Higher costs of team-managed approach must be weighed against benefits
CHICAGO - A home-based primary care intervention program by the Department of Veterans Affairs significantly improved health-related quality of life and satisfaction for patients and their caregivers, according to an article in the December 13 issue of The Journal of the American Medical Association (JAMA).
Susan L. Hughes, D.S.W., of Edward A. Hines Jr. Veterans Affairs Hospital, Hines, Ill., and colleagues conducted a multi-site randomized controlled trial for the Department of Veterans Affairs (VA) Cooperative Study Group on Home-Based Primary Care. A total of 1,966 patients and 1,883 caregivers took part in the study, conducted from October 1994 to September 1998 in 16 VA medical centers. The authors assessed the impact of Team-Managed Home-Based Primary Care (TM/HBPC) on patient functional status, patient and caregiver health-related quality of life (HR-QoL) and satisfaction with care, caregiver burden, hospital readmissions, and costs over 12 months.
According to background information cited in the study, an early study of a primary care home-based care model for the Department of Veterans Affairs found significant benefits. The VA Home-Based Primary Care (HBPC) program differs in important ways from the Medicare home health care benefit. Clinicians are able to exercise considerable clinical judgment regarding patient targeting and length of home care stay. Physicians are salaried staff who designate a specific percentage of time to the HBPC program. This feature enables referring physicians to transfer primary care management of patients at discharge to the HBPC physician and medical team who continue to provide primary care management inside and outside of the hospital until the patients are discharged from the program. Other disciplines encompassed by the home care team can include social workers, dietitians, therapists, pharmacists, and health technicians (paraprofessional aides).
Patients in the 1994-1998 study were a mean age of 70 years, and had two or more activities of daily living impairments or a prognosis of terminal illness. Patients who did not meet those criteria, but were homebound with a primary diagnosis of congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD) were also included. A total of 985 patients in the control group received customary VA and private sector care. The other 981 patients had home-based primary care, including a primary care manager, 24-hour contact for patients, prior approval of hospital readmissions, and HBPC team participation in discharge planning.
"Functional status as assessed by the Barthel Index did not differ for terminal or non-terminal (those with severe disability or who had CHF or COPD) patients by treatment group. Significant improvements were seen in terminal TM/HBPC patients in HR/QoL scales of emotional role function, social function, bodily pain, mental health, vitality, and general health," the authors write.
"Team-Managed HBPC non-terminal patients had significant increases of 5 to 10 points in 5 of 6 satisfaction with care scales," they continue. The authors also report consistent benefits were seen for the treatment group in caregiver outcomes. "The caregivers of terminal patients in the TM/HBPC group improved significantly in HR-QoL measures except for vitality and general health," they write. "Caregivers of non-terminal patients improved significantly in QoL measures and reported reduced caregiver burden."
Although about half the patients in the control group received private sector (mainly Medicare) home health care, neither they nor their caregivers showed the same improvements in HR-QoL and satisfaction. "Thus, this hospital-based primary care home care model appears to promote better patient and caregiver outcomes. We believe that greater perceived continuity and coordination of care that is possible within a vertically integrated care system is responsible for these outcomes," the authors write.
"These patient and caregiver benefits were accompanied by an 8 percent reduction in proportion of patients with hospital readmissions and a 22 percent reduction in number of hospital readmissions among the patients with severe disability in the TM/HBPC group at six months that were not sustained at 12 months, and no reduction in number of days or cost of bed days was seen at either time period," the authors report.
The authors compared costs for the treatment group and the control group at six and 12 months. "Total mean per person costs were 6.8 percent higher in the TM/HBPC group at six months ($19,190 vs. $17,971) and 12.1 percent higher at 12 months ($31,401 vs. 28,008)," they write.
"The TM/HBPC intervention improved most HR-QoL measures among terminally ill patients and satisfaction among non-terminally ill patients. It improved caregiver QoL, satisfaction with care, and caregiver burden and reduced hospital readmissions at six months, but it did not substitute for other forms of care. The higher costs of TM/HBPC should be weighed against these benefits," the authors conclude. (JAMA. 2000; 284:2877-2885)
Editor's Note: This study was funded by the Health Services Research and Development Service and the Cooperative Studies Program of the Department of Veterans Affairs, VA Headquarters, Washington, D.C.
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