David Oliver: Is hospital avoidance an elusive holy grail?BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l746 (Published 19 February 2019) Cite this as: BMJ 2019;364:l746
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Hospital at Home: the Holy Grail found? Re: David Oliver: Is hospital avoidance an elusive holy grail?
I read with interest the two short “views and reviews” by David Oliver with the title: ”Is hospital avoidance an elusive holy grail?”1,2. The author compares avoiding admissions with the Holy Grail, giving to understand that both are legendary goals that we should give up searching for, accepting instead living in the real world.
Interestingly, in a similar date, Sean P. Collins and Peter S. Pang, publish in Circulation an editorial titled:” ACUTE Heart Failure Risk Stratification: A step Closer to the Holy Grail”3. They comment on an article by Lee and colleagues published in the same issue of Circulation, showing the results of a prospective and external validation of their EHMRG7 and EHMRG30 risk scores used in Acute Heart Failure (AHF)4. Collins and Pang mention that these and other HF risk scores are a help in the search for ”the holy grail of safe ED discharge”, meaning that many hospital admissions due to AHF could be avoided and the patients safely discharged from the ED but this goal, is as elusive as finding the holy grail. The “Emergency physicians’ overestimation of risk in low risk patients” seems to be one of the factors involved.
Related to these two points of view, we have recently communicated our experience treating in Hospital at Home (HaH) 214 patients diagnosed as Acutely Decompensated Chronic Heart Failure (ADCHF) at the Hospital Emergency Department and sent directly to Hospital at Home (stay in ED less than 12 h), hence avoiding hospital admission5. The patients are visited by a nurse and a doctor in their homes in the first morning after discharge from the ED and daily or every two days afterwards, and that meets the requirement of “mandatory early outpatient follow-up” raised by Dr Collins and Dr Pang. A retrospective analysis of these patients showed that the number of hospital admissions due to HF during the year before and the score on the EFFECT scale (also described by Lee and colleagues in 20036) are useful to estimate the risk of returning to hospital. Using these two variables we were able to differentiate a group of 101 patients with low risk (9,1%) whereas the remaining 113 patients had a risk of 29,6% (R.R. =3,26 (1,7-6,2). HaH was an effective way for avoiding the admission of 91% of patients in the first group and 70% in the second one.
Collins and Pang are right: HF risk assessment scores are a help and a step closer to the goal of decreasing the “>80% of patients with acute heart failure (AHF) that are admitted to the hospital”. Davidson is right as well when he says: “Let’s perhaps acknowledge that hospital is often necessary and appropriate”. Using risk prediction rules for selecting patients and sending them directly to HaH allows making the synthesis of the Collins and Pang and Davidson apparently opposed conceptions: hospital admission can be efficiently avoided; at the same time are admitted to the hospital, and receive similar treatment, but within a ward outside the hospital building. The holy grail found?
1. Oliver D. Is hospital avoidance an elusive holy grail? BMJ 2019;364:l746 doi: 10.1136/bmj.l746.
2. Oliver D. Avoiding hospital admission—are we really falling short? BMJ 2019;364:l747 doi: 10.1136/bmj.l747.
3. Collins SP, Pang PS. ACUTE Heart Failure Risk Stratification: A Step Closer to the Holy Grail? Circulation. 2019;139:1157–1161. DOI: 10.1161/CIRCULATIONAHA.118.038472.
4. Lee DS, Lee JS, Schull MJ, Borgundvaag B, Edmonds ML, Ivankovic M, McLeod SL, Dreyer JF, Sabbah S, Levy PD, O’Neill T, Chong A, Stukel TA, Austin PC, Tu JV. Propsective validation of the emergency heart failure mortality risk grade for acute heart failure: the ACUTE Study. Circulation. 2019;139:1146–1156. doi: 10.1161 / CIRCULATION AHA.118.035509.
5. Regalado De Los Cobos J.; Delgado Vicente M.; Medrano Laporte J.; Gómez Rodríguez de Mendarozqueta M.; Oceja Barrutieta E.; De Juan Rodríguez M; Apraiz Garmendia L; Frago Marquínez I. HOSPITAL AT HOME IN THE TREATMENT OF ACUTELY DECOMPENSATED CHRONIC HEART FAILURE: PREDICTION OF EFFICACY. Int J Clin Pract 2019;73, S186:1-21. DOI: 10.1111/ijcp.13326 1th (Special Issue : World Hospital at Home Congress, 5-6 April 2019. Madrid, Spain).
6. Lee DS, Austin PC, Rouleau JL, Liu PP, Naimark D, Tu JV. Predicting Mortality Among Patients Hospitalized for Heart Failure Derivation and Validation of a Clinical Model. JAMA. 2003;290:2581-2587.
Competing interests: No competing interests