Differences in Results and Related Factors Between Hospital-at-Home Modalities in Catalonia: A Cross-Sectional Study

Home-First or Hospital-First? A Propensity Score-Weighted Retrospective Cohort Study

OBJECTIVES

This study aimed to compare clinical and utilization outcomes between home-first and hospital-first models of care in the operation of a hospital-at-home (HaH) program.

DESIGN

This is a retrospective cohort study in which the primary outcome was a composite of oxygenation, intensive care unit admission, and all-cause mortality and the primary utilization outcome was length of stay (hospital and home bed days).

SETTINGS AND PARTICIPANTS

The study sample included 1025 patients with COVID-19 admitted to an HaH program in Singapore from September 23, 2021, to February 29, 2022.

METHODS

Propensity score weighting and regression analysis were used to adjust for confounding between both groups.

RESULTS

There was no significant difference in the odds of occurrence of the primary outcome between the home-first and hospital-first groups (OR, 1.17; 95% CI, 0.44-3.10). Home-first patients had a shorter length of stay by an average of 2.02 (95% CI, 1.10-2.93) days with no statistically significant difference in clinical outcomes compared with hospital-first patients.

CONCLUSIONS AND IMPLICATIONS

Patients with COVID-19 suitable for HaH should be considered for direct admission to HaH without need for an initial hospital stay.

The value of admission avoidance: cost-consequence analysis of one-year activity in a consolidated service

BACKGROUND

Many advantages of hospital at home (HaH), as a modality of acute care, have been highlighted, but controversies exist regarding the cost-benefit trade-offs. The objective is to assess health outcomes and analytical costs of hospital avoidance (HaH-HA) in a consolidated service with over ten years of delivery of HaH in Barcelona (Spain).

METHODS

A retrospective cost-consequence analysis of all first episodes of HaH-HA, directly admitted from the emergency room (ER) in 2017-2018, was carried out with a health system perspective. HaH-HA was compared with a propensity-score-matched group of contemporary patients admitted to conventional hospitalization (Controls). Mortality, re-admissions, ER visits, and direct healthcare costs were evaluated.

RESULTS

HaH-HA and Controls (n = 441 each) were comparable in terms of age (73 [SD16] vs. 74 [SD16]), gender (male, 57% vs. 59%), multimorbidity, healthcare expenditure during the previous year, case mix index of the acute episode, and main diagnosis at discharge. HaH-HA presented lower mortality during the episode (0 vs. 19 (4.3%); p < 0.001). At 30 days post-discharge, HaH-HA and Controls showed similar re-admission rates; however, ER visits were lower in HaH-HA than in Controls (28 (6.3%) vs. 34 (8.1%); p = 0.044). Average costs per patient during the episode were lower in the HaH-HA group (€ 1,078) than in Controls (€ 2,171). Likewise, healthcare costs within the 30 days post-discharge were also lower in HaH-Ha than in Controls (p < 0.001).

CONCLUSIONS

The study showed higher performance and cost reductions of HaH-HA in a real-world setting. The identification of sources of savings facilitates scaling of hospital avoidance.

REGISTRATION

ClinicalTrials.gov (26/04/2017; NCT03130283).

Outpatient parenteral antimicrobial therapy with continuous infusion of meropenem: A retrospective analysis of three years of clinical experience

INTRODUCTION

Data regarding outpatient parenteral antimicrobial therapy (OPAT) with continuous infusion of meropenem (CIM) remain scarce and controversial. We aimed to analyze its outcomes.

METHODS

We conducted a retrospective analysis of a cohort of patients who received OPAT with CIM during a three-year period at a single center in northwest Spain. Demographics, clinical data and OPAT outcomes were recorded.

RESULTS

Since January 2017-December 2019, 34 patients received 35 OPAT episodes with CIM. The median age was 75 years, and 18 (51.4%) had a Charlson comorbidity index>2. Twelve (34.3%) had respiratory infection, 11 (31.4%) urinary tract infection, and 12 (34.3%) other infections. Twenty-one (60%) received a dose of 6g/day, and 27 (77.1%) received combined antibiotic therapy. The duration of OPAT with CIM was 10 median days. Pseudomonas aeruginosa was the most frequently (34.3%) isolated microorganism and 10 (28.6%) infections were polymicrobial. During OPAT and hospital at home unit admission, 4 (11.4%) patients had any adverse reaction that required CIM withdrawal, 2 (5.7%) were readmitted, and 3 (8.8%) died (2 infection-related deaths). After 30 days from discharge 6 (18.8%) of 32 not-censored patients had unplanned readmissions (2 infection-related), 6 (18.8%) developed recurrence (3 relapses, 3 reinfections) and 1 (3.1%) died (none-infection-related death). Twenty-three (71.9%) of these 32 patients did not experience unplanned readmission, recurrence or death.

CONCLUSION

CIM can be an option to be administrated in OPAT programs in selected patients. Further studies are warranted to increase evidence regarding its use, and to externally validate our findings.

Digital health as an enabler for hospital@home: A rising trend or just a vision?

Background

Hospital@home is a model of healthcare, where healthcare professionals actively treat patients in their homes for conditions that may otherwise require hospitalization. Similar models of care have been implemented in jurisdictions around the world over the past few years. However, there are new developments in health informatics including digital health and participatory health informatics that may have an impact on hospital@home approaches.

Objectives

This study aims to identify the current state of implementation of emerging concepts into the hospital@home research and models of care; to identify strengths and weaknesses, opportunities, and threats associated with the models of care; and to suggest a research agenda.

Methods

We employed two research methodologies, namely, a literature review and a SWOT (strengths, weaknesses, opportunities, and threats) analysis. The literature from the last 10 years was collected from PubMed using the search string "hospital at home" OR "care at home" OR "patient at home." Relevant information was extracted from the included articles.

Results

Title and abstract review were conducted on 1,371 articles. The full-text review was conducted on 82 articles. Data were extracted from 42 articles that met our review criteria. Most of the studies originated from the United States and Spain. Several medical conditions were considered. The use of digital tools and technologies was rarely reported. In particular, innovative approaches such as wearables or sensor technologies were rarely used. The current landscape of hospital@home models of care simply delivers hospital care in the patient's home. Tools or approaches from taking a participatory health informatics design approach involving a range of stakeholders (such as patients and their caregivers) were not reported in the literature reviewed. In addition, emerging technologies supporting mobile health applications, wearable technologies, and remote monitoring were rarely discussed.

Conclusion

There are multiple benefits and opportunities associated with hospital@home implementations. There are also threats and weaknesses associated with the use of this model of care. Some weaknesses could be addressed by using digital health and wearable technologies to support patient monitoring and treatment at home. Employing a participatory health informatics approach to design and implementation could help to ensure the acceptance of such care models.

Comprehensive Geriatric Hospital at Home: Adaptation to Referral and Case-Mix Changes During the COVID-19 Pandemic

OBJECTIVES

To describe the evolution of a Hospital at Home (HAH) based on comprehensive geriatric assessment (CGA), including its adaptability to changing case-mixes and pathways during the COVID-19 pandemic.

DESIGN

Observational study of consecutive admissions to a combined step-up (admissions from home) and step-down (hospital discharge) HAH during 3 periods: prepandemic (2018‒February 2020) vs pandemic (March‒December 2020, and January‒December 2021).

SETTING AND PARTICIPANTS

Participants were all consecutive patients admitted to a CGA-based HAH, located in Barcelona, Spain. Referrals followed acute events or exacerbation of chronic conditions, by either primary care (step-up) or after post-acute discharge (step-down).

METHODS

HAH intervention based on CGA and incorporated geriatric rehabilitation. Patient case-mix, functional evolution (Barthel index), and mortality were compared across periods and between pathways.

RESULTS

HAH capacity expanded 3 fold from 15 to 45 virtual beds and altogether managed 688 consecutive patients [mean age (SD) = 82.5 (9.6) years; 59% women]. Pandemic case-mix was slightly older (mean age = 83.5 vs 82 years, P = .012) than prepandemic, with greater mobility impairment. Across periods, step-up increased (26.1%, 40.9%, 48.2%, P < .01) because of medical events, skin ulcers, and post-acute stroke, whereas step-down decreased; multivariable models showed no differences in functional improvement or mortality. When comparing pathways, step-up featured older patients with higher comorbidity, worse functional status, and lower absolute functional gain than step-down (5.6 vs 13 points of Barthel index, P < .01), remaining statistically significant after adjusting for covariates (P = .003); no differences in mortality were observed.

CONCLUSIONS AND IMPLICATIONS

A multipurpose, step-down and step-up CGA HAH expanded its activity and adapted to changing case-mixes and pathways throughout COVID-19 pandemic waves. Although further quantitative and qualitative studies are needed to assess the impact of this model, our results suggest that harnessing the adaptability of HAH may help advance a paradigm shift toward more person-centered, cost-effective models of clinical care aimed at older adults.