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Hospital-at-Home Interventions vs In-Hospital Stay for Patients With Chronic Disease Who Present to the Emergency Department

Key Points Question Are hospital-at-home interventions consisting of, at minimum, home visits from nurses or physicians associated with better patient outcomes for adult patients with a chronic disease who present to an emergency department? Findings This systematic review of 9 randomized clinical trial studies, including 959 adult patients with a chronic disease, found that although patients receiving hospital-at-home care had an average length of treatment of 5.4 days longer than that of in-hospital patients and a similar mortality risk, they had a lower risk for readmission by 26% and a lower risk for long-term care admission relative to the in-hospital group. Patients who received hospital-at-home care also had lower depression and anxiety scores than patients receiving in-hospital care, but there was no difference in functional status. Meaning This systematic review provides further evidence that hospital-at-home interventions with at least 1 home visit from a nurse or physician may be a promising substitute to in-hospital care, especially for patients with chronic diseases who present to the emergency department.


Outcome definitions
Mortality: Mortality was defined as the total number of deaths recorded at the available time points for each study.
Readmission: Readmission was defined as the number of patients who were admitted (HaH) or readmitted (in-hospital group) to the hospital at the available time points of each study. All-cause readmissions were considered, except for one study that reported readmissions due only to the disease of the population (Chronic Heart Failure, CHF) (Mendoza et al. 2009). Nutrition status: Nutrition status was defined as the change in a nutrition score at the available time points.

Length of treatment:
Functional status: Functional status was defined as the change in a functional status score at the available time points.
Neurological deficit: Neurological status was defined as the change in a neurological status score at the available time points.

Efforts to obtain more information and data
To clarify methods, interventions and outcome definitions from studies and include as many studies as possible (and reduce heterogeneity), as well as to clarify or obtain more data, we contacted authors by email or system-based communication, up to three times, following methods described in Godard-Sebillotte et al. (2018). If we did not obtain this information, the data was considered incomplete and not included in our analyses.
We contacted the authors of five studies for additional information or data. We received clarifications and unpublished data on length of treatment in the HaH group for one study (Echevarria et al. 2018 Ricauda et al. (2008); Ricauda et al. (2004) excluding studies with patients other than chronic heart failure Legend COPD: Chronic obstructive pulmonary disorder; CHF: Chronic heart failure; SD: standard deviation; RR: Risk Ratio; MD: Mean difference; CI: Confidence interval. *significance level changed from statistically significant (original analysis) to not statistically significant (sensitivity analysis).             HaH: Hospital at Home; RR: Risk Ratio; RD: Risk Difference; CI: Confidence interval  2 : variance between studies; I 2 : proportion of variance due to heterogeneity between studies. Total number of observations used was sample size at baseline.