May home hospitalisation (HH) improve outcome than conventional hospitalisation in patients affected with selected chronic diseases ? Dr. Federico Ruggeri

May home hospitalisation (HH) May home hospitalisation (HH) improve outcome than improve outcome than

conventional hospitalisation in conventional hospitalisation in patients affected with selected patients affected with selected

chronic diseases ?chronic diseases ?Dr. Federico Ruggeri – Dr. Mariano Barberini*Dr. Federico Ruggeri – Dr. Mariano Barberini*

Service of Service of AnesthesiaAnesthesia and Intensive Care and Intensive CareHospital“G.Ceccarini” Riccione AUSL RiminiHospital“G.Ceccarini” Riccione AUSL Rimini

*Dept. Of internal Medicine*Dept. Of internal MedicineS.Salvatore Hospital Pesaro S.Salvatore Hospital Pesaro

ItalyItaly

Home hospitalisation (HH)Home hospitalisation (HH)

In these years, the increasing number of In these years, the increasing number of emergency medical admissions caused emergency medical admissions caused higher requests of hospital beds for critically higher requests of hospital beds for critically ill patients.ill patients.

Improving the community services may be a Improving the community services may be a method for reducing the pressure on method for reducing the pressure on emergency hospitals. emergency hospitals.


Home hospitalisation (HH) has acquired Home hospitalisation (HH) has acquired great importance in clinical practice, great importance in clinical practice, because it is necessary to find alternative because it is necessary to find alternative models of assistance in chronically ill models of assistance in chronically ill patients, in order to reduce duration of patients, in order to reduce duration of hospital medical treatment and its cost or to hospital medical treatment and its cost or to avoid new hospital admissions, if they are avoid new hospital admissions, if they are not strictly required.not strictly required.


If we consider our problem only under an If we consider our problem only under an economy point view, it’s recently economy point view, it’s recently demonstrated that in Italy over75 elderly demonstrated that in Italy over75 elderly people, representing the 6.5% of total, people, representing the 6.5% of total, spend the 28% of the Medicare spend the 28% of the Medicare expenditures (ISTAT) expenditures (ISTAT)

Statistic indexesStatistic indexes

Elderly indexElderly index Over 75Over 75 Dependency indexDependency index


The “hospital at home” The “hospital at home” model provides cares - model provides cares - that are usually available that are usually available only in hospital - at only in hospital - at patient's home, such as patient's home, such as observation, administration observation, administration of drugs, respiratory and of drugs, respiratory and nutritionial support, nursing nutritionial support, nursing care, and rehabilitation. care, and rehabilitation.


Our group’s aim is to promote health and Our group’s aim is to promote health and well-being in patients affected with chronic well-being in patients affected with chronic diseases, undergoing several treatments, in diseases, undergoing several treatments, in order to make easier the therapeutic activity order to make easier the therapeutic activity of implicated medical doctors. of implicated medical doctors.


Usually, these patients Usually, these patients are referred for their are referred for their first HH admission first HH admission after few days of after few days of hospital stay , caused hospital stay , caused by cardiovascular by cardiovascular and/or respiratory and/or respiratory diseases, old age diseases, old age disorders or cancer.disorders or cancer.


HH care may be cost effective in patients HH care may be cost effective in patients who are partially self-sufficient but need who are partially self-sufficient but need drugs or technical support, such as those drugs or technical support, such as those receiving intravenous antimicrobial therapy receiving intravenous antimicrobial therapy or artificial nutritional support or artificial nutritional support


Supporting old patients, keeping their Supporting old patients, keeping their independence of life, restoring and independence of life, restoring and encouraging self-management in those with encouraging self-management in those with chronic diseases: these are ways for chronic diseases: these are ways for increasing health-related quality of life, increasing health-related quality of life, reducing costs of National Health.reducing costs of National Health.

Home hospitalisation (HH): Home hospitalisation (HH): objectivesobjectives

Patient’s satisfaction, good clinical outcomes and Patient’s satisfaction, good clinical outcomes and cost savings are the targets we must get. cost savings are the targets we must get.

Patients with chronic conditions often benefit from Patients with chronic conditions often benefit from follow-up access by our team: during HH, follow-up access by our team: during HH, integrated care was delivered by a specialised integrated care was delivered by a specialised team. team.

Home clinical controls must be numerous and Home clinical controls must be numerous and repeated, clinical cares must be individualised. repeated, clinical cares must be individualised.


In a retrospective study, we analysed the In a retrospective study, we analysed the Medicare patients, affected with chronic deseases. Medicare patients, affected with chronic deseases.

We collected data that described the number of We collected data that described the number of home controls and hospital re-entry, the levels of home controls and hospital re-entry, the levels of home medical/nursing therapies and the results home medical/nursing therapies and the results we got. we got.

This study was necessary in order to have better This study was necessary in order to have better educational backgrounds and to enable replies. educational backgrounds and to enable replies.

Home Artificial NutritionHome Artificial Nutrition

Home Artificial Nutrition (HAN) is one of the Home Artificial Nutrition (HAN) is one of the aspects of the Home hosptalization ideated aspects of the Home hosptalization ideated with the target to reduce duration of hospital with the target to reduce duration of hospital medical treatment and its costs.medical treatment and its costs.

Home Artificial NutritionHome Artificial Nutrition Undernourishment is common in critically ill patients, in Undernourishment is common in critically ill patients, in

hospital and after discharge. hospital and after discharge. It often develops insidiously and its diagnosis is frequently It often develops insidiously and its diagnosis is frequently

delayed or missed: in Italy recent epidemilogic studies delayed or missed: in Italy recent epidemilogic studies have shonwn high under-nourish levelshave shonwn high under-nourish levels

-20-50% in Hospitalized patients-20-50% in Hospitalized patients -40-50% in Hospitalized pediatrics patients-40-50% in Hospitalized pediatrics patients -10-85% in RSA-10-85% in RSA -10%-30% in Home patients-10%-30% in Home patients

New protocols of AN and a wide number of parenteral and New protocols of AN and a wide number of parenteral and enteral nutrition products let us to create the basis of the enteral nutrition products let us to create the basis of the service of HANservice of HAN


Patients are eligible for HAN when there Patients are eligible for HAN when there conditions are present:conditions are present:

Hypo-aphagiaHypo-aphagia Life expentancy 3 months or moreLife expentancy 3 months or more Collaboration of patient/relatives for self-Collaboration of patient/relatives for self-

managementmanagement Adequate backgroundAdequate background Informed consentInformed consent

Modality of Modality of nutritionnutrition

New Cases New Cases

million ab/yearmillion ab/year

pathologiespathologies

NED adultsNED adults 135135

(range 62/457)(range 62/457)

40% neurol.40% neurol.

50% cancer50% cancer

NPDNPD 10/1510/15 cancercancer

NPDNPD 02 /4.602 /4.6 Intestinal chronic Intestinal chronic infiammatory disease infiammatory disease

NED pediatricsNED pediatrics 1717 othersothers

NPD pediatricsNPD pediatrics 0,2 /4,90,2 /4,9 Intestinal chronic Intestinal chronic infiammatory diseaseinfiammatory disease

Home Artificial Nutrition Home Artificial Nutrition

HEN: nutritional liquid formulas are given through HEN: nutritional liquid formulas are given through feeding tubes in patients with swallowing feeding tubes in patients with swallowing impairment, narrowing of the pharingeal-impairment, narrowing of the pharingeal-esophageal passage, who cannot take food esophageal passage, who cannot take food orally, or to avoid aspiration pneumonia in patients orally, or to avoid aspiration pneumonia in patients in coma.in coma.

HPN:it is used when patient has a disease of guts HPN:it is used when patient has a disease of guts or digestive organs which makes impossible for or digestive organs which makes impossible for the patients to digest food, so nutrition is given the patients to digest food, so nutrition is given through a central or periferical vein line.through a central or periferical vein line.

NADNAD

We treated 302 patients in Home Enteral We treated 302 patients in Home Enteral and Parenteral Nutrition (1999-2003), mainly and Parenteral Nutrition (1999-2003), mainly applied in patients with neoplasias (36%) or applied in patients with neoplasias (36%) or neurological alterations (35%).neurological alterations (35%).

In enteral nutrition,the most commonly In enteral nutrition,the most commonly access route is the nasogastric tube, access route is the nasogastric tube, although there is an observed increase in although there is an observed increase in the application of Percutaneous the application of Percutaneous Gastrostomy (31%).Gastrostomy (31%).

Distribution nad (302 cases)Distribution nad (302 cases)

GICoth.CAgeIctusMICTr.HIVOth.

NADNAD

In parenteral nutrition, we treated mainly In parenteral nutrition, we treated mainly neoplasias and mesenteric ischemia: the neoplasias and mesenteric ischemia: the majority of patients have non tunnelled tube majority of patients have non tunnelled tube or periferic vein cath (67%) and 33% have or periferic vein cath (67%) and 33% have an implanted tube.an implanted tube.

There is an obseved complications index There is an obseved complications index 0,05 episodes/patient-year and our index of 0,05 episodes/patient-year and our index of hospitalizations is 0,56 hospitalizations/ hospitalizations is 0,56 hospitalizations/ patient-year.patient-year.

HH: New cases/yearHH: New cases/year

0

5

10

15

20

25

30

35

40

45

1998 1999 2000 2001 2002 2003

HENHPN

NADNAD

These percentages are similar in licterature, These percentages are similar in licterature, although better education and greater although better education and greater awareness are requred to improve the awareness are requred to improve the quality of care and the clinical outcome for quality of care and the clinical outcome for patients treated by parenteral and enteral patients treated by parenteral and enteral nutrition in hospital and at home.nutrition in hospital and at home.


The service has an important role at the time of The service has an important role at the time of passage of the patient from hospital to homepassage of the patient from hospital to home

In this period, after the choice of model of nutrition, In this period, after the choice of model of nutrition, it’s necessary to teach the patient’s relatives the it’s necessary to teach the patient’s relatives the method of home feeding, its characteristics and method of home feeding, its characteristics and possible problems, with the help of medical and possible problems, with the help of medical and nurses’ staffnurses’ staff

Prognosis of terminally ill patients: The median Prognosis of terminally ill patients: The median physician prognosis was 75 days from hospice physician prognosis was 75 days from hospice admission admission

Prognosis of NAPrognosis of NA

The main duration of NED is 3 years for a The main duration of NED is 3 years for a nerologic patientnerologic patient

Some months of NPD in patients wih cancerSome months of NPD in patients wih cancer

Some years or all the life for a pediatric Some years or all the life for a pediatric patient with infiammatory intestinal chronic patient with infiammatory intestinal chronic deseasedesease


The main target of the service is the self-The main target of the service is the self-management of the AN by the patients and, management of the AN by the patients and, if necessary, with the help of medicalif necessary, with the help of medical

(experts in nutrition, intensive care and (experts in nutrition, intensive care and surgery, nurses) or not medical staff surgery, nurses) or not medical staff (relatives, supporting people, volunteers)(relatives, supporting people, volunteers)

Objectives of HHObjectives of HH

Optimization of the therapyOptimization of the therapy Therapeutic continuity between hospital and Therapeutic continuity between hospital and

homehome Decrease of costs and complication Decrease of costs and complication Reduction of costs for therapeutic protocolsReduction of costs for therapeutic protocols Integration between hospital and homeIntegration between hospital and home Good quality of patient’s lifeGood quality of patient’s life Reduction of new admissions into hospitalReduction of new admissions into hospital

CostsCosts

We have calculated that one of these We have calculated that one of these patients costs in eurs/one day (with the patients costs in eurs/one day (with the same patology):same patology):

353 in intensive care353 in intensive care 257 in post intensive care 257 in post intensive care 197 in RSA197 in RSA 55 in home hospitalization 55 in home hospitalization

Home hospitalisation (HH): Home hospitalisation (HH): conclusionsconclusions

Our opinion is that HH causes better Our opinion is that HH causes better outcomes at lower costs than conventional outcomes at lower costs than conventional care, in terms of patient’s satisfaction, good care, in terms of patient’s satisfaction, good clinical outcome and cost saving. clinical outcome and cost saving.

This last effect is due to the shortness of This last effect is due to the shortness of patient’s hospitalisation.patient’s hospitalisation.

Home hospitalisation (HH):Home hospitalisation (HH):conclusionsconclusions

Furthermore, higher ratios of patients had Furthermore, higher ratios of patients had better knowledge of their diseases, better better knowledge of their diseases, better self-management of their conditions and the self-management of their conditions and the level of satisfaction was greater in many of level of satisfaction was greater in many of them and in their families.them and in their families.

ConclusionsConclusions

HHHH provides a well-tolerated long term support in provides a well-tolerated long term support in many patients.many patients.

These patients have usually poor prognosis,These patients have usually poor prognosis,

caused by many factors, the most important of caused by many factors, the most important of which are age and underlying desease.which are age and underlying desease.

To have optimal results, it is important to use To have optimal results, it is important to use accurate selection criteria and good evaluation of accurate selection criteria and good evaluation of this impact on life quality.this impact on life quality.

Documents

May home hospitalisation (HH) improve outcome than conventional hospitalisation in patients affected with selected chronic diseases ? Dr. Federico Ruggeri