**4. Current knowledge on home care for COPD exacerbations**

COPD is often associated with exacerbations of symptoms. Exacerbations, particularly that result in admission to hospital, are significant events in the natural history of the disease. They are disruptive and distressing for patients, and account for a significant proportion of the total costs of caring for patients with COPD.

There is no generally agreed definition for an exacerbation of COPD. Definitions currently rely on clinical empiricism with little evidence-based scientific support (Caramori et al., 2009). Most common international guidelines and working groups provide very similar definition of a COPD exacerbation: "*an event in the natural course of the disease characterized by a change in the patient's baseline dyspnea, cough and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD"* (ATS/ERS guidelines, Celli et al., 2004; GOLD, 2009; BTS guidelines, 2007; CTS guidelines, O'Donnel et al., 2008; SEPAR/ALAT joint guidelines, Peces-Barba et al., 2008; Rodriguez-Roisin, 2000).

used for respiratory disease treatment are due to COPD, such that COPD accounts for more than one million "bed days" each year in hospitals in the UK (NICE guidelines, update

The impact of hospitalization for acute exacerbations is significant; mortality during admission is > 10% and mortality during the year after discharge following treatment for

An acute exacerbation of COPD is not an exceptional or unique event. The Risk Factors of COPD Exacerbation Study (EFRAM) found that 63% of patients were readmitted during the year following an exacerbation (Garcia-Aymerich et al., 2003). Patients with COPD experience exacerbations one to three times a year, with treatment often requiring emergency room care or hospitalization, which contributes substantially to the financial

Various observational studies have found that inpatient care accounts for 50-75% of the direct medical costs of COPD. This cost increases with disease severity: inpatient costs of patients with stage III (severe) disease are double those of patients with stage II (moderate) disease and 6.5 times greater than those of patients with stage I (mild) disease (Dalal et al.,

The indirect cost of COPD are substantial with an impact on annual productivity amounting to an estimated 24 million lost working days per annum. There is little data available to quantify other indirect costs such as carer time and inability to carry out non-occupationally

There continues to be high demand for acute care hospital beds for patients with an exacerbation of COPD. Recent reports highlight the fact that although the acute hospital is the standard venue for providing acute medical care, it may be hazardous for older persons, who commonly experience iatrogenic illness, functional decline, and other adverse events. One way to decrease or avoid admissions to hospital is to provide people with acute care

COPD is often associated with exacerbations of symptoms. Exacerbations, particularly that result in admission to hospital, are significant events in the natural history of the disease. They are disruptive and distressing for patients, and account for a significant proportion of

There is no generally agreed definition for an exacerbation of COPD. Definitions currently rely on clinical empiricism with little evidence-based scientific support (Caramori et al., 2009). Most common international guidelines and working groups provide very similar definition of a COPD exacerbation: "*an event in the natural course of the disease characterized by a change in the patient's baseline dyspnea, cough and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD"* (ATS/ERS guidelines, Celli et al., 2004; GOLD, 2009; BTS guidelines, 2007; CTS guidelines, O'Donnel et al., 2008; SEPAR/ALAT joint guidelines, Peces-Barba et

**4. Current knowledge on home care for COPD exacerbations** 

acute COPD exacerbation is 25-40% (Escarrabill, 2009).

burden of the disease (Dalal et al., 2011).

related activity (NICE guidelines, update 2010).

the total costs of caring for patients with COPD.

al., 2008; Rodriguez-Roisin, 2000).

2010).

2011).

treatment at home.

When an exacerbation of COPD has been diagnosed, to define its severity is essential. Quantification of severity is important in medical management as well as in determing the setting of care (Celli et al., 2004). At present, there is not a validated method for quantifying the severity of exacerbation. Generally, the intensity of the underlying COPD must be considered, as well as comorbidity and a history of previous exacerbations. In addition to these factors, the progression of the symptoms, response to therapy, and availability of adequate home care must be considered in order to decide whether hospitalization is necessary. However, grading of the severity of mild to moderate exacerbations remains contentious since they can be categorised either on clinical presentation (essentially symptoms) or healthcare use resources (Rodriguez-Roisin, 2006).

The most recent position paper of the American Thoracic Society and the European Respiratory Society (ATS/ERS task force) provide a three levels operational classification of severity of COPD exacerbations which allows to identify the best setting of care according to specific elements of clinical evaluation and diagnostic procedures. Level I: patient can be treated at home, Level II: requires hospitalization, Level III: leads to respiratory failure (Celli et al., 2004).

In the National Institute for Clinical Excellence (NICE) guidelines (update 2010), hospital-athome and assisted-discharge schemes are recommended as a safe and effective alternative to conventional hospitalization (Grade A), particularly for patients with less severe exacerbations. The same authors admit that, currently, there are insufficient data to make firm recommendations about which patients with an exacerbation are most suitable for hospital-at-home or early discharge, and patient selection should depend on the resources available, absence of factors associated with worse prognosis and patient's preference (NICE guidelines, update 2010).

The joint guidelines of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) and the Latin American Thoracic Society (ALAT) indicate home hospitalization only for patient without signs of severity such as diminished level of consciouness, abnormal chest radiograph, hypercapnia with acidosis, significant comorbidities, need of ventilatory support (Peces-Barba et al., 2008).

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines (update 2009) state that "admission of patient with severe COPD exacerbations to intermediate or special respiratory care units may be appropriate if personnel, skills, and equipment exist to identify and manage acute respiratory failure successfully" (GOLD, 2009).

A first feasibility analysis of home-based services to prevent conventional hospitalization of COPD exacerbations was reported in 1999 by Gravil and collegues (Gravil et al., 1998). Subsequent controlled trials confirmed both safety and cost reduction when these types of services were applied to selected COPD patients (Cotton et al., 2000; Davies et al., 2000; Hernandez et al., 2003; Ojoo et al., 2002; Skwarska et al., 2000).

In a review and a meta-analysis including 7 robust RCTs (n=754 patients) Ram and collegues evaluated the overall efficacy of hospital at home schemes, showing that selected patients presenting to hospital emergency departments with acute exacerbation of COPD can be successfully treated at home when supported by visiting respiratory nurses at home. Authors suggested that approximately 25% of the patients with COPD who presented at the

Hospital at Home for Elderly Patients

Shepperd et al., 2009b).

**5. The Hospital at Home Service of Torino** 

patients with severe chronic or relapsing illnesses*.* 

2005, 2008; Tibaldi et al., 2004, 2009).

patients, as part of the HHS service.

telephone if problems arise.


neoplastic diseases.

activity are:

with Acute Exacerbation of Chronic Obstructive Pulmonary Disease 381

for a limited time period. The key is that if the hospital at home service was not available, then the patient would need to be admitted to an acute hospital ward. In a systematic review of avoidance of admission through the provision of hospital care at home, 10 randomized trials involving elderly patients with medical condition were included (with a total of 1327 patients). For 5 of these trials individual patient data were obtained for metaanalysis, representing 87% of potentially eligible patients. Authors reported a significantly lower mortality at 6 months for patients who received hospital care at home, greater satisfaction and lower costs (if costs of informal care are excluded). (Shepperd et al., 2008;

In October 1984, with Resolution N. 1134/41/84, the Management Committee of the Local

In October 1985 a team of doctors and nurses of the Turin Department of Geriatrics started an experiment that was unique in Italy at that time: medical treatment (including examinations and related medical and nursing services) at home rather than in hospital for

The Hospital at Home Service (HHS) is operating in Torino at S. Giovanni Battista Hospital, a large urban University teaching and tertiary-care hospital (Aimonino Ricauda et al., 2004,

The HHS is a service that provides diagnostic and therapeutic treatments by health care professionals, in the patient's home, of a condition that otherwise would require acute hospital in-patient care. A quick admission to hospital is possible for examinations or interventions that cannot be carried out at home. Transport and acceptance are free for these

The HHS normally operates 12 hours a day (from 8 am to 8 pm), seven day a week. At night our Regional Emergency Unit ("118") can be contacted. For selected patients, medical staff is on-call 24 hours a day. Caregivers are instructed in the emergency plan and encouraged to

The HHS team, equipped with 7 cars, is multidisciplinary and consists of 4 geriatricians*,* 13

The main feature of HHS is that physicians and nurses work together as a team (Figure 1), with daily meeting to discuss the needs of each patient and to organize individualized medical care plans and day-to-day work. The three most important aspects of the nursing


The team looks after 25 patients per day and 500 patients per year, on average. The most common diseases treated at home are cardiac, respiratory, cerebrovascular, metabolic and

nurses*,* 1 nurse coordinator*,* 2 physiotherapists, 1 social worker, 1 counsellor.


for specialistic consultations or exams which can be done only in hospital

Health Unit 1/23 of Turin set up the 'Experimental Project of Home Hospitalisation'.

emergency department with acute exacerbations would be suitable for home treatment (Ram et al., 2003, 2004).

In conclusion, there is an international consensus on home care for COPD exacerbations, especially for less severe episodes, although data on specific characteristics of patients suitable for this form of care are currently insufficient. In addition, the confusion on definition of "home hospitalization" and "hospital at home" can make difficult to clear up this problem.

Intermediate care is a treatment model which bridges the interface between hospital and community care. A specific subtype of intermediate care is Hospital-at-Home. There is a consensus on defining "Hospital-at-Home" a model of care where "active treatment is provided by healthcare professionals in the patient's home for a condition that otherwise would require hospital care, always for a limited period" (Cochrane Database of Systematic Review, Shepperd et al., 2001). Many disparate models exist with the general nomenclature of "Hospital at Home", "Home hospitalization". These include usual community-based care, outpatient infusion centre, nurse-only outpatient care and the direct clinical unit model of care. These models have distinct features.

Established models for delivering hospital-level care in the home setting exist internationally, including United States, Canada, Israel, Australia, New Zeland, Spain, United Kingdom, Italy, France (Leff et al., 2005; Lemelin et al., 2007; Stessman et al., 1996; Caplan et al., 1999; Montalto, 2002; Richards et al., 2005; Cerrillo –Rodriguez et al., 2009; Pérez-Lopez et al., 2008; Kalra et al., 2008; Wilson et al., 1999; Myles et al., 1996; Aimonino Ricauda et al., 2008).

For patients with exacerbations of COPD, over the last few years there has been considerable interest especially in hospital-based rapid assessment units and early discharge or admission avoidance hospital at home schemes.

**Rapid assessment units** aim to identify those patients that can be safely be managed at home. These units generally involve a full assessment of the patient in the hospital by a multidisciplinary team and discharge to the community with appropriate support (e.g. nebuliser and compressor or oxygen concentrator, nursing and medical supervision from respiratory specialists, increased social support). Patients remains under the care of the hospital but General Pratictioners are made aware of the fact that their patients are receiving home care.

**Early or assisted or supported discharge schemes** aim to identify patients in hospital who could be discharge before they have fully recovered by providing increased support in their homes. These schemes involve getting people out of hospital as quickly as possible. In a recent review Shepperd and collegues have demonstrated that mortality and disability for patients recovering from stroke, COPD or surgical interventions are similar in hospital and in early/supported discharge services. Patients may also be more satisfied with their care at home, and at the same time their cares, in most cases, do not report additional burden. However, authors concluded that there is little evidence of cost savings to the health care system (Shepperd et al., 2009a).

The **admission avoidance schemes** provide active treatment by hospital health care professionals (doctors, nurses and other professional figures) in the patient's home, always

emergency department with acute exacerbations would be suitable for home treatment

In conclusion, there is an international consensus on home care for COPD exacerbations, especially for less severe episodes, although data on specific characteristics of patients suitable for this form of care are currently insufficient. In addition, the confusion on definition of "home hospitalization" and "hospital at home" can make difficult to clear up

Intermediate care is a treatment model which bridges the interface between hospital and community care. A specific subtype of intermediate care is Hospital-at-Home. There is a consensus on defining "Hospital-at-Home" a model of care where "active treatment is provided by healthcare professionals in the patient's home for a condition that otherwise would require hospital care, always for a limited period" (Cochrane Database of Systematic Review, Shepperd et al., 2001). Many disparate models exist with the general nomenclature of "Hospital at Home", "Home hospitalization". These include usual community-based care, outpatient infusion centre, nurse-only outpatient care and the direct clinical unit model of

Established models for delivering hospital-level care in the home setting exist internationally, including United States, Canada, Israel, Australia, New Zeland, Spain, United Kingdom, Italy, France (Leff et al., 2005; Lemelin et al., 2007; Stessman et al., 1996; Caplan et al., 1999; Montalto, 2002; Richards et al., 2005; Cerrillo –Rodriguez et al., 2009; Pérez-Lopez et al., 2008; Kalra et al., 2008; Wilson et al., 1999; Myles et al., 1996; Aimonino

For patients with exacerbations of COPD, over the last few years there has been considerable interest especially in hospital-based rapid assessment units and early discharge

**Rapid assessment units** aim to identify those patients that can be safely be managed at home. These units generally involve a full assessment of the patient in the hospital by a multidisciplinary team and discharge to the community with appropriate support (e.g. nebuliser and compressor or oxygen concentrator, nursing and medical supervision from respiratory specialists, increased social support). Patients remains under the care of the hospital but General Pratictioners are made aware of the fact that their patients are receiving

**Early or assisted or supported discharge schemes** aim to identify patients in hospital who could be discharge before they have fully recovered by providing increased support in their homes. These schemes involve getting people out of hospital as quickly as possible. In a recent review Shepperd and collegues have demonstrated that mortality and disability for patients recovering from stroke, COPD or surgical interventions are similar in hospital and in early/supported discharge services. Patients may also be more satisfied with their care at home, and at the same time their cares, in most cases, do not report additional burden. However, authors concluded that there is little evidence of cost savings to the health care

The **admission avoidance schemes** provide active treatment by hospital health care professionals (doctors, nurses and other professional figures) in the patient's home, always

(Ram et al., 2003, 2004).

care. These models have distinct features.

or admission avoidance hospital at home schemes.

this problem.

Ricauda et al., 2008).

home care.

system (Shepperd et al., 2009a).

for a limited time period. The key is that if the hospital at home service was not available, then the patient would need to be admitted to an acute hospital ward. In a systematic review of avoidance of admission through the provision of hospital care at home, 10 randomized trials involving elderly patients with medical condition were included (with a total of 1327 patients). For 5 of these trials individual patient data were obtained for metaanalysis, representing 87% of potentially eligible patients. Authors reported a significantly lower mortality at 6 months for patients who received hospital care at home, greater satisfaction and lower costs (if costs of informal care are excluded). (Shepperd et al., 2008; Shepperd et al., 2009b).
