Developing the Home as an Alternative for Care
Regardless of the healthcare system and its payment formulas, the real value of the new treatment option is in avoiding hospital stays by treating early – before the patient is unstable and requires inpatient care. The key challenge is to find the right patient at the right time.
Early Preventive Use
Early preventive use will invariably result in the treatment of a number of patients who might not have moved on to inpatient stay. For example, they might have responded well to an increase in oral medication. This concept is known as the Number Needed to Treat (NNT). NNT is the number of patients you need to treat to prevent one additional bad outcome, in this case, a hospitalization.
For subcutaneous furosemide is all about patient selection.
The more careful clinicians are in identifying the patient with the highest risk for hospitalization, the lower the NNT will be. If the selection is difficult or poorly done many patients are treated relative to the number of hospital stays avoided.
Place of Service
Many systems are experimenting with treating episodes of worsening heart failure patients in a lower cost setting. The goal is to reduce hospital admissions this way.
Patients who may normally be admitted for e.g., 3-5 days to receive IV diuretics may now still be be treated with daily parenteral furosemide but now in a lower cost setting. This could for example be in an eldercare facility, nursing homeor or residence with the help of a home health service.
One of these models is the “Hospital at Home” program originally pioneered by Johns Hopkins. A combination of home health services and remote monitoring allows certain patients to be treated at home at a lower cost while avoiding the risks and inconvenience of an inpatient stay.
New subcutaneous treatment may facilitate these alternative site care programs by avoiding the need to place an IV and allowing caregivers other than certified nurses and EMTs to administer furosemide.
As with the early treatment, alternate site treatment programs also require careful patient selection. In practice, it is often more the environment of the alternate site than patient characteristics. Many patients do not necessarily need to be in a hospital bed for diuresis treatment. However it requires a good home/nursing home setup where the heart failure patient can receive custodial care, support and observation needed during the episode of congestion and treatment.
Beyond Money
Avoiding inpatient care is more than avoiding an expensive bill. Hospitalizations are especially hard on elderly patients. The elderly always lose muscle mass, often lose self-care functions and are at risk for complications from the stay.
Hospitalizations are not only costly; they also carry risks, including:
Infection
Older people are more likely to acquire hospital infections.
Delirium
Older people are prone to experiencing delirium during a hospital stay.
Immobility
Immobility may increase or aggravate skin problems including pressure ulcers.
Incontinence
40% – 50% of hospitalized patients aged 65+ are incontinent, many within a day of hospitalization.
Decline in Independence
12% of patients aged 70+ see a decline in their ability to undertake key daily activities (bathing, dressing, eating, moving around and toileting) during their hospital stay.
Muscle Loss
Older people have a lower muscle mass and experience a more rapid decline with bed rest. Elderly may experience a loss in muscle mass and strength of 11-12% per week as a result of bed rest. Reduced muscle mass results in a loss of function and self-sufficiency and an increased risk of falls.
Unnecessary Bed Rest
Patients who suffer from fluid overload generally do not require bed rest. Bed rest is the default position for someone who is admitted to an acute care hospital, regardless of whether bed rest is required for the treatment. This increases risks and adverse consequences that may be avoided with alternative therapies.
Disrupted Sleep
The hospital environment disrupts sleep patterns because of bright lights, loud machines, hallway conversations, regular status checks, and early morning blood draws.