The RAD-HOME Project: A Pilot Study of Home Delivery of Radiology Services FREE

For decades, acute medical care has been delivered in a hospital. However, among frail elderly patients, hospitalization often results in delirium, nosocomial infections, pressure sores, and falls.¹ Appropriate home care has been shown to decrease hospitalization and nursing home use without compromising medical outcomes. In addition, providing traditional hospital-based care in the familiar surroundings of a patient's home might have the advantage of reducing the incidence of iatrogenic illness.²

The delivery of medical services at home has been greatly facilitated by recent advances in technology and communications. In this randomized controlled pilot study, we explored the quality of imaging and clinical outcomes of using mobile, light-weight x-ray equipment to provide radiologic examinations to frail elderly patients at home.

We conducted a randomized controlled trial among patients in the Hospital at Home Service (HHS) of San Giovanni Battista Hospital of Torino, Italy.^3- 4 Eligible participants were immobilized or chair bound, acutely ill, at intermediate or high risk of delirium according to the criteria of Inouye,⁵ and in need of a radiological examination of the chest, pelvis, hips, joints, upper or lower limbs, hands, or feet. Patients were excluded if they had delirium according to the Confusion Assessment Method,⁶ were in need of urgent examination (within 24 hours), or needed x-ray examinations not suitable at home. The study protocol was approved by the ethics committee of HHS, and all participants provided informed consent.

At baseline, all patients underwent assessment for eligibility, demographics, health status, depression, mental status, and comorbidities and an evaluation for delirium using the Confusion Assessment Method. Evaluation for delirium was repeated after the radiological examination. Whenever an episode of delirium occurred, the Delirium Rating Scale was completed. Patient satisfaction with home radiography was evaluated after the radiological examination.

Participants were randomly assigned to have radiological imaging performed at home or to have the imaging performed in the hospital. Outcomes were the feasibility and quality of radiological imaging at home, the incidence of delirium after the x-ray examination, and patient satisfaction.

Radiological examinations at home were performed by qualified radiology technicians using a light-weight, portable, high-frequency x-ray tube, improved cassettes (with imaging plate inside), and a mobile radiological station (Computed Radiography POC 260; Carestream Health, Rochester, New York) with remote visualization and real-time processing of acquired images. The equipment, transported in a small van, was in conformity with all applicable laws and the radiation safety standards of the relevant national and international organizations. The operators position themselves and the equipment to prevent anyone, except the patient, from entering the controlled area during x-ray exposure. If it is necessary to stand within the controlled area, the operators wear protective clothing.

Using the Picture Archive and Communication System, the radiology technicians directly transmitted the images acquired at home via wireless broadband Internet to the radiologists in the hospital who read radiographs in real time. Radiologists who read the examinations were blinded to the origin of the studies.

Evaluation of the quality of the images was conducted on chest x-rays of patients who performed this examination in the emergency department and repeated the radiography at home as a control.

The image quality was independently assessed by a group of 7 fully qualified clinical radiologists blinded to the origin of the radiographs. Radiologists used the European Guidelines on Quality criteria, modified for supine radiographs, to intraindividually compare the quality of chest images.⁷ The following criteria were rated: symmetrical reproduction of the thorax; reproduction of the whole rib cage above the diaphragm; visually sharp reproduction of vascular pattern in the whole lung, trachea and proximal bronchi, borders of the heart and aorta, diaphragm, and lateral costophrenic angles; visualization of retrocardiac lung, mediastinum, and spine through the heart shadow; and small round details in the whole lung, including the retrocardiac area.

Of the 463 patients admitted to the HHS between June 2008 and June 2009, 123 were eligible and 69 (55%) were enrolled and randomly assigned to radiography performed at home (n = 34) or in the hospital (n = 35).

At baseline, the 2 study groups were similar in all sociodemographic and clinical characteristics (Table). The mean age of the participants was 78 years and 45% were male. Most radiographs were performed for suspected exacerbation of congestive heart failure, exacerbation of chronic obstructive pulmonary disease, or pneumonia, and there were no differences in indication for radiography between the home and hospital radiography groups. In both groups, radiographs confirmed the clinical suspicion in approximately 70% of cases.

After radiological examination, an acute confusional state requiring treatment occurred in 17% of patients in the hospital radiography group, whereas no patient in the home radiography group developed delirium. The onset of delirium (100 % of patients were hyperactive) occurred within few hours of hospital radiological examination, and the mean (SD) duration of the episode was 1.2 (4.2) days. The mean (SD) score of the Delirium Rating Scale was 0.79 (3.6). Satisfaction with home radiography was very good or excellent for 94% of patients.

There were no significant differences in the quality of chest radiographies performed at home and those performed in hospital.

Among frail elderly patients, radiographs performed at home were of similar quality to those performed after admission to the hospital, and resulted in a significantly lower incidence of delirium. Almost all patients were highly satisfied undergoing imaging studies at home. Modern portable x-ray units are light enough to be easily transported and used in the home and may spare frail patients the trauma of transportation and unfamiliar surroundings, as well as other hospital-associated adverse effects.^8- 9

Our sample size was small and the findings may not be generalizable, given that the study was conducted at only 1 center and by an operationally mature hospital-at-home unit. Nevertheless, this is a pilot trial suggests that “health care is going home.”¹⁰