Managing low-risk acute care without hospitalization appears to be safe and reduces costs

A comprehensive review of studies evaluating strategies for treating certain acute medical conditions without hospital admission finds that all four evaluated strategies appear to be safe, often improve patient and caregiver satisfaction, and reduce health care costs. The report is being published online in JAMA Internal Medicine.

"Patients often prefer to obtain care at home and avoid hospitalization, as long as safety and quality are not compromised," says Jared Conley, MD, PhD, of the Massachusetts General Hospital (MGH) Department of Emergency Medicine, lead author of the report. "The growing body of evidence demonstrating the safety and increased desirability of managing low-risk acute care without hospitalization may give us the opportunity to improve the health of populations and of individual patients at a more affordable and sustainable cost."

Current efforts to redesign the U.S. health care system focus on improving patient outcomes while also striving to reduces costs, the authors note; and identifying the best settings to diagnose and manage the treatment of acute conditions - serious conditions with a sudden onset - can be an important strategy for limiting hospital costs. In recent years, several alternative care delivery models have been developed, some relying on new technologies for diagnosis and treatments. These approaches fall into four categories:

• Outpatient management after initial diagnosis and workup in an outpatient clinic or hospital emergency department;
• Quick diagnostic units designed to rapidly diagnose serious conditions, such as certain cancers, that would traditionally be handled with an inpatient hospital admission;
• Hospital at home programs that deliver inpatient-level care in patients' homes following initial evaluation in an emergency department or outpatient clinic;
• Observation units within hospitals that provide care according to defined protocols for up to 24-48 hours with outpatient follow-up.

For the current investigation, the research team searched major study databases to identify systemic reviews published between 1995 and 2016 that examined one of the above models to manage conditions usually treated in an inpatient setting. They identified 22 review articles that examined studies of these alternative management strategies for conditions such as pulmonary embolism, deep venous thrombosis, pneumonia, chest pain, kidney stones, or worsening symptoms of heart failure or emphysema. While not all studies analyzed every factor, results across all four models suggest that alternative management approaches improved patient and caregiver satisfaction and reduced costs, sometimes significantly, without compromising patient safety or increasing mortality risk.

Among the studies that the researchers reviewed, there were a few instances where there was insufficient evidence to recommend the alternative strategies, indicating the need for further study. In addition, the primary exceptions to generally similar or improved outcomes were higher-than-anticipated return hospitalization rates for management of several conditions in quick diagnostic units and for outpatient management of chemotherapy-induced febrile neutropenia, a drop in a type of white blood cell caused by certain cancer treatments.

Senior author Donna Zulman, MD, MS, Stanford University Department of Medicine, notes that the overall positive findings are likely due in part to careful patient selection. "In the studies we examined, clinicians were careful to select low-risk patients within each acute medical condition who could safely be managed without hospitalization. Importantly, patients who are at risk for rapid deterioration of their condition are unlikely to be appropriate candidates for these alternative management approaches."

While these management strategies have been tested for a number of different clinical conditions, Conley notes that their widespread adoption is likely to require "payment models that encourage the development of innovative approaches to align patient health care needs with the best setting for care delivery."