Friday, 28 February 2014

Can unnecessary hospitalizations be avoided?

It is said that the best savings in health is in avoidable hospitalisation that doesn’t occur, especially since the use of a hospital bed is the most expensive health resource of all the health offers, but also because if one person, let’s imagine an elderly one with several chronic conditions, can avoid being admitted in hospital, his/her health will suffer less compromising situations. For this reason, all health systems are very active in trying to launch all kinds of measures to reduce the admission of chronic and frail patients.

Dr. Sara Purdy, family physician and Senior Consultant at the University of Bristol, published under the auspices of the King’s Fund, in late 2010, an analysis of what actions reduce the unnecessary hospital admissions and which ones do not. The work of Dr. Purdy is focused only on organisational actions such as home hospitalisation or case management, and, in contrast, does not include strictly clinical factors such as the impact of a new drug for asthma conditions.

See below what actions have been proven to reduce unnecessary hospitalisations (for the source of evidence, consult the King’s Fund paper):

1. Continuing care offered by the family doctor. There is evidence that avoidable admissions occur with greater intensity after working hours (nights and weekends) when the usual primary care service is unavailable.

2. Home hospitalization as an alternative to hospital admission. These programs have shown that if the choice of patients is a good fit, the results are comparable to those of hospital admission, albeit at a somewhat lower or similar cost.

3. Case management specifically geared to mental health. Multidisciplinary action programs in the community are effective, especially if they focus on patients with repeated admissions.

4. Self-care promotion. It seems that if chronic patients understand how their illness affects them and how they should cope with the symptoms that affect them, their dependence on specialised hospital care is reduced. According to experts, the key to success lies in the development of individual action plans.

5. The presence of senior medical staff in the hospitals’ emergency departments. The cited studies show that, to be effective, these doctors (already trained) should review at an early stage those cases arriving at the emergency department not having been sent by a family doctor.

6. Multidisciplinary interventions and remote monitoring for patients with heart problems. The most effective interventions are those that combine monitoring of vital signs with telephone follow-up by nurses, actions that should be part of a personalised plan with the support of specialised equipment.

7. The integration of primary care and specialised care. For this action to be effective, the integration must be effective too i.e. simply moving specialists from hospitals to health centres is not effective.

What is clear from reading the report is that in the seven actions mentioned above, there is evidence of the effectiveness in reducing unnecessary hospital admissions, although the economic studies are either not mentioning this or the results are not sufficiently clear.

There are three other actions that have shown little or no evidence of effectiveness in reducing hospitalisations:

1. Pharmacist at home to check the understanding and the adherence to the medication.
2. Intermediate care: hospitalisation units run by nurses.
3. Case management within the community (except mental health).

In a first reading of the report, it’s disappointing that the case management, which is so trendy now, does not get good results, but as seen in other studies, is a matter of gradual progress and therefore of resources: note that an American program called Evercare regarding the specific performance of nursing in nursing homes, managed to reduce hospitalisations by half (Kane 2003), while in the Hospital of Calella, a even more intensive program than Evercare, with geriatric assessment and a multidisciplinary team, for the intervention within the nursing homes, emergency admissions also decreased significantly (Díaz-Gegúndez 2011). On the other hand, in England a more simplistic approach with only a nurse for case management (Gravelle 2007) failed to reduce hospitalisations. It should be noted that none of these programs include cost estimates and therefore cannot conclude anything about cost-effectiveness.

To end this review, I would like to share a small excerpt from the conclusions of a report from the American Robert Wood Johnson Foundation on the drawing near to the community of patients with complex health needs.

"Care Management defines specialised nursing interventions supported by the doctors and the ancillary equipment. These CM programs are much more effective than a standard case management of telephone follow up from generalist nurses in the primary care units (...)”

"(...) One of the success factors of Care Management is the patients’ choice. CMs programs of intensive performance that group high-risk patients at a single point of performance are very promising. Such programs can be liberating for primary care, in the sense that there would be a small number of highly needy patients that would stop distracting them from their usual work."

Bibliographic reference
  • Purdy S. Avoiding hospital admisiones. What does the research evidence say? The King's Fund. December 2010. Se puede bajar libremente de internet.
  •  Kane RL, Keckhafer G, Flood S, Bershadsky B, Siadaty MS. The Effect of Evercare on Hospital Use. JAGS 2003; 51:1427-34.
  • Díaz-Gegúndez M, Paluzie G, Sanz-Ballester C, Boada-Mejorana M, Terré-Ohme S, Ruiz-Poza D. Evaluación de un programa de intervenciones en residencias geriátricas para reducir la frecuentación hospitalaria. Rev Esp Geriatr Gerontol. 2011; 46:261-4.
  • Gravelle H, Dusheiko M, Sheaffer R, Sargent P, Boada R, Pickard S, Parker S, Roland M. Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data. BMJ 2007; 334:31-4.
  • Bodenheimer T, Berry-Millett R. Care Management of patients with complex health care needs. The Synthesis project. Robert Wood Johnson Foundation. December 2009. Se puede descargar libremente. 

Jordi Varela

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