Innovative home hospitalization preserves resources without adversely affecting quality
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 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 controlled 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 homehospitalization 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.
Abstract: Levine DM, Ouchi K, Blanchfield B, et al. Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Ann Intern Med. 2020;172(2):77-85.
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.
EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA
As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows, we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill. Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.