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Study: Hospital-at-home might be good for some acutely ill people at ED

Med Page Today reports:

“Hospital-at-home (HaH) care may be a good replacement for traditional inpatient services among some patients who arrive at the emergency department (ED) with an acute condition, a health system reported.

“In 2014, the Icahn School of Medicine at Mount Sinai in New York City was given a Health Care Innovation Award by the Centers for Medicare & Medicaid Services to demonstrate the clinical effectiveness of HaH care bundled with a 30-day postacute period of home-based transitional care. Since then, the institution’s Albert Siu, MD, MSPH, and colleagues observed that several measures did favor HaH care over inpatient hospitalization:

  • “Acute period length of stay: 3.2 versus 5.5 days (weighted P<0.001)
  • “All-cause 30-day hospital readmissions: 8.6% versus 15.6% (weighted P<0.001)
  • “ED revisits: 5.8% versus 11.7% (weighted P<0.001)
  • “Admissions to skilled nursing facilities: 1.7% versus 10.4% (weighted P<0.001)
  • Rating their hospital care highly: 68.8% versus 45.3% (weighted P<0.001)

“Yet rates of referral to a certified home healthcare agency yielded no difference between groups, Siu’s group reported online in JAMA Internal MedicineEven so, they maintained that that their findings justify creation of a new payment model within Medicare’s current portfolio of shared savings programs.”

To read the entire Med Page Today article, please hit this link.

To read the stud in JAMA InternaL Medicine, please hit this link.



What if they leave ‘against medical advice’?

What  can and  should happen when a patient, sometimes elderly and sometimes with dementia, decides to leave a hospital “against medical advice” (A.M.A.)?

As a New York Times story reports:

“Such events happen more commonly than one might think. Though A.M.A. discharges occur far more frequently in younger patients, a recent study in The Journal of the American Geriatrics Society analyzed a large national sample from 2013 and found that 50,650 hospitalizations of patients over age 65 ended with A.M.A. discharges.

“This is a very conservative number,”’ the senior author, Dr. Jashvant Poeran, an epidemiologist at New York’s Icahn School of Medicine at Mount Sinai, told The Times, which reported that had “he included outpatients who left emergency rooms against medical advice and those who simply walked out and never actually signed a form, the total would have been much higher.”

“’It’s always been one of the most difficult ethical dilemmas,’ said Dr. Arthur Derse, who directs the Center for Bioethics and Medical Humanities at the Medical College of Wisconsin.“Patients come and seem to be in need of help, and then they say, ‘Sorry, I’ve got to leave.’”

The Times said: “They may be feeling better or fear a procedure; they might simply want to go home and feed the cat. Finances could play a role: Older patients discharged against advice, the Mount Sinai study found, were more likely to have low incomes.”

To read the article,  please hit this link.

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