Managing Acute Complications with Outpatient Interventions: A Scoping Review

Rates of use of emergency departments (ED) and hospital admission are high among patients with chronic kidney disease (CKD), particularly among patients with CKD requiring dialysis. Patients receiving maintenance dialysis have, on average, three visits to the ED per year, a rate that is three to eight times higher than among the general population. Of those ED visits, a significant proportion result in hospital admission. Further, ED and in-patient care are drivers of medical costs for patients with CKD, and are associated with significant emotional burden for patients and their caregivers.

Meghan J. Elliott, MD, MSc, and colleagues posit that outpatient care may provide an alternative to ED and inpatient care in patients with CKD. The researchers conducted a scoping review of quantitative and qualitative studies to examine the scope of outpatient interventions used to manage acute complications of chronic diseases and highlight places to adapt and test interventions in patients with CKD. Results of the review were reported in the American Journal of Kidney Diseases [2020;76(6):794-805].

The review identified studies of outpatient interventions for adults experiencing acute complications related to one of five chronic disease (CKD, chronic respiratory disease, cardiovascular disease, cancer, and diabetes). The researchers searched MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, grey literature, and conference abstracts to December 2019. Standardized tools were used to extract data on intervention and study characteristics.

The search yielded 16,621 unique citations. Of those, the researchers retrieved 218 articles for full-text review. Following the review, 137 were excluded; reasons for exclusion were setting ineligibility (n=17), intervention ineligibility (n=72), population (n=24), study design (n=21), or other (n=3). The final review included 77 studies (with four companion reports). The 77 studies reported on 57 unique interventions for adults with acute complications of one of the five chronic diseases of interest.

Most of the 77 included studies were observational (n=29) or randomized controlled trials (n=25). Other study designs were uncontrolled before-after (n=12), quasi-experimental (n=5), qualitative (n=4), and mixed-methods (n=2). The studies were conducted in the United States (n=29), the United Kingdom (n=14), and Spain (n=14), as well as nine other countries. More than a third of the studies were published within the past 6 years. There were no identified studies describing outpatient management strategies for acute complications of CKD or kidney failure.

The researchers categorized the 57 interventions as: hospital at home (n=16); observation unit (n=9); ED-based specialist service (n=4); ambulatory program (n=18); and telemonitoring (n=10). The interventions were most commonly used for patients experiencing acute exacerbations of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF) and complications related to cancer. There were no interventions identified for management of acute complications of CKD or kidney failure. The home setting was the most common setting for the interventions; interventions were conducted by healthcare providers, including specialist physicians and nurses.

Twenty-six published reports described 16 unique hospital-at-home interventions designed to provide hospital-level care in the patient’s home setting. Most treated patients with COPD (n=11) and/or CHF (n=6). Nine hospital-at-home interventions had home visits provided by physicians; all 16 had home visits provided by nurses. Nearly half were operational 7 days a week, mostly during daytime hours. Four specified after-hours nursing or physician telephone support. All 16 provided standard medical therapies in the home for patients who met eligibility criteria; only four studies indicated patient education as part of the program.

Thirteen studies described nine observation unit interventions that were most commonly provided to patients with decompensated CHF (n=5) or asthma exacerbations (n=3). The observation unit was a designated area within or next to the ED and was staffed by ED physicians and nurses. Eight of the interventions specified a maximum length of stay in the observation unit between 8 and 48 hours prior to a decision regarding hospital admission or discharge.

Among cancer patients, there were four unique interventions based on ED-based specialist services. This intervention reflected either a specialty ED or a model of care where a specialist physician was embedded as a consultant to the general ED.

Twenty studies described 18 ambulatory care interventions. Most were specialist-run day hospitals or rapid access clinics in cancer and chronic respiratory disease populations. Other ambulatory care interventions were outpatient treatment pathways and scheduled follow-up for chemotherapy-related febrile neutropenia and telephone hotline services.

Ten interventions providing telemonitoring were described in 14 studies. The interventions aided in prompt identification of acute complications of respiratory conditions. The intervention included daily self-monitoring of physiologic parameters such as oxygen saturation or peak expiratory flow using a device that transmitted data to the patient care team remotely.

The researchers classified outcomes as improved, unchanged, or worsened in the intervention group versus a control or comparator group. Based on those classifications, 160 outcomes were reported: 34% improved, 17% no change, 1% worsened, and 19% mixed results. The studies most commonly reported comparative outcomes on domains of healthcare use (e.g., hospital admissions; 62%) and patient outcomes (e.g., disease control and mortality; 45%).

The least commonly reported outcomes were adverse effects or harms associated with the interventions. When assessed in between-group comparisons, cost savings were reported (87%), including all of the hospital-at-home studies; use and patient outcomes improved in 44% and 21% of the studies, respectively. Fewer than half of the studies reported on those outcomes.

The limitations to the study cited by the authors were primarily related to the challenges  inherent in synthesis of heterogeneous data across studies. The inability to collect data for the interventions for acute complications related to CKD was another limitation.

The researchers said, “In summary, we identified and described five main types of interventions for managing acute complications of common chronic disease in the outpatient setting. The lack of studies on identified interventions for those with advanced CKD highlights an important knowledge gap and opportunity for evaluating novel outpatient strategies for management of acute complications in this population.”

Takeaway Points

  1. Researchers conducted a scoping review of outpatient interventions for the management of acute complications of chronic diseases to examine opportunities to adapt and test interventions among patients with chronic kidney disease.
  2. The review included 77 studies that described 57 unique interventions, including hospital at home, ED-based specialist service, ambulatory programs, and telemonitoring.
  3. Most of the interventions delivered cost savings; however improvements were not consistently observed in other outcome domains.