Evidence Review of Alternative Strategies to Inpatient Hospitalization for Acute Medical Conditions
One important area of healthcare redesign is identifying the best management setting for the diagnosis and/or treatment of acute medical conditions conventionally managed in a hospital inpatient setting. Alternative management approaches to hospitalization are currently organized into four models of care delivery: 1) Outpatient management – emergency department (ED) or clinic work-up and treatment with close outpatient follow-up; 2) Quick diagnostic units (QDUs) – organized clinics that obtain rapid diagnoses for serious illnesses (e.g. malignancy); 3) Hospital-at-home – evaluation in the ED or clinic, followed by delivery of inpatient-level care within the patient's home; and 4) Observation units – protocol-driven management for up to 24-48 hours with subsequent discharge for outpatient follow-up. This evidence review examined the effectiveness, safety, and cost of treating acute medical conditions in settings outside of a hospital inpatient unit. Investigators reviewed several databases from January 1995 through February 2016 for systematic reviews that evaluated alternative management strategies to hospital admission, with 25 reviews (representing 123 unique studies) meeting inclusion criteria.
For low-risk patients with a range of acute medical conditions, evidence suggests that alternative management strategies to inpatient care can achieve comparable clinical outcomes and patient satisfaction at lower costs. Specific findings include:
Across all alternative management strategies, cost data were heterogeneous but showed near-universal savings when assessed.
- Outpatient management: Several acute medical conditions had no significant difference in mortality, disease-specific outcomes, or patient satisfaction compared with inpatient admission.
- Quick diagnostic units: The evidence was more limited but did demonstrate low mortality rates and high patient satisfaction.
- Hospital-at-home: A variety of acute medical conditions had mortality rates, disease-specific outcomes, and patient and caregiver satisfaction that were either improved or no different compared with inpatient admission.
- Observation units: Several acute medical conditions were found to have no difference in mortality, a decreased length of stay, and improved patient satisfaction compared to inpatient admission; results for some conditions were more limited.
- For some alternative management strategies, the countries represented in these studies were diverse; therefore, it is important to account for relevant differences in health care systems when assessing U.S. applicability.
- Evidence for some alternative management strategies was moderate owing to the lack of level 1 evidence; as such, some caution is warranted in interpreting these results.
Dr. Zulman was supported by an HSR&D Career Development Award and is part of HSR&D's Center for Innovation to Implementation (Ci2i) in Palo Alto, CA
Conley J, O’Brien C, Leff B, Bolen S, and Zulman D. Alternative Strategies to Inpatient Hospitalization for Acute Medical Conditions: A Systematic Review. JAMA Internal Medicine. November 1, 2016;176(11):1693-1702.