Alternative Management Strategies Achieve Comparable Clinical Outcomes

A recently published review suggests that alternatives to inpatient hospitalization do not jeopardize the treatment of several acute medical conditions.

These approaches, which also appear to achieve similar levels of patient satisfaction, could substantially reduce the cost of health care for patients at low risk for complications, according to Jared Conley, MD, PhD, MPH, of the department of emergency medicine at Massachusetts General Hospital, and colleagues. 

“Conventionally, many acute medical conditions have been managed in a hospital inpatient setting; however, innovative care delivery models are challenging the status quo, often with the support of biotechnological advancement,” the researchers wrote in JAMA Internal Medicine. “These newer approaches suggest that safe, alternative management strategies exist that obviate the need for inpatient admission.”

Despite previous systematic reports of various alternative management strategies — which include outpatient management, quick diagnostic units, observation units, and hospital-at-home strategies — no study has presented a comprehensive evaluation across multiple conditions and approaches. 

To rectify this, Dr Conley and colleagues parsed databases to identify 25 systematic reviews gauging alternative management for conditions conventionally cared for in the hospital. After grading and assessing the quality of each review and its primary evidence, they compiled the data to examine the effectiveness, safety, cost and patient satisfaction of these alternative strategies.

Overall, the researchers found the methodological quality of the 25 reviews to be of moderate quality, and across each of the four major alternative strategies they found consistent evidence of cost savings compared to inpatient care. Outpatient management strategies for several acute medical conditions demonstrated no significant changes in mortality, disease, specific outcomes, or patient satisfaction, they wrote, while hospital-at-home strategies showed either no difference or an improvement in these same endpoints. Data was limited for quick diagnostic units, but included evidence of low mortality and high satisfaction. Studies evaluating observation unit care showed no differences or improvements for certain acute medical conditions, but limited data for others.

The only notable exception to these trends that Dr Conley and colleagues found was return hospitalizations for quick diagnostic units and outpatient management of chemotherapy-induced febrile neutropenia. Regardless, they stressed the importance of continued investigation into these strategies as a strategy to combat the rising costs of patient care.

“Safe and effective care can be achieved in lower cost settings with positive or neutral impact on patient satisfaction,” they wrote. “Further examination with RCT and high-quality comparative observational studies for some conditions and models of care is warranted.” —Dave Muoio