Advanced Home Health Care and Home Rehabilitation- Reviewing the Scientific Evidence on Costs and Effects

SBU Summary and Conclusions

Background

"Advanced home health care" was introduced in Sweden 20 yearsago as an alternative to hospitalization. The basic intent behind advancedhome health care was to offer patients and family an alternative to hospitalizationwhich would enhance the quality of care for all parties. Naturally, manypatients preferred care at home where they could retain their integrityand be close to family, particularly during the severe stages of diseasenear the end of life. A survey by the Federation of Swedish County Councilsin 1998 showed that a large majority of the interviewees preferred to receivecare at home.

The percentage of elderly in the population has increased steadily duringthe final decades of the 1900s. As the risk for disease increases with age,so does the number of individuals in the population with health disorders.Furthermore, less invasive methods have enabled providers to offer a widerrange of technological and medical interventions, even to those in the higherage groups. Healthcare finances have become increasing strained, which hasled to a reduction in the number of inpatient beds. To compensate for bedreductions, home health care has been extended as a less expensive alternativeto hospitalization.

Given the situation described above, there is a risk that the originalconcepts underlying home health care, ie, free choice and quality care,will be overshadowed. There is a risk that patients will be referred tohome health services without freely choosing this alternative and withoutbeing assured of quality care. Family members may feel overloaded and anxious.Furthermore, there is concern that even advanced long-term care, eg, foradvanced dementia and the frail elderly, will be carried out in the home.Pressure on family members may become too great if this type of care mustbe provided over an extended period. For home health care to be successful,patients must have a home which is well adapted to the care situation andfamily members who are willing to provide such care. The expected durationof care is a decisive factor.

In Sweden, women have a high rate of employment outside of the home.This fact, along with gender roles, must be considered when planning advancedhome health care. If not, the expansion of home health services may resultin adding the care of the elderly to the already heavy responsibilitieswhich women now bear for the care of newborns, children, and grandchildren.

Hence, whether advanced home health care and home rehabilitation aresuperior to, or less expensive than, hospital care is a question of majorimportance from humanitarian, social, and economic perspectives. Part ofthe literature shows home health care to be less expensive, yet other researchhas found it to be more expensive than hospital care. The purpose of thisreport is to synthesize what has actually been reported in the extensivebody of scientific literature.

This report focuses on advanced home health services, also referred toas hospital-at-home, organized around physician-managed teams equipped toreplace hospital care. The report also addresses home rehabilitation aimedat reducing the hospital length of stay and replacing day-care. Home rehabilitationmay also continue for an extended period, to some extent replacing rehabilitationvia normal outpatient services. The basic question addressed here is whetheror not the scientific literature shows advanced home health care and homerehabilitation to be superior to, or less expensive than, hospital basedalternatives.

 

Methods

To determine the scope and cost of home health care and home rehabilitationin Sweden, SBU commissioned Spri to inventory these services throughoutthe country during the autumn of 1998. The results were compared with previousstudies.

Scientific publications addressing the effects and costs of home healthcare were identified by searching databases (1966–1999), checking referencelists, monitoring scientific conferences, and manually searching relevantjournals. In many cases, direct contacts were established with active researchersin the relevant fields.

The minimum criterion for including a study in this review was whetherthe study compared the effects and/or costs of advanced home health care/homerehabilitation with the effects and/or costs of conventional care alternatives.Accepted studies were then classified into one of three quality grades:

- High quality evidence: Usually the results of studies that comparerandomly selected groups.

- Moderate quality evidence: Studies with control groups from other geographicareas, and studies where researchers made special efforts to enhance comparability.

- Low quality evidence: Studies using other types of control groups,since these groups are selected and hence are not adequately comparable.

The same minimum criterion was applied to control groups in the coststudies. The quality of economic estimates were assessed according to aspecial rating scale, and the best studies received more weight when formulatingthe conclusions.

The special areas addressed by the report are:

 

Advanced Home Health Care

- Palliative home health care
- Other advanced home health care

Home Rehabilitation

- Following stroke
- Following orthopedic surgery

An attempt was also made to identify other systematic overview articles.

The conclusions presented in the summary for each special area of theliterature review were graded as A, B, or C, with A representing the strongestscientific evidence and C the weakest.

Results

Scope and Costs

The survey, commissioned by SBU and conducted during the autumn of 1998by Spri, showed that approximately 50 organizations in Sweden offered advancedhome health care. Annually, 10 000 to 12 000 patients received home healthservices. Palliative care in the final phase of life dominated. However,at least one third of the patients received care for earlier stages of chronicdisease. The average length of care was 55 days. Patients age varied from1 to 103 years, 70% were over 65 years of age, and 56% were women.

Based on the 1998 survey, an estimated 662 000 care days per year couldbe provided by home health services. The total cost for these services wasestimated at 580 million SEK in 1997. Home health care assumes that familymembers provide voluntary care. Economic studies have not considered thisfactor. Likewise, the costs for reserve hospital beds have not been included.Hence, the costs to society for home health care might be underestimated.

Given 11.5 million inpatient hospital days, advanced home health carerepresents approximately 5% of the total number of care days per year. Onaverage, this corresponds to a capacity of approximately 29 patients per100 000 population. Where home health care is most frequent in Sweden, thecapacity is doubled.

In 1998, home rehabilitation services were provided to around 5 000 patientsat a cost of approximately 44 million SEK. Hip surgery and stroke patientsdominated. Their median age was 80 years, 67% were women and the averagelength of stay was 27 days. Home rehabilitation might free 2 to 6 hospitalinpatient days per patient, ie, 10 000 to 30 000 inpatient days per year.Releasing beds means that more patients in the aging population have accessto hospital care, eg, for hip surgery or stroke care, without needing toadd expensive inpatient beds.

Literature Search

The literature search yielded different results within the differentsubject areas. In total,
7 207 studies were listed with titles and short summaries. At least twopersons in the group, independent of each other, reviewed the studies. Studiesthat did not contain information relevant to our hypothesis were eliminated.From the large body of scientific publications, 464 were chosen as potentiallyrelevant, and the full articles were acquired. After review, 95 were chosenfor more thorough analysis. Among these were all studies included in thisreport. In many cases, these studies have been published in a series ofdifferent articles. Other review articles were also included, as were severalstudies that were eventually eliminated since they did not meet the minimumquality standards.

Among the studies which met the quality norms, very few were Swedishor Nordic. This observation should be considered when applying the findingsto the situation in Sweden. However, at least within palliative care andhome rehabilitation Swedish studies are available which could be consideredwhen formulating conclusions.

Table 1.1 Number of scientific publications, by subject area,included in various stages of the review process.

Chapter  Subject Area
Initial Search +
Additions
Articles Ordered
Thorough Review
8 Advanced Home Health Care  
8.1 - Palliative home care
5 792
 159
 21
8.2 - Other advanced home health care      
  Acute geriatrics
531
71
9
  Neurology
33
33
2
  Infusion
4
4
-
  Pulmonary diseases
192
40
4
  Pediatrics
181
38
10
9. Home Rehabilitation      
9.1 Following stroke
204
89
29
9.2 Following orthopedic surgery
270
30
20
   Total
7 207
464
95

Palliative Home Health Care

The report includes 21 studies on palliative care involving 7 817 patients.These studies were based on relatively short periods of care in the finalphase of life, and the following conclusions could be drawn from the data.

The scientific literature shows that both patients and family membersare more frequently satisfied with home care than with hospital care (A-gradeevidence). Regarding symptom control, functional ability, and perceivedquality of life, the results of advanced home health care and hospitalizationwere similar (A).

Cost estimates of acceptable quality were presented in five studies judgedto be of moderate to high quality. A large, controlled, nonrandomized studyshowed lower per diem costs for home health care than for hospital care.Three studies showed no statistically significant difference among the directmedical costs of the care alternatives. The fourth, a smaller study, showedlower costs for home health care, but it is uncertain whether this was werestatistically significant.

Hence, the cost estimates are uncertain. However, the scientific evidenceshows that palliative home health care results in patients and family memberswho are more satisfied, while the quality of care is not lower.

 

Other Advanced Home Health Care

The field of acute geriatrics is poorly defined and studied. Severalstudies of elderly individuals with mixed disorders suggested that the numberof hospital days could be reduced (B-grade evidence) without a deteriorationin quality (B). Whether this led to lower costs is unclear.

Home health care for severe chronic pulmonary disease is characterizedby the periodic demand for advanced interventions, thereby replacing hospitalization.In the interim periods, relatively few interventions are needed. Four studiesinvolving 565 patients found that care outcomes defined as lung function,quality of life, and mortality are similar among the types of care (B).Although it was possible to reduce the number of hospital days and acutevisits with home health care teams (B) the costs did not appear to be lowerthan for hospital-based care (C).

Home health care of children was assessed in several high-quality, randomizedstudies and a few smaller studies of lower quality. Treatment outcomes weresimilar among the types of care (B), but home health care resulted in higherquality of life for sick children (B) and their parents, who also were moresatisfied (B). The scientific literature does not show whether home healthcare for children is less expensive than hospital care.

There are no studies on the effects of home health care on neurologicaldisorders. Likewise, infusion treatment of the elderly at home is inadequatelyassessed.

 

Home Rehabilitation Following Stroke and OrthopedicSurgery

Home rehabilitation following stroke has been assessed in seven studiesof relatively high quality, involving 1 487 patients. The outcomes of rehabilitationfor these patients were similar to the outcomes from regular care. Hence,home rehabilitation was shown to be neither better nor worse as regardsthe patients' ability to manage on their own or resume social activities(A-grade evidence). Depression, stress, and reduction in quality of lifewere common among patients and family, to the same extent in home rehabilitationas in other types of rehabilitation (A). Satisfaction with care was alsosimilar (A). Regarding the costs, it was shown that home rehabilitationfor stroke was less expensive than regular day-care during a correspondingperiod, largely due to the high costs for transportation of day-care patientsand full-day treatment several times per week (B). However, when home rehabilitationwas compared with conventional care (ie, hospital care, day care, outpatientvisits, and combinations of these services according to need) the costswere approximately the same even though it was possible to reduce hospitalinpatient days (B).

Home health care involving rehabilitation following orthopedic interventionswas analyzed in ten studies (including 2 302 patients) that met the minimumquality requirements. The outcomes of home health care regarding patientsymptoms, quality of life, and mortality were similar to the outcomes fromhospital care (B) and also the degree of satisfaction among patients (B).The hospital length of stay could be shortened via these interventions (B).However, hospital stays are currently so short that the relevance of previousstudies is questionable. Cost comparisons are uncertain, but do not indicatein this context that home health care and rehabilitation result in economicgains.

 

Conclusions

  • Advanced home health care may serve patients well and in accordance with the ideal image of humanitarian care for adults in the final phase of life and for children. It requires freedom of choice and an effective care organization of good quality with readily accessible hospital beds.

 

  • All studies included in this report address care for shorter periods of time. In palliative care and care of children, both the patients and family members are more satisfied with home health care than with hospital care. Otherwise, the outcomes are similar. There is no solid evidence to show that home health care results in either higher or lower total costs than other care alternatives. At present, freedom of choice and the quality of care should therefore be the driving factors in planning advanced home health care.

 

  • The outcomes of home rehabilitation following stroke and orthopedic surgery are similar to outcomes in alternative types of rehabilitation, and the costs are probably comparable. Even here, the freedom of choice and local conditions should be guiding factors in how to best organize this type of care.

 

Need for Further Research

Since there are few studies concerning Swedish and Nordic conditions,further research is essential. The findings from foreign studies may beless applicable due to social and cultural differences. Relatively comprehensivebackground data are available on the effects of advanced home health careduring the final phase of life and on home rehabilitation of stroke patients.Some information has also been published on Swedish findings in this area.

Regarding other diseases and patient groups, the outcomes of advancedhome health care in Sweden are poorly known. The need for well-designedstudies is especially great, in particular, as regards longer term care,where outcomes and costs have not been investigated. The cost data are generallyuncertain and need to be studied with reliable methodology applicable toSwedish conditions.

Research must incorporate new, well-assessed methods for measuring patientand family experiences regarding the quality of care and life situations.Methods must also be developed and applied to include family inputs whencalculating the positive/negative effects and the costs of informal care.

As regards stroke rehabilitation, there is a major need for studies totest methods aimed at the common problems of depression and reduced qualityof life among patients and their families.

Furthermore, it is necessary to assess advanced home health care andhome rehabilitation in everyday. Scientific studies tend to analyze recentlyestablished activities compared to routine hospital-based care. An importantquestion to consider is whether outcomes deteriorate when new activitiesbecome routine and enthusiasm declines, or whether they improve with increasedexperience.