Why the "Hospital at Home" May Be How You Get Care In the Near Future
/A new randomized trial finds that providing hospital-level care at home is more effective, and cheaper than traditional in-hospital care.
Whenever I’m rounding in the hospital, I come across a patient that just feels 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, it’s way cheaper than the traditional inpatient ward.
The study was out of Brigham and Women’s hospital. Over a seven-month period, 91 patients seen in the ED 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.
Cool telemedicine patch from VitalConnect.
The group sent home got: a visit by a nurse twice a day and a visit by a physician once a day. They had video chat access to the treatment team at any time as well. 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, IV infusion, respiratory therapy, and point-of-care blood tests. Participants were also monitored continuously using this patch which tracks heart rate, position, movement, and respiratory rate as well.
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 ED were used to ensure that the patients were at low risk of ICU transfer 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, which at the Brigham, is saying something.
Cost reductions in the at-home care group.
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 building that in, the at-home group was about 16% cheaper.
Why?
Cost-savings are largely driven by lower utilization
We can see some important differences in health-care utilization across the groups. For example, only 14% of the at-home patients got an imaging study, compared to 44% of the hospitalized patients. Only 1 at-home patient got a specialty consult compared to 30% of the control patients.
Outcomes were pretty good in the at-home group as well. The length of stay was 4.5 days, compared to 3.8 in the hospital group, but just 7% of the at-home group were readmitted within 30-days compared to 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 roll-out 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 ICU is maybe quicker if it’s only an elevator ride away.
I was also worried about caregiver burden here. Are we just transferring the burden of care from hospital staff to family members? I asked lead author Dr. David Levine about that issue.
Lead author Dr. David Levine, MD MPH MA
Brigham and Women’s Hospital
“We measured caregiver burden very carefully in the trial. We actually were able to show that caregiver burden was lower in the intervention arm, believe it or not”.
Yes – these patients are 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 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 (gasp) actually benefit patients as well. It’s not too often something like that comes around. Hospital-at-home: coming soon to a catchment area near you.