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1 Post Acute Care Services, Prince of Wales Hospital, Sydney, Australia.
2 School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.
Address correspondence to Dr. Gideon Caplan, Post Acute Care Services, Prince of Wales Hospital, Randwick NSW 2031, Sydney, Australia. E-mail: g.caplan{at}unsw.edu.au
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Abstract |
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Methods. One hundred patients (mean age 70) presenting to the emergency department and assessed by a senior doctor to require admission were randomized to be treated in hospital or at home. We measured the Barthel index, Instrumental Activities of Daily Living (IADL) index, and Mental Status Questionnaire (MSQ) on admission and at discharge.
Results. The HITH-treated group improved in the IADL and MSQ indices, whereas the hospital-treated group improved only in the MSQ. The improvement in IADL scores remained significant after adjusting for age, sex, living arrangements, development of confusion, and length of stay.
Conclusions. HITH offers a safe option for treatment of older patients with a functional advantage over in-hospital care.
Geriatric evaluation and management hospital units improve physical and cognitive function status compared to general medical units by specifically addressing functional impairment, but also by ameliorating the impact of hospitalization on older patients (5). Undoubtedly some of the decline in function is due to the illness, but admission to hospital increases the risk above that of acute illness alone in older patients with and without cognitive impairment (6).
We conducted a randomized controlled trial of Hospital in the Home and have already reported a lower rate of geriatric complications (confusion, urinary and bowel problems), higher patient and caregiver satisfaction, and lower cost; however, we did not report change in functional status (7–9). A recent United States nonrandomized study (10) suggested that treating older patients at home, instead of in hospital, may lead to improved functional outcomes. This prompted us to examine the effects of hospitalization on functional decline in acutely ill elderly patients. We now report the data on physical and cognitive function on admission and discharge.
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METHODS |
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Participants
One hundred patients requiring admission to hospital were randomized to HITH treatment (intervention group) or treatment in hospital (control group). We targeted patients older than 65 years, including those living in nursing homes, but also accepted younger patients. Patients were accepted only if they had been assessed as requiring admission by the relevant medical or surgical team, who were not part of the study team. The medical, surgical, and emergency department (ED) staff were encouraged to refer patients with acute (pneumonia, urinary tract infections, and cellulitis) and subacute (endocarditis and osteomyelitis) infections requiring treatment with intravenous antibiotics, deep venous thrombosis (DVT), minor cerebrovascular accidents (not affecting mobility or swallowing), and cardiac failure.
Patients were excluded from the study if they had evidence of shock (systolic blood pressure < 100 mmHg); if they required oxygen (PaO2 < 60 mmHg); if they were judged too unwell by the study team for any reason other than previously stated; if they had no available caregiver; if they lived outside the local area; or if their home was unsuitable for home treatment (lack of running water, electricity, or an inside toilet; concerns about safety; or dangerous pets).
If any doubts about home suitability arose during the ED assessment, a study nurse visited the home before randomization. The HITH team reserved the ultimate decision as to whether a patient was suitable for home treatment, but this was done before randomization. After informed consent was obtained from the patient (written) and the patient's caregiver (verbal), randomization (stratified according to whether the patient lived at home or in a nursing home, or had DVT) was achieved by computer-generated random numbers coded into sealed envelopes.
The study protocol required that patients in the HITH group be discharged from the hospital within 24 hours of diagnosis. Patients admitted during the day were taken home on the same day, but if they were admitted at night they were kept in the ED until morning. On average, patients went home after 8 hours in the ED, whereas patients waiting for a hospital bed spent an average of 12 hours in the ED. HITH patients receiving intravenous antibiotics were given the first dose in the hospital. The study protocol was approved by the hospital's Research Ethics Committee.
Assessment
Data collection.--
For all study patients, study nurses completed a Barthel index of Activities of Daily Living (ADL) (11), a modified Instrumental Activities of Daily Living (IADL) index (12), and a Mental Status Questionnaire (MSQ) (13) on admission and discharge solely on questionnaire, based on the patients' abilities at the time of admission and discharge. Where patients could not answer, or if there was any doubt, information was corroborated with caregivers. Baseline demographic data on current medical diagnoses, a detailed social history, physical function, medications, and allergies were also recorded. Baseline data was collected prior to randomization, and therefore blind to the patients group allocation, but discharge data was collected at the site of treatment.
Intervention
Hospital treatment.--
Hospital patients (control group) were admitted under the appropriate physician or surgeon of the day and treated in accordance with standard regimens without the intervention of the study team. The hospital team treating the patient was notified that the patient had been included in the trial.
HITH treatment.-- HITH patients (intervention group) were treated according to the presenting diagnosis by the hospital community outreach team. The range of treatments in the study protocol included administration of parenteral antibiotics and other medications, and blood transfusions. Infections were generally treated with once-daily intravenous antibiotics such as ceftriaxone, gentamicin, or vancomycin, as appropriate, according to the result of bacteriological tests, if positive, or by diagnosis. Intravenous access was usually via cannulas inserted by study nurses. Owing to safety concerns, some patients with dementia did not have cannulas left in situ, and were cannulated daily with butterfly cannulas. Patients requiring long term treatment or with difficult venous access were treated via a peripherally inserted central cannula. Patients with DVT were treated with daily subcutaneous enoxaparin injections (1.5 mg/kg) and oral warfarin until their international normalized ratio was 2.0 or above. On average, patients treated at home were seen on 9.0 occasions by a study nurse, 0.8 times by their local doctor, 0.9 times by a doctor from the hospital, 0.2 times by a physiotherapist, and 0.1 times by an occupational therapist. This translates to one visit per day by a study nurse, given that each patient was also seen by a study nurse in the ED.
Follow-Up
All patients were followed for 6 months to ascertain (a) whether they were still alive and (b) their accommodation.
Statistical Analyses
The study had a power of 80%, assuming alpha = 0.05, to find a difference of 20% in the occurrence of complications. All analyses were performed on the basis of intention to treat, using the SPSS for Windows statistical packages (SPSS, Chicago, IL). Continuous data are expressed as means and standard error and were compared by t tests. Fisher's exact test was used to compare proportions. All statistical tests were two-tailed.
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DISCUSSION |
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Why should this difference in functional scores exist, which has been replicated in a nonrandomized trial (10), whereby IADLs change (but not basic ADLs), as measured by the Barthel index? It may be that IADL scores are more responsive to change in the context of acute illness, or perhaps this study lacked the power to detect a change in Barthel scores.
Could there be no change in basic ADLs associated with hospitalization? Many studies which have associated hospital admission with decline in basic ADLs have assessed patients at various times before and after hospitalization (6,14,15). This means that the decline may not have occurred during the admission, but may be a perihospital phenomenon. Mapping of decline in basic ADLs associated with hospitalization in a study of 2200 older patients suggest that more patients (43% of patients aged 70 and older), experience functional decline during the 2 weeks prior to admission compared to the 17% who experience decline during admission (16). However the two groups are not mutually exclusive, with 5% of patients declining prior to as well as during hospitalization. Overall, 35% of patients were discharged with worse function than they had 2 weeks prior to admission. Sager and colleagues (17) found that preadmission IADL scores, along with age and Mini-Mental Status Examination scores, are better predictors of functional decline than are basic ADL scores, but was still able to document significant levels of basic ADL decline. Overall, most studies that investigated ADLs and IADLs as predictors of functional decline found that they were both significant (3). However, because it is much more difficult for patients to keep doing IADLs in the hospital, IADLs may be more likely to decline, or decline faster, in these patients than in patients at home who are able to continue performing their IADLs.
Our study did lack power to detect a small but significant change in Barthel scores. We found a 6% difference in IADL change between the the HITH and hospital groups, whereas there was only a 2% difference in Barthel scores. A power calculation suggests that we would need a sample size more than 10 times larger to find a 2% difference significant. This study also found that both groups significantly improved in their MSQ scores from admission to discharge, although there was no difference between groups. We previously reported that 20% of the hospitalized patients developed confusion in the hospital, whereas none of the HITH patients developed confusion at home; these episodes were almost all short-lived and mid-admission, and would not have changed the results of a test of cognitive function on admission or at discharge (7). It is common for older patients to have some temporary cognitive impairment associated with hospitalization, but whereas there are many studies of delirium we have not been able to find a study that documented the course of cognitive function during admission for all older patients. From experience we know that many patients' cognitive function does improve during admission but, because the studies dwell on patients who deteriorate, one would not realize that on average older patients' cognitive function improves during an acute medical admission.
Why should function decline in the hospital? We know from the many studies already cited that physical function often does decline in the hospital (1–6,14–17). Even when patients are not restricted by stated orders to rest in bed, there are unstated barriers to maintaining functional independence. Patients may stay sitting in a chair because they don't want to get in the way, or because they are waiting for someone to come and tell them to walk, whereas at home they do not need permission to get up to tend to simple tasks or simply to stroll around. So although our study is from a single center, because it is supported by a multicenter study from another country (10), and has an understandable mechanism, we feel it is generalizable.
Previous studies (7–9) demonstrated that HITH treatment as an admission substitution for older ED patients results in less confusion and other geriatric complications such as bowel and bladder problems, greater patient and caregiver satisfaction, lower use of pathology, and lower overall cost. This study confirms the multicenter but nonrandomized finding that HITH treatment also results in improved functional outcomes (10). This suggests some long-term benefit from short-term HITH treatment because we know that functional impairment associated with hospitalization is long lasting (14–17).
If there are so many benefits from HITH treatment, why is it not more popular? Partly because some studies of HITH treatment as early discharge have not found similar benefits (18,19), partly because they did not look for it, and partly because they were providing a different health service. We would argue that this demonstrates the importance of health service design, implementation, investigation, and probably also terminology. HITH/admission substitution is very different from HITH/early discharge although the literature tends to aggregate them (20). Our study supports an expansion of HITH/admission substitution programs, although it does not mean that all hospitals can be closed or that older patients should never be admitted to the hospital. But where clinicians have more options, they can plan care that better matches an individual's needs, whatever the patient's age.
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Footnotes |
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Received April 17, 2004
Accepted June 7, 2004
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