Hospital-level care at home for patients with acute respiratory disease: A descriptive analysis.

BACKGROUND: Home hospital (HH) is hospital-level substitutive care delivered at home for acutely ill patients who would traditionally be cared for in the hospital. Despite HH programs operating successfully for years, and scientific evidence of similar or better outcomes compared to bricks and mortar care, HH outcomes in the US for respiratory disease have not been evaluated. RESEARCH QUESTION: Do outcomes differ between patients admitted to HH with acute respiratory illness vs other acute general medical conditions? STUDY DESIGN AND METHODS: Retrospective evaluation of prospectively collected data of patients admitted to HH (2017-21). We compared patients requiring admission with respiratory disease (asthma exacerbation (26%), acute exacerbation for COPD [AECOPD] (33%), and non-COVID-19 pneumonia [PNA] (41%)) to all other HH patients. During HH, patients received 2 nurse and 1 physician visit daily, intravenous medications, advanced respiratory therapies, and continuous heart and respiratory rate monitoring. MAIN OUTCOMES: acute and post-acute utilization and safety. RESULTS: We analyzed 1,031 patients; 24% were admitted for respiratory disease. Patients with and without respiratory disease were similar: mean age 68 (SD, 17), 62% female, and 48% White. Respiratory patients were more often active smokers (21% vs 9%; p<0.001). FEV1/FVC ≤70 in 80% of cases; 28% had severe or very severe obstructive pattern (n=118). During HH, respiratory patients had less utilization: length of stay (mean days, 3.4 vs 4.6), laboratory orders (median, 0 vs 2), intravenous medication (43% vs 73%) and specialist consultation (2% vs 7%) (p all <0.001). 96% of patients completed the full admission at home with no mortality in the respiratory group. Within 30-days of discharge, both groups had similar readmission, ED presentation and mortality rates. INTERPRETATION: HH is as safe and effective for patients with acute respiratory disease as for those with other acute general medical conditions. If scaled, it can generate significant high-value capacity for health systems and communities, with opportunities to advance the complexity of care delivered.

Upper extremity deep venous thrombosis after BNT162b2 mRNA COVID-19 vaccine case report.

We describe a case of an otherwise healthy 60-year-old female patient who presented 6 days after receipt of the second dose of the BNT162b2 mRNA COVID-19 (Pfizer/BioNTech) vaccine and was found to have upper extremity deep venous thrombosis.

A national qualitative study of Hospital-at-Home implementation under the CMS Acute Hospital Care at Home waiver.

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) announced the Acute Hospital Care at Home (AHCaH) waiver program in November 2020 to help expand hospital capacity to cope with the COVID-19 pandemic. The AHCaH waived the 24/7 on-site nursing requirement and enabled hospitals to obtain full hospital-level diagnosis-related group (DRG) reimbursement for providing Hospital-at-Home (HaH) care. This study sought to describe AHCaH implementation processes and strategies at the national level and identify challenges and facilitators to launching or adapting a HaH to meet waiver requirements. METHODS: We conducted semi-structured interviews to explore barriers and facilitators of HaH implementation. The analysis was informed by the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework. Interviews were audio recorded for transcription and thematic coding. PRINCIPAL FINDINGS: We interviewed a sample of clinical leaders (N = 18; clinical/medical directors, operational and program managers) from 14 new and pre-existing U.S. HaH programs diverse by size, urbanicity, and geography. Participants were enthusiastic about the AHCaH waiver. Participants described barriers and facilitators at planning and implementation stages within three overarching themes influencing waiver program implementation: 1) institutional value and assets; 2) program components, such as electronic health records, vendors, pharmacy, and patient monitoring; and 3) patient enrollment, including eligibility and geographic limits. CONCLUSIONS: Implementation of AHCaH waiver is a complex process that requires building components in compliance with the requirements to extend the hospital into the home, in coordination with internal and external partners. The study identified barriers that potential adopters and proponents should consider alongside the strategies that some organizations have found useful. Clarity regarding the waiver's future may expedite HaH model dissemination and ensure longevity of this valuable model of care delivery.

Remote vs In-home Physician Visits for Hospital-Level Care at Home: A Randomized Clinical Trial.

Importance: Home hospital care is the substitutive provision of home-based acute care services usually associated with a traditional inpatient hospital. Many home hospital models require a physician to see patients at home daily, which may hinder scalability. Whether remote physician visits can safely substitute for most in-home visits is unknown. Objective: To compare remote and in-home physician care. Design, Setting, and Participants: This randomized clinical trial assessed 172 adult patients at an academic medical center and community hospital who required hospital-level care for select acute conditions, including infection, heart failure, chronic obstructive pulmonary disease, and asthma, between August 3, 2019, and March 26, 2020; follow-up ended April 26, 2020. Interventions: All patients received acute care at home, including in-home nurse or paramedic visits, intravenous medications, remote monitoring, and point-of-care testing. Patients were randomized to receive physician care remotely (initial in-home visit followed by daily video visit facilitated by the home hospital nurse) vs in-home care (daily in-home physician visit). In the remote care group, the physician could choose to see the patient at home beyond the first visit if it was felt to be medically necessary. Main Outcomes and Measures: The primary outcome was the number of adverse events, compared using multivariable Poisson regression at a noninferiority threshold of 10 events per 100 patients. Adverse events included a fall, pressure injury, and delirium. Secondary outcomes included the Picker Patient Experience Questionnaire 15 score (scale of 0-15, with 0 indicating worst patient experience and 15 indicating best patient experience) and 30-day readmission rates. Results: A total of 172 patients (84 receiving remote care and 88 receiving in-home physician care [control group]) were randomized; enrollment was terminated early because of COVID-19. The mean (SD) age was 69.3 (18.0) years, 97 patients (56.4%) were female, 77 (45.0%) were White, and 42 (24.4%) lived alone. Mean adjusted adverse event count was 6.8 per 100 patients for remote care patients vs 3.9 per 100 patients for control patients, for a difference of 2.8 (95% CI, -3.3 to 8.9), supporting noninferiority. For remote care vs control patients, the mean adjusted Picker Patient Experience Questionnaire 15 score difference was -0.22 (95% CI, -1.00 to 0.56), supporting noninferiority. The mean adjusted 30-day readmission absolute rate difference was 2.28% (95% CI, -3.23% to 7.79%), which was inconclusive. Of patients in the remote group, 16 (19.0%) required in-home visits beyond the first visit. Conclusions and Relevance: In this study, remote physician visits were noninferior to in-home physician visits during home hospital care for adverse events and patient experience, although in-home physician care was necessary to support many patients receiving remote care. Our findings may allow for a more efficient, scalable home hospital approach but require further research. Trial Registration: ClinicalTrials.gov Identifier: NCT04080570.

The Association of the First Surge of the COVID-19 Pandemic with the High- and Low-Value Outpatient Care Delivered to Adults in the USA.

BACKGROUND: The first surge of the COVID-19 pandemic entirely altered healthcare delivery. Whether this also altered the receipt of high- and low-value care is unknown. OBJECTIVE: To test the association between the April through June 2020 surge of COVID-19 and various high- and low-value care measures to determine how the delivery of care changed. DESIGN: Difference in differences analysis, examining the difference in quality measures between the April through June 2020 surge quarter and the January through March 2020 quarter with the same 2 quarters' difference the year prior. PARTICIPANTS: Adults in the MarketScan® Commercial Database and Medicare Supplemental Database. MAIN MEASURES: Fifteen low-value and 16 high-value quality measures aggregated into 8 clinical quality composites (4 of these low-value). KEY RESULTS: We analyzed 9,352,569 adults. Mean age was 44 years (SD, 15.03), 52% were female, and 75% were employed. Receipt of nearly every type of low-value care decreased during the surge. For example, low-value cancer screening decreased 0.86% (95% CI, -1.03 to -0.69). Use of opioid medications for back and neck pain (DiD +0.94 [95% CI, +0.82 to +1.07]) and use of opioid medications for headache (DiD +0.38 [95% CI, 0.07 to 0.69]) were the only two measures to increase. Nearly all high-value care measures also decreased. For example, high-value diabetes care decreased 9.75% (95% CI, -10.79 to -8.71). CONCLUSIONS: The first COVID-19 surge was associated with receipt of less low-value care and substantially less high-value care for most measures, with the notable exception of increases in low-value opioid use.

Home hospital as a disposition for older adults from the emergency department: Benefits and opportunities.

The $1 trillion industry of acute hospital care in the United States is shifting from inside the walls of the hospital to patient homes. To tackle the limitations of current hospital care in the United States, on November 25, 2020, the Center for Medicare & Medicaid Services announced that the acute hospital care at home waiver would reimburse for "home hospital" services. A "home hospital" is the home-based provision of acute services usually associated with the traditional inpatient hospital setting. Prior work suggests that home hospital care can reduce costs, maintain quality and safety, and improve patient experiences for select acutely ill adults who require hospital-level care. However, most emergency physicians are unfamiliar with the evidence of benefits demonstrated by home hospital services, especially for older adults. Therefore, the lead author solicited narrative inputs on this topic from selected experts in emergency medicine and home hospital services with clinical experience, publications, and funding on home hospital care. Then we sought to identify information most relevant to the practice of emergency medicine. We outline the proven and potential benefits of home hospital services specific to older adults compared to traditional acute care hospitalization with a focus on the emergency department.

Telehealth in US hospitals: State-level reimbursement policies no longer influence adoption rates.

OBJECTIVES: Prior to COVID-19, levels of adoption of telehealth were low in the U.S., though they exploded during the pandemic. Following the pandemic, it will be critical to identify the characteristics that were associated with adoption of telehealth prior to the pandemic as key drivers of adoption and outside of a public health emergency. MATERIALS AND METHODS: We examined three data sources: The American Telemedicine Association's 2019 state telehealth analysis, the American Hospital Association's 2018 annual survey of acute care hospitals and its Information Technology Supplement. Telehealth adoption was measured through five telehealth categories. Independent variables included seven hospital characteristics and five reimbursement policies. After bivariate comparisons, we developed a multivariable model using logistic regression to assess characteristics associated with telehealth adoption. RESULTS: Among 2923 US hospitals, 73% had at least one telehealth capability. More than half of these hospitals invested in telehealth consultation services and stroke care. Non-profit hospitals, affiliated hospitals, major teaching hospitals, and hospitals located in micropolitan areas (those with 10-50,000 people) were more likely to adopt telehealth. In contrast, hospitals that lacked electronic clinical documentation, were unaffiliated with a hospital system, or were investor-owned had lower odds of adopting telehealth. None of the statewide policies were associated with adoption of telehealth. CONCLUSIONS: Telehealth policy requires major revisions soon, and we suggest that these policies should be national rather than at the state level. Further steps as incentivizing rural hospitals for adopting interoperable systems and expanding RPM billing opportunities will help drive adoption, and promote equity.

Derivation of a Clinical Risk Score to Predict 14-Day Occurrence of Hypoxia, ICU Admission, and Death Among Patients with Coronavirus Disease 2019.

BACKGROUND: Uncertainty surrounding COVID-19 regarding rapid progression to acute respiratory distress syndrome and unusual clinical characteristics make discharge from a monitored setting challenging. A clinical risk score to predict 14-day occurrence of hypoxia, ICU admission, and death is unavailable. OBJECTIVE: Derive and validate a risk score to predict suitability for discharge from a monitored setting among an early cohort of patients with COVID-19. DESIGN: Model derivation and validation in a retrospective cohort. We built a manual forward stepwise logistic regression model to identify variables associated with suitability for discharge and assigned points to each variable. Event-free patients were included after at least 14 days of follow-up. PARTICIPANTS: All adult patients with a COVID-19 diagnosis between March 1, 2020, and April 12, 2020, in 10 hospitals in Massachusetts, USA. MAIN MEASURES: Fourteen-day composite predicting hypoxia, ICU admission, and death. We calculated a risk score for each patient as a predictor of suitability for discharge evaluated by area under the curve. KEY RESULTS: Of 2059 patients with COVID-19, 1326 met inclusion. The 1014-patient training cohort had a mean age of 58 years, was 56% female, and 65% had at least one comorbidity. A total of 255 (25%) patients were suitable for discharge. Variables associated with suitability for discharge were age, oxygen saturation, and albumin level, yielding a risk score between 0 and 55. At a cut point of 30, the score had a sensitivity of 83% and specificity of 82%. The respective c-statistic for the derivation and validation cohorts were 0.8939 (95% CI, 0.8687 to 0.9192) and 0.8685 (95% CI, 0.8095 to 0.9275). The score performed similarly for inpatients and emergency department patients. CONCLUSIONS: A 3-item risk score for patients with COVID-19 consisting of age, oxygen saturation, and an acute phase reactant (albumin) using point of care data predicts suitability for discharge and may optimize scarce resources.

Remote Patient Monitoring Program for Hospital Discharged COVID-19 Patients.

OBJECTIVE: We deployed a Remote Patient Monitoring (RPM) program to monitor patients with coronavirus disease 2019 (COVID-19) upon hospital discharge. We describe the patient characteristics, program characteristics, and clinical outcomes of patients in our RPM program. METHODS: We enrolled COVID-19 patients being discharged home from the hospital. Enrolled patients had an app, and were provided with a pulse oximeter and thermometer. Patients self-reported symptoms, O2 saturation, and temperature daily. Abnormal symptoms or vital signs were flagged and assessed by a pool of nurses. Descriptive statistics were used to describe patient and program characteristics. A mixed-effects logistic regression model was used to determine the odds of a combined endpoint of emergency department (ED) or hospital readmission. RESULTS: A total of 295 patients were referred for RPM from five participating hospitals, and 225 patients were enrolled. A majority of enrolled patients (66%) completed the monitoring period without triggering an abnormal alert. Enrollment was associated with a decreased odds of ED or hospital readmission (adjusted odds ratio: 0.54; 95% confidence interval: 0.3-0.97; p = 0.039). Referral without enrollment was not associated with a reduced odds of ED or hospital readmission. CONCLUSION: RPM for COVID-19 provides a mechanism to monitor patients in their home environment and reduce hospital utilization. Our work suggests that RPM reduces readmissions for patients with COVID-19 and provides scalable remote monitoring capabilities upon hospital discharge. RPM for postdischarge patients with COVID-19 was associated with a decreased risk of readmission to the ED or hospital, and provided a scalable mechanism to monitor patients in their home environment.