Dr. Nagaraj
Clinical question: Can hospital-level care be provided in the home environment to reduce costs without compromising the quality of care in the U.S.?
Background: Inpatient care is expensive, and is a major contributor to rising health care costs in the U.S. The U.S. health care system continues to experience challenges with overcrowded emergency departments (EDs), lack of inpatient capacity, and quality issues (e.g., readmissions and “post-hospital syndrome” due to deconditioning and lack of sleep). Home hospital-level care is already provided in several developed countries, such as Australia and Spain. However, the literature on this type of care in the U.S. is sparse and limited to a few nonrandomized studies that have suggested that hospital-level care provided in a home setting for select patients can result in reduced cost and improved quality of care.
Study design: Parallel design, randomized, controlled trial
Setting: An academic medical center and a community hospital in Massachusetts between June 12, 2017, and January 16, 2018
Synopsis: A total of 91 adult patients were randomly assigned to either inpatient hospital care (48 patients) or home hospital care (43 patients). Patients were excluded if they lived in a long-term care or rehabilitation facility, required routine administration of controlled substances, required the assistance of more than one person to the bedside commode, or were at high risk for clinical deterioration based on validated, disease-specific, risk algorithms. At baseline, patients in both groups had similar characteristics. However, patients who received inpatient hospital care were younger, more often Black, and less often insured through Medicare. The adjusted mean cost of the acute care episode was 38% lower (95% CI, 24%-49%; P <0.001) for those managed with home hospital care versus inpatient hospital care. Patients who received home hospital care had fewer readmissions within 30 days after discharge (7% versus 23%) and were less often sedentary (median, 12% versus 23%) in comparison to those who received inpatient hospital care. Fewer safety events (9% versus 15%) were observed in the home hospital care group versus the inpatient hospital care group.
Bottom Line: In addition to reducing health care costs, home hospital care may be an opportunity to solve the problem of overcrowded hospitals and EDs across the U.S., which has been exacerbated by the COVID-19 pandemic.
Citation: Levine DM, et al. Hospital-level care at home for acutely ill adults: a randomized controlled trial. Ann Intern Med. 2020;172(2):77-85. doi:10.7326/M19-0600.
Dr. Nagaraj is an assistant professor of internal medicine at Wake Forest School of Medicine, Winston-Salem, N.C.