David M. Levine, MD, MPH, MA; Kei Ouchi, MD, MPH; Bonnie Blanchfield, ScD; Agustina Saenz, MD, MPH; Kimberly Burke, BA; Mary Paz, BA; Keren Diamond, RN, MBA; Charles T. Pu, MD; Jeffrey L. Schnipper, MD, MPH
Presented in part at the Society of General Internal Medicine Annual Meeting, Denver, Colorado, 11–14 April 2018.
Acknowledgment: The authors thank the home hospital clinicians who cared for the home hospital patients; John Orav, PhD, for his insightful comments on a prior draft of the manuscript; and various departments at Brigham Health that were instrumental to the success of the home hospital program: Cardiology, Emergency Medicine, General Internal Medicine and Primary Care, Hospital Medicine Unit, Pharmacy, Laboratory, and Population Health.
Financial Support: By the Partners HealthCare Center for Population Health and internal departmental funds.
Disclosures: Dr. Levine reports grants from Biofourmis outside the submitted work. Dr. Blanchfield reports consulting income from Verily, GreyBird Ventures, and Atlas5D outside the submitted work. Dr. Schnipper reports grants from Mallinckrodt Pharmaceuticals and Portola Pharmaceuticals outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-0600.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Data Sharing Statement: The authors have indicated that they will not be sharing data.
Corresponding Author: David M. Levine, MD, MPH, MA, Harvard Medical School, Brigham and Women's Hospital, Division of General Internal Medicine and Primary Care, 1620 Tremont Street, 3rd Floor, Boston, MA 02120; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Levine, Blanchfield, Saenz, and Schnipper; Ms. Burke; and Ms. Paz: 1620 Tremont Street, 3rd Floor, Boston, MA 02120.
Dr. Ouchi: 75 Francis Street, Boston, MA 02115.
Ms. Diamond: 281 Winter Street, Suite 240, Waltham, MA 02451.
Dr. Pu: 399 Revolution Drive, Suite 1030, Somerville, MA 02145.
Author Contributions: Conception and design: D.M. Levine, K. Ouchi, B. Blanchfield, C.T. Pu, J.L. Schnipper.
Analysis and interpretation of the data: D.M. Levine, K. Ouchi, B. Blanchfield, J.L. Schnipper.
Drafting of the article: D.M. Levine.
Critical revision of the article for important intellectual content: D.M. Levine, K. Ouchi, B. Blanchfield, K. Diamond, C.T. Pu, J.L. Schnipper.
Final approval of the article: D.M. Levine, K. Ouchi, B. Blanchfield, A. Saenz, K. Burke, M. Paz, K. Diamond, C.T. Pu, J.L. Schnipper.
Provision of study materials or patients: D.M. Levine, K. Ouchi, K. Burke, M. Paz.
Statistical expertise: D.M. Levine.
Obtaining of funding: D.M. Levine, J.L. Schnipper.
Administrative, technical, or logistic support: D.M. Levine, K. Ouchi, K. Burke, M. Paz, K. Diamond.
Collection and assembly of data: D.M. Levine, K. Ouchi, A. Saenz, K. Burke, M. Paz.
Substitutive hospital-level care in a patient's home may reduce cost, health care use, and readmissions while improving patient experience, although evidence from randomized controlled trials in the United States is lacking.
To compare outcomes of home hospital versus usual hospital care for patients requiring admission.
Randomized controlled trial. (ClinicalTrials.gov: NCT03203759)
Academic medical center and community hospital.
91 adults (43 home and 48 control) admitted via the emergency department with selected acute conditions.
Acute care at home, including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing.
The primary outcome was the total direct cost of the acute care episode (sum of costs for nonphysician labor, supplies, medications, and diagnostic tests). Secondary outcomes included health care use and physical activity during the acute care episode and at 30 days.
The adjusted mean cost of the acute care episode was 38% (95% CI, 24% to 49%) lower for home patients than control patients. Compared with usual care patients, home patients had fewer laboratory orders (median per admission, 3 vs. 15), imaging studies (median, 14% vs. 44%), and consultations (median, 2% vs. 31%). Home patients spent a smaller proportion of the day sedentary (median, 12% vs. 23%) or lying down (median, 18% vs. 55%) and were readmitted less frequently within 30 days (7% vs. 23%).
The study involved 2 sites, a small number of home physicians, and a small sample of highly selected patients (with a 63% refusal rate among potentially eligible patients); these factors may limit generalizability.
Substitutive home hospitalization reduced cost, health care use, and readmissions while increasing physical activity compared with usual hospital care.
Partners HealthCare Center for Population Health and internal departmental funds.
Levine DM, Ouchi K, Blanchfield B, et al. Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Ann Intern Med. 2019;:. [Epub ahead of print 17 December 2019]. doi: https://doi.org/10.7326/M19-0600
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Published: Ann Intern Med. 2019.
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