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BackgroundHospitals are standard of care for acute illness, but hospitals can be unsafe, uncomfortable, and expensive. Providing substitutive hospital-level care in a patient’s home potentially reduces cost while maintaining or improving quality, safety, and patient experience, although evidence from randomized controlled trials in the US is lacking.ObjectiveDetermine if home hospital care reduces cost while maintaining quality, safety, and patient experience.DesignRandomized controlled trial.ParticipantsAdults admitted via the emergency department with any infection or exacerbation of heart failure, chronic obstructive pulmonary disease, or asthma.InterventionHome hospital care, including nurse and physician home visits, intravenous medications, continuous monitoring, video communication, and point-of-care testing.Main MeasuresPrimary outcome was direct cost of the acute care episode. Secondary outcomes included utilization, 30-day cost, physical activity, and patient experience.Key ResultsNine patients were randomized to home, 11 to usual care. Median direct cost of the acute care episode for home patients was 52% (IQR, 28%; p = 0.05) lower than for control patients. During the care episode, home patients had fewer laboratory orders (median per admission: 6 vs. 19; p < 0.01) and less often received consultations (0% vs. 27%; p = 0.04). Home patients were more physically active (median minutes, 209 vs. 78; p < 0.01), with a trend toward more sleep. No adverse events occurred in home patients, one occurred in control patients. Median direct cost for the acute care plus 30-day post-discharge period for home patients was 67% (IQR, 77%; p < 0.01) lower, with trends toward less use of home-care services (22% vs. 55%; p = 0.08) and fewer readmissions (11% vs. 36%; p = 0.32). Patient experience was similar in both groups.ConclusionsThe use of substitutive home-hospitalization compared to in-hospital usual care reduced cost and utilization and improved physical activity. No significant differences in quality, safety, and patient experience were noted, with more definitive results awaiting a larger trial.Trial Registration NCT02864420.

To compare program adherence and functional capacity between women referred to supervised mixed-sex, supervised women-only, or home-based cardiac rehabilitation (CR). Cardiac Rehabilitation for Heart Event Recovery (CR4HER) was a single-blind, 3 parallel-arm, pragmatic randomized controlled trial. The study took place between November 1, 2009, and July 31, 2013. Low-risk patients with coronary artery disease were recruited from 6 hospitals in Ontario, Canada. Consenting participants completed a preprogram survey, and clinical data were extracted from charts. Participants were referred to CR at 1 of 3 sites. After intake assessment, including a graded exercise stress test, eligible patients were randomized to supervised mixed-sex, supervised women-only, or home-based CR. Six months later, CR adherence and exit assessment data were ascertained. Of the 264 consenting patients, 169 (64.0%) were eligible and randomized. Twenty-seven (16.0%) did not attend, and 43 (25.4%) attended a different model. Program adherence was moderate overall (54.46%±35.14%). Analysis of variance revealed no significant differences based on per-protocol analysis (P=.63), but as-treated, home-based participants attended significantly more than did women-only participants (P<.05). Overall, there was a significant increase in functional capacity preprogram to postprogram (P<.001). Although there were no significant differences in functional capacity by model at CR exit based on per-protocol analysis, there was a significant difference on an as-treated basis, which sustained adjustment. Women attending mixed-sex CR attained significantly higher post-CR functional capacity than did women attending home-based programs (P<.05). Offering women alternative program models may not promote greater CR adherence or functional capacity; however, replication is warranted. Other proven strategies such as action planning and self-monitoring should be applied. clinicaltrials.gov Identifier: NCT01019135.

IntroductionHome respiratory polygraphy (HRP) may be a cost-effective alternative to polysomnography for the diagnosis of sleep apnoea-hypopnoea syndrome (SAHS), but stronger evidence is needed. Normally, patients transport HRP equipment from the hospital to home and back, which may create difficulties for some patients.ObjectivesTo determine both the diagnostic efficacy and cost of HRP (with and without a transportation service moving the device and telematic transmission of data) in a large sample compared with in-hospital polysomnography.MethodsPatients suspected of having SAHS were included in a multicentre study (eight hospitals). They were assigned to home and hospital protocols in random order. Receiver operating characteristic curves were constructed for manual respiratory polygraphy scoring protocol and different polysomnographic cut-off points. Diagnostic efficacies for several polysomnographic cut-off points were explored and costs for two equally effective alternatives were calculated.ResultsOf 366 randomised patients, 348 completed the protocol. The best receiver operating characteristic curve was obtained with a polysomnographic cut-off of the apnoea-hypopnoea index (AHI)≥5. The sensitive HRP AHI cut-off point (<5) had a sensitivity of 96%, a specificity of 57% and a negative likelihood ratio (LR) of 0.07; the specific cut-off (>10) had a sensitivity of 87%, a specificity of 86% and a positive LR of 6.25. The cost of HRP was half that of polysomnography. Telematic transmission costs were similar if the patients' costs were taken in to account.ConclusionHRP is an alternative to polysomnography in patients with suspected SAHS. Telematic procedures may help patients with limited mobility and those who live a long way from the sleep centre.

IntroductionThe combination of a reduction in the Danish hospital bed count, the shortage of hospital staff and demographic changes challenges the Danish hospital capacity. This was further highlighted during the COVID-19 pandemic when hospitals worldwide were overwhelmed by infected patients requiring acute hospital care. To address these challenges, a hospital-at-home (HaH) programme offers an alternative to conventional in-hospital admission. Furthermore, HaH has the potential to improve patient outcomes, reduce costs and increase patient satisfaction. However, few studies have evaluated HaH in a Scandinavian setting, and this article describes the protocol for a randomised controlled trial (RCT) comparing an HaH model with continued conventional in-hospital admission. The main aim of the trial is to evaluate physical activity level and mental wellbeing in patients admitted at home compared with conventionally admitted patients.Methods and analysis110 clinically stable patients from two internal medical wards at Nordsjaellands Hospital in Denmark will be included and randomised in a ratio of 1:1 to either continued conventional in-hospital admission (control group) or virtual HaH model (intervention group). The control group will receive standard hospital treatment, and the intervention group will be transferred home for continued treatment (eg, intravenous antibiotics or oxygen treatment). The primary outcome measures are physical activity assessed using daily step count (during the first 24 hours after inclusion, as an intermediary indicator of the risk of adverse events) and treatment satisfaction (assessed using a patient satisfaction survey). Secondary outcome measures are adverse events of special interest, escalation of care, readmission rate postdischarge (30 days and 90 days), mortality (associated and 7 days, 30 days and 90 days postdischarge), process data (eg, the number of teleconsultations) and a health economic evaluation.Ethics and disseminationThe study was approved by the Danish Research Ethics Committees (no. 2303051) and the Danish Medicines Agency (CIV-23-03-042542) and will be monitored by the Copenhagen University Hospital Good Clinical Practice unit. Results will be published in peer-reviewed journals and presented at relevant national and international conferences. We also plan to communicate the results to relevant stakeholders in the Danish healthcare system.Trial registration numberNCT05920304.

IntroductionThe increasing elderly population has led to a growing demand for healthcare services. A hospital at home treatment model offers an alternative to standard hospital admission, with the potential to reduce readmission and healthcare consumption while improving patients’ quality of life. However, there is little evidence regarding hospital at home treatment in a Danish setting. This article describes the protocol for a randomised controlled trial (RCT) comparing standard hospital admission to hospital at home treatment. The main aim of the intervention is to reduce 30-day acute readmission after discharge and improve the quality of life of elderly acute patients.Methods and analysisA total of 849 elderly acute patients will be randomised in a 1:2 ratio to either the control or intervention group in the trial. The control group will receive standard hospital treatment in a hospital emergency department while the intervention group will receive treatment at home. The primary outcomes of the trial are the rate of 30-day acute readmission and quality of life, assessed using the European Quality of Life-5 Dimensions-5-Level instrument. Primary analyses are based on the intention-to-treat principle. Secondary outcomes are basic functional mobility, resource use in healthcare, primary and secondary healthcare cost, incremental cost-effectiveness ratio, and the mortality rate 3 months after discharge.Ethics and disseminationThe RCT was approved by the Ethical Committee, Central Denmark Region (no. 1-10-72-67-20). Results will be presented at relevant national and international meetings and conferences and will be published in international peer-reviewed journals. Furthermore, we plan to communicate the results to relevant stakeholders in the Danish healthcare system.Trial registration number NCT05360914.

Background Despite growing emphasis on transitional care to reduce costs and improve quality, few studies have examined transitional care improvements in socioeconomically disadvantaged adults. It is important to consider these patients separately as many are high-utilizers, have different needs, and may have different responses to interventions. Objective To evaluate the impact of a multicomponent transitional care improvement program on 30-day readmissions, emergency department (ED) use, transitional care quality, and mortality. Design Clustered randomized controlled trial conducted at a single urban academic medical center in Portland, Oregon. Participants Three hundred eighty-two hospitalized low-income adults admitted to general medicine or cardiology who were uninsured or had public insurance. Intervention Multicomponent intervention including (1) transitional nurse coaching and education, including home visits for highest risk patients; (2) pharmacy care, including provision of 30 days of medications after discharge for those without prescription drug coverage; (3) post-hospital primary care linkages; (4) systems integration and continuous quality improvement. Measurements Primary outcomes included 30-day inpatient readmission and ED use. Readmission data were obtained using state-wide administrative data for all participants (insured and uninsured). Secondary outcomes included quality (3-item Care Transitions Measure) and mortality. Research staff administering questionnaires and assessing outcomes were blinded. Results There was no significant difference in 30-day readmission between C-TraIn (30/209, 14.4 %) and control patients (27/173, 16.1 %), p  = 0.644, or in ED visits between C-TraIn (51/209, 24.4 %) and control (33/173, 19.6 %), p  = 0.271. C-TraIn was associated with improved transitional care quality; 47.3 % (71/150) of C-TraIn patients reported a high quality transition compared to 30.3 % (36/119) control patients, odds ratio 2.17 (95 % CI 1.30–3.64). Zero C-TraIn patients died in the 30-day post-discharge period compared with five in the control group (unadjusted p  = 0.02). Conclusions C-TraIn did not reduce 30-day inpatient readmissions or ED use; however, it improved transitional care quality.

BACKGROUND A randomised trial was performed on patients presenting to hospital with an exacerbation of chronic obstructive pulmonary disease (COPD) to compare outcomes in those managed at home with support with those admitted to hospital in the standard manner. METHODS Over an 18 month period all patients presenting to the Royal Infirmary of Edinburgh on weekdays (n=718) with a diagnosis of an exacerbation of COPD were assessed for inclusion in the trial. Patients with impaired level of consciousness, acute confusion, acute changes on radiography, or an arterial pH of <7.35 or with other serious medical or social reasons for admission were excluded. Patients randomised to home support were discharged with an appropriate treatment package (antibiotics, corticosteroids, nebulised bronchodilators and, if necessary, home oxygen). They were visited by a nurse the following day and thereafter at intervals of 2–3 days until recovery when they were discharged from follow up. Parallel observations were made on patients allocated to normal hospital admission up to the point of discharge. Patients in both groups were assessed at home eight weeks after the initial assessment. RESULTS Among weekday patients 353 (50%) were considered obligatory admissions, 140 (19%) were admitted because of co-morbidity, 17 (2%) because of poor social circumstances, and 24 (3%) did not consent to the trial. The remaining 184 (26%) were randomised (2:1) either to home support or to a standard hospital admission. The median time to discharge was 7 days for the home support group and 5 days for the admitted group (p<0.01); 25% of the home support group and 34% of the admitted group were readmitted before the final assessment at eight weeks (p>0.05). There were no significant differences between the groups in attendances by GPs and carers or in health status measured eight weeks after the initial assessment. Satisfaction with the service was good. The mean total health service cost per patient was estimated as £877 for the home support group and £1753 for the admitted group. CONCLUSIONS This study shows that home supported discharge is a well tolerated, safe, and economic alternative to hospital admission for a proportion of patients referred to hospital for admission for an exacerbation of COPD.

Abstract Objectives: To compare hospital at home care with inpatient hospital care in terms of patient outcomes. Design: Randomised controlled trial with three month follow up. Setting:District general hospital and catchment area of neighbouring community trust. Subjects: Patients recovering from hip replacement (n=86), knee replacement (n=86), and hysterectomy (n=238); elderly medical patients (n=96); and patients with chronic obstructive airways disease (n=32). Interventions: Hospital at home care or inpatient hospital care. Main outcome measures:Dartmouth COOP chart to measure patients' general health status; SF-36 to measure possible limitations in physical functioning of patients with hysterectomy; disease specific measures chronic respiratory disease questionnaire, Barthel index for elderly medical patients, Oxford hip score, and Bristol knee score; hospital readmission and mortality data; carer strain index to measure burden on carers; patients' and carers' preferred form of care. Results: At follow up, there were no major differences in outcome between hospital at home care and hospital care for any of the patient groups except that those recovering from hip replacement reported a significantly greater improvement in quality of life with hospital at home care (difference in change from baseline value 0.50, 95% confidence interval 0.13 to 0.88). Hospital at home did not seem suitable for patients recovering from a knee replacement, as 14 (30%) of patients allocated to hospital at home remained in hospital. Patients in all groups preferred hospital at home care except those with chronic obstructive airways disease. No differences were detected for carer burden. Carers of patients recovering from knee replacement preferred hospital at home care, while carers of patients recovering from a hysterectomy preferred hospital care. Conclusions: Few differences in outcome were detected. Thus, the cost of hospital at home compared with hospital care becomes a primary concern. Key messages Hospital at home schemes are a popular alternative to standard hospital care, but there is uncertainty about their cost effectiveness In our randomised controlled trial we compared hospital at home care with inpatient hospital care for patients recovering from hip replacement, knee replacement, and hysterectomy; elderly medical patients; and those with chronic obstructive airways disease There were no major differences in patients' reported health outcomes between the two treatments, but, because of complications commonly needing hospitalisation, patients recovering from knee replacement did not seem suitable for hospital at home care All patient groups except those with chronic obstructive airways disease preferred hospital at home care Carers of patients recovering from a hysterectomy preferred hospital care, while those of patients recovering from a knee replacement preferred hospital at home care

Exploring new models of medical care requires evaluating the impact of new care strategies not only on physiological parameters but also on the quality of life of the patient. On the other hand the presence of anxiety together with depression requires further consideration when planning appropriate management strategies. The aim of this study was to examine the effectiveness of a home-based cardiac rehabilitation program incorporating an e-Health technology on health-related quality of life associated with symptoms of anxiety and depression in moderate-risk patients. A multicenter, randomized controlled clinical trial was designed to compare a traditional hospital based cardiac rehabilitation program (n = 38, 35 male) with a mixed home surveillance program where patients exercised at home with a remote electrocardiographic monitoring device (n = 33, 31 male). The Short Form-36 (SF-36) Health Survey and the Goldberg questionnaire were used to evaluate quality of life and the presence of symptoms of anxiety and depression respectively. The results of this study show that the type of cardiac rehabilitation program did not influence the improvement in quality of life (p = 0.854), but the presence of symptoms of anxiety and depression did (p = 0.001). Although both programs achieved a decrease in anxiety and depression symptoms and improved functional capacity (p ≤ 0.001), a significant interaction effect was found between the group with or without anxiety and depression symptoms and the type of program in the bodily pain dimension (p = 0.021). Trial registration : Retrospectively registered NCT02796404 (10/06/2016) in clinialtrials.gov.

Acutely ill older persons often experience adverse events when cared for in the acute care hospital. To assess the clinical feasibility and efficacy of providing acute hospital-level care in a patient's home in a hospital at home. Prospective quasi-experiment. 3 Medicare-managed care (Medicare + Choice) health systems at 2 sites and a Veterans Administration medical center. 455 community-dwelling elderly patients who required admission to an acute care hospital for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis. Treatment in a hospital-at-home model of care that substitutes for treatment in an acute care hospital. Clinical process measures, standards of care, clinical complications, satisfaction with care, functional status, and costs of care. Hospital-at-home care was feasible and efficacious in delivering hospital-level care to patients at home. In 2 of 3 sites studied, 69% of patients who were offered hospital-at-home care chose it over acute hospital care; in the third site, 29% of patients chose hospital-at-home care. Although less procedurally oriented than acute hospital care, hospital-at-home care met quality standards at rates similar to those of acute hospital care. On an intention-to-treat basis, patients treated in hospital-at-home had a shorter length of stay (3.2 vs. 4.9 days) (P = 0.004), and there was some evidence that they also had fewer complications. The mean cost was lower for hospital-at-home care than for acute hospital care (5081 dollars vs. 7480 dollars) (P < 0.001). Possible selection bias because of the quasi-experimental design and missing data, modest sample size, and study site differences. The hospital-at-home care model is feasible, safe, and efficacious for certain older patients with selected acute medical illnesses who require acute hospital-level care.