Analyses of the effectiveness of a Brazilian pediatric home care service: a preliminary study

Technological advances in the treatment of health problems over recent years have provided better care conditions and increased survival of prematurely born children, as well as an increase in life expectancy and a decrease in child mortality [1], which provides an improvement to chronic health conditions throughout the world [2].

However, we conceptualized children with chronic health conditions of up to 1 year as a limiting and evolving condition, characterized by loss of locomotion capacity and loss of social relationships. In addition to the need for technological devices, the use of controlled and continuous medications, with gastrointestinal problems, mainly related to deglutition; psychological and cognitive alterations, dependent on neuropsychomotor stimulation, in addition to specialized educational and health services [3].

Several countries have tried to adapt to this new demand for offered care, due in particular to issues of economic viability [4]. This has strengthened the emergence of new strategies and mechanisms for health care, such as Home Care Services (HCS), which combines technological and scientific resources present in the hospital with the family environment [5]. The domicile, owing to its humanizing characteristic and the demographic and epidemiological profile of the population, is a place with potential to expand and qualify care processes [6].

The development of HCS around the world has been accompanied by demographic and epidemiological changes [7] and is related to reduction of risks of infections [8], humanization of care and quality of life, greater involvement of relatives with patient disease, tightening of health staff/patient/family relationship [9], reduction of costs, increased turnover of hospital beds with bed management, de-hospitalization [10], lower rates of clinical worsening and acute complications, lower demand for emergency and emergency services, lower rates of re-hospitalization [11], implementation of palliative care [12] and effective prevention, promotion and recovery of health actions [13].

Despite the expansion of HSC in several countries, there is still a need to investigate whether this type of service is as effective as the service provided in the hospital environment, this was performed using four primary variables: quantitative infections, number of readmissions, optimization of hospital beds and the number of procedures [8]. Therefore, this study had as its objective to evaluate the effectiveness of a Home Care Service, regarding pediatrics care [7, 14].

For the analysis of readmissions, we verified how many days after the date of admission into the HCS these patients were submitted to the first hospital readmission, in a time interval before and after 30 days [16]. We also took as a reference the total number of days of re-hospitalization (Table 2).

Infection, outcome and procedure rates were calculated considering the total number of records divided by the total number of days of hospitalization (home or hospital) of each group. Thus, the rate found did not depend on the number of participants in each sample, but on the occurrence of these events within their respective groups (Table 3).

Table 3 Comparative analysis of procedures, infections, days of hospitalization and clinical outcome. Brazil, 2012–2016.

Regarding the optimization of beds, the following analysis and subsequent calculation were used in order to verify the sum of the total days of hospitalization of home group patients, between 01/01/2012 and 12/31/2016. There were found to be 31,922 days of hospitalization in this service; this number divided by the average number of hospitalization days per patient in the pediatric ward, arrives at 9.80 days (Source: Hospital information management and statistical sector). Thus, we reached 3257.35 days available for HCS. By dividing this number (3257.35 days) by the number of active beds (32 beds) in the pediatric unit, it would be possible, over five (5) years, to hospitalize around 102 patients in the hospital studied.

In order to evaluate the effectiveness of a Home Care Service, comparative and equivalent to that offered by in-hospital service, from four variables, those being the number of infections, the number of readmissions, the optimization of hospital beds and the number of hospitalizations procedures. The study showed that HCS has low infection rates, procedures and readmissions, while optimizing hospital beds, which all can be considered as an indication of its effectiveness.

Regarding the number of infections, the hospital group presented an infection rate 6.04 times higher than the home group. A study carried out in a French university hospital showed that infections were the main cause of death in hospitalized patients [17]. The length of hospital stay is a contributing factor for occurrence of infections related to hospital or nosocomial resistance [18]. A review conducted in 2014 found that antimicrobial resistance could cause the death of up to 10 million people per year by 2050 [19]. Indeed, measures for prevention of Health Care Related Infections (HCRI) should be adopted in all health care settings, either in the hospital setting, in chronic care facilities or in home care, in light of this growing threat to global public health [20].

In order to verify optimization of hospital beds, according to the calculation demonstrated previously. HCS stands out for its contribution to the optimization of hospital beds. It is an effective care tool that contributes to reducing the need for the hospitalization of patients with high utilization rates of hospital services [21].

Regarding the procedures, the results showed that patients in the hospital group were submitted to 6.43 times more procedures than patients from the home group in the same time interval, this result is very similar to the infection rate. In fact, in recent decades, public expenditures on health has increased exponentially, mainly due to the excess number of laboratory and radiographic examinations requested by doctors, performed in an inadequate and/or unnecessary way [22]. Since 1998, 95% of the examinations performed are repetitively requested, and as such contribute to increasing the cost of care for patients admitted to hospitals [23]. Although the tests are useful for diagnosis, it is necessary to consider the high financial cost involved for health services [24]. According to an English systematic review, with 109 articles aimed at reducing the use of laboratory tests by physicians, showed that educational measures were more effective when it came to reducing their use [25]. In Brazil, the Ministry of Health did not set a limit for exams [26]. In light of the aforementioned, one notes that HCS is a promising instrument in terms of the reduction of health costs, when referring to the relevance of procedures.

In terms of the 36 home care patients who participated in this study, 15 (41.66%) were never re-hospitalized and 21 (58.33%) had one or more readmissions, and 5 patients returned to the hospital within 10 to 30 days (23.81%), 16 patients after 30 days (76.19%) and 13 after 3 months (24.07%) from the date of hospital discharge. We point out that all re-hospitalizations occurred in the same reference hospital for the care of these patients, according to an agreement made between the Public Prosecutor’s Office, family members and the health institution, during the process of de-hospitalization. In 2002, a Spanish study identified low readmission rates of 10, 28 days, and 3 months of 3.6, 9.7 and 13.5%, respectively [27]. In fact, hospital readmissions are a frequent problem in health institutions. They are also an indicator of quality of care, based on the analysis of people admitted for the first time to the hospital within 30 days after discharge [16]. This indicator assesses the progressive capacity of the service provider in terms of helping patient recovery to happen as effectively as possible, with regard to patient care after hospital discharge [28]. In fact, there is a dearth of data in medical literature for the evaluation of early hospital readmissions in pediatrics with a specific focus on home care.

The study, however, contains limitations for its retrospective treatment and data collection, both performed through the analysis of medical records, which at times present incomplete and/or illegible records. As HCS has recent legal norms for implementation and regulation, there are few studies regarding the effectiveness of HCS in Brazil, addressing pediatric patients. Another complicating factor is the lack of parameters for analysis, where the quantity of exams is considered to be in excess, since the Ministry of Health does not establish any normative indication.

This preliminary study showed that HCS-assisted patients underwent fewer procedures and demonstrated a significant reduction in their use, in addition to a low number of infections compared to hospitalized patients. Moreover, HCS presented lower readmissions rates and optimized hospital beds, which could be considered an indication of effectiveness.