A similar proportion of older patients who received hospital-level care at home and those who were hospitalized were living at home after six months, a recent randomized trial found.
Researchers conducted the trial to assess the clinical effectiveness of hospital at home (HAH) in older participants who were medically unwell, were physiologically stable, and were referred for a hospital admission at nine hospital and community sites in the U.K. Participants most commonly presented with acute functional deterioration (37%), falls (21%), shortness of breath (12%), and delirium, confusion, or dementia (7%). Most had cognitive impairment (72%) and reported moderate to severe problems with mobility (63%). Using 2:1 randomization, the researchers assigned participants to either HAH with comprehensive geriatric assessment or hospital admission with comprehensive geriatric assessment when available.
The HAH intervention is a rapid-response service that aimed to assess a patient within an average of two hours of referral and included four main components: geriatrician-led admission-avoidance HAH; a multidisciplinary team; health care guided by the principles of comprehensive geriatric assessment, including virtual rounds; and direct access to acute hospital-based health care, such as diagnostics and transfer to hospital. Results were published online on April 20 by Annals of Internal Medicine.
A total of 1,055 older patients (mean age, 83.3 years; 60.6% women) were included in the trial, 700 randomly assigned to the intervention group and 355 to hospitalization. Initial average length of stay was 6.89 days with HAH and 5.25 days for those in the hospital. Among patients who completed follow-up, there was no evidence of a difference in the primary outcome of being alive and living at home at six months (78.6% in the HAH group vs. 75.3% in the hospital group; relative risk [RR], 1.05 [95% CI, 0.95 to 1.15]; P=0.36) or at 12 months (RR, 0.99 [95% CI, 0.89 to 1.10]; P=0.80). There was also no significant difference in deaths by six months (16.9% vs. 17.7%; RR, 0.98 [95% CI, 0.65 to 1.47]; P=0.92) or 12 months (RR, 1.14 [95% CI, 0.80 to 1.62]; P=0.47). The HAH group had a lower rate of long-term residential care at six months than the hospital group (5.7% vs. 8.7%; RR, 0.58 [95% CI, 0.45 to 0.76]; P<0.001), and this finding persisted at 12 months (RR, 0.61 [95% CI, 0.46 to 0.82]; P<0.001).
There was an increased risk for readmission or transfer to the hospital in the HAH group at one month (RR, 1.32 [95% CI, 1.06 to 1.64]; P=0.012) but not at six months (RR, 0.95 [95% CI, 0.86 to 1.06]; P=0.40). While there was no difference between groups for the presence of delirium at three days (RR, 1.12 [95% CI, 0.54 to 2.29]; P=0.76) or five days (RR, 0.93 [95% CI, 0.34 to 2.47]; P=0.87), there was a relative decrease in the HAH group at one month (RR, 0.38 [95% CI, 0.19 to 0.76]; P=0.006). Participants who received HAH reported higher levels of satisfaction regarding their care, including length of time waiting for care to start, understanding the aims of care, knowing how to contact staff, and discussions on further care.
The study authors noted that the finding of a decrease in delirium at one month in the HAH group is limited by the small number of cases identified. They added that the HAH services they assessed were established before the study, potentially limiting generalizability of the results to services that are beyond their initial setup phase.
An accompanying editorial noted that the addition of comprehensive geriatric assessment to HAH was the most distinctive feature of the study and may have contributed to the findings. “The goal of [comprehensive geriatric assessment] is to maximize overall health in older adults, and the goal of HAH is to treat an acute episode of illness,” the editorialist wrote. “This research shows how combining 2 care approaches benefits older persons with frailty while keeping them at home.”
However, 22% of participants who were randomly assigned to hospitalization either declined admission and received HAH services or were diverted to HAH because of issues with bed capacity, the editorial said. “While 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,” the editorialist wrote.