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July 22, 1996

Preferences for Home vs Hospital Care Among Low-Risk Patients With Community-Acquired Pneumonia

Author Affiliations

From the Medical Practices Evaluation Center and Medical Services, Massachusetts General Hospital, and Harvard Medical School, Boston, Mass (Drs Coley and Singer); Departments of Biostatistics (Dr Li), Health Services Administration (Dr Lave), and Medicine (Drs Fine and Kapoor and Ms Medsger), University of Pittsburgh, Pittsburgh, Pa; Departments of Medicine and Microbiology, Victoria General Hospital and Dalhousie University, Halifax, Nova Scotia (Dr Marrie); Department of Health Policy and Management, Harvard School of Public Health, Boston (Dr Weinstein); and Departments of Health Administration and Medicine, University of Toronto, and Division of General Internal Medicine and Clinical Epidemiology, The Toronto Hospital, Toronto, Ontario (Dr Detsky).

Arch Intern Med. 1996;156(14):1565-1571. doi:10.1001/archinte.1996.00440130115012

Objective:  To measure preferences for initial outpatient vs hospital care among low-risk patients who were being actively treated for community-acquired pneumonia (CAP).

Methods:  Study patients included 159 patients with CAP, 57 (36%) initially hospitalized, who were identified as being at low risk for early mortality using a validated prediction model. Subjects were enrolled from university and community health care facilities located in Boston, Mass, Halifax, Nova Scotia, and Pittsburgh, Pa, participating in the Pneumonia Patient Outcome Research Team prospective cohort study of CAP. Three utility assessment techniques (category scaling, standard gamble, and willingness to pay) were used to measure the strength of patient preferences for the site of care for low-risk CAP. At the time of initial therapy or during the early recuperative period, patient preferences were assessed across a spectrum of potential clinical outcomes using 7 standardized pneumonia clinical vignettes.

Results:  Responses to the 7 pneumonia scenarios indicated that most patients consistently preferred outpatient-based therapy. This pattern was observed regardless of whether patients had actually been treated initially at home or in a hospital. Patients (74%) who stated that they generally preferred home care for low-risk CAP were willing to pay a mean of 24% of 1 month's household income to be assured of this preference. Preference for home care, as measured by the category scaling and the willingness to pay, persisted after adjustment for sociodemographic and baseline health status covariates. Sixty-nine percent of interviewed patients said that their physician alone determined whether they would be treated in the hospital or at home. Only 11% recalled being asked if they had a preference for either site of care.

Conclusions:  Most patients, even those treated initially in a hospital, who were at low risk for mortality from CAP prefer outpatient treatment. However, most physicians appear not to involve patients in the site-of-care decision. More explicit discussion of patient preferences for the location of care would likely yield more highly valued care by patients, as well as less costly treatment for CAP.Arch Intern Med. 1996;156:1565-1571

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