'Home Hospital' Halves Costs in Small Randomized Trial

Marcia Frellick

February 09, 2018

Findings from the first pilot randomized controlled trial of in-home, hospital-level care in the United States show sharply lower costs compared with usual hospital care, with no reduction in quality or safety.

David M. Levine, MD, MPH, a physician and researcher in the division of general internal medicine and primary care at Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, and colleagues published the results online Wednesday in the Journal of General Internal Medicine.

In the study, nine patients were randomly assigned to home care and 11 to usual in-hospital care. The average cost for an acute care episode for patients in the home-care group was 52% (interquartile range [IQR], 28%; P = .05) lower than for patients in the usual-care group.

Patients treated at home received a median of one visit from a physician per day (range, 1 - 3), as well as two visits from a nurse (range, 2 - 4). However, they had significantly fewer laboratory orders compared with controls (median per admission: 6 vs 19; P < .01) and received consultations less often (0% vs 27%; P = .04).

Home patients had more than twice as much physical activity each day (median minutes, 209 vs 78; P < .01) as did those in the hospital and tended to get more sleep (5.4 hours vs 4.1; P = .33).

No adverse events occurred in home patients, but one occurred in the control group. Pain scores and patient experience were similar in both groups.

"We haven't dramatically changed the way we've taken care of acutely ill patients in this country for almost a century," Dr Levine said in a press release. "There are a lot of unintended consequences of hospitalization. Being able to shift the site of care is a powerful way to change how we care for acutely ill patients and it hasn't been studied in the U.S. with intense rigor."

The authors add that emergency department waits are often long, and when patients are admitted to hospitals 20% experience delirium and more than 5% get hospital-acquired infections.

30-Day Costs Further Reduced

When the 30-day postdischarge period was added in cost calculations, average costs were 67% lower in the home group (IQR, 77%; P < .01) than in the control group and patients tended to use fewer home-care services (22% vs 55%; P = .08). In-home hospital patients also had fewer readmissions (11% vs 36%; P = .32).

"No significant differences in quality, safety, and patient experience were noted," the authors write.

Patients were recruited among adults admitted to the emergency department at Brigham and Women's Hospital or Brigham and Women's Faulkner Hospital. Patients were eligible if they were aged over 18 years, lived in the hospital catchment area, and had any infection, heart failure, chronic obstructive pulmonary disease (COPD), or asthma.

During home hospital care, patients could receive tailored medical meals and services from a home health aide, social worker, physical therapist, and/or occupational therapist.

All patients had continuous monitoring of heart and respiratory rates, telemetry, movement, falls, and sleep. In addition, the home hospital was able to provide oxygen, respiratory therapies, intravenous medications with infusion pump, radiology, and blood diagnostics.

Home hospital care is common in some other developed countries but only two nonrandomized trials have been done in the United States, according to the authors.

Results of this trial are similar to others globally, the authors note. Two randomized controlled trials in Italy showed similar results for patients with heart failure exacerbations and COPD and reduced readmissions. Another trial in Australia found a 51% reduction in cost.

Researchers say a larger, ongoing, randomized trial may help make options clearer in the future of acute care. The trial has already enrolled 90 patients and will likely report preliminary findings in the next 2 months, Dr Levine said. In addition, the team has several ongoing home hospital studies.

"Reimagining the best place to care for select acutely ill adults holds enormous potential," they write.

The authors have disclosed no relevant financial relationships.

Partners HealthCare Population Health Management provided funding for the home hospital clinical program.

J Gen Intern Med. Published online February 6, 2018. Abstract

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