Home infusion services in Saudi Arabia: Where are we standing?

Introduction

Diseases management has reached the highest level of complexity and cost in history. It has been reported that healthcare expenditure in the United States (US) alone reached $4.1 trillion in 2020 ( Halloush et al., 2022 ; Hartman, Martin, Washington, Catlin, & Team, 2022). More than 30% of this cost burden was driven by hospital admissions and hospital care, which was reported to cost more than $1.24 trillion of all healthcare expenditures ( Hartman et al., 2022 ). Unfortunately, it was estimated that almost 30% of all hospital stays were unnecessary ( Shrank, Rogstad, & Parekh, 2019 ). In Saudi Arabia, the Ministry of Health (MOH) reported that there were approximately 3.1 million admissions in 2021, with hospital stays that reached 27.7 days per patient with chronic diseases with an average hospital stay of 22.3 days per admission ( Ministry of Health Saudi Arabia, 2021 ).

Further, more than 5 million patients are suffering from chronic conditions in Saudi Arabia, which is expected to increase to 8–10 million cases by 2030 ( Almulla & Hassouneh, 2022 ). Many recent innovative measures have been taken to reduce unnecessary hospital stays ( Almangour and Alhifany, 2020 , Taylor et al., 2020 ). One is to provide medication management in outpatient settings ( Hales and Pronovost, 2006 , Scott, 2010 ). Such services were also found to improve patients’ satisfaction and comply with their preferences.

Many studies have assessed the cost-savings and benefits of continuing parenteral medication administration in outpatient settings such as outpatient parenteral antimicrobial therapy (OPAT) and home infusion services ( Andersen et al., 2007 , Docherty et al., 2020 , Lippert et al., 2017 , Restelli et al., 2019 ).

Home infusion services are widely spread worldwide. In 2019, more than 3 million patients utilized home infusion services in the US alone ( National home infusion association, 2022 ). Home infusion does not necessarily mean administering medication as intravenous injections; it can also refer to “giving medications by different parenteral routes” such as: subcutaneous (SC), intramuscular, and epidural ( Docherty et al., 2020 ). Home infusion therapy is done in multiple steps. First, a qualified physician writes a prescription order for infusion therapy, then a pharmacist reviews the prescription and prepares the ordered medication; after that, it is delivered to the patient’s home. Finally, it is administered by a trained healthcare provider ( Sexton & Seldomridge, 2002 ).

To our knowledge, home infusion services are not fully implemented in Saudi Arabia. The availability of these services is limited to a few large governmental and private hospitals. Despite that, these programs are only considered for limited conditions; therefore, the desired outcomes may not be fully accomplished. Hence, this narrative review aims to emphasize the expected benefits and challenges of such services and the applicability of their implementation in Saudi Arabia.

Search strategy

A literature search has been conducted via PubMed database by using keywords ((home infusion) OR (home care infusion) AND (Cost)). The search involved all published studies from inception until March 24th, 2023. This narrative review emphasized the expected impact of home infusion from various aspects, including length of hospital stay, cost savings, patient satisfaction, and safety. Our inclusion criteria were articles written in English that examined home infusion from the perspectives above. Articles that were duplicates, published in languages other than English, or the ones that did not meet the inclusion criteria were excluded. Fig. 1 shows the flow chart summarizing the literature search method (“ Creating a PRISMA flow diagram: PRISMA 2020 ,”).

Discussion

This narrative review emphasized the expected benefits and challenges of home infusion services in Saudi Arabia. Eight papers met the inclusion criteria and summarized below.

Home infusion services benefits

Length of stay

Extended unnecessary hospital stay is considered one of the major problems that negatively influences the cost burden on hospitals. However, the home infusion effectively reduced patients’ hospital stays and bed occupancy. This review identified four studies discussing the benefits of home infusion services in reducing the length of hospital stay. Details of these studies are provided in Table 1 . The first study was a prospective quasi-experiment conducted in the US, enrolled 455 patients aimed to evaluate the feasibility and outcomes of home care program. The authors found that the mean length of stay for patients treated at hospitals was 4.9 days compared to 3.2 days for those treated at the home care program ( Leff et al., 2005 ). Another retrospective study in the UK evaluated the impact of management of Deep Vein Thrombosis (DVT) using low molecular weight heparin (Tinzaparin) at home compared to hospital for 172 patients in both settings. The results indicated that the mean length of hospital stays in home treated group was 2.1 days compared to 12 days in the hospital group ( Rymes, Lester, Connor, Chakrabarti, & Fegan, 2002 ). The study by Perreault et al. of 27 included patients demonstrated that home-based intravenous immunoglobulin (IVIG) therapy initiative had reduced visits by 26.6 visits per month and consequently reduced infusion chair occupancy by 106 h per month ( Perreault et al., 2021 ). Finally, the study by García-Queiruga et al. proved that home treatment of 102 patients using elastomeric pumps avoided a total of 1,409 days of hospital stay ( García-Queiruga, Cortizas, Alfonsín, Diaz, & Martín-Herranz, 2021 ).

Cost-savings

Five studies proved that home infusion had economic benefits to different healthcare systems. For example, one retrospective observational study was conducted in Spain for 24 months aimed to illustrate the cost-effectiveness of Home Infusion of antibiotics using elastomeric pumps. Consequently, 102 patients were transferred to their homes to continue their therapy leading to a total cost savings of €580,788.28. These cost savings were calculated based on the mean difference between the cost of treatment in a hospital setting versus home setting per day which was €528.95 and €80.70, respectively ( García-Queiruga et al., 2021 ). Furthermore, the same study stated that the mean cost per patient per admission at a hospital was €7,031. On the other hand, the mean cost per patient receiving treatment at home was €1,696.4. This shows that home infusion services in Spain have led to cost reduction by 75 to 85%. Since the average cost of hospitalized patients in a tertiary hospital in Saudi Arabia per day is equivalent to SAR 2,752.42 ( Mehmood, Ahmed, Ghilan, Damad, & Azeez, 2021 ), we estimate a total cost savings of SAR 2,339.55 per patient per day of hospital stay if home infusion services were implemented.

Another pilot prospective study in France was conducted between May 2011 and August 2014 to evaluate the cost-effectiveness of Subcutaneous (SC) bortezomib in 50 patients administered at home-based versus hospital settings. The results showed a 20% reduction of the cost of each bortezomib SC injection administered at home versus in-hospital and an overall total savings of €187,000 during the study period ( Lassalle et al., 2016 ). Similarly, an observational retrospective study conducted in Spain (between January 2015 and December 2017) demonstrated the cost-effectiveness of home-administered piperacillin/tazobactam (PIP/TAZ) in 35 patients for treating Pseudomonas aeruginosa infection using elastomeric pump compared to conventional therapy in hospitals. The results showed that home treatment with PIP/TAZ was more cost-effective than hospital treatment, with total savings of €1,609.74 per patient during the study period ( Ferreiro et al., 2021 ). In addition, a cost-utility analysis study was performed in Thailand for 6 months to compare home-based chemotherapy for 53 patients and hospital-based chemotherapy for 264 patients, in treating stage III colon cancer. This study has shown that home-based chemotherapy was more cost-effective than hospital-based chemotherapy, with total savings of $1,513.37 per patient during the study period ( Kulthanachairojana et al., 2021 ). Another recent study aimed to evaluate the impact of home-based intravenous or SC immunoglobulin infusions in high-risk immunosuppressed patients during the COVID-19 pandemic; one of the many established benefits was the reduction in recurrent clinic visits and occupied beds with an estimated cost-savings of $476.9 per patient during the study period ( Perreault et al., 2021 ) (See Table 2 ).

Patient satisfaction

Another important benefit of home infusion was discussed in four studies, which is the observed satisfaction with patients receiving their medications at home. For instance, a two-year retrospective chart review study conducted in the US focused on the benefits of home versus hospital-infused infliximab for 10 participants. Patient satisfaction was one of the identified benefits, which was measured on a scale from 1 to 10 (10, being the most satisfied). The study found that the mean patients' satisfaction with home-infused infliximab was 9.2 compared to 8.2 for hospital-treated patients ( Condino, Fidanza, & Hoffenberg, 2005 ). Another study conducted in Canada related to patient satisfaction treated at home for hematological and oncological diseases ( Lippert et al., 2017 ) showed that homecare enabled 136 patients to continue their daily life activities, reduced financial stress related to hospital visits and number of days off work without pay, and improved their quality of life ( Lippert et al., 2017 ). Moreover, a study by Goodwin et al. assessed the satisfaction of 424 patients with home parenteral therapy program and found that around 60% were satisfied, 24% were moderately satisfied, 6% were not very satisfied, and only 5% were totally dissatisfied ( Goodwin, Hanson, & Berry, 2002 ). Similarly, A pilot prospective study from France enrolled 50 patients showed that 98% of the participants were satisfied with the home-based administration of SC injections of bortezomib and preferred it over the hospital administration ( Lassalle et al., 2016 ).

Safety

This review found that home infusion has been considered a safe alternative to hospital treatment. Perreault et al. (2021) , found that transitioning patients from hospital-based to home-based treatment with immunoglobulin during the recent COVID-19 pandemic had zero percent risk of COVID-19 exposure ( Perreault et al., 2021 ). Similarly, in 2002, Goodwin et al. concluded that the home parenteral therapy program avoided the high risk of developing nosocomial infections when 2405 patients were referred from the hospital to home-based therapy ( Goodwin et al., 2002 ).

Home infusion services challenges

Per our literature search, no study investigated challenges to providing home care infusion services in Saudi Arabia. Nevertheless, there are numerous challenges that can be predicted from our narrative review. The main obstacle that would hinder the full implementation of home care infusion services in Saudi Arabia is the absence of a universal healthcare system and health insurance and, consequently, the lack of unified healthcare services. Furthermore, one of the major obstacles to the safe administration of medication through home infusion is the need for extensive training and education for patients, healthcare providers, and cargivers if needed. Additionally, specialized equipment and supplies, such as intravenous pumps, catheters, and tubing, are required for this type of therapy, and ensuring their proper maintenance, calibration, and sterility in the home setting can pose a significant challenge. Moreover, effective communication and coordination between healthcare providers, patients, and caregivers is essential for successful home infusion therapy. However, this can be challenging, particularly in cases where patients have complex medical conditions ( Beer, McBride, Mitzner, & Rogers, 2014 ) .

Recommendations

Addressing previously mentioned challenges requires a comprehensive approach involving policy changes, healthcare infrastructure development, qualified training programs, and stakeholders collaboration. Overcoming these obstacles, can enhance the implementation and success of home infusion services in Saudi Arabia, leading to improved patient outcomes and healthcare system efficiency.

We encourage researchers to pursue further investigations into establishing and assessing home care infusion services, expanding our knowledge and enhancing patient care.

Conclusion

Home infusion services have gained global popularity and demonstrated numerous benefits. Despite advancements in technologies and equipment that have made home infusion more affordable and accessible, its full implementation in Saudi Arabia is hindered by the absence of a universal healthcare system and a comprehensive health insurance. These factors pose significant barriers to the country's widespread adoption of home infusion services.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgment

The authors extend their appreciation to the King Salman Center For Disability Research for funding this work through Research Group no KSRG-2023-087.

Footnotes

Peer review under responsibility of King Saud University.

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