Journal of General Internal Medicine

, Volume 13, Issue 8, pp 522–527 | Cite as

Older persons’ preferences for site of treatment in acute illness

  • Terri R. Fried
  • Carol van Doorn
  • Mary E. Tinetti
  • Margaret A. Drickamer
Original Articles


OBJECTIVE: To explore how older persons form preferences for site of medical care by examining their perceptions of home care and hospital care.

DESIGN: Qualitative analysis of in-depth interviews using the constant comparative method.

SETTING: Respondents’ homes.

PARTICIPANTS: Twenty-nine persons age 65 to 89 years who had been hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia and were receiving home care services.

MAIN RESULTS: Respondents, who thought of home care only as a means to provide low-intensity and low-frequency services, were initially skeptical about expanded home care services to treat acute illness. Regardless of their opinions about home and hospital, all respondents preferred the site associated with the greatest chance of survival. If the sites offered equal survival, 52% of the respondents preferred treatment at home because of freedom from the constraints of the hospital and the comfort of familiar surroundings. For respondents who preferred the hospital, the home represented a frightening and lonely place to be sick. Respondents’ views of the home and hospital were shaped by their social supports, self-reliance, religious beliefs, and past illness experiences.

CONCLUSIONS: Because survival appears to be the most important determinant of preference, home treatment of acute illness is a viable alternative only if it provides outcomes equivalent to those of hospitalization. Strongly held perceptions that home care can only be a low-intensity service may limit preferences for home treatment. When expected outcomes at the two sites are similar, the challenge to the health care system will be incorporating patient preference about the process of care into decisions about the appropriate site of care.

Key Words

patient preference home care qualitative research 


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  1. 1.
    Leff B, Burton JR. Acute medical care in the home. J Am Geriatr Soc. 1996;44:603–5.PubMedGoogle Scholar
  2. 2.
    Leff B, Burton L, Bynum JW, et al. Prospective evaluation of clinical criteria to select older persons with acute medical illness for care in a hypothetical home hospital. J Am Geriatr Soc. 1997;45:1066–73.PubMedGoogle Scholar
  3. 3.
    Arras JD. The technological tether: an introduction to ethical and social issues in high-tech home care. Hastings Cent Rep. 1994;24:S1–2.Google Scholar
  4. 4.
    Steel K. Home care for the elderly: the new institution. Arch Intern Med. 1991;151:439–42.PubMedCrossRefGoogle Scholar
  5. 5.
    Ruddick W. Transforming homes and hospitals. Hastings Cent Rep. 1994;24:S11–4.Google Scholar
  6. 6.
    Campion EW. New hope for home care? N Engl J Med. 1995;333:1213–4.PubMedCrossRefGoogle Scholar
  7. 7.
    Coley CM, Li Y-H, Medsger AR, et al. Preferences for home vs hospital care among low-risk patients with community-acquired pneumonia. Arch Intern Med. 1996;156:1565–71.PubMedCrossRefGoogle Scholar
  8. 8.
    Lofland J, Lofland LH. Analyzing Social Settings: A Guide to Qualitative Observation and Analysis. 2nd ed. Belmont, Calif: Wadsworth Publishing Company; 1984.Google Scholar
  9. 9.
    Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. Chicago, Ill: Aldine Publishing Company; 1967.Google Scholar
  10. 10.
    Lynn J, Teno JM, Phillips RS, et al. Perceptions by family members of the dying experience of older and seriously ill patients. Ann Intern Med. 1997;126:97–106.PubMedGoogle Scholar
  11. 11.
    Danis M, Patrick D, Southerland LI, Green M. Patients’ and families’ preferences for medical intensive care. JAMA. 1988;260:797–802.PubMedCrossRefGoogle Scholar
  12. 12.
    Kassirer JP. Incorporating patients’ preferences into medical decisions. N Engl J Med. 1994;330:1895–6.PubMedCrossRefGoogle Scholar
  13. 13.
    Barry MJ, Mulley AG, Fowler FJ, Wennberg JW. Watchful waiting vs immediate transurethral resection for symptomatic prostatism. JAMA. 1988;259:3010–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Koopman MMW, Prandoni P, Piovella F, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. N Engl J Med. 1996;334:682–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Stessman J, Ginsberg G, Hammerman-Rozenberg R, et al. Decreased hospital utilization by older adults attributable to a home hospitalization program. J Am Geriatr Soc. 1996;44:591–8.PubMedGoogle Scholar
  16. 16.
    Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336:243–50.PubMedCrossRefGoogle Scholar
  17. 17.
    Rosenthal GE, Harper DL, Shah A, Covinsky KE. A regional evaluation of variation in low-severity hospital admissions. J Gen Intern Med. 1997;12:416–22.PubMedCrossRefGoogle Scholar
  18. 18.
    Gillick MR. Talking with patients about risk. J Gen Intern Med. 1988;3:166–70.PubMedCrossRefGoogle Scholar
  19. 19.
    Forrow L. The green eggs and ham phenomenon. Hastings Cent Rep. 1994;24:S29–32.CrossRefGoogle Scholar
  20. 20.
    Meyer GS, Gibbons RV. House calls to the elderly—a vanishing practice among physicians. N Engl J Med. 1997;337:1815–20.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 1998

Authors and Affiliations

  • Terri R. Fried
    • 2
    • 1
  • Carol van Doorn
    • 1
  • Mary E. Tinetti
    • 1
  • Margaret A. Drickamer
    • 2
    • 1
  1. 1.Yale University School of MedicineWest Haven
  2. 2.Geriatrics & Extended Care 111CVA CT Healthcare SystemWest Haven

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