Resurrecting the House Call

New at-home strategies for hematologic conditions offer improved outcomes and patient satisfaction

Physician home visits have become a thing of the past: Nearly a century ago, house calls made up 40 percent of U.S. doctors’ visits, but in 2015, they represented just 1 percent of all consultations.1

That trend could be reversing, as medical advances – and a growing body of evidence favoring treating certain conditions at patients’ homes – have helped drive a new “at-home” treatment movement.

The availability of oral chemotherapy agents, for example, has made it possible for patients with malignant hematologic conditions to receive treatment in the comfort of their own homes, significantly improving quality-of-life measures compared with treatment delivered in the hospital. Management of deep vein thrombosis (DVT) also has transitioned away from the inpatient setting, with most patients now being treated at home with direct oral anticoagulants (DOACs) after an initial clinic visit. Researchers are even evaluating home-based hematopoietic cell transplantation (HCT) and blood transfusions for hematology patients.

“Over time, I think we are going to see hospitals evolving into basically large buildings that have emergency rooms, operating rooms, and intensive care units,” Bruce Leff, MD, director of the Center for Transformative Geriatric Research at Johns Hopkins Medicine in Baltimore, told ASH Clinical News. “We are going to see many fewer people in what we tend to think of as the traditional hospital setting.”

The list of treatments being considered for the home is expanding. Still, not all patients will qualify for at-home treatment, depending on the intensity of the intervention, required follow-up, and evidence supporting its use. ASH Clinical News spoke with Dr. Leff and other clinicians and researchers about the possibilities for “hospital-at-home” programs and the obstacles to moving services into the home – including patient and provider reluctance.

Bringing the Hospital to the Patients

During the 1990s, Dr. Leff and other clinicians at Johns Hopkins developed a Hospital at Home program after witnessing the deleterious effects that hospital stays can have on older patients, including functional and cognitive declines and a higher risk for adverse drug reactions.2

“[At-home treatment] has become much more mainstream because at-home management of DVT is easier and involves less hassle [than hospital-based care].”

—Michael Streiff, MD

Johns Hopkins’ Hospital at Home clinical model launched in 1995. Through the program, older adults who meet certain eligibility criteria can receive acute hospital-level care in the home setting, rather than being admitted to the hospital.3

In a pilot study of the home-based treatment concept, researchers demonstrated that completely substituting acute inpatient care with at-home care reduced costs by approximately 30 percent. Compared with traditional inpatient care, at-home care also led to fewer clinical services required and higher patient satisfaction.

“We found that patients wanted this care,” Dr. Leff said. “[At-home treatment] helped patients avoid significant complications, improved mortality, produced better functional outcomes, lowered costs, and led to a better patient-caregiver experience.”

Since its establishment, the Hospital at Home model has been implemented in the Medicare managed care setting with similar outcomes. The program now provides tools to support the adoption and implementation of the home-based model, including guides for recruiting patients and assessing their eligibility, checking home environments, and managing follow-up with at-home or virtual visits.

Several other organizations also have developed models of at-home care. In 2016, Atrius Health, a large physician organization based in Massachusetts, founded the Medically Home program.4 Under this model, the company contracts with nurses who visit patients at home and coordinate care, medical supplies, and physician oversight through a central “command center.”

Physicians at the command center review patient vitals and, depending on their findings, can deploy X-ray technicians to visit patients at home or connect with other doctors over video chat to assess patient needs.

Another model, Clinically Home, is based in Tennessee and was designed in collaboration with staff at Johns Hopkins. It follows a similar approach: Staff provide at-home hospital services, such as managing intravenous (IV) lines and performing diagnostic tests.5 Although the model relies heavily on physicians and nurses, doctors do not make house calls. Instead, they engage with patients – or with nurses and nurse practitioners making home visits – through video technology.

“Hem/Onc, I’m Home!”

Home-based care has been implemented in many disease settings, but Dr. Leff acknowledged that the list of conditions that qualify for care through the Hospital at Home program contains few hematology/oncology diagnoses, and a small portion of patients in the initial experiences had hematologic disorders.

“One of the more interesting areas of innovation is the idea of broadening the scope of diagnoses that are handled through the Hospital at Home program, as well as broadening the use cases for Hospital at Home,” he said.

The transition to at-home care has already begun in certain areas of hematology, and one of the most substantial shifts in care has occurred in the care of patients with DVT.

Home-based treatment of DVT appears to offer substantial advantages over in-hospital treatment, according to a meta-analysis of seven trials comparing outcomes of patients who received initial treatment with low-molecular-weight heparin at home with those who received unfractionated heparin in the hospital.6 There were no statistically significant differences between the groups for major bleeding, minor bleeding, or mortality, but patients treated at home were less likely to experience a recurrence of DVT (relative risk = 0.58; p=0.007).

The availability of DOACs also has made more patients eligible for home treatment of DVT.

“With the advent of these agents, [at-home treatment] has become much more mainstream because at-home management of DVT is easier and involves less hassle [than hospital-based care],” said Michael Streiff, MD, a professor of medicine and pathology at Johns Hopkins.

He also noted that DVT was an ideal candidate for at-home management because it did not require a major shift in how care is administered: Typically, a DVT is diagnosed in a doctor’s office using a duplex ultrasound. After receiving a prescription for a DOAC, patients are sent home and scheduled for later follow-up with their doctor.

While home treatment is becoming the norm for patients diagnosed with DVT, Dr. Streiff noted two exceptions to this rule: patients with extensive clots that are causing significant pain or those who need advanced therapies (such catheter-directed thromboylysis or surgical thrombectomy) to remove the clot and require hospitalization. “Hospitals are great places if you are critically ill and require close monitoring, but for patients who are not critically ill, it is much better to be at home,” he said, adding that hospitals can often be “petri dishes” of germs and bacteria.

Researchers also are looking at other areas where home-based treatment would be reasonable – and preferable, in some cases, including for patients with low-risk pulmonary embolism (PE). While U.S. patients and practitioners readily embraced at-home management of DVT, they have been slower to warm up to at-home management of PE, Dr. Streiff commented.

“In Canada and Europe, PE is managed more frequently in the outpatient setting, but we take a more conservative approach in the U.S.,” he said.

Home-based management of blood clots is being addressed in the American Society of Hematology’s (ASH’s) upcoming guidelines for the treatment of venous thromboembolism. At the time of publication, this chapter of the guidelines was not yet publicly available, but, according to Kendall Alexander, manager of practice guidelines in ASH’s Quality Improvement Programs department, the recommendations will provide guidance about which patients should receive at-home or in-hospital treatment based on disease severity, patient history, and patient preference. ASH also is creating guidelines for the management of immune thrombocytopenia, with expected publication at the end of 2019, that will address at-home care options and considerations.

Sickle cell disease (SCD) is another area of exploration for at-home treatment. Adopting a home-based treatment model would overcome one of the largest barriers to treatment for the SCD population: transportation.

Many patients do not live close to a specialized SCD center and instead may seek treatment for SCD-related complications at an emergency department. “By providing some of these services at home, practitioners have reported fewer missed appointments and are able to offer better care,” said Ifeyinwa Osunkwo, MD, MPH, director of SCD Enterprise at the Levine Cancer Institute/Atrium Health in Chapel Hill, North Carolina.

In this home-based program, staff identify patients who live far from the clinic and may have difficulty traveling to the center for care. The program also was designed to lessen the burden on overloaded staff: Physicians follow up through virtual house calls, while nurse practitioners and emergency medical technicians are recruited to visit patients to perform basic assessments or check vital signs.

Patients with cancer have also started to receive therapy in the comfort of their own homes – if not for treatment of the malignancy itself, then for management of adverse events that can occur during treatment.

One such target is febrile neutropenia. While the condition typically has been treated in the emergency department followed by an inpatient stay, recent evidence suggested that low-risk patients with febrile neutropenia can be safely treated with oral antibiotics and discharged. In a review of three studies, the proportion of patients who were re-admitted to the hospital after discharge ranged from 17 to 21 percent, and the mortality rate ranged from 0 to 4 percent. “Low-risk” factors in the studies included living near the hospital, having a caregiver living in the home, and having a temperature lower than 100.3 degrees; a diagnosis of a hematologic malignancy was considered a low-risk exclusion criterion.7

“Treatment outcomes of low-risk febrile neutropenic patients in the inpatient and outpatient setting are comparable,” the authors concluded.

At-Home Stem-Cell Transplants?

HCT is a demanding undertaking that, while extending patients’ survival, also disrupts their lives. Patients undergoing an HCT spend four weeks or even longer in the hospital. Patients often undergo immunosuppression before and after the procedure, so they are placed under strict isolation protocols while in the hospital and after discharge.

“Over time, the medical community has become aware that hospitals aren’t the cleanest of environments,” said Anthony Sung, MD, an assistant professor of medicine at Duke University School of Medicine in Durham, North Carolina.

This realization led to the emergence of “day hospitals,” or outpatient facilities where patients can receive treatment or undergo assessment and then return home each night. Keeping the patient at home also decreases risks of other complications related to lengthy hospital stays, like delirium, inactivity, poor diet, and hospital-acquired infections.

In an initial, small phase I study, Dr. Sung and colleagues evaluated the complications, effects on quality of life, and resource use associated with at-home HCT.8 To be eligible for the trial, patients had to live within a 30-minute drive of a transplant center and have a suitable living environment that passed a home inspection (free from black mold, fall risks, etc.). Participants followed the normal pretransplant procedures and received conditioning at the hospital or day hospital, then were discharged after receiving their stem cell infusion.

Per study protocol, nurse practitioners or physician assistants made house calls each morning to conduct assessments, examine patients, and draw blood for laboratory studies. Another nurse would return in the afternoon to provide IV fluids, electrolytes, or antibiotics or to perform home blood transfusions or other interventions as necessary.

Complications from the HCT were managed in the home as much as possible, but patients returned to the clinic for treatment of events like febrile neutropenia and for routine procedures like IV administration of methotrexate for graft-versus-host disease prophylaxis. As a preventive measure, patients received their first post-HCT blood transfusion in the day hospital.

Twenty-two patients were involved in the study. Those who received allogeneic HCT were able to spend 72 percent of their days entirely at home, while patients in the autologous group spent 52 percent of their days at home. Febrile neutropenia was the main reason for returning to the clinic.

The researchers found that, overall, patients treated at home had low rates of infectious complications, with only four patients developing bloodstream infections.

Patients reported high quality of life with home-based HCT, Dr. Sung added. “They were so happy to be at home and they felt greater freedom,” he said. “They were able to eat better, exercise better, and they just felt better overall.”

Dr. Sung also reported that the at-home HCT model was well received by physicians and caregivers. “Although outpatient transplant has a lot of benefits for the patient, it puts a lot of strain on the caregiver, like having to get patients out of bed and dressed and to the clinic on time for their appointments,” Dr. Sung said. “At-home transplant will have great effects on the caregivers, as well as the patients.”

Based on the success of the phase I study, the researchers are now conducting a National Cancer Institute–funded randomized, phase II trial comparing home care versus standard care. The study, which focuses on patients undergoing allogeneic HCT, aims to demonstrate that staying in their usual environment preserves patients’ gut microbiomes and reduces the incidence of graft-versus-host disease.

Although there may be higher upfront costs to the program, Dr. Sung believes that shortening hospital stays and preventing complications will have tremendous cost savings for health-care systems.

Hospice at Home

Palliative-care specialists have long advocated for earlier integration of palliative services in patients’ care plans, and surveys have revealed that most patients would prefer dying at home. Still, most patients with hematologic disorders never make it to hospice care and often die in the hospital.

“[At-home care for sickle cell disease] can be done, but … not everybody will fit the perfect profile of a patient who would get IV medication at home.”

—Ifeyinwa Osunkwo, MD, MPH

As Adam J. Olszewski, MD, and colleagues found in a review of hospice use among Medicare beneficiaries with leukemia, dependence on red blood cell transfusions is a substantial barrier to accessing palliative or end-of-life services.9 Fewer than half (47%) of transfusion-dependent patients were enrolled in hospice before death, and often just for a few days.

Home-based models could augment palliative services for transfusion-dependent patients as they reach the end of life. Rather than entering a clinic to receive these services, they could be treated at home.

“Many hospices won’t do transfusion support from a practical standpoint, because they can’t handle the cost or the logistics,” said Thomas LeBlanc, MD, an associate professor of Medicine at Duke University School of Medicine and co-author on the study. “They don’t have a way, for example, to get blood to the person’s home or they don’t feel they could safely do that.”

Now, to bring more hematology patients the end-of-life care they need, researchers are exploring the possibility of offering transfusions at home as part of hospice care.

Jennifer Holter-Chakrabarty, MD, an associate professor of medicine at the Stephenson Cancer Center at the University of Oklahoma and a member of the ASH Committee on Government Affairs, is participating in a pilot project studying the effects of at-home transfusion services on patients’ quality of life and clinical outcomes.

The study will include 20 patients, half of whom will receive palliative care as they normally would (with transfusions in a center according to standard hospice guidelines) and half of whom will receive home-based transfusions (either on a weekly schedule, or on an as-needed basis to manage symptoms).

“If we can prove that home-based transfusions can be done in this setting, I bet we will see a huge difference in patients’ quality of life,” Dr. Holter-Chakrabarty said. She also believes this home-based model may increase the overall number of hematology patients who are able to benefit from hospice services.

The researchers also will need to allay clinicians’ concerns about safety of at-home transfusions: Transfusion-related reactions can be severe and, without the continual support available in the clinic, these complications could be problematic for patients.

“I think that the fears about this being a serious issue are probably overstated,” Dr. LeBlanc said. “Several groups, mostly out of Europe, have published results showing that they have implemented home-based transfusion programs without any significant problems like that.”

For example, in a 2018 study published in Transfusion, clinicians operating a Hospital at Home program in Spain that provided home transfusions found that, over three decades of existence, the rate of adverse events was just 2.68 percent.10

The rate “decreased significantly with time,” the authors reported, adding that at-home transfusion was performed “on selected patients by dedicated Hospital at Home units with well-trained staff, under specific protocols.”

Taking the Long Way Home

Shifting services to the home setting has improved patients’ quality of life and reduced overall health-care costs in the management of many diseases, but the researchers who spoke with ASH Clinical News acknowledged that it won’t be feasible in all settings or conditions.

In SCD, for example, opioids have been prescribed to help patients manage painful episodes without requiring those patients to come to the hospital. But, in response to the growing opioid epidemic in the U.S., physicians have become more conservative with opioid prescribing. According to Dr. Osunkwo, health-care organizations also are moving away from providing IV pain medicines at home, given the concerns about the suitability of the home environment, accessibility, complications, and staffing.

Providing at-home treatment may also discourage patients from taking personal responsibility for their care. If patients can receive IV fluids at home, Dr. Osunkwo said, they might be less motivated to drink fluids on their own.

“It can be done, but I think you have to realize that not everybody will fit the perfect profile of a patient who would get IV medication at home,” she said. The decision to provide at-home treatment requires a close evaluation of patients’ eligibility for the intervention, psychosocial makeup, and level of family or caregiver support.

To solve the issues around accessibility, many at-home programs rely on telemedicine. It’s often an effective means of bringing patient and doctor together, regardless of the miles between them. The challenge, however, lies in getting paid for these services.

“Insurance companies will pay for telemedicine services if there is a lack of specialists in a patient’s county,” Dr. Osunkwo explained. However, she noted, “if you think about it, there may be hematologists within a rural county, but no specialists with SCD expertise.” Proving the need for specialized SCD care (and reimbursement for that care) remains a challenge.

At-home programs are positioned to help solve many problems associated with inpatient hospitalizations – improving access to care, improving quality of life, lowering infection risk – but the model has its problems. Clinicians have expressed concerns about maintaining continuity of care or treatment adherence if a home-based program doesn’t include sufficient monitoring and follow-up.

Health-care systems may be able to save money on resources, but transitioning to a home-based model also could make organizations more vulnerable to malpractice claims or delay reimbursement for services.

“There is a lot that we can do at home, but whatever we do, it needs to be safe,” Dr. Leff concluded. —By Jill Sederstrom


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