Acute illness outcomes with admission-avoidance home care plus CGA similar to inpatient care

Pairing admission-avoidance hospital at home (HAH) with comprehensive geriatric assessment (CGA) may offer an alternative to hospitalization for some older patients, U.K., researchers reported.

In a randomized trial done in nine hospital and community sites, among 1,055 people (mean age: 83.3) who were deemed medically unwell but physiologically stable, and referred for hospital admission, 78.6% in the HAH-CGA group were living at home at six months versus 75.3% of those in the hospital group (relative risk 1.05, 95% CI 0.95 to 1.15, P=0.36), according to Sasha Shepperd, MSc, DPhil, of the University of Oxford in England, and co-authors.

Also at six-month follow-up, fewer patients in the HAH-CGA group died compared with those in the hospital group (16.9% vs 17.7%, respectively; RR 0.98, 95% CI, 0.65 to 1.47, P=0.92); and 5.7% versus 8.7% were in long-term residential care (RR, 0.58, 95% CI 0.45 to 0.76, P<0.001), they stated in the Annals of Internal Medicine, adding that “[p]atient satisfaction was in favor of CGA HAH.”

HAH was defined as “active treatment by healthcare professionals in the patient’s home for a condition that otherwise would require acute hospital inpatient care, and always for a limited time period,” according to Shepperd and colleagues in a 2016 Cochrane review. Adding CGA to HAH “may reduce the risk for serious complications for older adults who are more likely to maintain their existing care arrangements and routines when receiving health care in their home,” they explained in the current study.

Their latest findings add weight to data on HAH from the U.S. and other countries, such as China and the Netherlands, as well as a Cochrane review. These “programs are often initiated to control burgeoning health care costs, address hospital capacity, and avoid common in-hospital complications, such as nosocomial infections and delirium,” said Karen Titchener, MS, APRN, RN, of the Huntsman Cancer Institute at the University of Utah in Salt Lake City, in an editorial accompanying the study.

She also noted that the pandemic has hastened the development of HAH programs. For instance, in November 2020, CMS announced a strategy to provide acute care at home, and in JAMA Health Forum article, health policy experts offered other steps that CMS should take to with HAH to ease the pandemic-related burden on the healthcare system.

But there were some “significant challenges” in terms of the current trial design, Titchener pointed out, mainly that “only 22% of those randomly assigned to hospitalization either declined hospital admission and received HAH services or were diverted to HAH because of issues with bed capacity,” which underscoring the desirability and need for HAH to address settings with limited bed capacity, this “tempers confidence in the study’s findings because it represents more of a real-world evaluation than a controlled experiment.”

And while the combination of HAH and CGA was a “distinctive feature,” of the study, “the primary outcome of living at home at 6 months may be more of a reflection of the CGA than of the single HAH admission for acute care,” according to Titchener. She suggested that specific outcomes that were “more directly attributable to each component of the intervention could provide more insight into the value of a combined approach.”

Shepperd’s group looked at an intervention of HAH with CGA versus hospital admission with, or without, CGA, using 2:1 randomization. Most participants (77.6%) were recruited from a hospital short-stay acute medical assessment unit while 22.1% were recruited from primary care, they explained.

More than 60% of participants in both groups were female, while 37% had acute functional deterioration and about 45% were diagnosed with infection. There was no delirium in >94% of the patients, but about three-quarters had an abnormal Montreal Cognitive Assessment score (<26). The mean score on the Charlson Comorbidity Index was approximately 6. Also, more than 60% of participants reported moderate or severe problems with mobility, and 38% reported difficulties with activities of daily living.

The authors explained that 23 participants were not included in the analysis for various reasons, including consent withdrawal or health deterioration, and reported the following:

  • Initial average length of stay: 6.89 days in the HAH-CGA group and 5.25 days in the hospital group.
  • Average length of stay for HAH-CGA patients admitted to the hospital: 1.39 days.
  • Decreased long-term residential care in the HAH-CGA group at 6 months and 12 months: RR 0.58 (95% CI 0.45 to 0.76, P<0.001) and RR 0.61 (95% CI 0.46 to 0.82, P<0.001), respectively.
  • Increased risk for readmission or transfer to hospital in the HAH-CGA group at 1 month: RR 1.32 (95% CI 1.06 to 1.64, P=0.012).
  • Decreased risk for readmission or transfer to hospital in the HAH-CGA group at 6 months: RR 0.95 (95% CI 0.86 to 1.06, P=0.40).

Shepperd and co-authors also found no evidence of a difference in the risk for cognitive impairment, activities of daily living, comorbidity, quality of life at six months, or presence of delirium at three or five days. In fact, they reported a relative decrease in presence of delirium in the HAH-CGA group at one month (RR, 0.38, 95% CI 0.19 to 0.76, P=0.006).

One person in the HAH-CGA had an “unexpected serious adverse event that was fatal because of metabolic acidosis caused by alcohol excess and poor diabetic control,” and that the HAH-CGA group had a 32% relative increase in transfer to hospital at 1-month follow-up, but not at six months.

However, “the finding of a decrease in delirium at one month in the CGA HAH group is limited by the small number of cases identified, possibly because of the selection of older people considered suitable for home management or under detection of delirium,” Shepperd’s group stated.

Other study limitations included the fact that the population was “old older,” which may explain similar mortality rates at 6 months, and the analysis of pre-established HAH-CGA services, “which may limit the findings to services that are beyond the initial setup phase,” they cautioned.

The authors called for more research looking at a number of elements, such as how the “shift of care from hospitals to the home fits with existing hospital- and community-based services and financing,” and what role remote monitoring plus multidisciplinary care may play in the care needs of this population.

  1. Admission-avoidance hospital at home (HAH) with comprehensive geriatric assessment (CGA) resulted in similar outcomes to hospital admission in the proportion of older people living at home as well as a decrease in admissions to long-term residential care at six months.

  2. HAH plus CGA service can provide an alternative to hospitalization for selected older patients.

Shalmali Pal, Contributing Writer, BreakingMED™

The study was supported by the National Institute for Health Research (NIHR) Health Services and Delivery Research Programme.

Shepperd reported support from the NIHR. Co authors reported support from, and/or relationships with, NIHR, the NHS Scotland’s Chief Medical Officer, and the Scottish Cabinet Secretary for Health and Sport.

Titchener disclosed no relevant relationships.

Cat ID: 494

Topic ID: 398,494,282,494,730,192,255,925