Advocates for Evidence-Based Health Policy Speakers
Healing at Home
Emergency physicians understand that hospital admissions are far from benign. Between the physical burden – the sedentary state, blood draws, imaging, invasive procedures, sleep deprivation – and the financial burden, the toll of admission is far from negligible. Hospital admission, however, is the standard of care in the United States for many conditions. How much of this collateral damage, however, could be mitigated with care provided in the comfort and convenience of one’s own home? This is the question Dr. David Levine et al ask and attempt to quantify in their randomized control trial.
A “home hospital” that provides acute care services traditionally offered exclusively in an inpatient hospital setting has been suggested and utilized in the past. No RCTs had been performed to assess actual comparative utility and efficacy. Levine et al’s trial matched patients with primary diagnosis of any infection, heart failure exacerbation, chronic obstructive pulmonary disease exacerbation, asthma exacerbation, or selected other conditions from two Brigham and Woman’s Hospital sites to either home hospital care (intervention) or traditional hospital care (control). Then, they compared the total direct cost of the acute care in addition to both health care use and physical activity during the acute care episode and at 30 days.
The study found that home care had an adjusted average cost that was 38% lower for home patients than control patients. Additionally, compared with usual care, 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%).
In a field praised for innovation, the structure and care of inpatient hospitalization has been largely unchanged for 50 years. Innovative home hospitalization allows for decreased utilization of nursing and physician time, hospital utilities, improved physical activity, and decreased 30-day readmission to the hospital and the ED, all without changing quality, safety, or patient experience. Further corroboration of these data will be required, but home-hospitalization shows promise in achieving policy and public health goals we aspire to as patient-centered physicians: improving quality of care and outcomes while simultaneously reducing financial burdens.
This Health Policy Journal Club review is a collaboration between Policy Prescriptions® and the Emergency Medicine Residents’ Association. It is written by Michael Rushton, DO who is an emergency medicine resident at Spectrum Health/Michigan State University.
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.
PMID: 31842232
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