RESUMEN
BACKGROUND: The "hospital-at-home" model may provide adequate care without an adverse effect on clinical outcome, and is generally well received by users. Our objective was to compare hospital-at-home and in-patient hospital care for neuromuscular disease (NMD) patients with respiratory tract infections. METHODS: We conducted a prospective randomized controlled trial in a university teaching hospital offering secondary care service to a population of approximately 500,000. We recruited selected NMD patients with respiratory tract infection for whom hospital admission had been recommended after medical assessment. Hospital-at-home was provided as an alternative to in-patient admission. The main outcome measures were need for hospitalization, treatment failure, time to recovery, death during the first 3 months following exacerbation, and cost of patient care. RESULTS: Among 59 consecutive NMD patients eligible for the study, 53 met the criteria for hospital-at-home. Twenty-six subjects were randomized to home care and 27 to hospital care. No significant differences were found in treatment failure (8/26 vs 13/27, P = .19), time to recovery (8.9 ± 4.6 vs 9 ± 8.9 d, P = .21), or mortality at 3 months (3/26 vs 4/27 deaths, P = .42) between the groups. Hospital-at-home failure was independently correlated with type of NMD (P = .004) with an odds ratio of failure of 17.3 (95% CI 2.1 to infinity) for subjects with amyotrophic lateral sclerosis. The total and daily direct cost of patient healthcare was significantly lower for the subjects who were successfully treated at home, compared to the hospitalized individuals. CONCLUSIONS: Hospital-at-home is an effective alternative to hospital admission for selected NMD patients with respiratory tract infections.
Asunto(s)
Servicios de Atención a Domicilio Provisto por Hospital , Hospitalización , Enfermedades Neuromusculares , Infecciones del Sistema Respiratorio , Adulto , Anciano , Costos y Análisis de Costo , Femenino , Servicios de Atención a Domicilio Provisto por Hospital/economía , Servicios de Atención a Domicilio Provisto por Hospital/estadística & datos numéricos , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Hospitales Universitarios/estadística & datos numéricos , Humanos , Italia , Masculino , Persona de Mediana Edad , Enfermedades Neuromusculares/complicaciones , Enfermedades Neuromusculares/terapia , Evaluación de Procesos y Resultados en Atención de Salud , Selección de Paciente , Proyectos Piloto , Infecciones del Sistema Respiratorio/etiología , Infecciones del Sistema Respiratorio/terapia , Análisis de Supervivencia , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
Undifferentiated connective tissue diseases (UCTDs) are clinical entities characterised by signs and symptoms suggestive of a systemic autoimmune disease, which do not fulfil the diagnostic criteria for a defined connective tissue disease. Lung involvement can complicate the course and management of the disease, often determining a worse outcome. Respiratory dysfunction as the first clinical manifestation has seldom been reported.We describe a case of a female patient who developed significant respiratory dysfunction as the principal clinical sign. Video-assisted thoracoscopy was performed and a histological pattern of nonspecific interstitial pneumonia (NSIP) was found. A pathological diagnosis suggested careful follow-up with extensive immunological screening which then detected Raynaud's phenomenon and positivity of antinuclear antibodies. After a multidisciplinary discussion (pneumologist, radiologist, pathologist and rheumatologist) a final diagnosis of NSIP associated with UCTD was made. The diagnosis of UCTD should be considered when NSIP is diagnosed even in cases with evident first clinical manifestations of severe respiratory dysfunction. A multidisciplinary approach in the field of interstitial lung disease with NSIP, also including rheumatologic expertise, is fundamental to achieve a prompt and correct diagnosis.