Perioperative medicine training resources: U6M8: Hospital substitution models

Abstract
Background: While most people say they would prefer to be cared for and to die at home, this outcome is often not achieved. This represents a service gap that general practitioners (GPs) are optimally positioned to fill.

Objectives: The aim of this paper is to synthesise existing evidence-based frameworks of palliative care together with other resources, to present a cohesive model of care that GPs can easily systematise to guide high-quality home-based palliative care.

Discussion: Key clinical processes include advance care planning and development of medical goals of patient care plans and terminal care plans. Three essential elements for high-quality palliative care incorporated into the model include a compassionate GP, the care team and various practical resources. Palliative care sits well within the GP specialist scope of practice. GPs have at their disposal many resources that effectively and efficiently support them in their palliative care practice.

Abstract
Objectives: To determine whether an in-home palliative care intervention for terminally ill patients can improve patient satisfaction, reduce medical care costs, and increase the proportion of patients dying at home.

Design: A randomized, controlled trial.

Setting: Two health maintenance organizations in two states.

Participants: Homebound, terminally ill patients (N=298) with a prognosis of approximately 1 year or less to live plus one or more hospital or emergency department visits in the previous 12 months.

Intervention: Usual versus in-home palliative care plus usual care delivered by an interdisciplinary team providing pain and symptom relief, patient and family education and training, and an array of medical and social support services.

Measurements: Measured outcomes were satisfaction with care, use of medical services, site of death, and costs of care.

Results: Patients randomized to in-home palliative care reported greater improvement in satisfaction with care at 30 and 90 days after enrollment (P<.05) and were more likely to die at home than those receiving usual care (P<.001). In addition, in-home palliative care subjects were less likely to visit the emergency department (P=.01) or be admitted to the hospital than those receiving usual care (P<.001), resulting in significantly lower costs of care for intervention patients (P=.03).

Conclusion: In-home palliative care significantly increased patient satisfaction while reducing use of medical services and costs of medical care at the end of life. This study, although modest in scope, presents strong evidence for reforming end-of-life care.

Abstract
Objectives: To compare treatment of acute illness at home and in hospital, assessing safety, effect on geriatric complications, and patient/carer satisfaction.

Design: Randomised controlled trial.

Setting: A tertiary referral hospital affiliated with the University of New South Wales.

Participants: 100 patients (69% older than 65 years) with a variety of acute conditions, who were assessed in the emergency department as requiring admission to hospital.

Interventions: Patients were allocated at random to be treated by a hospital-in-the-home (HIH) service in their usual residence or to be admitted to hospital.

Main outcome measures: Geriatric complications (confusion, falls, urinary incontinence or retention, faecal incontinence or constipation, phlebitis and pressure areas), patient/carer satisfaction, adverse events, and death.

Results: There was a lower incidence of confusion (0 v. 20.4% [95% CI, 9.1%-31.7%]; P = 0.0005), urinary complications (incontinence or retention) (2.0% [95% CI, -1.8%, 5.8%] v. 16.3% [95% CI, 6.0%, 26.6%]; P = 0.01), and bowel complications (incontinence or constipation) (0 v. 22.5% [95% CI, 10.7%, 34.1%]; P = 0.0003) among HIH-treated patients. No significant difference in number of adverse events and deaths (to 28 days after discharge) in the two groups was found (although numbers were small). Patient and carer satisfaction was significantly higher in the HIH group.

Conclusions: Home treatment appears to provide a safe alternative to hospitalisation for selected patients, and may be preferable for some older patients. We found high levels of both patient and carer satisfaction with home treatment.

Abstract
The escalating physiological, psychological, social and financial burdens of wounds and wound care on patients, families and society demand the immediate attention of the health care sector. Many forces are affecting the changes in health care provision for patients with chronic wounds, including managed care, the limited number of wound care therapists, an increasingly ageing and disabled population, regulatory and malpractice issues, and compromised care. The physician is also faced with a number of difficult issues when caring for chronic wound patients because their conditions are time consuming and high risk, represent an unprofitable part of care practice and raise issues of liability. Telemedicine enhances communication with the surgical wound care specialist. Digital image for skin lesions is a safe, accurate and cost-effective referral pathway. The two basic modes of telemedicine applications, store and forward (asynchronous transfer) and real-time transmission (synchronous transfer, e.g. video conference), are utilized in the wound care setting. Telemedicine technology in the hands of an experienced physician can streamline management of a problem wound. Although there is always an element of anxiety related to technical change, the evolution of wound care telemedicine technology has demonstrated a predictable maturation process.

Abstract
To assess the feasibility, acceptability, and preliminary effectiveness of a peer-delivered and technology supported integrated medical and psychiatric self-management intervention for older adults with serious mental illness. Ten older adults with serious mental illness (i.e., schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder) and medical comorbidity (i.e., cardiovascular disease, obesity, diabetes, chronic obstructive pulmonary disease, hypertension, and/or high cholesterol) aged 60 years and older received the PeerTECH intervention in their homes. Three certified peer specialists were trained to deliver PeerTECH. Data were collected at baseline, one-month, and three-month. The pilot study demonstrated that a three-month, peer-delivered and technology-supported integrated medical and psychiatric self-management intervention ("PeerTECH") was experienced by peer specialists and participants as feasible and acceptable. PeerTECH was associated with statistically significant improvements in psychiatric self-management. In addition, pre/post, non-statistically significant improvements were observed in self-efficacy for managing chronic health conditions, hope, quality of life, medical self-management skills, and empowerment. This pre/post pilot study demonstrated it is possible to train peers to use technology to deliver an integrated psychiatric and medical self-management intervention in a home-based setting to older adults with serious mental illness with fidelity. These findings provide preliminary evidence that a peer-delivered and technology-supported intervention designed to improve medical and psychiatric self-management is feasible, acceptable, and is potentially associated with improvements in psychiatric self-management, self-efficacy for managing chronic health conditions, hope, quality of life, medical self-management skills, and empowerment with older adults with serious mental illness and chronic health conditions.

Abstract
Background: Specialised disease management programmes for heart failure aim to improve care, clinical outcomes and/or reduce healthcare utilisation. Since the last version of this review in 2010, several new trials of structured telephone support and non-invasive home telemonitoring have been published which have raised questions about their effectiveness.

Objectives: To review randomised controlled trials (RCTs) of structured telephone support or non-invasive home telemonitoring compared to standard practice for people with heart failure, in order to quantify the effects of these interventions over and above usual care.

Search methods: We updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology AsseFssment Database (HTA) on the Cochrane Library; MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), Science Citation Index Expanded (SCI-EXPANDED), Conference Proceedings Citation Index- Science (CPCI-S) on Web of Science (Thomson Reuters), AMED, Proquest Theses and Dissertations, IEEE Xplore and TROVE in January 2015. We handsearched bibliographies of relevant studies and systematic reviews and abstract conference proceedings. We applied no language limits.

Selection criteria: We included only peer-reviewed, published RCTs comparing structured telephone support or non-invasive home telemonitoring to usual care of people with chronic heart failure. The intervention or usual care could not include protocol-driven home visits or more intensive than usual (typically four to six weeks) clinic follow-up.

Data collection and analysis: We present data as risk ratios (RRs) with 95% confidence intervals (CIs). Primary outcomes included all-cause mortality, all-cause and heart failure-related hospitalisations, which we analysed using a fixed-effect model. Other outcomes included length of stay, health-related quality of life, heart failure knowledge and self care, acceptability and cost; we described and tabulated these. We performed meta-regression to assess homogeneity (the null hypothesis) in each subgroup analysis and to see if the effect of the intervention varied according to some quantitative variable (such as year of publication or median age).

Main results: We include 41 studies of either structured telephone support or non-invasive home telemonitoring for people with heart failure, of which 17 were new and 24 had been included in the previous Cochrane review. In the current review, 25 studies evaluated structured telephone support (eight new studies, plus one study previously included but classified as telemonitoring; total of 9332 participants), 18 evaluated telemonitoring (nine new studies; total of 3860 participants). Two of the included studies trialled both structured telephone support and telemonitoring compared to usual care, therefore 43 comparisons are evident.Non-invasive telemonitoring reduced all-cause mortality (RR 0.80, 95% CI 0.68 to 0.94; participants = 3740; studies = 17; I² = 24%, GRADE: moderate-quality evidence) and heart failure-related hospitalisations (RR 0.71, 95% CI 0.60 to 0.83; participants = 2148; studies = 8; I² = 20%, GRADE: moderate-quality evidence). Structured telephone support reduced all-cause mortality (RR 0.87, 95% CI 0.77 to 0.98; participants = 9222; studies = 22; I² = 0%, GRADE: moderate-quality evidence) and heart failure-related hospitalisations (RR 0.85, 95% CI 0.77 to 0.93; participants = 7030; studies = 16; I² = 27%, GRADE: moderate-quality evidence).Neither structured telephone support nor telemonitoring demonstrated effectiveness in reducing the risk of all-cause hospitalisations (structured telephone support: RR 0.95, 95% CI 0.90 to 1.00; participants = 7216; studies = 16; I² = 47%, GRADE: very low-quality evidence; non-invasive telemonitoring: RR 0.95, 95% CI 0.89 to 1.01; participants = 3332; studies = 13; I² = 71%, GRADE: very low-quality evidence).Seven structured telephone support studies reported length of stay, with one reporting a significant reduction in length of stay in hospital. Nine telemonitoring studies reported length of stay outcome, with one study reporting a significant reduction in the length of stay with the intervention. One telemonitoring study reported a large difference in the total number of hospitalisations for more than three days, but this was not an analysis of length of stay per hospitalisation. Nine of 11 structured telephone support studies and five of 11 telemonitoring studies reported significant improvements in health-related quality of life. Nine structured telephone support studies and six telemonitoring studies reported costs of the intervention or cost effectiveness. Three structured telephone support studies and one telemonitoring study reported a decrease in costs and two telemonitoring studies reported increases in cost, due both to the cost of the intervention and to increased medical management. Adherence was rated between 55.1% and 98.5% for those structured telephone support and telemonitoring studies which reported this outcome. Participant acceptance of the intervention was reported in the range of 76% to 97% for studies which evaluated this outcome. Seven of nine studies that measured these outcomes reported significant improvements in heart failure knowledge and self-care behaviours.

Authors' conclusions: For people with heart failure, structured telephone support and non-invasive home telemonitoring reduce the risk of all-cause mortality and heart failure-related hospitalisations; these interventions also demonstrated improvements in health-related quality of life and heart failure knowledge and self-care behaviours. Studies also demonstrated participant satisfaction with the majority of the interventions which assessed this outcome.

Abstract
Patient-centred care by a coordinated primary care team may be more effective than standard care in chronic disease management. We synthesised evidence to determine whether patient-centred medical home (PCMH)-based care models are more effective than standard general practitioner (GP) care in improving biomedical, hospital, and economic outcomes. MEDLINE, CINAHL, Embase, Cochrane Library, and Scopus were searched to identify randomised (RCTs) and non-randomised controlled trials that evaluated two or more principles of PCMH among primary care patients with chronic diseases. Study selection, data extraction, quality assessment using Joanna Briggs Institute (JBI) appraisal tools, and grading of evidence using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach were conducted independently. A quantitative synthesis, where possible, was pooled using random effects models and the effect size estimates of standardised mean differences (SMDs) and odds ratios (ORs) with 95% confidence intervals were reported. Of the 13,820 citations, we identified 78 eligible RCTs and 7 quasi trials which included 60,617 patients. The findings suggested that PCMH-based care was associated with significant improvements in depression episodes (SMD -0.24; 95% CI -0.35, -0.14; I2 = 76%) and increased odds of remission (OR 1.79; 95% CI 1.46, 2.21; I2 = 0%). There were significant improvements in the health-related quality of life (SMD 0.10; 95% CI 0.04, 0.15; I2 = 51%), self-management outcomes (SMD 0.24; 95% CI 0.03, 0.44; I2 = 83%), and hospital admissions (OR 0.83; 95% CI 0.70, 0.98; I2 = 0%). In terms of biomedical outcomes, with exception to total cholesterol, PCMH-based care led to significant improvements in blood pressure, glycated haemoglobin, and low-density lipoprotein cholesterol outcomes. The incremental cost of PCMH care was identified to be small and significantly higher than standard care (SMD 0.17; 95% CI 0.08, 0.26; I2 = 82%). The quality of individual studies ranged from "fair" to "good" by meeting at least 60% of items on the quality appraisal checklist. Additionally, moderate to high heterogeneity across studies in outcomes resulted in downgrading the included studies as moderate or low grade of evidence. PCMH-based care has been found to be superior to standard GP care in chronic disease management. Results of the review have important implications that may inform patient, practice, and policy-level changes.

Keywords: chronic disease management; collaborative care; enhanced primary care; meta-analysis; patient-centred medical home.

Abstract
Purpose: The pulmonary rehabilitation program has become a cornerstone in the management of patients with chronic obstructive pulmonary disease (COPD). Programs based in hospital and treatment facilities, however, are inconvenient and underutilized. A home-based program is a promising alternative, but studies of its effectiveness have yielded inconsistent results. The purpose of this study is to evaluate the impact of home-based pulmonary rehabilitation programs on health-related quality of life (HRQoL) and other health outcomes in patients with COPD.

Methods: Randomized controlled trials (RCTs) of home-based pulmonary rehabilitation programs published between February 1991 and February 2012 were retrieved from electronic databases (PubMed, Cochrane Library, Science Direct, China National Knowledge Infrastructure [CNKI], and Wanfang Database). Two reviewers independently assessed topical relevance and trial quality, extracted data for meta-analysis using the Review Manager v5.1 software, and contacted the original studies' authors for additional information.

Findings: Eighteen trials, comprising 733 randomized patients, were included in the meta-analysis. COPD patients experienced significant relief in dyspnea status, measured by the Borg score (Fixed effects model, WMD = -0.92, 95% CI: -1.61~-0.23, p = .009) and baseline dyspnea index (BDI) (Fixed effects model, WMD = -1.77, 95% CI: -2.65~-0.89, p < .0001) after 12 weeks of home-based intervention. Home-based intervention also improved patients' HRQoL scores, measured by the Chronic Respiratory Questionnaire (CRQ) and St. George's Respiratory Questionnaire (SGRQ) (Fixed effects model, WMD = -11.33, 95% CI: -16.37~-6.29, p < .0001, SGRQ total scores after 12 weeks of intervention); exercise capacity (measured by the 6-minute walking distance test (6MWD) (Fixed effects model, WMD = 35.88, 95% CI: 9.38~62.38, p = .008, after 12 weeks of intervention); and pulmonary functions (measured by forced expiratory volume in one-second/forced vital capacity (FEV1 /FVC) [Random effects model, WMD = -10.72, 95% CI: -15.86~-5.58, p < .0001, after 12 weeks of intervention), as compared with the nonintervention control group; however, no statistically significant changes were seen in maximal workload, hospital admission, cost of care, or mortality between the two groups.

Conclusions and clinical relevance: Home-based pulmonary rehabilitation programs represent effective therapeutic intervention approaches for relieving COPD-associated respiratory symptoms and improving HRQoL and exercise capacity. Rigorously designed, large-scale RCTs are still needed to identify an optimal standard home-based pulmonary rehabilitation program.

Abstract
Despite the increasing use of home blood pressure monitoring (HBPM) in daily practice and the growing awareness in the scientific community about its positive impact on the diagnostic and therapeutic management of patients with high blood pressure (BP), the potential advantages offered by HBPM have not yet been fully exploited. Indeed, use of the information offered by HBPM is often incomplete and imprecise, with the BP values reported by patients in handwritten logbooks being frequently inaccurate, illegible to physicians, or unreliable. Although a practical solution for improvement may come from the use of devices equipped with a storage memory, a step forward in this regard has been taken more recently with the introduction and refinement of systems for the remote telemonitoring of BP values measured at home. However, although several studies have provided evidence on the clinical usefulness of HBPM, only limited data are available on the clinical impact of home blood pressure (HBP) telemonitoring, because of a number of reasons. First, most of the available studies are characterized by a small sample size, and in some cases, the patients were neither randomized nor even matched with a control group. Moreover, technological solutions used in the different studies carried out so far are often heterogeneous, some of them being particularly difficult to use for the patients, thus limiting the effectiveness of the results. BP monitoring programmes, number of BP readings and transmission schedules are often different among the various studies. In addition, patient selection criteria are different from study to study. Finally, different study objectives and important diversities in the types of centres involved (ranging from general practices, to specialists' offices, hospitals or university centres) may have also influenced the quality of results. Large-scale randomized controlled studies, based on easy-to-use technologies, are thus still needed to show the superiority and clinical usefulness of HBP telemonitoring as compared with conventional HBPM. This study summarizes the evidence available on the clinical usefulness and current limitations of this approach, highlighting the results of meta-analyses and randomized controlled trials on this issue. The role of HBP teletransmission in the context of integrated patients' management programmes is also addressed, with indications for further progress in this field.

Abstract
Deprescribing is a holistic process of medication cessation that encompasses gaining a comprehensive medication list, identifying potentially inappropriate medications, deciding if the identified medication can be ceased, planning the withdrawal regimen and monitoring, support and follow-up. It is currently being investigated as a mechanism to reduce unnecessary or redundant medications. However, given the systematic and patient-centred nature of the deprescribing process, it is possible that it may also confer additional benefits such as improving adherence to medications, even if there is no net reduction in overall medication use. Specifically, deprescribing may improve adherence via reducing polypharmacy, reducing the financial costs associated with medication taking, increasing the patient's medication knowledge through education, increasing patient engagement in medication management and resolution of adverse drug reactions. More research into deprescribing must be conducted to establish if these potential benefits can be realised, in addition to establishing any negative consequences.

Abstract
Background: 'Early discharge hospital at home' is a service that provides active treatment by health care professionals in the patient's home for a condition that otherwise would require acute hospital in-patient care. If hospital at home were not available then the patient would remain in an acute hospital ward.

Objectives: To determine, in the context of a systematic review and meta-analysis, the effectiveness and cost of managing patients with early discharge hospital at home compared with in-patient hospital care.

Search strategy: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register , MEDLINE (1950 to 2008), EMBASE (1980 to 2008), CINAHL (1982 to 2008) and EconLit through to January 2008. We checked the reference lists of articles identified for potentially relevant articles.

Selection criteria: Randomised controlled trials recruiting patients aged 18 years and over. Studies comparing early discharge hospital at home with acute hospital in-patient care. Evaluations of obstetric, paediatric and mental health hospital at home schemes are excluded from this review.

Data collection and analysis: Two authors independently extracted data and assessed study quality. Our statistical analyses were done on an intention-to-treat basis. We requested individual patient data (IPD) from trialists, and relied on published data when we did not receive trial data sets or the IPD did not include the relevant outcomes. For the IPD meta-analysis, where at least one event was reported in both study groups in a trial, Cox regression models were used to calculate the log hazard ratio and its standard error for mortality and readmission separately for each data set. The calculated log hazard ratios were combined using fixed-effect inverse variance meta-analysis.

Main results: Twenty-six trials were included in this review [n = 3967]; 21 were eligible for the IPD meta-analysis and 13 of the 21 trials contributed data [1899/2872; 66%]. For patients recovering from a stroke and elderly patients with a mix of conditions there was insufficient evidence of a difference in mortality between groups (adjusted HR 0.79, 95% CI 0.32 to 1.91; N = 494; and adjusted HR 1.06, 95% CI 0.69 to 1.61; N = 978). Readmission rates were significantly increased for elderly patients with a mix of conditions allocated to hospital at home (adjusted HR 1.57; 95% CI 1.10 to 2.24; N = 705). For patients recovering from a stroke and elderly patients with a mix of conditions respectively, significantly fewer people allocated to hospital at home were in residential care at follow up (RR 0.63; 95% CI 0.40 to 0.98; N = 4 trials; RR 0.69, 95% CI 0.48 to 0.99; N =3 trials). Patients reported increased satisfaction with early discharge hospital at home. There was insufficient evidence of a difference for readmission between groups in trials recruiting patients recovering from surgery. Evidence on cost savings was mixed.

Authors' conclusions: Despite increasing interest in the potential of early discharge hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit or improved health outcomes.

Abstract
Background: Understanding the impact of overcrowding in pediatric emergency departments (PEDs) on quality of care is a growing concern. Boarding admitted patients in the PED and increasing emergency department (ED) visits are two potentially significant factors affecting quality of care.

Objectives: The objective was to describe the impact ED boarding time and daily census have on the timeliness of care in a PED.

Methods: Pediatric ED boarding time and daily census were determined each day from July 2003 to July 2007. Outcome measures included mean length of stay (LOS), time to triage, time to physician, and patient elopement during a 24-hour period.

Results: For every 50 patients seen above the average daily volume of 250, LOS increased 14.8 minutes, time to triage increased 6.6 minutes, time to physician increased 18.2 minutes, and number of patient elopements increased by three. For each increment of 24 hours to total ED boarding time, LOS increased 7.6 minutes, time to triage increased 0.6 minutes, time to physician increased 3 minutes, and number of patient elopements increased by 0.6 patients.

Conclusions: ED boarding time and ED daily census show independent associations with increasing overall LOS, time to triage, time to physician, and number of patient elopements in a PED.

Abstract
Background: Evidence suggests that elective cardiac patients are at risk of functional and psychological deterioration in the time preceding surgery. This poses a risk to successful post-operative rehabilitation. This prospective one-group pre-test, post-test evaluation was designed to assess a clinical Pre-operative Rehabilitation (PREHAB) home-based exercise programme, to optimise pre-operative physical function and frailty in patients awaiting elective Coronary Artery By-Pass Graft (CABG) or Valve Surgery.

Method: Consenting patients awaiting cardiac surgery, with wait time ≥ 6 weeks were referred to a Senior Physiotherapist for baseline assessment. Patients were offered PREHAB in the form of functional home-based exercise that was prescribed from baseline physical outcomes. All patients were followed up via telephone to ensure progression of exercise and any problems associated with it. This continued weekly until the patient attended Surgical Pre-assessment clinic, where all outcome measures were re-assessed.

Results: Twenty two patients, out of a total number of 36 patients seen in the surgical clinic between March 2016 and August 2016, participated in the prehab clinical evaluation. Twenty patients completed their prescribed exercises on a weekly basis prior to surgery. No adverse events or cardiac symptoms were reported as a result of the home exercise intervention. Paired t-Test analyses revealed a significant mean difference in clinical frailty score (CFS) of -0.53 ± 0.51 (95% CI [-0.774, -0.279], P = 0.0003). Significant mean difference in six-minute walk test (6MWT) distance of 42.5 ± 27.8 m (95% CI [23.840, 61.251], P = 0.0005), 6MWT walking speed of 0.5 ± 0.4kmh (95% CI, [0.2433, 0.7567], P = 0.001), and short physical performance battery (SPPB) total score of 2.2 ± 1.7, (95% CI [3.066, 1.200], P = 0.0002) were also observed. The change in 6MWT distance was shown to be significantly associated with hospital length of stay (LOS) (r = 0.7; P = 0.03).

Conclusion: This small exploratory evaluation suggests that providing a home-based PREHAB programme for frail patients undergoing CABG or Valve surgery may be able to improve functional ability and reduce hospital length of stay for those patients undergoing cardiac surgery. A frailty score with greater sensitivity may be required to elucidate the influence frailty could have in reducing length of stay. A large randomised controlled study is required to reveal the potential beneficial effects of PREHAB in this patient population.

Keywords: Cardiac surgery; Frailty; Length of stay; Prehab; Rehabilitation.