Efficacy of Hospital at Home

Hospital-at-home interventions vs in-hospital stay for patients with chronic disease who present to the Emergency Department. Arsenault-Lapierre, G., Henein, M., Gaid, D., Le Berre, M., Gore, G., & Vedel, I. (2021). JAMA Network Open, 4(6). https://doi.org/10.1001/jamanetworkopen.2021.11568

  • Systematic review of nine randomized clinical trials with data on 959 adult patients with chronic disease, demonstrating patient outcomes between an experimental, HaH group and a control, in-hospital care group.
  • Risk of readmission and risk of long-term care admission was lower in the HaH group compared to the in-hospital care group.
  • Patients who received HaH interventions had lower depression and anxiety than those who remained in-hospital, but there was no difference in functional status.

 A meta‐analysis of “hospital in the home”. Caplan, G. A., Sulaiman, N. S., Mangin, D. A., Aimonino Ricauda, N., Wilson, A. D., & Barclay, L. (2012). Medical Journal of Australia, 197(9), 512–519. https://doi.org/10.5694/mja12.10480

  • A 2012 meta-analysis of randomized controlled trials, evaluating HaH as substitutive care for patients aged 16 years and older. There were 6,992 patients who met inclusion criteria across a broad range of studies (medical, surgical, rehabilitation, and psychiatric).
  • The results demonstrated statistically significant findings favoring HaH to in-hospital care: 19% lower mortality, 25% lower readmission rate, lower cost in HaH, 21 of 22 studies favored HaH for patient satisfaction, and 8 of 11 studies favored HaH for caregiver satisfaction.

Costs for ‘hospital at home’ patients were 19 percent lower, with equal or better outcomes compared to similar inpatients. Cryer, L., Shannon, S. B., Van Amsterdam, M., Leff, B. (2012). Health Affairs, 31(6), 1237–1243. https://doi.org/10.1377/hlthaff.2011.1132

  • Study of 323 patients from Albuquerque, New Mexico–based Presbyterian Healthcare Services opting for HaH care compared to a similar group of hospital inpatients over a two-year period between January 2009 and December 2010.
  • HaH patients experienced shorter average length of stay (3.3 days vs 4.5 days), lower rates of falls (0% vs 0.8%), lower mortality (0.93% vs. 3.4%), and higher patient satisfaction (mean score 90.7 vs. 83.9) than inpatient comparison group.
  • HaH patient costs were 19% lower than costs for similar inpatients and were predominately derived from lower average length of stay and fewer lab and diagnostic testing in HaH patients.
  • This study advances the Triple Aim of clinical quality, affordability, and exceptional patient experience.

Association of a bundled hospital-at-home and 30-Day postacute transitional care program with clinical outcomes and patient experiences. Federman, A. D., Soones, T., DeCherrie, L. V., Leff, B., & Siu, A. L. (2018). JAMA Internal Medicine, 178(8), 1033. https://doi.org/10.1001/jamainternmed.2018.2562

  • Case-control study of 507 participants comparing Mount Sinai Hospital and Mount Sinai St Luke’s Hospital ED patients that either received HaH care or traditional inpatient care from November 2014 to August 2017.
  • HaH patients (n = 295) were older than controls (n = 212) and more likely to have a pre-acute functional impairment.
  • HaH patients had statistically significant shorter LOS (3.2 days vs. 5.5 days), lower rates of 30-day all-cause hospital readmissions (8.6% vs. 15.6%), lower 30-day ED revisits (5.8% vs 11.7%) and lower SNF admissions (1.7% vs. 10.4%) than control patients. 
  • HaH patients were also more likely to rate their hospital care highly (68.8% vs. 45.3%).

Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Leff, B., Burton, L., Mader, S., Naughton, B., Burl, J., Inouye, S., Greenough, W., Guido, S., Langston, C., Frick, K., Steinwachs, D., Burton, J. (2005). Annals of Internal Medicine, 143(11), 798. https://doi.org/10.7326/0003-4819-143-11-200512060-00008

  • Prospective quasi-experiment in three Medicare-managed care (Medicare + Choice) plans at two sites and at a Veterans Administration medical center to evaluate the clinical feasibility and efficacy of patient care for older adults receiving HaH care from November 2001 to September 2002.
  • Patients treated in HaH had a shorter length of stay (3.2 vs. 4.9 days), higher patient and family member satisfaction, and there was some evidence of fewer complications.
  • The study noted no differences between patients in the HaH group and those in the acute hospital group for mean number of ED visits, inpatient hospital readmissions, admissions to SNFs, or home health visits.
  • The mean cost of care was lower for patients in the HaH group than patients receiving acute hospital care ($5081 vs. $7480).

Comparison of functional outcomes associated with hospital at home care and traditional Acute Hospital Care. Leff, B., Burton, L., Mader, S. L., Naughton, B., Burl, J., Greenough, W. B., Guido, S., & Steinwachs, D. (2009). Journal of the American Geriatrics Society, 57(2), 273–278. https://doi.org/10.1111/j.1532-5415.2008.02103.x

  • This prospective, nonrandomized clinical trial of HaH measured changes in activity of daily living (ADL) and instrumental activity of daily living (IADL) scores to compare functional outcomes experienced by patients cared for in HaH and traditional acute hospital care. 
  • HaH care is associated with modestly better improvements in IADL status and trends toward more improvement in ADL status than traditional acute hospital care.
  • Patients treated in HaH experienced modest improvements in ADL (0.39 vs. -0.60) and IADL (0.74 vs. -0.70) performance scores, whereas those treated in the acute care hospital declined.
  • A greater proportion of HaH patients improved in function and smaller proportions declined or had no change in ADLs (44% vs 25%, P=.10) or IADLs (46% vs 17%, P=.04).

Comparison of stress experienced by family members of patients treated in hospital at home with that of those receiving traditional acute hospital care. Leff, B., Burton, L., Mader, S. L., Naughton, B., Burl, J., Koehn, D., Clark, R., Greenough, W. B., Guido, S., Steinwachs, D., & Burton, J. R. (2008). Journal of the American Geriatrics Society, 56(1), 117–123. https://doi.org/10.1111/j.1532-5415.2007.01459.x

  • A survey questionnaire completed by the family members of 214 elderly patients included in a prospective, nonrandomized clinical trial of a substitutive HaH care model.
  • HaH is associated with lower levels of family member stress than traditional acute hospital care and does not appear to shift the burden of care from hospital staff to family members. 

Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Levine DM, Ouchi K, Blanchfield B, et al. Ann Intern Med. 2020;172(2):77-85. doi:10.7326/M19-0600

  • A parallel-design, randomized controlled trial that enrolled 91 adult patients presenting to the ED at Brigham and Women’s Hospital and Brigham and Women’s Faulkner Hospital in HaH care (intervention) or traditional hospital care (control).
  • HaH reduced healthcare use and 30-day readmissions. HaH patients had fewer laboratory orders (median per admission, 3 vs. 15), imaging studies (median, 14% vs. 44%), consultations (median, 2% vs. 31%), and 30-day readmissions (7% vs. 23%).
  • Despite having a longer average length of stay compared to the control group (4.5 days vs. 3.8 days), the mean cost of the acute care episode was 38% lower for HaH patients. 
  • Patients in both groups had similar pain scores, frequency of delirium reported, and high satisfaction with care.

Avoiding hospital admission through provision of hospital care at home: A systematic review and meta-analysis of individual patient data. Shepperd, S., Doll, H., Angus, R. M., Clarke, M. J., Iliffe, S., Kalra, L., Ricauda, N. A., Tibaldi, V., & Wilson, A. D. (2009). Canadian Medical Association Journal, 180(2), 175–182. https://doi.org/10.1503/cmaj.081491

  • A 2009 meta-analysis of randomized controlled trials that evaluated HaH as substitutive care. Data was obtained for 844 adult patients, of which, 441 were enrolled in HaH. The most common diagnoses included chronic obstructive pulmonary disease (COPD), community-acquired pneumonia, stroke, cellulitis.
  • The statistically significant findings included 38% lower mortality at 6 months in HaH, higher patient satisfaction in HaH, lower length of stay (LOS) in HaH, and fewer patients in HaH discharged to an institutional setting.