Hospital-at-Home vs In-Hospital Care: Outcomes of the Chronically Ill

Updated: Jun 16



Evidence of the efficacy of Hospital-at-Home care continues to mount, which is leading to the increasing implementation of at-home health care programs throughout the United States. The most recent example of scientific support comes from an in-depth systematic review and meta-analysis of nine randomized clinical trial studies consisting of nearly 1,000 adult patients with a chronic disease. The meta-analysis focused on adult patients with a chronic disease who presented to an emergency department. The clinical outcomes of patients receiving hospital-at-home care were compared to those receiving treatment in a hospital.


Key findings include a 26% lower risk of readmission as well as a lower risk of admission for long-term care for hospital-at-home patients. Furthermore, patients treated at home demonstrated lower rates of depression and anxiety. The promising outcomes for hospital-at-home interventions demonstrate a perhaps more effective yet less costly treatment alternative for those with chronic diseases who typically require more care.


The excerpts below were taken from the original article published in JAMA Network Open entitled: Hospital-at-Home Interventions vs In-Hospital Stay for Patients With Chronic Disease Who Present to the Emergency Department: A Systematic Review and Meta-analysis

June 8, 2021


Key Points


Question: Are hospital-at-home interventions consisting of, at minimum, home visits from nurses or physicians associated with better patient outcomes for adult patients with a chronic disease who present to an emergency department?


Findings: This systematic review of 9 randomized clinical trial studies, including 959 adult patients with a chronic disease, found that although patients receiving hospital-at-home care had an average length of treatment of 5.4 days longer than that of in-hospital patients and a similar mortality risk, they had a lower risk for readmission by 26% and a lower risk for long-term care admission relative to the in-hospital group. Patients who received hospital-at-home care also had lower depression and anxiety scores than patients receiving in-hospital care, but there was no difference in functional status.


Meaning: This systematic review provides further evidence that hospital-at-home interventions with at least 1 home visit from a nurse or physician may be a promising substitute to in-hospital care, especially for patients with chronic diseases who present to the emergency department.


Importance: Hospitalizations are costly and may lead to adverse events; hospital-at-home interventions could be a substitute for in-hospital stays, particularly for patients with chronic diseases who use health services more than other patients. Despite showing promising results, heterogeneity in past systematic reviews remains high.


Objective: To systematically review and assess the association between patient outcomes and hospital-at-home interventions as a substitute for in-hospital stay for community-dwelling patients with a chronic disease who present to the emergency department and are offered at least 1 home visit from a nurse and/or physician.


Main Outcomes and Measures: Outcomes of interest were patient outcomes, which included mortality, long-term care admission, readmission, length of treatment, out-of-pocket costs, depression and anxiety, quality of life, patient satisfaction, caregiver stress, cognitive status, nutrition, morbidity due to hospitalization, functional status, and neurological deficits.


Conclusions and Relevance: The results of this systematic review and meta-analysis suggest that hospital-at-home interventions represent a viable substitute to an in-hospital stay for patients with chronic diseases who present to the emergency department and who have at least 1 visit from a nurse or physician. Although the heterogeneity of the findings remained high for some outcomes, particularly for length of treatment, the heterogeneity of this study was comparable to that of past reviews and further explored.


Introduction


Hospitalization is associated with adverse events, nosocomial infections, delirium, and even death and represents important costs for the health care system. Furthermore, patients may prefer being cared for at home. Thus, alternatives to hospitalization have been considered.


Hospital-at-home (HaH) interventions were developed to reduce health risks for patients and costs for the system. These interventions consist of treatment delivered to patients who present with an acute condition; a health care professional provides this treatment in the patient’s home for a condition that would normally require hospitalization. In other words, HaH is the delivery of hospital-level care in patients’ homes as a substitute for an in-hospital stay. Services usually include monitoring, face-to-face clinical care from nurses and physicians, diagnostic testing (eg, laboratory investigations, electrocardiograms, and radiography), and treatment (eg, intravenous medication) in patients’ homes.


Hospital-at-home interventions have attracted widespread interest. A meta-review of HaH interventions has demonstrated its association with better health outcomes and system costs in patients with acute conditions. However, systematic reviews on complex interventions, like HaH, suffer from high heterogeneity, thereby hindering conclusions made from meta-analyses.


One source of this heterogeneity may be the variability of pooled studies with various interventions and populations. Systematic reviews often do not distinguish between early discharge and a substitute for the in-hospital stay altogether. Previous systematic reviews also pooled studies recruiting patients from various entry points (the community, emergency department [ED], and/or during an in-hospital stay). However, the reasons patients choose to go to the ED rather than visiting their physician vary, one of these being perceived urgency and health care needs.


The interventions’ key components also varied in the systematic reviews, including home visits, phone access, or coordination with home-based services, all of which may influence heterogeneity. Home visits offer an invaluable opportunity to better understand the needs of patients. When carried out by physicians or by nurses collaborating closely with physicians, home visits could provide care that is more consistent with in-hospital care than providing only hospital equipment at home (eg, intravenous therapy) or coordinating home-based services (eg, nurse visits from community services). Furthermore, home visits have been identified as a key component of transitional care and HaH interventions in older patients with chronic diseases.


Hospital-at-home interventions may be particularly fitting for patients with chronic diseases, as these patients tend to use health services more frequently. Systematic reviews on HaH interventions are usually focused on acute conditions or specific chronic diseases (eg, chronic obstructive pulmonary disease [COPD]) and rarely examine the association of HaH on health outcomes across multiple chronic diseases. Specifically, examining patients with chronic diseases (in consideration of their higher service use than those without chronic diseases) could reduce heterogeneity.


The safety of HaH in terms of patient outcomes, such as mortality and readmission, has been demonstrated. However, other patient outcomes (eg, patients’ satisfaction, caregiver stress, and out-of-pocket costs) remain inconsistent or unexplored in systematic reviews. In a previous meta-review, 3 of 6 reviews showed an association between HaH and patient satisfaction, 2 showed no difference, and 1 did not compare patient satisfaction between groups. The reviews that demonstrated an association included studies with various acute conditions, whereas the reviews on specific chronic diseases did not show significant associations.


Given the continuously growing interest in HaH interventions and the high heterogeneity of these complex interventions, it is important to systematically review the literature and assess the association between patient outcomes and HaH interventions considering intervention and population specifics.


The objective of our study was to assess the association between better patient outcomes and HaH interventions aimed at avoiding an in-hospital stay, which included home visits by nurses and/or physicians, for patients with chronic diseases who presented to the ED.


Discussion


In this systematic review and meta-analysis, study results suggest that patients with chronic diseases who presented to the ED and were treated with HaH interventions had a lower risk of hospital readmission and long-term care admission than those who received in-hospital care. We found no difference in mortality between the 2 groups, but we found that length of treatment was longer in the HaH group than in the in-hospital group. Taken together, our findings suggest that for patients with chronic diseases who present to the ED, HaH interventions may be as safe as hospitalization (with no difference in mortality) and a preferred alternative (with lower risk of readmission). Furthermore, we found that HaH intervention may be associated with better anxiety and depression scores but not with functional status.


The results of our meta-analysis are consistent with those of other systematic reviews that found lower risk of readmission and no difference in risk of mortality. Since the writing of our manuscript, a new RCT was published and reported similar results.


The results from our narrative synthesis for lower anxiety and depression were also similar to previous systematic reviews. Although another review article that evaluated various medical conditions has shown better patient satisfaction for HaH interventions than that of their control, we found mixed results. This was probably due to the variety of assessment tools measuring different concepts of satisfaction.


Although costs related to the health care system have been shown to be lower for HaH interventions than for in-hospital care, none of the studies in our review reported out-of-pocket costs. It is possible that in HaH interventions, some costs are transferred to patients and caregivers. Considering the longer length of treatment in the HaH group, it will be important to assess out-of-pocket costs in future studies.


Source Citation:

Arsenault-Lapierre G, Henein M, Gaid D, Le Berre M, Gore G, Vedel I. Hospital-at-Home Interventions vs In-Hospital Stay for Patients With Chronic Disease Who Present to the Emergency Department: A Systematic Review and Meta-analysis. JAMA Netw Open. 2021;4(6):e2111568. doi:10.1001/jamanetworkopen.2021.11568

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