A continuous shift in the age of the population utilizing the SOS doctors’ network was observed. An increasing number of patients requesting home visits in the age group 60-90 was observed, particularly for the second half of this age group. On the contrary, the number of patients in the other age groups and particularly those ≥91 and < 16 years old declined in time. In this study, approximately 70% of patients were over 60 years old. In a previous analysis, the respective proportion was approximately 51% . These changes may partially reflect the change in demographics of the aging population in Greece, or a higher need for follow up visits. However, this could not account for the unexpected decrease in home visits for the most frail, those older than 90 years old, as home health care is proportional to the number of chronic conditions and the functional impairments . On the other hand, it may reflect a change in the preferences or priorities among different patient populations or close relatives providing care to older or disabled patients. For example, the current financial crisis in Greece affected mainly younger ages (increase of unemployment and immigration, lower wages), while older individuals were primarily affected through a decrease in pensions.
The preferred medical specialty was also studied in association with patients’ age. Patients examined by internists and general practitioners were younger than those examined by all other specialties. An explanation for this could be the higher prevalence of chronic diseases with advancing age. This has been shown in a study in the USA . In that study, the mean age of patients at cardiology practices was higher than that in internal and family medicine. In addition these patients had also more co-morbidity and worse functional status. The system of care was also related to patients’ age in that study . Another explanation could be the decline in the percentage of home visits for infections with advancing age seen in our study (from approximately 65% in the age group 16-30 years to < 20% in those aged over 90, data not shown).
Significant changes in the gender and timing of the received calls were not observed between the current and a previous analysis. Females requested the majority of the calls in both periods . Most of the calls were performed during office hours, with 2 evident peaks, identical in the two analyses . On the other hand, we observed changes in the distribution of the etiology of the calls. Although infections remained the primary cause, their proportion was reduced to 29% (compared to 33.6% in the period 2001-2005). More importantly, since 2009 an almost 50% reduction in the calls for infections has been observed. An increase in the proportion of calls for cardiovascular diseases, musculoskeletal complaints, gastrointestinal diseases, neurological, respiratory and skin diseases was seen. In contrast calls for ear-nose-throat disorders, psychiatric, and genitourinary diseases were reduced.
The SOS doctors network in Greece covered mainly for acute conditions (infections, uncontrolled pain of multiple origin, vertigo etc), or acute exacerbations of chronic diseases. Follow up and routine evaluations had subtle contribution in home visits. This can be attributed to the cost (the service is not covered by the public primary health care provider in Greece), habits of the population or the physician, or the difficulty in tracking and following up patients with chronic diseases at home (physicians’ schedule, coordination, trip planning issues, chronic conditions require files for follow up). On the other hand, it may reflect the perception of patients regarding the diseases that can be managed at home or may not require further investigation or hospitalization. It may also reflect conditions for which patients are willing to pay for (out-of-pocket service for acute, often debilitating or quality of life modifying conditions in comparison to stable chronic diseases). Finally, this may also reflect different approaches in healthcare management, as for example, post-discharge requests for continuing intravenous therapy at home were largely absent.
A peak in the number of calls was observed in 2009, and thereafter the number of calls dropped annually to reach a plateau in the years 2013-2015. As the majority of calls were due to infections of the respiratory tract, it could be suggested that the increase in the number of calls in 2009 could be attributed to the influenza pandemic observed in this year. Although the number of calls due to respiratory tract infections was not very different during that period compared to other years, non-infectious complications of influenza may have equally contributed to the increase in home visits .
Someone could argue that the financial crisis in Greece could be the main reason behind this fall during the initial period (2010-2013) of the financial crisis. However, other reasons may also apply. For example, a home visit may reflect a need for disabled individuals or convenience for wealthier, younger patients. Therefore, the chief complaint or the underlying disease or patient condition may not justify the physician’s visit. The sudden decrease in calls for respiratory tract infections (especially upper ones) denotes that convenience and house comfort could be among the main drive for the increase in the number of calls up to 2009. In this regard, the financial crisis might have contributed to fewer calls for mild to moderate or self limited (from the patient/community view) diseases.
Hospital admission was recommended in approximately 9% of visits. Thus, home visits prevented a significant number of emergency department visits. Other reasons for declining hospital services included the patient’s or their first degree relative’s refusal to go to the hospital and advanced directives and preferences on goals of care. A previous patient’s will to receive treatment at home instead of a hospital , is well documented in the medical literature . Additionally, caregivers expressed occasionally their concerns regarding the quality of care their old relative would receive in the hospital.
In most countries of the developed world, several companies or organizations (including hospitals and insurers) offer house-call visits mainly by general practitioners and family physicians; other services can include nurse practitioners (an increasingly used service in the USA), nurses, social workers, psychologists, or a multidisciplinary approach providing care with 2 or more of the aforementioned professionals [19, 20]. In contrast to the worldwide practice, the SOS network in Greece offers house-call visits by specialists. Although internists perform the great majority of visits, most of the remaining specialties are also available and their share in the care of patients, especially of the elderly, is increasing. This innovative approach may have advantages and disadvantages. The advantage is the high quality of services provided by specialists in their field. The disadvantage could be the higher cost for the visit, especially for countries like Greece in which the insurers do not reimburse for the visits.
Home visits are expected to increase over the following years for reasons pertaining to physicians’, community’s/state’s and patients’ interests. Patients specific causes include older age, frailty, disabilities that affect not only their capability to walk but also to perform their daily activities, and terminal illnesses (cancer, heart failure, neurologic diseases). In this regard, immobility or short walking distance ability, cognitive impairment, psychological/emotional disorders, need for assessment of home care (environment, care givers), or severe current status of the patients (unconsciousness, severe debilitation from dehydration/paresis/hemodynamic instability) can justify a home-visit. Furthermore, house calls can strengthen the relationship between the physician and the patient.
Difficulties in providing healthcare services at home for acute and chronic conditions include the need to carry the necessary supplies (drugs for parenteral administration or non-oral routes especially for homebound individuals, sets for intravenous administration of fluids and drugs, wound care dressings and cleansers), cooperation with nurses and non-medical staff (physical therapist, dietician, speech therapist, social workers), and possibly the cost for the patients (the service in Greece is out-of-pocket, with partial coverage in case of selected patients with private insurance; in our study only 1.5% of patients had their visit paid by a private insurance).
Recently published studies showed that young physicians dismiss home visits . Besides financial incentives, key factors that could enhance the physician’s willingness to participate in a home call include override of barriers like schedules and travel time, personal safety and liability, and further development of applications (diagnostic devices/tests, communication with doctors of other specialties) through technological advances that could increase the degree of certainty in working diagnosis [1, 2]. Home visits enhance the ability of the physician to understand the patients’ needs and environment. The structure and organization of SOS doctors, the exploitation of available resources as well as the competitive compensation provide a means to overcome several of the obstacles that may prevent a physician to perform home visits. Help by professional networks like the SOS doctors or similar agencies around the world could provide effective guidance and help to primary care physicians. The expertise provided by specialized physicians is a unique feature of the Greek SOS network and a significant opportunity for the expansion of home visits.
In addition, home healthcare can reduce the overall cost of healthcare; it may also improve the quality of life of the patients and their families by reducing unnecessary hospitalizations. Using historical data, the Alliance for Home Health Quality and Innovation forecasted potential savings of $10.3 billion over 10 years (2014-2023) in the USA by reducing regional hospital readmissions through the use of home health as the first line to handle post-acute care episodes . Furthermore, when patients can stay home, hospital beds and personnel can focus on the most acute cases. Depending on healthcare economics, other countries could probably achieve relevant savings. Studies showed that patients prefer to receive healthcare services in the comfort and privacy of their own homes for the treatment of an acute or chronic condition . Finally, lowering the cost by preventing frail, prone to iatrogenic complications patients from reaching more expensive treatment settings, e.g. hospitals, would be the strongest motive for governments to develop home-based, physician assisted health care programs [10, 23, 24].
It is difficult to assess or compare the effectiveness of house call visits in individual studies as it depends on several factors, including the frailty of the patients, the targeted intervention, the outcome measure, the study design and the composition of the treating team. Thus, it was not surprising that published reviews, meta-analyses and individual studies on e.g. the effectiveness of preventive home visits to the elderly, came up with conflicting results [5, 25,26,27,28]. The usefulness of such programs should not be judged only by their effectiveness on measurable outcomes but also on their ability to meet special social needs. In fact, such services may be considered mainly as a social process than a treatment program . On the other hand, hospital-level care can be effectively delivered to carefully selected, older patients with acute illnesses at their homes . In addition, it was the preferred modality of care among older patients, with high patient and family member satisfaction rate .
The patient satisfaction rate after home visits by both physicians and non-physicians has been documented by several studies [3, 30, 31]. In a previous study, home visits satisfaction rate was high and increased by early physician arrival and younger age of the patient. Other commonly encountered factors, such as gender, family income, employment or marital status do not seem to affect patients’ satisfaction rate . In the present study the satisfaction rate was very high (97.7%) without major discrepancies according to patient’s age. The prompt arrival of the physician and the relatively low cost of the service should have increased the satisfaction rate. Whether this could be also attributed to the utilization of specialists instead of general practitioners should be evaluated in comparative studies in the future.
The study findings are limited by the lack of data regarding the patient population that could ask for this out-of-pocket medical service. Although potentially all inhabitants in the greater metropolitan areas of Athens and Thessaloniki could use the service, the number of patients willing to receive it due to financial and other reasons cannot be accurately estimated. Other factors like population aging, emergence of companies providing similar services and changes in the private economy (including private insurance holders which were < 3% throughout the study period) in Greece during the crisis might have influenced the findings. On the other hand, the organization and function of SOS Doctors did not change substantially throughout the study period besides changes in the number of participating doctors and the increased demand for radiology services.