Hospital-Level Care at Home for Acutely Ill Adults: a Pilot Randomized Controlled Trial

Abstract

Background: Hospitals are standard of care for acute illness, but hospitals can be unsafe, uncomfortable, and expensive. Providing substitutive hospital-level care in a patient's home potentially reduces cost while maintaining or improving quality, safety, and patient experience, although evidence from randomized controlled trials in the US is lacking.

Objective: Determine if home hospital care reduces cost while maintaining quality, safety, and patient experience.

Design: Randomized controlled trial.

Participants: Adults admitted via the emergency department with any infection or exacerbation of heart failure, chronic obstructive pulmonary disease, or asthma.

Intervention: Home hospital care, including nurse and physician home visits, intravenous medications, continuous monitoring, video communication, and point-of-care testing.

Main measures: Primary outcome was direct cost of the acute care episode. Secondary outcomes included utilization, 30-day cost, physical activity, and patient experience.

Key results: Nine patients were randomized to home, 11 to usual care. Median direct cost of the acute care episode for home patients was 52% (IQR, 28%; p = 0.05) lower than for control patients. During the care episode, home patients had fewer laboratory orders (median per admission: 6 vs. 19; p < 0.01) and less often received consultations (0% vs. 27%; p = 0.04). Home patients were more physically active (median minutes, 209 vs. 78; p < 0.01), with a trend toward more sleep. No adverse events occurred in home patients, one occurred in control patients. Median direct cost for the acute care plus 30-day post-discharge period for home patients was 67% (IQR, 77%; p < 0.01) lower, with trends toward less use of home-care services (22% vs. 55%; p = 0.08) and fewer readmissions (11% vs. 36%; p = 0.32). Patient experience was similar in both groups.

Conclusions: The use of substitutive home-hospitalization compared to in-hospital usual care reduced cost and utilization and improved physical activity. No significant differences in quality, safety, and patient experience were noted, with more definitive results awaiting a larger trial. Trial Registration NCT02864420.

Keywords: home hospital; home-based care; hospital alternative; hospital at home.

Conflict of interest statement

Prior Presentations

Society of General Internal Medicine—national conference; Washington, DC, 2017. Awarded Lipkin Award.

Conflicts of Interest

The authors declare that they do not have a conflict of interest.

Figures

Fig. 1

Participant flow. The Consolidated Standards of Reporting Trials flow diagram. One patient in the home group was excluded from analysis. This patient was a pre-specified “n of one” attempt at a separate model of early transfer to home hospital after stabilization in the traditional hospital