COMMENTARY

Home Sweet Home -- Now With Hospital-Level Care

F. Perry Wilson, MD, MSCE

Disclosures

December 18, 2019

Welcome to Impact Factor, your weekly dose of commentary on a new medical study. I'm Dr F. Perry Wilson.

Whenever I'm rounding in the hospital, I come across patients who just feel stuck there. Not because they are too sick, but because some seemingly trivial thing is keeping them in the hospital: They need an intravenous antibiotic, or they are waiting on a stress test, or the INR isn't therapeutic yet. It seems like they would do fine at home if there were some way to send a doctor, a nurse, and a lab tech to the house every day.

But then I think, Well, we couldn't possibly afford to offer hospital-level care at home. It's a pipe dream.

And then I saw this study appearing in the Annals of Internal Medicine that suggests that for certain patients, hospital at home is not only feasible, but it's way cheaper than the traditional inpatient ward.

The study was out of Brigham and Women's Hospital. Over a 7-month period, 91 patients seen in the emergency department who were admitted to the medical service were randomized to usual care (in the hospital) or home hospital care. You all know what in-hospital care looks like.

The home hospital is a bit different.

The group sent home got a visit by a nurse twice a day and a visit by a physician once a day. They also had access to video chats with the treatment team at any time. If needed, they got medical meals, a home health aide, a social worker, a physical therapist, and telemedicine consults with specialists. There was in-home x-ray, intravenous infusion, respiratory therapy, and point-of-care blood tests. Participants were also monitored continuously using VitalPatch, which tracks heart rate, position, movement, and respiratory rate.

Were these the sickest patients? Of course not. They had a variety of diagnoses, ranging from community-acquired pneumonia to gout exacerbation, but diagnosis-specific risk scores calculated in the emergency department were used to ensure that the patients were at low risk for transfer to the intensive care unit or sudden clinical decline.

Still, remember that all of these patients had been admitted to the hospital before they were enrolled, so they met that threshold.

OK, big things first. Nothing terrible happened. No one in the hospital-at-home group had to be rushed back to the hospital. No one died.


 

And the cost? Dramatically lower in the hospital-at-home group—41% lower, to be exact. Now that's without accounting for physician labor, but even after building that in, the at-home group was about 16% cheaper.

Why?

We can see some important differences in healthcare utilization across the groups. For example, only 14% of the at-home patients got an imaging study, compared with 44% of the hospitalized patients. Only one at-home patient got a specialty consult compared with [31%] of the control patients.


 

Outcomes were pretty good in the at-home group as well. The length of stay was 4.5 days, compared with 3.8 in the hospital group, but just 7% of the at-home group were readmitted within 30 days, compared with 23% of the in-hospital group. That's a pretty crazy reduction.

Is this a model for the future of hospital care? The Brigham seems to think so. They stopped the trial early in order to expedite a wider rollout of their hospital-at-home program.

I will point out that this study is way too small to detect important safety signals. I think the big risk of hospital at home is that some important but rare complications get missed—your pulmonary emboli, your aspiration events. And if a significant decompensation event occurs, getting someone to the intensive care unit is quicker if it's only an elevator ride away.

I was also worried about caregiver burden. Are we just transferring the burden of care from hospital staff to family members? I asked lead author Dr David Levine about that issue.


 

Yes, these patients are at home and caregivers are often making meals and changing bedsheets. But they're not spending their day in the hospital, waiting for the team to round or unsure of what will happen next. This may, counterintuitively, be a less burdensome care paradigm, provided that the appropriate services are available.

I think what we have here is a new model of care delivery that might actually solve multiple problems in our current healthcare system (I'm looking at you, overcrowded emergency room) and actually benefit patients as well. It's not too often that something like that comes around. Hospital at home: coming soon to a catchment area near you.

F. Perry Wilson, MD, MSCE, is an associate professor of medicine and director of Yale's Program of Applied Translational Research. His science communication work can be found in the Huffington Post, on NPR, and here on Medscape. He tweets @methodsmanmd and hosts a repository of his communication work at www.methodsman.com.

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