"Jane gets better when she's at home, and you don't have to pay as much for her to get better."

Sunday, March 31, 2002

Clinical evidence demonstrates home care's savings

TUSCON, Ariz. - Sixteen years after a prominent synthesis of clinical literature found that homecare services had little impact on mortality, on hospitalization, nursing home placements and actually increased the cost of care by 15%, a fresh look at the clinical literature is yielding a far more optimistic view of home care as a cost-saving alternative.

In a presentation of preliminary findings at AAHomecare's Leadership Conference Feb. 21, Rodney Hornbake, M.D., said that the literature now shows that home care can shorten in-patient hospital stays, reduce the cost of care and improve clinical outcomes.

Hornbake's findings seem to confirm anecdotes and non-scientific claims that have long posited home care as a more cost-effective means of providing certain forms of health care.

"We need the data so we can go to the government and say, 'Not only does Jane feel good when she's at home, but Jane gets better when she's at home, and you don't have to pay as much for her to get better," said David Savitsky, vice chairman of Tender Loving Care. "We think that by showing that this is the case, this is going to help us in the overall picture."

As chairman of AA-Homecare, Savitsky asked Hornbake to produce an evidence-based analysis for this year's conference, entitled "Demonstrating the Value of Home Care." Hornbake's conclusions are drawn from a review of 309 relevant articles and scrutiny of 22 of those articles. He is now preparing an article that he plans to submit for publication in a peer-review journal - an article that may well stand as the most significant rebuttal to the Hedrick-Inui findings of 1986.

Several studies in Hornbake's synthesis examine the impact of home care on COPD. In two U.K. studies of 265 COPD patients discharged early for home care, home care did not impact patient outcomes and did render more cost-effective care. In a Danish study of 344 patients with a minimum age of 75, home care intervention resulted in a reduction of nursing home visits and hospital days.

The U.K. was particularly fertile ground for scientific data. "They set aside a significant portion for health services research," said Hornbake. "That's unique. We don't do that. We go ahead, try it and see what happens." Consequently, U.S. healthcare providers are left with lots of anecdotal evidence, but less data. The relative dearth of data in the states was decried by members of a panel that convened following Hornbake's presentation.

"This industry needs to consider this a life or death struggle," said one panelist, Grant Bagley, M.D., a partner in the Washington, D.C. law firm, Arnold & Porter.

At the same time, Bagley was skeptical about the clout that respectable clinical data carries at CMS, where he formerly served as director of the coverage and analysis group. Respectable clinical data invariable misses the mark, he said.

"They change the bull's-eye after the arrow has been shot," said Bagley.

Shooting the arrow, according to another panelist, Bob Fary, corporate director of respiratory services at Apria, is complicated by a relatively empty quiver. Fary pointed out that "science" has yet to make a rock-solid case for non-invasive pressure ventilation. And beyond the landmark NOTT (Nocturnal Oxygen Therapy Trial) study, which set the stage for the home oxygen industry, Fary hasn't encountered much more data on home oxygen.

Like Bagley, Fary believed the home medical equipment industry needs to lean more heavily on data, but he's frustrated by the reluctance of people to share information.

"In my 15 years in this industry, I've found people to be relatively secretive when it comes to sharing information about outcomes and providing therapies in general," he said. "We need a repository." HME