A Hospital-at-Home Pilot in Singapore: A Prospective Quasi-Experimental Cohort Study
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 发起方
- 入组人数
- 378
- 试验地点
- 2
- 主要终点
- Cost of care
研究概览
简要总结
Hospital-at-home models seek to address the impending shortage of hospital beds by reimagining the way we deliver acute hospital-level care - substituting the ward for a patient's home. Such programmes have been well established in other countries such as Australia, Europe and USA to be a less costly way to provide inpatient care as a result of a reduction of fixed costs of building and running hospitals, with equivalent variable costs and comparable clinical outcomes. Acute services are provided at home, including regular visits by doctors, nurses and therapists, intravenous therapy, simple investigations and 24/7 access to doctors. The clinical service is tech-enabled, by remote monitoring and telecommunication technologies.
Although overseas experience suggests that hospital-at-home programmes are an effective, safe and scalable substitute for inpatient beds, and promising strategy to meet the bed demands of our ageing population, the outcomes in the local environment is unclear. Singapore has a unique healthcare system compared to primarily insurance driven (USA) or publicly funded (UK and Australia), which favours subsidies of inpatient care compared to community-based care. In addition, cultural beliefs of hospitals as a source of comfort and healing and unfamiliarity with healthcare providers performing home visits may provide unique challenges which may affect outcomes of a hospital-at-home programme in Singapore. In an Asian setting, family and informal caregivers are heavily involved in the care of patients and may pose unique barriers and facilitators to such care at home that may not be evident in similar models in Western countries.
This study aims to evaluate the effectiveness, feasibility and processes of a new hospital-at-home programme in Singapore.
详细描述
- Hypothesis
We hypothesise that hospital-at-home programmes may reduce cost of delivering care with comparable clinical outcomes (readmissions, mortality, and hospital-acquired complications) and positive patient and staff experiences. 2. Specific Aims
The primary objective of this study is:
- To compare the mean direct cost of care per day of index hospitalisation for patients receiving HaH care to similar patients receiving usual inpatient care.
The secondary objectives in this study are:
研究设计
- 研究类型
- Observational
- 观察模型
- Cohort
- 时间视角
- Prospective
入排标准
- 年龄范围
- 21 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Admitted to one of the following wards:
- •Episodic short stay patients
- •NUH Extended Diagnosis and Treatment Unit (EDTU)
- •AH Extended Diagnosis and Treatment Unit (EDTU)
- •NUH Acute Medical Unit (AMU)
- •Long stay patients requiring ongoing treatment or monitoring
- •NUH general medicine wards
- •AH general medicine wards
- •Speciality specific treatment and monitoring with a protocolised approach
- •Fluid overload admissions from NUH cardiology service
- •Fluid overload admissions from NUH nephrology service
- •≥ 21 years old
- •Lives within the Western Cluster of Singapore (pre-specified list of postcodes)
- •Requires continued hospitalisation
- •The EDTU is a ward within the emergency department that patients can stay for up to 24hours for diagnosis and treatment and meant for discharge after. Some of these patients subsequently require hospital admission, which would be the target group for the pilot. The AMU is a short-stay ward at NUH which aims to discharge patients within 72 hours of stay.
排除标准
- •Lives in nursing home
- •Suitable for discharge to other community programmes
- •Planned for discharge the next day (D-1)
- •Haemodynamic instability defined as NEWScore >2 at time of recruitment (a NEWScore ≤2 in a local setting showed very low rates of transfer to intensive care and death in 24 hours )
- •Requires oxygen (long term oxygen therapy is acceptable)
- •Acute psychosis or suicidal intent
- •Need for negative pressure isolation
- •Anticipated to deteriorate
- •Planned for imaging, endoscopy, blood transfusion, cardiac stress test, surgery, interventional radiology procedures or ongoing non-medical specialist review
- •Need for intravenous controlled drugs (e.g. morphine)
- •Unable to establish venous access in emergency department
- •Current or former intravenous drug user
- •History of violence towards healthcare workers
- •Cannot provide meals at home
- •Does not have a bed, table and fridge at home
- •Patient or caregiver unable to use a phone
- •House is unsuitable for home visits and medical equipment
- •Unable to be homebound independent, or have a full-time caregiver to assist with daily activities if not homebound independent
- •Caregivers unable or unwilling to manage patient's care at home
- •Projected to require more than 2 weeks of rehab
- •For fluid overload cases, acute myocardial infarction within 5 days
- •Anticipated to require sliding scale insulin more than twice a day, where patient and/or caregiver are not able to measure BSL or administer insulin doses at home independently
- •Unable to understand simple instructions for oral self-administration of medication
结局指标
主要结局
Cost of care
时间窗: At completion of intervention (an average of 7 days)
The primary outcome is cost of care which the sum of the following: 1. Itemised consumables 2. Labour cost of physicians, estimated by the average time spent delivering care multiplied by standard salary (plus benefits) estimates of physicians' respective paygrades. 3. Labour cost of nurses, estimated by the average time spent delivering care multiplied by standard salary (plus benefits) estimates of nurses' respective paygrades 4. Labour cost of allied health (e.g. phlebotomists, physiotherapists) will be estimated by the average time spent delivering care multiplied by standard salary (plus benefits) estimates of their respective paygrades. 5. Any additional costs incurred by the intervention group (e.g. telemonitoring, transport of blood tests) will be itemised as well.
次要结局
- 30-day readmission rate and attendance rate to emergency department(30 days from completion of intervention (an average of 7 days))
- Iatrogenic events during treatment period(At completion of intervention (an average of 7 days))
- Caregiver Burden (if applicable)(At completion of intervention (an average of 7 days))
- Care transitions experience(Within a month after completion of intervention (an average of 7 days))
- Number of bed days in hospital(At completion of intervention (an average of 7 days))
- Duration of treatment period(At completion of intervention (an average of 7 days))
- Death during treatment(At completion of intervention (an average of 7 days))
- 30-day mortality(30 days from enrolment)
- Improvement in HR-QoL (EQ-5D)(Between enrolment and 14 days post-enrolment, a higher score means better outcome, ranging from 0 to 1)
- Quality-adjusted-life-days gained(Measurements from baseline, at completion of intervention (an average of 7 days) and 14 days post enrolment)
- Patient-reported activity during treatment period(At completion of intervention (an average of 7 days))
- ICU/HD transfers(At completion of intervention (an average of 7 days))
- Improvement in HR-QoL (EQ-VAS)(Between enrolment and 14 days post-enrolment)
- Patient satisfaction score(At completion of intervention (an average of 7 days))
研究者
Stephanie Ko
Associate Consultant
National University Health System, Singapore