (those that required physician evaluation within 30 minutes, such as the development of acute shortness of breath) or critical complications (death, transfer to intensive care setting, intubation, or myocardial infarction) occurred. Clinical care was examined with regard to completion of illness-specific standards of care (19-21). Eligible patients who consented to participate completed a baseline interview that included demographic information, self-reported health status, assessment of sleep, Katz activities (22), Lawton instrumental activities of daily living (23), continence, mobility, the Geriatric Depression Scale (24), Jaeger vision test, the Mini-Mental State Examination (MMSE) (25), the Digit Span Test (26), and evaluation by the Confusion Assessment Method (CAM) (27). Subsequently, patients were evaluated daily until discharge by using a structured interview consisting of the MMSE, Digit Span Test, and CAM rating. A family member, caregiver, or person who knew the patient well was interviewed at the time of admission to complete the modified Blessed Dementia Rating Scale (28). At 2 weeks after admission, patients and family members were interviewed by telephone to obtain the patients current functional status and to assess his or her satisfaction with care. Intervention: The Hospital-at-Home Model of Care The hospital-at-home model of care has been described previously (15). Briefly, a patient requiring admission to the acute care hospital for a target illness was identified in an emergency department or ambulatory site and his or her eligibility status was determined. Nonstudy medical personnel, usually emergency department physicians, made the decision to hospitalize the patient. All patients who were offered but who declined hospital-at-home care were admitted to the acute care hospital. After informed consent was obtained, the patient was transported home by an ambulance. Patients were evaluated by the hospital-at-home physician either in the emergency department or shortly after arriving at home. Patients who required oxygen therapy were sent home with a portable oxygen apparatus pending delivery of home oxygen therapy. The hospital-at-home nurse met the ambulance at the patients home. The patient had subsequent direct one-on-one nursing supervision for an initial period of at least 8 hours at site 3 and for a period of 24 hours at sites 1 and 2. When direct nursing supervision was no longer required, the patient had intermittent nursing visits at least daily. The hospital-at-home physician made at least daily home visits and was available 24 hours a day for urgent or emergent visits. Nursing and other care components, such as durable medical equipme

Immunohistochemical and functional correlations of renal cyclooxygenase-2 in experimental diabetes

Prostaglandins (PGs) generated by the enzyme cyclooxygenase (COX) have been implicated in the pathological renal hemodynamics and structural alterations in diabetes mellitus, but the role of individual COX isoenzymes in diabetic nephropathy remains unknown. We explored COX-1 and COX-2 expression and hemodynamic responses to the COX-1 inhibitor valeryl salicylate (VS) or the COX-2 inhibitor NS398 in moderately hyperglycemic, streptozotocin-diabetic (D) and control (C) rats. Immunoreactive COX-2 was increased in D rats compared with C rats and normalized by improved glycemic control. Acute systemic administration of NS398 induced no significant changes in mean arterial pressure and renal plasma flow in either C or D rats but reduced glomerular filtration rate in D rats, resulting in a decrease in filtration fraction. VS had no effect on renal hemodynamics in D rats. Both inhibitors decreased urinary excretion of PGE(2). However, only NS398 reduced excretion of thromboxane A(2). In conclusion, we documented an increase in renal cortical COX-2 protein expression associated with a different renal hemodynamic response to selective systemic COX-2 inhibition in D as compared with C animals, indicating a role of COX-2-derived PG in pathological renal hemodynamic changes in diabetes.

Satisfaction with Hospital at Home Care

OBJECTIVES: To examine differences in satisfaction with acute care between patients who received treatment in a physician‐led substitutive Hospital at Home program and those who received usual acute hospital care.

Altered Endothelial Nitric Oxide Synthase Targeting and Conformation and Caveolin-1 Expression in the Diabetic Kidney

Experimental diabetes is associated with complex changes in renal nitric oxide (NO) bioavailability. We explored the effect of diabetes on renal cortical protein expression of endothelial NO synthase (eNOS) with respect to several determinants of its enzymatic function, such as eNOS expression, membrane localization, phosphorylation, and dimerization, in moderately hyperglycemic streptozotocin-induced diabetic rats compared with nondiabetic control rats and diabetic rats with intensive insulin treatment to achieve near-normal metabolic control. We studied renal cortical expression and localization of caveolin-1 (CAV-1), an endogenous modulator of eNOS function. Despite similar whole-cell eNOS expression in all groups, eNOS monomer and dimer in membrane fractions were reduced in moderately hyperglycemic diabetic rats compared with control rats; the opposite trend was apparent in the cytosol. Stimulatory phosphorylation of eNOS (Ser1177) was also reduced in moderately hyperglycemic diabetic rats. eNOS colocalized and interacted with CAV-1 in endothelial cells throughout the renal vascular tree both in control and moderately hyperglycemic diabetic rats. However, the abundance of membrane-localized CAV-1 was decreased in diabetic kidneys. Intensive insulin treatment reversed the effects of diabetes on each of these parameters. In summary, we observed diabetes-mediated alterations in eNOS and CAV-1 expression that are consistent with the view of decreased bioavailability of renal eNOS-derived NO.

Comparison of functional outcomes associated with hospital at home care and traditional acute hospital care

OBJECTIVES: To compare differences in the functional outcomes experienced by patients cared for in Hospital at Home (HaH) and traditional acute hospital care.

Age-related changes in vascular adrenergic signaling: clinical and mechanistic implications

A large and growing segment of the general population are age 65 or older, and this percentage will continue to rise. Primary care of this population has, and is becoming a priority for clinicians. Hypertension, orthostatic hypotension, arterial insufficiency, and atherosclerosis are common disorders in the elderly that lead to significant morbidity and mortality. One common factor to these conditions is an age-related decline in beta-adrenergic receptor (beta-AR)-mediated function and subsequent cAMP generation. Presently, there is no single cellular factor that can explain this age-related decline, and thus the primary cause of this homeostatic imbalance is yet to be identified. However, the etiology is clearly associated with an age-related change in the ability of beta-AR receptor to respond to agonist at the cellular level. This article will review what is presently understood regarding the molecular and biochemical basis of age-impaired beta-AR receptor-mediated signaling. A fundamental understanding of why beta-AR-mediated vasorelaxation is impaired with age will provide new insights and innovative strategies for the management of the multiple clinical disorders that effect older people.

Comparison of Stress Experienced by Family Members of Patients Treated in Hospital at Home with That of Those Receiving Traditional Acute Hospital Care

OBJECTIVES: To compare differences in the stress experienced by family members of patients cared for in a physician‐led substitutive Hospital at Home (HaH) and those receiving traditional acute hospital care.

Program at home: a Veterans Affairs Healthcare Program to deliver hospital care in the home.

The Portland Veterans Affairs Medical Center (PVAMC) participated in a research‐based National Demonstration and Evaluation Study of Hospital at Home Care for Elderly Patients. PVAMC continued hospital at home care in a modified form based on the results of that research phase and feedback from patients, families, and staff. The modified clinical program (referred to as Program @ Home) provided care for the same diagnoses (exacerbation of congestive heart failure, exacerbation of chronic obstructive pulmonary disease, community‐acquired pneumonia, cellulitis) but differed from the research‐based demonstration project in that it accepted patients of all ages, accepted early‐discharge patients from the hospital, and provided a less‐intensive physician and nursing model. In the first 42 months, 290 patients were admitted; 23% came from the emergency room, 54% were early hospital discharge, and the remainder came from an outpatient clinic or home care. Average length of stay was 3.2 days, and 37% were younger than 65. The results describe how a home hospital program has been integrated into the clinical care offerings of a managed care health system and how it supports inpatient, primary, emergency, and home care programs.

Identification and management of orthostatic hypotension in older and medically complex patients

Orthostatic hypotension is defined as a drop in systolic blood pressure (BP) of at least 20 mmHg or of diastolic BP of at least 10 mmHg within 3 min of standing. It is uncommon in the healthy elderly. However, it occurs in 30–50% of elderly persons with known risk factors and is another example of a multifactorial geriatric syndrome similar to falls and delirium. Most patients with orthostatic hypotension either have no symptoms or atypical symptoms, and therefore, screening BPs should be taken in all patients with risk factors. The treatment approach is not standardized but a stepped-care algorithm is presented that is likely to be successful for many patients. Future studies need to focus on the potential benefits of screening and treating patients with this disorder.

Viral-Mediated Gene Delivery Of Constitutively Activated GΑS Alters Vasoreactivity

1. Decline in β‐adrenoceptor (β‐AR)‐mediated function occurs with increasing age, as well as in multiple disease conditions. The mechanisms responsible for this decline include alterations in β‐AR itself, β‐AR coupling proteins, such as G‐proteins, or other β‐AR‐linked proteins, such as G‐protein receptor kinases and/or phosphatases.