Hospitalization at Home for Patients With Acute Exacerbation of Chronic Disease—Further Evidence to Inform Practice | Emergency Medicine | JAMA Network Open | JAMA Network
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Invited Commentary
Health Policy
June 8, 2021

Hospitalization at Home for Patients With Acute Exacerbation of Chronic Disease—Further Evidence to Inform Practice

Author Affiliations
  • 1Healthcare Transformation Lab, Massachusetts General Hospital, Boston
  • 2Department of Emergency Medicine, Massachusetts General Hospital, Boston
  • 3Harvard Medical School, Boston, Massachusetts
JAMA Netw Open. 2021;4(6):e2111680. doi:10.1001/jamanetworkopen.2021.11680

With the recent announcement from the Center for Medicare & Medicaid Services (CMS) of an Acute Hospital Care at Home program, clinicians and health care administrators are considering or actively pursuing this alternative management strategy for patients requiring hospitalization. In fact, within the first 3 months of the program’s announcement, more than 100 hospitals across the United States applied for and received a waiver from CMS to participate. As a general model of acute care delivery, hospital at home (HaH) has robust randomized clinical trial (RCT) evidence, across a diversity of patient populations and countries. However, there are different models of HaH, including admission-avoidance HaH and early supported discharge (or transfer) HaH, as well as differences in mode of admission-avoidance enrollment, including direct admission from the emergency department (ED), outpatient clinic, or home. Understanding how to optimally deliver HaH care and which patient populations are most appropriate to receive such care remain outstanding areas of scientific inquiry.

Elsewhere in JAMA Network Open, Arsenault-Lapierre and colleagues1 report their findings of a systematic review and meta-analysis of HaH as a substitute for inpatient care. In an effort to further elucidate which patient populations are best suited for HaH, the study focused on patients with chronic illness presenting to the ED. Their findings synthesize data from 9 RCTs that evaluate admission-avoidance HaH compared with inpatient care for chronic obstructive pulmonary disease (COPD), heart failure, asthma, stroke, and neuromuscular disease. The included RCTs were performed in 4 countries, including the United States, Italy, Spain, and England, from 2000 to 2018. Their findings demonstrate no change in mortality and a reduced risk of readmission for HaH compared with inpatient care. At the same time, there was an increased length of treatment but lower risk of long-term care admission in HaH vs inpatient care. Both readmission and length of treatment had significant heterogeneity, limiting interpretation. Patient-reported outcomes showed improvement in depression and anxiety in patients receiving HaH care compared with those receiving in-hospital care. No data were identified for out-of-pocket patient costs; hospital or payer cost analyses were not the focus of this study.

This study corroborates many findings from other similar systematic reviews and meta-analyses on HaH.2-5 Prior studies of individual chronic diseases (particularly COPD and heart failure) have shown mortality rates to not be compromised when HaH is instituted, and readmission rates have also been shown to be comparable with inpatient care.3-5 Importantly, one of the studies analyzed by the authors (and the only US-based RCT) had a follow-up study published in 2020 showing continued favorable outcomes for HaH—including safer and less expensive care, lower readmissions, and no difference in median length of stay.6

Health care delivery science is designed to inform us regarding not just whether an intervention improves health but for whom it should be applied. A new contribution of the present study was its specific focus on whom HaH was potentially appropriate for, ie, all patients with chronic disease who present to the ED needing hospitalization. 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 US population and have been demonstrated to have very substantial health care utilization.7 At the same time, an important limitation of the present study is the somewhat outdated nature of some of the analyzed studies. Given developments in risk stratification, admission criteria, technology, and other health care advancements, some of the included studies are likely not as relevant to today’s practice of medicine.

What are the remaining knowledge gaps in the health care delivery science of HaH? This study found that patients who present first to an ED could safely be enrolled in HaH care. One area of important inquiry is whether the diagnostic and therapeutic capacity of the ED is necessary as the initial point of evaluation before enrollment in HaH. The current regulations for the CMS Acute Hospital Care at Home program require such initial ED workup for Medicare beneficiaries. Further research is needed to understand which patient populations might be safe to be enrolled in HaH directly from their home or an outpatient clinic setting as well as what diagnostic evaluations, if any, need to be performed before such enrollment occurs. Another important area of inquiry pertains to patient selection. While current HaH programs have developed basic inclusion and exclusion criteria, there is opportunity to develop risk scoring algorithms and use machine learning techniques to best determine who is safe and appropriate for this model of acute care delivery in the home. Further underrepresented areas of research in HaH patient selection exist for a variety of acute and chronic diseases and patient populations (based on service needs rather than diagnosis), including cancer, postsurgical care, and pediatrics. Additionally, with the ongoing digital transformation of health care, including advancements in remote patient monitoring and telemedicine, generating a scientific foundation for when and how to best use these technologies in HaH is warranted.

Health care delivery science, technological advancements, and payment model innovation continue to redefine the relationship between the site of care and the provision of care. Hospital capacity constraints and infectious concerns during the COVID-19 pandemic have further accelerated this work. With the Acute Hospital Care at Home program, the participation of several state Medicaid programs, and increasing private sector interest, new US HaH programs and the expansion of existing programs will undoubtedly give us the opportunity to gain more insight into the what, whom, when, and how of HaH. Many important research questions remain, but the growing evidence of safety, efficacy, and cost savings cannot be ignored. To date, most clinicians and patients do not know much about HaH and its supporting evidence; consequently, it has yet to be integrated into much of US clinical practice. The time has come for this to change. However, in doing so, it remains requisite that clinicians and researchers effectively execute the ongoing research agenda, appropriate implementation, and broader dissemination of HaH—all for the benefit of patients, who desire to obtain the best health outcomes while maximizing time at home.

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Article Information

Published: June 8, 2021. doi:10.1001/jamanetworkopen.2021.11680

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Conley J. JAMA Network Open.

Corresponding Author: Jared Conley, MD, PhD, MPH, Healthcare Transformation Lab, Massachusetts General Hospital, 50 Staniford St, Boston, MA 02114 (jconley@mgh.harvard.edu).

Conflict of Interest Disclosures: Dr Conley reported receiving personal fees from Biofourmis and Change Healthcare outside the submitted work.

References
1.
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.2021.11568Google Scholar
2.
Conley  J, O’Brien  CW, Leff  BA, Bolen  S, Zulman  D.  Alternative strategies to inpatient hospitalization for acute medical conditions: a systematic review.   JAMA Intern Med. 2016;176(11):1693-1702. doi:10.1001/jamainternmed.2016.5974PubMedGoogle ScholarCrossref
3.
Qaddoura  A, Yazdan-Ashoori  P, Kabali  C,  et al.  Efficacy of hospital at home in patients with heart failure: a systematic review and meta-analysis.   PLoS One. 2015;10(6):e0129282. doi:10.1371/journal.pone.0129282PubMedGoogle Scholar
4.
Jeppesen  E, Brurberg  KG, Vist  GE,  et al.  Hospital at home for acute exacerbations of chronic obstructive pulmonary disease.   Cochrane Database Syst Rev. 2012;5(5):CD003573. doi:10.1002/14651858.CD003573.pub2PubMedGoogle Scholar
5.
McCurdy  BR.  Hospital-at-home programs for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD): an evidence-based analysis.   Ont Health Technol Assess Ser. 2012;12(10):1-65.PubMedGoogle Scholar
6.
Levine  DM, Ouchi  K, Blanchfield  B,  et al.  Hospital-level care at home for acutely ill adults: a randomized controlled trial.   Ann Intern Med. 2020;172(2):77-85. doi:10.7326/M19-0600PubMedGoogle ScholarCrossref
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Buttorff  C, Ruder  T, Bauman  M. Multiple chronic conditions in the United States. RAND Corporation. Published 2017. Accessed March 8, 2021. https://www.rand.org/pubs/tools/TL221.html
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