August 20, 2018

Hospital at Home?

For years, I’ve been arguing that frail older patients are often better off being treated for acute medical problems at home than in the hospital. I began making this claim during my residency when I wrote about The Ethics of Cardiopulmonary Resuscitation,” claiming that it created cognitive dissonance for physicians in hospitals to go all out for some patients and to withhold selected treatments for others. Better, I suggested, to keep those individuals who didn’t want everything under the sun, and particularly those who didn’t want attempted cardiopulmonary resuscitation, out of the hospital altogether. 

I picked up the theme during my geriatrics fellowship in a paper entitled “Adverse Consequences of Hospitalization in the Elderly," which quantified the frequency with which older patients developed iatrogenic complications, unrelated to the medical problem for which they had been admitted and found it was 40.5 percent in those aged 70 or older, compared to 8.8 percent in those under 70. And instead of suggesting that we build higher siderails—or institute the kinds of interventions that eventually were adopted by Acute Care for the Elderly (ACE) units—we try to avoid hospitalization altogether. 

Over time, increasing evidence has accumulated that many people can be cared for at home and that this approach not only decreases the chance of adverse events (including unwanted treatment), but also results in comparable outcomes. A new study in JAMA Internal Medicine  suggests a way to pay for “hospital at home” model--by paying a single fee for acute care plus 30 days of post-acute care.
The Hospital at Home model (which, unlike the study authors, I won’t abbreviate as HaH since that makes it seem like a joke) used in this study offers hospital-style care for any of 19 common medical conditions (including pneumonia, urinary tract infection, flare of heart failure, and cellulitis) in clinically stable, interested adults who have adequate home supports. Their outcomes were compared to those of contemporaneously hospitalized adults who were eligible but either declined to participate in the study or couldn’t participate because services could not be set up for them at the particular time (night time) or day (weekends) when they showed up in the emergency department.
The results were overwhelmingly positive. Patients cared for at home, when compared to controls, were much less likely to be (re)hospitalized for any reason in the month after discharge (8.6 percent vs 15.6 percent); they were less likely to go to a skilled nursing facility after treatment of the acute episode (1.7 percent vs 10.4 percent); and they were far more likely to rate the quality of their care as excellent (68 percent vs 45 percent). While 12.2 percent of the Hospital at Home patients did end up in the hospital for treatment of the acute illness, there were no differences in mortality. There were also no differences in complications such as falls or infections, but the number of either of these adverse events was too small to draw any definitive conclusions.
On the other hand, as the authors of the accompanying commentary indicate, the study was a case control study, not a randomized trial, and the “controls” were significantly different from the cases: they were younger (a lot younger—an average of 71.5 compared to 76.0), less well educated, and better functioning (55.5 percent had at least one area of difficulty in daily activities, compared to 71.5 percent in the Hospital at Home patients). However, finding that the home care patients fared at least as well and, in many instances, better than their hospitalized counterparts, even though they were older and frailer suggests that they may have more to gain by staying out of the institution.
It's heartwarming to see evidence that treating many medical problems at home is achievable without sacrificing any important benefits and to discover there are plausible ways of paying for such care. My concern is that the “hospital at home” model, while an improvement over the hospital environment precisely because it takes place in a familiar location, may bring too much hospital technology with it. I would like to have a better understanding of just what hospital at home includes. I’m reminded of the final days of Pope John Paul II, dying of Parkinson’s disease and its complications. The Pope was cared for at home—but with a feeding tube, a ventilator, and physician care. He was, for all intents and purposes, receiving ICU care at home. So, by all means, let’s make medical care available to older people at home; let’s keep them out of the hospital if possible. But that should not mean bringing the hospital in entirety to them.

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