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Surgical Innovation
April 28, 2021

Home Hospital for Surgery

Author Affiliations
  • 1Department of Surgery, University of Chicago, Chicago, Illinois
  • 2Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
  • 3Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
  • 4Harvard Medical School, Boston, Massachusetts
  • 5Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
  • 6Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
JAMA Surg. 2021;156(7):679-680. doi:10.1001/jamasurg.2021.0597

In November 2020, the US Centers for Medicare and Medicaid Services announced the Acute Hospital Care at Home waiver, an innovative payment and delivery system reform focused on the home hospital delivery model (HH). Home hospital delivers monitored at-home treatment that would otherwise require inpatient hospital admission.1 This care can include nursing and paramedic support, daily clinician and therapist visits, point-of-care laboratory and imaging tests, and administration of IV medications. There is evidence that HH is safer, cheaper, and more effective than traditional inpatient care, particularly for older adults. Home hospital programs have been established as beneficial for a wide range of conditions and are widely used in the United Kingdom, Spain, and Australia. Home hospital for surgery is an emerging option for perioperative care, with uses including preoperative monitoring, postoperative care, and even operation at home. Early efforts for general surgery have focused on ileostomy dysfunction.2 Routine postoperative care of patients undergoing orthopedic and bariatric surgery may be use cases for HH, and there is a burgeoning industry of private companies offering HH services. In the era of enhanced recovery after surgery (ERAS) and site-of-care optimization as a source of value in alternative payment models, HH is the next step in this progression toward patient-centered, value-based care. Home hospital also carries the potential to reduce surgical inequities by extending care to patients and geographic areas historically deprived of care.3

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    1 Comment for this article
    EXPAND ALL
    Home Hospital for Surgery, here to stay
    David Nicolas, MD PhD | Hospital at Home Unit - Hospital Clínic Barcelona
    We read with great interest the Viewpoint from Dr. Bryan and colleagues (1) offering some interesting insights about what we believe is the present and future of hospitalization. COVID-19 pandemic has boosted the surge of alternatives to avoid overcrowded, concrete-built, hospitals (2). Hospital at Home units (HaH) have proven to be a safe and cost-efficient model (3) and surgical patients, might be one of the groups benefiting the most. Surgical patients, both complicated and non-complicated post-surgeries, might be one of the groups benefiting the most.

    During the last year, the HaH of the Hospital Clínic Barcelona, a
    public tertiary centre, has started several post-surgical programs in collaboration with the different surgical services and in the context of the ERAS program (4). These programs aim to shorten the conventional hospital stay, avoiding the complications associated to hospitalization such as nosocomial infections or myopathy and accelerating the functional recovery. Since November 2020, we are developing a fast-track HaH program for gastric bypass on day 1 post-surgery (5 patients to the date), uncomplicated appendicitis on day 0 (10 patients), kidney transplant on day 4 (26 patients), radical cystectomy on day 4 (12 patients), with a total of approximately 200 days of hospital-stay saved so far. Patients are selected in the pre-surgery consultation by the surgeon and nurse, and a full medical and social assessment is performed by the HaH team after surgery. At home patients receive daily visits by the HaH staff, and telematic consultations with a designated surgeon of each department, and a 24/7 call centre. Only two patients (2,8%) required transfer back to hospital due to clinical worsening not treatable at home.

    Some of the barriers found are related to the selection of patients, with patients living alone or out of the area of catchment being the main criteria for HaH rejection. These two factors may be overcome with the deployment of temporary home alternatives, such as adapted hotels or apartments. The other barrier refers to the ability to safely manage high complexity surgical patients at home, whom may need a more intense monitoring and caring. Technology may bring some light in this sense, with telemedicine and remote vital sign monitoring providing the tools for assuring a safe and high-quality assistance out of the hospital setting (5).

    Our preliminary date shows that HaH for surgery is already here, and with all certainty it is here to stay. In the immediate future, innovative solutions to overcome the last barriers will be proposed and validated.


    David Nicolás MD PhD

    Irene Bachero MD

    Jose M Balibrea MD PhD

    Hospital Clínic Barcelona, University of Barcelona, Spain.



    REFERENCES

    1. Bryan AF, Levine DM, Tsai TC. Home Hospital for Surgery. JAMA Surg. Published online April 28, 2021. doi:10.1001/jamasurg.2021.0597

    2. Coloma E, Nicolás D Hospital at Home units in the post-COVID 19 era. Eur J Clin Invest. 2020 Nov;50(11):e13390. doi: 10.1111/eci.13390. Epub 2020 Sep 14.PMID: 32852794

    3. Shepperd S, Doll H, Broad J, Gladman J, Iliffe S, Langhorne P, Richards S, Martin F, Harris R. Early discharge hospital at home. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD000356. doi: 10.1002/14651858.CD000356.pub3. Update in: Cochrane Database Syst Rev. 2017 Jun 26;6:CD000356..

    4. Liu VX, Rosas E, Hwang J, et al. Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery Syst
    CONFLICT OF INTEREST: None Reported
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