Outpatient strategies for some acute conditions effective and cheaper

(Reuters Health) - Many acute medical conditions can be treated without admitting patients to the hospital, with no increased risk and, in some cases, higher patient satisfaction, according to a new review.

Researchers analyzed past studies on four alternatives to hospital admission for serious situations like chest pain, heart failure or cancer diagnosis and treatment. The alternatives included emergency room or clinic workup with close outpatient follow-up, specialty quick diagnostic units, “hospital-at-home” care and short stays in dedicated observation units with subsequent outpatient follow-up.

“Importantly, initial work-up in an emergency room or clinic is necessary for risk stratification and initial treatment, but subsequent clinical management can occur in an observation unit, an outpatient clinic or the home,” said lead author Dr. Jared Conley of Massachusetts General Hospital and Harvard Medical School in Boston.

The team studied 25 existing research reviews which included a total of 123 prior studies of outpatient management strategies for acute conditions. Not all of the papers included data on death rates compared to hospitalized patients with the same condition.

But for common serious conditions like pulmonary embolism, community-acquired pneumonia and chemotherapy-induced febrile neutropenia (fever and low blood counts associated with cancer treatment) mortality risk was the same for inpatient and outpatient management.

In general, there was low mortality and high patient satisfaction for quick diagnostic units, and one study found costs were $2,000 to $3,000 lower per patient for quick diagnostic units compared to inpatient care.

For heart failure, chronic obstructive pulmonary disease (COPD) flare-ups, stroke and other conditions, four reviews found no mortality difference between inpatient treatment and hospital-at-home treatment while two reviews found mortality lower at home.

For asthma, chest pain and atrial fibrillation, mortality was the same for observation units and for inpatient management, but patient satisfaction was higher and costs were lower with observation units, the study team reports in JAMA Internal Medicine.

“It should be noted, however, that not all patients within each condition would qualify - only those deemed low-risk (for rapid clinical deterioration) based on inclusion/exclusion criteria and/or clinical scoring systems,” Conley told Reuters Health by email.

Patients often prefer care at home rather than a hospital, he said. “The added benefit of making care more affordable through the use of these alternative management strategies further promotes such care redesign,” Conley said.

“When an acute medical episode arises and care is sought in the clinic or the ER, patients can now better engage in shared-decisionmaking discussions with their doctor regarding disposition, having more options than simply hospital admission or home for qualifying conditions and clinical risk categories,” he said.

For example, with flare ups of COPD patients feel short of breath and need oxygen for a few days, which increasingly can be done in people’s homes with some community support, said Dr. James Chalmers of Ninewells Hospital and Medical School in Dundee, U.K., who was not part of the new study.

“Another good example is for antibiotic treatment - patients needing injection antibiotics used to have to stay in hospital for seven or 14 days - now I have patients every week where we train them to give themselves injections of antibiotics so they can do it at home,” he told Reuters Health by email.

“We need to do more of this and many places including the United States and the U.K. have been moving more and more in this direction for several years. It is really the only way that healthcare will remain sustainable over the next 20-30 years in my opinion,” Chalmers said.

SOURCE: JAMA Internal Medicine, online October 3, 2016.