Studies suggest that hospital-level care provided in the patient's home may have beneficial effects on outcomes, but few trials of home hospital care have been done in the United States. This randomized controlled trial compared the effects of home hospital versus usual hospital care on direct costs and other outcomes among patients who required hospital admission.
Abstract
Background:
Substitutive hospital-level care in a patient's home may reduce cost, health care use, and readmissions while improving patient experience, although evidence from randomized controlled trials in the United States is lacking.
Objective:
To compare outcomes of home hospital versus usual hospital care for patients requiring admission.
Design:
Randomized controlled trial. (ClinicalTrials.gov: NCT03203759)
Setting:
Academic medical center and community hospital.
Patients:
91 adults (43 home and 48 control) admitted via the emergency department with selected acute conditions.
Intervention:
Acute care at home, including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing.
Measurements:
The primary outcome was the total direct cost of the acute care episode (sum of costs for nonphysician labor, supplies, medications, and diagnostic tests). Secondary outcomes included health care use and physical activity during the acute care episode and at 30 days.
Results:
The adjusted mean cost of the acute care episode was 38% (95% CI, 24% to 49%) lower for home patients than control patients. Compared with usual care patients, home patients had fewer laboratory orders (median per admission, 3 vs. 15), imaging studies (median, 14% vs. 44%), and consultations (median, 2% vs. 31%). Home patients spent a smaller proportion of the day sedentary (median, 12% vs. 23%) or lying down (median, 18% vs. 55%) and were readmitted less frequently within 30 days (7% vs. 23%).
Limitation:
The study involved 2 sites, a small number of home physicians, and a small sample of highly selected patients (with a 63% refusal rate among potentially eligible patients); these factors may limit generalizability.
Conclusion:
Substitutive home hospitalization reduced cost, health care use, and readmissions while increasing physical activity compared with usual hospital care.
Primary Funding Source:
Partners HealthCare Center for Population Health and internal departmental funds.
References
- 1. Centers for Disease Control and Prevention. FastStats: health expenditures. 2017. Accessed at www.cdc.gov/nchs/fastats/health-expenditures.htm on 3 December 2018. Google Scholar
- 2.
Hung WW ,Ross JS ,Farber J ,et al . Evaluation of the Mobile Acute Care of the Elderly (MACE) service. JAMA Intern Med. 2013;173:990-6. [PMID: 23608775] doi:10.1001/jamainternmed.2013.478 CrossrefMedlineGoogle Scholar - 3.
Horwitz LI ,Green J ,Bradley EH . US emergency department performance on wait time and length of visit. Ann Emerg Med. 2010;55:133-41. [PMID: 19796844] doi:10.1016/j.annemergmed.2009.07.023 CrossrefMedlineGoogle Scholar - 4.
Krumholz HM . Post-hospital syndrome—an acquired, transient condition of generalized risk. N Engl J Med. 2013;368:100-2. [PMID: 23301730] doi:10.1056/NEJMp1212324 CrossrefMedlineGoogle Scholar - 5.
Jencks SF ,Williams MV ,Coleman EA . Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418-28. [PMID: 19339721] doi:10.1056/NEJMsa0803563 CrossrefMedlineGoogle Scholar - 6.
Leff B . Defining and disseminating the hospital-at-home model. CMAJ. 2009;180:156-7. [PMID: 19153385] doi:10.1503/cmaj.081891 CrossrefMedlineGoogle Scholar - 7.
Leff B ,Burton L ,Mader SL ,et al . Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005;143:798-808. [PMID: 16330791] LinkGoogle Scholar - 8.
Cryer L ,Shannon SB ,VanAmsterdam M ,et al . Costs for ‘hospital at home' patients were 19 percent lower, with equal or better outcomes compared to similar inpatients. Health Aff (Millwood). 2012;31:1237-43. [PMID: 22665835] doi:10.1377/hlthaff.2011.1132 CrossrefMedlineGoogle Scholar - 9.
Tibaldi V ,Isaia G ,Scarafiotti C ,et al . Hospital at home for elderly patients with acute decompensation of chronic heart failure: a prospective randomized controlled trial. Arch Intern Med. 2009;169:1569-75. [PMID: 19786675] doi:10.1001/archinternmed.2009.267 CrossrefMedlineGoogle Scholar - 10.
Caplan GA ,Sulaiman NS ,Mangin DA ,et al . A meta-analysis of “hospital in the home”. Med J Aust. 2012;197:512-9. [PMID: 23121588] CrossrefMedlineGoogle Scholar - 11.
Shepperd S ,Doll H ,Angus RM ,et al . Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data. CMAJ. 2009;180:175-82. [PMID: 19153394] doi:10.1503/cmaj.081491 CrossrefMedlineGoogle Scholar - 12.
Shepperd S ,Iliffe S ,Doll HA ,et al . Admission avoidance hospital at home. Cochrane Database Syst Rev. 2016;9:CD007491. [PMID: 27583824] doi:10.1002/14651858.CD007491.pub2 CrossrefMedlineGoogle Scholar - 13.
Board N ,Brennan N ,Caplan GA . A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients. Aust N Z J Public Health. 2000;24:305-11. [PMID: 10937409] CrossrefMedlineGoogle Scholar - 14.
Caplan GA ,Coconis J ,Board N ,et al . Does home treatment affect delirium? A randomised controlled trial of rehabilitation of elderly and care at home or usual treatment (The REACH-OUT trial). Age Ageing. 2006;35:53-60. [PMID: 16239239] CrossrefMedlineGoogle Scholar - 15.
Caplan GA ,Coconis J ,Woods J . Effect of hospital in the home treatment on physical and cognitive function: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2005;60:1035-8. [PMID: 16127109] CrossrefMedlineGoogle Scholar - 16.
Federman AD ,Soones T ,DeCherrie LV ,et al . Association of a bundled hospital-at-home and 30-day postacute transitional care program with clinical outcomes and patient experiences. JAMA Intern Med. 2018;178:1033-40. [PMID: 29946693] doi:10.1001/jamainternmed.2018.2562 CrossrefMedlineGoogle Scholar - 17.
Montalto M . The 500-bed hospital that isn't there: the Victorian Department of Health review of the Hospital in the Home program. Med J Aust. 2010;193:598-601. [PMID: 21077817] CrossrefMedlineGoogle Scholar - 18.
Hernández C ,Aibar J ,Seijas N ,et al . Implementation of home hospitalization and early discharge as an integrated care service: a ten years pragmatic assessment. Int J Integr Care. 2018;18:12. [PMID: 30127696] doi:10.5334/ijic.3431 CrossrefMedlineGoogle Scholar - 19.
Levine DM ,Ouchi K ,Blanchfield B ,et al . Hospital-level care at home for acutely ill adults: a pilot randomized controlled trial. J Gen Intern Med. 2018;33:729-36. [PMID: 29411238] doi:10.1007/s11606-018-4307-z CrossrefMedlineGoogle Scholar - 20.
Raîche M ,Hébert R ,Dubois MF . PRISMA-7: a case-finding tool to identify older adults with moderate to severe disabilities. Arch Gerontol Geriatr. 2008;47:9-18. [PMID: 17723247] CrossrefMedlineGoogle Scholar - 21.
Galvin JE ,Roe CM ,Powlishta KK ,et al . The AD8: a brief informant interview to detect dementia. Neurology. 2005;65:559-64. [PMID: 16116116] CrossrefMedlineGoogle Scholar - 22.
Kroenke K ,Spitzer RL ,Williams JB . The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41:1284-92. [PMID: 14583691] CrossrefMedlineGoogle Scholar - 23.
Ader DN . Developing the Patient-Reported Outcomes Measurement Information System (PROMIS). Med Care. 2007;45Suppl 1 S1-2. doi:10.1097/01.mlr.0000260537.45076.74 CrossrefMedlineGoogle Scholar - 24.
Chew LD ,Bradley KA ,Boyko EJ . Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36:588-94. [PMID: 15343421] MedlineGoogle Scholar - 25.
van Hout B ,Janssen MF ,Feng YS ,et al . Interim scoring for the EQ-5D-5L: mapping the EQ-5D-5L to EQ-5D-3L value sets. Value Health. 2012;15:708-15. [PMID: 22867780] doi:10.1016/j.jval.2012.02.008 CrossrefMedlineGoogle Scholar - 26.
Lawton MP ,Brody EM . Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9:179-86. [PMID: 5349366] CrossrefMedlineGoogle Scholar - 27. Centers for Medicare & Medicaid Services. 3-Item Care Transitions Measure (CTM-3). 2018. Accessed at https://cmit.cms.gov/CMIT_public/ViewMeasure?MeasureId=1700 on 17 December 2018. Google Scholar
- 28.
Jenkinson C ,Coulter A ,Bruster S . The Picker patient experience questionnaire: development and validation using data from in-patient surveys in five countries. Int J Qual Health Care. 2002;14:353-8. [PMID: 12389801] CrossrefMedlineGoogle Scholar - 29.
American Geriatrics Society 2012 Beers Criteria Update Expert Panel . American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:616-31. [PMID: 22376048] doi:10.1111/j.1532-5415.2012.03923.x CrossrefMedlineGoogle Scholar - 30.
Inouye SK ,Kosar CM ,Tommet D ,et al . The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Ann Intern Med. 2014;160:526-33. [PMID: 24733193]. doi:10.7326/M13-1927 LinkGoogle Scholar - 31.
Goodman RA ,Posner SF ,Huang ES ,et al . Defining and measuring chronic conditions: imperatives for research, policy, program, and practice. Prev Chronic Dis. 2013;10:E66. [PMID: 23618546] doi:10.5888/pcd10.120239 CrossrefMedlineGoogle Scholar - 32.
Cheng J ,Montalto M ,Leff B . Hospital at home. Clin Geriatr Med. 2009;25:79-91, vi. [PMID: 19217494] doi:10.1016/j.cger.2008.10.002 CrossrefMedlineGoogle Scholar - 33.
Purdey S ,Huntley A . Predicting and preventing avoidable hospital admissions: a review. J R Coll Physicians Edinb. 2013;43:340-4. [PMID: 24350320] doi:10.4997/JRCPE.2013.415 CrossrefMedlineGoogle Scholar - 34.
Hansen LO ,Young RS ,Hinami K ,et al . Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155:520-8. [PMID: 22007045]. doi:10.7326/0003-4819-155-8-201110180-00008 LinkGoogle Scholar - 35.
Caplan GA ,Ward JA ,Brennan NJ ,et al . Hospital in the home: a randomised controlled trial. Med J Aust. 1999;170:156-60. [PMID: 10078179] CrossrefMedlineGoogle Scholar - 36.
Aimonino Ricauda N ,Tibaldi V ,Leff B ,et al . Substitutive “hospital at home” versus inpatient care for elderly patients with exacerbations of chronic obstructive pulmonary disease: a prospective randomized, controlled trial. J Am Geriatr Soc. 2008;56:493-500. [PMID: 18179503] doi:10.1111/j.1532-5415.2007.01562.x CrossrefMedlineGoogle Scholar - 37.
Agmon M ,Zisberg A ,Gil E ,et al . Association between 900 steps a day and functional decline in older hospitalized patients [Letter]. JAMA Intern Med. 2017;177:272-4. [PMID: 27918776] doi:10.1001/jamainternmed.2016.7266 CrossrefMedlineGoogle Scholar - 38.
Fong TG ,Tulebaev SR ,Inouye SK . Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol. 2009;5:210-20. [PMID: 19347026] doi:10.1038/nrneurol.2009.24 CrossrefMedlineGoogle Scholar - 39.
Rabin RF ,Jennings JM ,Campbell JC ,et al . Intimate partner violence screening tools: a systematic review. Am J Prev Med. 2009;36:439-45. [PMID: 19362697] doi:10.1016/j.amepre.2009.01.024 CrossrefMedlineGoogle Scholar - 40.
Chalmers JD ,Singanayagam A ,Hill AT . Systolic blood pressure is superior to other haemodynamic predictors of outcome in community acquired pneumonia. Thorax. 2008;63:698-702. [PMID: 18492742] doi:10.1136/thx.2008.095562 CrossrefMedlineGoogle Scholar - 41.
Charles PG ,Wolfe R ,Whitby M ,et al ;Australian Community-Acquired Pneumonia Study Collaboration . SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis. 2008;47:375-84. [PMID: 18558884] doi:10.1086/589754 CrossrefMedlineGoogle Scholar - 42.
Peterson PN ,Rumsfeld JS ,Liang L ,et al ;American Heart Association Get With the Guidelines–Heart Failure Program . A validated risk score for in-hospital mortality in patients with heart failure from the American Heart Association Get With the Guidelines program. Circ Cardiovasc Qual Outcomes. 2010;3:25-32. [PMID: 20123668] doi:10.1161/CIRCOUTCOMES.109.854877 CrossrefMedlineGoogle Scholar - 43.
Fonarow GC ,Adams KF ,Abraham WT ,et al ;ADHERE Scientific Advisory Committee, Study Group, and Investigators . Risk stratification for in-hospital mortality in acutely decompensated heart failure: classification and regression tree analysis. JAMA. 2005;293:572-80. [PMID: 15687312] CrossrefMedlineGoogle Scholar - 44.
Singer M ,Deutschman CS ,Seymour CW ,et al . The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315:801-10. [PMID: 26903338] doi:10.1001/jama.2016.0287 CrossrefMedlineGoogle Scholar
Author, Article, and Disclosure Information
David M. Levine,
Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (D.M.L., K.O., B.B., A.S., J.L.S.)
Brigham and Women's Hospital, Boston, Massachusetts (K.B., M.P.)
Partners HealthCare at Home, Waltham, Massachusetts (K.D.)
Harvard Medical School, Massachusetts General Hospital, and Partners HealthCare System Center for Population Health, Boston, Massachusetts (C.T.P.)
Presented in part at the Society of General Internal Medicine Annual Meeting, Denver, Colorado, 11–14 April 2018.
Acknowledgment: The authors thank the home hospital clinicians who cared for the home hospital patients; John Orav, PhD, for his insightful comments on a prior draft of the manuscript; and various departments at Brigham Health that were instrumental to the success of the home hospital program: Cardiology, Emergency Medicine, General Internal Medicine and Primary Care, Hospital Medicine Unit, Pharmacy, Laboratory, and Population Health.
Financial Support: By the Partners HealthCare Center for Population Health and internal departmental funds.
Disclosures: Dr. Levine reports grants from Biofourmis outside the submitted work. Dr. Blanchfield reports consulting income from Verily, GreyBird Ventures, and Atlas5D outside the submitted work. Dr. Schnipper reports grants from Mallinckrodt Pharmaceuticals and Portola Pharmaceuticals outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-0600.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Data Sharing Statement: The authors have indicated that they will not be sharing data.
Corresponding Author: David M. Levine, MD, MPH, MA, Harvard Medical School, Brigham and Women's Hospital, Division of General Internal Medicine and Primary Care, 1620 Tremont Street, 3rd Floor, Boston, MA 02120; e-mail, dmlevine@bwh.
Current Author Addresses: Drs. Levine, Blanchfield, Saenz, and Schnipper; Ms. Burke; and Ms. Paz: 1620 Tremont Street, 3rd Floor, Boston, MA 02120.
Dr. Ouchi: 75 Francis Street, Boston, MA 02115.
Ms. Diamond: 281 Winter Street, Suite 240, Waltham, MA 02451.
Dr. Pu: 399 Revolution Drive, Suite 1030, Somerville, MA 02145.
Author Contributions: Conception and design: D.M. Levine, K. Ouchi, B. Blanchfield, C.T. Pu, J.L. Schnipper.
Analysis and interpretation of the data: D.M. Levine, K. Ouchi, B. Blanchfield, J.L. Schnipper.
Drafting of the article: D.M. Levine.
Critical revision of the article for important intellectual content: D.M. Levine, K. Ouchi, B. Blanchfield, K. Diamond, C.T. Pu, J.L. Schnipper.
Final approval of the article: D.M. Levine, K. Ouchi, B. Blanchfield, A. Saenz, K. Burke, M. Paz, K. Diamond, C.T. Pu, J.L. Schnipper.
Provision of study materials or patients: D.M. Levine, K. Ouchi, K. Burke, M. Paz.
Statistical expertise: D.M. Levine.
Obtaining of funding: D.M. Levine, J.L. Schnipper.
Administrative, technical, or logistic support: D.M. Levine, K. Ouchi, K. Burke, M. Paz, K. Diamond.
Collection and assembly of data: D.M. Levine, K. Ouchi, A. Saenz, K. Burke, M. Paz.
This article was published at Annals.org on 17 December 2019.
Submit a Comment
Contributors must reveal any conflict of interest. Comments are moderated. Please see our information for authorsregarding comments on an Annals publication.
*All comments submitted after October 1, 2021 and selected for publication will be published online only.