HaH associated with lower readmission without increasing mortality

Hospital-at-home (HaH) interventions may decrease risk of hospital readmission and long-term care admission compared to in-hospital stay, without increasing mortality, according to results from a systematic review and meta-analysis.

HaH interventions—a substitute for in-hospital care that consists of hospital-level treatment delivered to patients by a health care professional in their own home—have gained widespread interest due to their potential benefit on health outcome and health system costs compared to traditional in-hospital care. And, according to Geneviève Arsenault-Lapierre, PhD, of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada, and colleagues, HaH interventions may be particularly well suited to treat patients with chronic diseases, who tend to use health services more frequently. However, previous systematic reviews of HaH interventions primarily focus on acute conditions or specific chronic diseases rather than assessing HaH-related outcomes across multiple chronic conditions, they explained in JAMA Network Open.

Arsenault-Lapierre and colleagues conducted their own systematic review of randomized clinical trials (RCTs) comparing HaH against in-hospital care in order to assess the association between improved patient outcomes and HaH, including home visits by nurses and/or physicians, for patients with chronic diseases who presented to an emergency department (ED).

“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,” they found. “We found no difference in mortality between the two 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).”

They also noted that HaH interventions might be associated with improved anxiety and depression scores, but not with functional status.

Jared Conley, MD, PhD, MPH, of Massachusetts General Hospital in Boston, writing in an invited commentary, noted that the analysis by Arsenault-Lapierre et al “corroborates many findings from other similar systematic reviews and meta-analyses on HaH.”

“A new contribution of the present study was its specific focus on whom HaH was potentially appropriate for, i.e., all patients with chronic disease who present to the ED needing hospitalization,” Conley wrote. “To date, HaH reviews have focused on a mix of both acute and chronic diseases, included patients admitted from various locations (home, clinic, ED, and inpatient floor), or studied a single chronic disease. The focus on the acute care management of chronic disease is particularly merited given that patients with chronic disease represent more than half of the U.S. population and have been demonstrated to have very substantial health care utilization.”

However, he also noted that the study is limited by the “somewhat outdated nature of some of the analyzed studies,” which he argued are “likely not as relevant to today’s practice of medicine.” And, he added, there are still questions regarding the implementation of HaH, including whether or not presenting to an ED is necessary and which patient populations may be safely enrolled in HaH directly from their home or an outpatient clinic; the best method for approaching patient selection, including inclusion/exclusion criteria; and when and how to best use remote patient monitoring and telemedicine for these interventions.

For their analysis, Arsenault-Lapierre and colleagues searched several databases—including Ovid MEDLINE, Ovid Embase, Ovid PsycINFO, CINAHL, Health Technology Assessment, the Cochrane Library, OVID Allied and Complementary Medicine Database, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov—from inception through March 4, 2019, to find RCTs in which the experimental group received HaH interventions and the control group received usual in-hospital care.

Included patients were 18 years or older with a chronic disease and presented to the ED. Primary outcomes were patient outcomes—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.

The authors ultimately included nine studies and a total of 959 participants (median age, 71.0 years; 613 men [63.9%]; 346 women [36.1%]).

“Mortality did not differ between the hospital-at-home and the in-hospital care groups (RR, 0.84; 95% CI, 0.61-1.15; I2=0%),” they found. “Risk of readmission was lower (RR, 0.74; 95% CI, 0.57-0.95; I2=31%) and length of treatment was longer in the hospital-at-home group than in the in-hospital group (mean difference, 5.45 days; 95% CI, 1.91-8.97 days; I2=87%). In addition, the hospital-at-home group had a lower risk of long-term care admission than the in-hospital care group (RR, 0.16; 95% CI, 0.03-0.74; I2=0%). Patients who received hospital-at-home interventions had lower depression and anxiety than those who remained in-hospital, but there was no difference in functional status. Other patient outcomes showed mixed results.”

Arsenault-Lapierre and colleagues noted that, while costs related to the health care system have been shown to be lower for HaH than for in-hospital care, none of the studies in this analysis reported out-of-pocket costs.

“It is possible that in HaH interventions, some costs are transferred to patients and caregivers,” they wrote. “Considering the longer length of treatment in the HaH group, it will be important to assess out-of-pocket costs in future studies.”

The study authors also acknowledged some limitations to their analysis, particularly regarding potential sources of heterogeneity (i.e., variations in HaH team compositions, patient characteristics, follow-up periods, etc. between studies). Another limitation was the relatively small number of reviews included in their analysis.

  1. Hospital-at-home (HaH) interventions led to lower risk of readmission or long-term care admission compared to in-hospital care—without increasing mortality—for patients with chronic conditions presenting to the emergency department (ED).

  2. HaH interventions may be associated with improved anxiety and depression scores among patients, but it did not lead to improved functional status.

John McKenna, Associate Editor, BreakingMED™

The study authors had no relevant relationships to disclose.

Conley reported receiving personal fees from Biofourmis and Change Healthcare outside the submitted work.

Cat ID: 254

Topic ID: 253,254,254,556,730,192,151,925