Preferences for home vs hospital care among low-risk patients with community-acquired pneumonia.

OBJECTIVE To measure preferences for initial outpatient vs hospital care among low-risk patients who were being actively treated for community-acquired pneumonia (CAP). METHODS Study patients included 159 patients with CAP, 57 (36%) initially hospitalized, who were identified as being at low risk for early mortality using a validated prediction model. Subjects were enrolled from university and community health care facilities located in Boston, Mass, Halifax, Nova Scotia, and Pittsburgh, Pa, participating in the Pneumonia Patient Outcome Research Team prospective cohort study of CAP. Three utility assessment techniques (category scaling, standard gamble, and willingness to pay) were used to measure the strength of patient preferences for the site of care for low-risk CAP. At the time of initial therapy or during the early recuperative period, patient preferences were assessed across a spectrum of potential clinical outcomes using 7 standardized pneumonia clinical vignettes. RESULTS Responses to the 7 pneumonia scenarios indicated that most patients consistently preferred outpatient-based therapy. This pattern was observed regardless of whether patients had actually been treated initially at home or in a hospital. Patients (74%) who stated that they generally preferred home care for low-risk CAP were willing to pay a mean of 24% of 1 month's household income to be assured of this preference. Preference for home care, as measured by the category scaling and the willingness to pay, persisted after adjustment for sociodemographic and baseline health status covariates. Sixty nine percent of interviewed patients said that their physician alone determined whether they would be treated in the hospital or at home. Only 11% recalled being asked if they had a preference for either site of care. CONCLUSIONS Most patients, even those treated initially in a hospital, who were at low risk for mortality from CAP prefer outpatient treatment. However, most physicians appear not to involve patients in the site-of-care decision. More explicit discussion of patient preferences for the location of care would likely yield more highly valued care by patients as well as less costly treatment for CAP.

[1]  M. Fine,et al.  Prognosis of patients hospitalized with community-acquired pneumonia. , 1990, The American journal of medicine.

[2]  A. Gafni Using willingness-to-pay as a measure of benefits , 1990 .

[3]  C. Sherbourne,et al.  The MOS 36-Item Short-Form Health Survey (SF-36) , 1992 .

[4]  S. Eastaugh Valuation of the Benefits of Risk-free Blood: Willingness to Pay for Hemoglobin Solutions , 1991, International Journal of Technology Assessment in Health Care.

[5]  H. Fineberg,et al.  Preferences for Health Outcomes , 1984, Medical decision making : an international journal of the Society for Medical Decision Making.

[6]  M. Hlatky Patient preferences and clinical guidelines. , 1995, JAMA.

[7]  L. McMahon,et al.  Variation in Hospital Admissions Among Small Areas: A Comparison of Maine and Michigan , 1989, Medical care.

[8]  Gordon Guyatt,et al.  Measuring Health-Related Quality of Life , 1993, Annals of Internal Medicine.

[9]  E P Steinberg,et al.  Comparison of the Rating Scale and the Standard Gamble in Measuring Patient Preferences for Outcomes of Gallstone Disease , 1994, Medical decision making : an international journal of the Society for Medical Decision Making.

[10]  N. Powe,et al.  Risk Reduction From Low Osmolality Contrast Media: What Do Patients Think It is Worth? , 1990, Medical care.

[11]  J. Neumann,et al.  Theory of games and economic behavior , 1945, 100 Years of Math Milestones.

[12]  K. McPherson,et al.  Will payment based on diagnosis-related groups control hospital costs? , 1984, The New England journal of medicine.

[13]  R. Kane,et al.  Methodology for measuring health-state preferences--II: Scaling methods. , 1989, Journal of clinical epidemiology.

[14]  R L Kane,et al.  Methodology for measuring health-state preferences--I: Measurement strategies. , 1989, Journal of clinical epidemiology.

[15]  J P Kassirer,et al.  Incorporating patients' preferences into medical decisions. , 1994, The New England journal of medicine.

[16]  A. O'Connor,et al.  Effects of framing and level of probability on patients' preferences for cancer chemotherapy. , 1989, Journal of clinical epidemiology.

[17]  J. Read,et al.  Feasibility of Willingness-to-Pay Measurement in Chronic Arthritis , 1984, Medical decision making.

[18]  John E. Wennberg,et al.  Using diagnosis-related groups for studying variations in hospital admissions , 1988, Health care financing review.

[19]  M. Fine,et al.  Prognosis and outcomes of patients with community-acquired pneumonia. A meta-analysis. , 1996, JAMA.

[20]  A Gafni,et al.  Willingness-to-pay as a measure of benefits. Relevant questions in the context of public decisionmaking about health care programs. , 1991, Medical care.

[21]  B. O'brien,et al.  Willingness to Pay , 1994, Medical decision making : an international journal of the Society for Medical Decision Making.