May home hospitalisation (HH)
improve outcome than
conventional hospitalisation in
patients affected with selected
chronic diseases ?
Dr. Federico Ruggeri – Dr. Mariano Barberini*
Service of Anesthesia and Intensive Care
Hospital“G.Ceccarini” Riccione AUSL Rimini
*Dept. Of internal Medicine
S.Salvatore Hospital Pesaro
Italy
Home hospitalisation (HH)
 In these years, the increasing number of
emergency medical admissions caused
higher requests of hospital beds for critically
ill patients.
 Improving the community services may be a
method for reducing the pressure on
emergency hospitals.
Home hospitalisation (HH)
 Home hospitalisation (HH) has acquired
great importance in clinical practice,
because it is necessary to find alternative
models of assistance in chronically ill
patients, in order to reduce duration of
hospital medical treatment and its cost or to
avoid new hospital admissions, if they are
not strictly required.
Home hospitalisation (HH)
 If we consider our problem only under an
economy point view, it’s recently
demonstrated that in Italy over75 elderly
people, representing the 6.5% of total,
spend the 28% of the Medicare
expenditures (ISTAT)
Statistic indexes
 Elderly index
 Over 75
 Dependency index
Home hospitalisation (HH)
 The “hospital at home”
model provides cares that are usually available
only in hospital - at
patient's home, such as
observation, administration
of drugs, respiratory and
nutritionial support, nursing
care, and rehabilitation.
Home hospitalisation (HH)
 Our group’s aim is to promote health and
well-being in patients affected with chronic
diseases, undergoing several treatments, in
order to make easier the therapeutic activity
of implicated medical doctors.
Home hospitalisation (HH)
 Usually, these patients
are referred for their
first HH admission
after few days of
hospital stay , caused
by cardiovascular
and/or respiratory
diseases, old age
disorders or cancer.
Home hospitalisation (HH)
 HH care may be cost effective in patients
who are partially self-sufficient but need
drugs or technical support, such as those
receiving intravenous antimicrobial therapy
or artificial nutritional support
Home hospitalisation (HH)
 Supporting old patients, keeping their
independence of life, restoring and
encouraging self-management in those with
chronic diseases: these are ways for
increasing health-related quality of life,
reducing costs of National Health.
Home hospitalisation (HH):
objectives
 Patient’s satisfaction, good clinical outcomes and
cost savings are the targets we must get.
 Patients with chronic conditions often benefit from
follow-up access by our team: during HH,
integrated care was delivered by a specialised
team.
 Home clinical controls must be numerous and
repeated, clinical cares must be individualised.
Home hospitalisation (HH)
 In a retrospective study, we analysed the
Medicare patients, affected with chronic deseases.
 We collected data that described the number of
home controls and hospital re-entry, the levels of
home medical/nursing therapies and the results
we got.
 This study was necessary in order to have better
educational backgrounds and to enable replies.
Home Artificial Nutrition
Home Artificial Nutrition (HAN) is one of the
aspects of the Home hosptalization ideated
with the target to reduce duration of hospital
medical treatment and its costs.
Home Artificial Nutrition
Undernourishment is common in critically ill patients, in
hospital and after discharge.
It often develops insidiously and its diagnosis is frequently
delayed or missed: in Italy recent epidemilogic studies
have shonwn high under-nourish levels
-20-50% in Hospitalized patients
-40-50% in Hospitalized pediatrics patients
-10-85% in RSA
-10%-30% in Home patients
New protocols of AN and a wide number of parenteral and
enteral nutrition products let us to create the basis of the
service of HAN
Home Artificial Nutrition
Patients are eligible for HAN when there
conditions are present:
 Hypo-aphagia
 Life expentancy 3 months or more
 Collaboration of patient/relatives for selfmanagement
 Adequate background
 Informed consent
Modality of
nutrition
New Cases
million ab/year
pathologies
NED adults
135
(range 62/457)
40% neurol.
50% cancer
NPD
10/15
NPD
02 /4.6
NED pediatrics
17
NPD pediatrics
0,2 /4,9
cancer
Intestinal chronic
infiammatory disease
others
Intestinal chronic
infiammatory disease
Home Artificial Nutrition
 HEN: nutritional liquid formulas are given through
feeding tubes in patients with swallowing
impairment, narrowing of the pharingealesophageal passage, who cannot take food orally,
or to avoid aspiration pneumonia in patients in
coma.
 HPN:it is used when patient has a disease of guts
or digestive organs which makes impossible for
the patients to digest food, so nutrition is given
through a central or periferical vein line.
NAD
 We treated 302 patients in Home Enteral
and Parenteral Nutrition (1999-2003), mainly
applied in patients with neoplasias (36%) or
neurological alterations (35%).
 In enteral nutrition,the most commonly
access route is the nasogastric tube,
although there is an observed increase in
the application of Percutaneous
Gastrostomy (31%).
Distribution nad (302 cases)
GIC
oth.C
Age
Ictus
MIC
Tr.
HIV
Oth.
NAD
 In parenteral nutrition, we treated mainly
neoplasias and mesenteric ischemia: the
majority of patients have non tunnelled tube
or periferic vein cath (67%) and 33% have
an implanted tube.
 There is an obseved complications index
0,05 episodes/patient-year and our index of
hospitalizations is 0,56 hospitalizations/
patient-year.
HH: New cases/year
45
40
35
30
25
HEN
HPN
20
15
10
5
0
1998 1999 2000 2001 2002 2003
NAD
 These percentages are similar in licterature,
although better education and greater
awareness are requred to improve the
quality of care and the clinical outcome for
patients treated by parenteral and enteral
nutrition in hospital and at home.
Home Artificial Nutrition
 The service has an important role at the time of
passage of the patient from hospital to home
 In this period, after the choice of model of nutrition,
it’s necessary to teach the patient’s relatives the
method of home feeding, its characteristics and
possible problems, with the help of medical and
nurses’ staff
 Prognosis of terminally ill patients: The median
physician prognosis was 75 days from hospice
admission
Prognosis of NA
 The main duration of NED is 3 years for a
nerologic patient
 Some months of NPD in patients wih cancer
 Some years or all the life for a pediatric
patient with infiammatory intestinal chronic
desease
Home Artificial Nutrition
 The main target of the service is the selfmanagement of the AN by the patients and,
if necessary, with the help of medical
(experts in nutrition, intensive care and
surgery, nurses) or not medical staff
(relatives, supporting people, volunteers)
Objectives of HH
 Optimization of the therapy
 Therapeutic continuity between hospital and
home
 Decrease of costs and complication
 Reduction of costs for therapeutic protocols
 Integration between hospital and home
 Good quality of patient’s life
 Reduction of new admissions into hospital
Costs
 We have calculated that one of these
patients costs in eurs/one day (with the
same patology):
 353 in intensive care
 257 in post intensive care
 197 in RSA
 55 in home hospitalization
Home hospitalisation (HH):
conclusions
 Our opinion is that HH causes better
outcomes at lower costs than conventional
care, in terms of patient’s satisfaction, good
clinical outcome and cost saving.
 This last effect is due to the shortness of
patient’s hospitalisation.
Home hospitalisation (HH):
conclusions
 Furthermore, higher ratios of patients had
better knowledge of their diseases, better
self-management of their conditions and the
level of satisfaction was greater in many of
them and in their families.
Conclusions
HH provides a well-tolerated long term support in
many patients.
These patients have usually poor prognosis,
caused by many factors, the most important of
which are age and underlying desease.
To have optimal results, it is important to use
accurate selection criteria and good evaluation of
this impact on life quality.