patient safety quality healthcare

September / October 2012
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Home Infusion Therapy:  Safety, Efficacy, and Cost-Savings

Home infusion is a clinically appropriate treatment option for patients with a wide range of acute and chronic conditions, ranging from bacterial infections to more complex conditions such as late-stage heart failure, bleeding disorders, nutrition support, and immune deficiencies. Home infusion affords patients independence and better quality of life because it is provided in the comfort of the patient’s home at a time that best fits his or her needs. In addition, home infusion can provide improved safety, better outcomes, and cost-effectiveness.

The home has been shown to be a safe setting for patients to receive infusion therapy (Souayah et al., 2011; Bhole et al, 2008). Additionally, patients who have been discharged from the hospital are at reduced risk of hospital-acquired infections, which can be caused by more virulent pathogens than those that are community-acquired. This is particularly important for vulnerable patients such as those who are immunocompromised, as hospital-acquired infections are increasingly caused by antibiotic-resistant pathogens (Wisplinghoff et al., 2004).

Home infusion can also play a role in improving medication adherence and reducing unplanned hospital readmissions. For instance, Walgreens Infusion Services has a 99.9% clinician-reported adherence rate, a less than 1% unplanned readmission rate, and a 98% rate of infusion encounters without incident (Walgreens data on file).

There are a variety of therapy- or condition-specific benefits to home infusion. Examples of therapy-specific outcomes documented by Walgreens Infusion Services include:
•    Nutrition: Parenteral nutrition patients—those who receive nutrition through an IV catheter—can safely begin their therapy at home when their care is carefully managed, according to one study (Jansonn et al., 2012). The study showed even patients at risk of re-feeding syndrome—a problem sometimes associated with parenteral nutrition therapy—were able to be safely started in the home, eliminating the need for hospital admission. Another study found more than one-third of enteral nutrition patients—those who receive nutrition through a tube into their stomach—were able to return to eating solid foods within 16 months or less, which is a goal for patients when clinically appropriate (Stout et al., 2012).

•    IG: Intravenous (IV) and subcutaneous (SubQ) immunoglobulin (IG) therapy is provided for patients with a range of immune-deficiency and immune-mediated autoimmune conditions. In a study of more than 4,000 consecutive infusions in 420 home infusion IVIG patients over 12 months, 99% experienced no or only mild adverse reactions (such as headache) and none experienced serious adverse reactions (Souayah et al., 2011).

•    Heart failure: Late-stage heart failure patients discharged home on inotropic infusion therapy have a 50% lower six-month rehospitalization rate compared to national data on less-severe patients, according to Walgreens outcomes outcomes (Walgreens data on file). Further, a study recently found 65.4% of heart failure patients who received home infusion of inotropic medications were able to spend their last days at home instead of in a hospital or other medical facility, compared to a national average of 35.9% (Taitel et al., 2012).

•    HAE: Hereditary angioedema (HAE) is a rare, life-threatening genetic immune system disorder that causes sudden episodes of swelling that can be dangerous and painful. About two-thirds of patients with hereditary angioedema (HAE) received emergency infusion at home within less than an hour of symptoms onset and 92% received it within two hours, compared to an average emergency room wait of 3.2 hours, according to one study (Kennedy et al.,2012; McCaig et al., Kennedy et al., 2004). The study showed home infusion for HAE is significantly more cost effective than emergency room delivery of the same therapy—while a home infusion nurse visit costs $150 on average, an emergency room visit for HAE costs $2,603 on average (Walgreens data on file; Toscani & Reidl, 2011).

There is a wide range of providers of home infusion; it is important to select one that employs strict protocols for patient treatment and utilizes best practices to ensure optimal patient care. Ideally, home infusion companies should have a dedicated staff of specially trained pharmacists, nurses, dietitians, and technicians who provide care individualized to meet each patient’s unique needs. These teams are responsible for a range of services, including compounding and administering medications, coordinating patients’ care and teaching patients and/or their family members about their condition and therapy. No matter the type and level of care required, home infusion is most successful when providers employ patient-centric best practices including:
•    Patient and home assessment: The home infusion team works with hospital staff to identify and assess hospitalized patients who are appropriate candidates for home infusion. The home infusion team meets with identified patients to assess their ability to understand and follow instructions related to their care, and to evaluate their home environment.

•    Care coordination: Home infusion providers work closely with hospital staff and/or physician offices to extend the physician’s care—following the doctor’s plan of care and providing patient status and updates as appropriate.

•    Individualized patient planning: At the infusion provider, teams of infusion nurses, pharmacists, and dietitians meet to discuss each patient and the goals of his or her therapy, including unique needs, comorbidities, and treatment challenges. The teams then develop individual care plans to best meet each patient’s needs, which are communicated back to the patient’s doctor.

•    Patient education: Home infusion providers teach patients how to take an active role in their health, empowering them to provide good self-care. The education process is ongoing throughout the treatment, and includes hands-on teaching, leave-behind materials and references for relevant patient resources, such as patient support groups. Patient education also focuses on identifying early warning signs that should be reported to home infusion nurses or dietitians to prevent or minimize complications.

•    Ongoing support: A pharmacist contacts the home infusion patient prior to his or her first infusion to align medications and therapy, verify medication tolerance, and help the patient understand the importance of medication adherence. The frequency of nurse and/or dietitian visits depends on the patient, therapy and condition, as well as payer authorization. However, patients should also have access to pharmacists, nurses, and dietitians by phone 24 hours a day, seven days a week.

•    Extensive coverage: Home infusion providers with a wide network – including geographic reach as well as payer coverage – can care for most if not all patients who need home infusion. Coast-to-coast geographic coverage is particularly important if patients are hospitalized far away from home, if they relocate, or if they must go out of town for work, family, or vacation.

Home infusion imparts significant cost savings as compared to the traditional infusion hospital setting (Home infusion therapy, 2010; Shelley, 2009; Einodshofer, 2012). Whereas hospitalization costs upwards of $1,500 to $2,500 per day, the average cost of home infusion is $150 to $200 per day (Shelley, 2009). One Walgreens’ study found infusion therapy provided at alternate sites of care – including the home – is significantly more cost effective than infusion therapy provided at other sites of care, such as the hospital, resulting in savings for patients and health plans of up to 60 percent (Einodshofer, 2012). Additionally, the potential savings accrued by preventing hospital-acquired infections are significant, as these infections result in direct costs to hospitals of $28 to $45 billion a year (Scott, 2009).

Home infusion therapy benefits patients, providers, and payers – providing patients with clinically appropriate treatment in the comfort and convenience of their own home, improving quality of life and yielding significant cost savings for all involved.

Steve Kennedy is director of pharmacy services for Walgreens Infusion Services. He may be contacted at This email address is being protected from spambots. You need JavaScript enabled to view it. .

References
Bhole, M. V., Burton, J., & Chapel, H. M. (2008). Self-infusion programmes for immunoglobulin replacement at home: Feasibility, safety and efficacy. Immunology and Allergy Clinics of North America, 28(4), 821-832.

Einodshofer, M. (2012). A plan for medical specialty medications – increase member access, affordability and outcomes while decreasing plan costs. Presented at: 2012 Pharmacy Benefit Management Institute Annual Drug Benefit Conference; 2012 Feb. 22-24; Scottsdale, Ariz.

Home infusion therapy: Differences between Medicare and private insurers’ coverage. (2010, June). United States Government Accountability Office Report to Congressional Requesters. Accessed July 23, 2012: http://www.gao.gov/assets/310/305261.pdf.

Jansson, L., Brand, S., Monahan, R., & Knowles, S. (2012). Home start parenteral nutrition—Yes we can! Presented at: American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Clinical Nutrition Week; 2012 Jan. 21-24, Orlando, Fla.

Kennedy, J., Rhodes, K., Walls, C. A., et al. (2004). Access to emergency care: Restricted by long waiting times and cost and coverage concerns. Annals of Emergency Medicine, 43, 567-573.

Kennedy, S., Curry, K., & Ford, D. (2012). Implementation and assessment of hereditary angioedema home infusion program. Presented at: the National Home Infusion Association, April 23-26, 2012, Phoenix, Ariz.

McCaig, L. F., & Burt, C. W. National Hospital Ambulatory Medicare Care Survey: 2002 Emergency Department Summary. Advance Data from Vital and Health Statistics; 2004.

Scott, R. D. (2009, March). The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Centers for Disease Control and Prevention. Accessed July 23, 2012, at http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf

Shelley, S. (2009, October 10). Home infusion providers struggle with unfriendly reimbursement policies, Pharmaceutical Commerce. Accessed August 1, 2012, at http://pharmaceuticalcommerce.com/index.php?pg=brand_communications&articleid=1722&keyword=infusion-home%20infusion-NHIA-igG-IVIG-chronic

Souayah, N., Hasan, A., Khan, H., et al. (2011). The safety profile of home infusion of intravenous immunoglobulin in patients with neuroimmunologic disorders. Journal of Clinical Neuromuscular Disease, 12(suppl 4), S1-10.

Stout, A. E., Carr, J. A., McGill, S. D., Cathcart, K. L., & Vaughn, J. E. (2012). So you think you can advance? Ability to return to an oral diet after initiation of home enteral therapy. Presented at: American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Clinical Nutrition Week; 2012 Jan. 21-24, 2012, Orlando, Fla.

Taitel, M., Meaux, N., Pegus, C., Verian, C., & Krimham, H. (2012, June). Place of death among patients with terminal heart failure in a continuous inotropic infusion program. American Journal of Hospital Palliative Care, 29(4), 249-252.

Toscani, M., & Reidl, M. (2011). Meeting the challenges and burdens associated with hereditary angioedema. Managed Care, 20(9), 44-51.

Wisplinghoff, H., Bischoff, T., Tallent, S. M., et al. (2004). Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clinical Infectious Disease, 39(3), 309-317.

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