Substitutive Hospital at Home for Older Persons: Effects on Costs

Volume 15: 49-56 January 2009 Number 1

Substitutive Hospital at Home for Older Persons: Effects on Costs

Kevin D. Frick, PhD; Lynda C. Burton, ScD; Rebecca Clark, BA; Scott I. Mader, MD; W. Bruce Naughton, MD; Jeffrey B. Burl, MD; William B. Greenough, III, MD;

Objective: To compare the cost of substitutive Hospital at Home care versus traditional inpatient care for older patients with community-acquired pneumonia, exacerbation of chronic obstructive pulmonary disease, exacerbation of congestive heart failure, or cellulitis.

Study Design: Prospective nonrandomized clinical trial involving 455 community-dwelling older patients in 3 Medicare managed care health systems and at a Department of Veterans Affairs medical center.

Methods: Costs were analyzed across all patients, within each of the separate health systems, and by condition. Generalized linear models controlling for confounders and using a log link and gamma family specification were used to make inferences about the statistical significance of cost differences. t Tests were used to make inferences regarding differences in follow-up utilization.

Results: The costs of the Hospital at Home intervention were significantly lower than those of usual acute hospital care (mean [SD], $5081 [$4427] vs $7480 [$8113]; P <.001). Laboratory and procedure expenditures were lower across all study sites and at each site individually. There were minimal significant differences in health service utilization between the study groups during the 8 weeks after the index hospitalization. As-treated analysis results were consistent with Hospital at Home costs being lower.

Conclusions: Total costs seem to be lower when substitutive Hospital at Home care is available for patients with congestive heart failure or chronic obstructive pulmonary disease. This result may be related to the study-based requirement for continuous nursing input. Savings may be possible, particularly for care of conditions that typically use substantial laboratory tests and procedures in traditional acute settings.
(Am J Manag Care. 2009;15(1):49-56)

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Hospital at Home is a model of care that provides hospital-level care to a patient in his or her home and substitutes entirely for an acute hospital admission.¹Several secular trends favor the development of this model. First, the Institute of Medicine found that the emergency medicine system is in crisis in part because emergency departments are unable to find inpatient hospital beds to send acutely ill patients.^2,3 Second, population and disease burden projections suggest that the supply of available acute hospital beds is not increasing at a rate sufficient to keep pace with national acute care needs.⁴ Third, Hospital at Home avoids the potentially hazardous effects of inpatient care such as functional decline,⁵delirium,⁶and other iatrogenic illnesses.

Controversy persists regarding the clinical and economic effectiveness of Hospital at Home.^7,8 Many models studied to date have been for early discharge of surgical patients rather than for substitutive care, and all previous studies have been in countries with single-payer healthcare systems. Cost implications of substitutive Hospital at Home from the perspective of third-party payers in the United States may be qualitatively different.

We have demonstrated that substitutive Hospital at Home care in the United States was clinically feasible, efficacious, and associated with reductions in complications, greater patient satisfaction, higher caregiver satisfaction, and lower caregiver stress.^5,9,10We also reported summary data on lower third-party payer costs for Hospital at Home patients.⁵ The aim of this study was to make more detailed comparisons of thirdparty payer costs in providing substitutive Hospital at Home care versus traditional acute hospital care for older patients with acute medical illness. The primary hypothesis was that total costs would be lower for Hospital at Home patients. Specifically, procedure, room, and hospital (not physician) costs were hypothesized to be lower.

METHODS
Study Design
The Hospital at Home National Demonstration and Evaluation Study has been described in detail previously.⁵ The study was a prospective non-randomized clinical trial conducted in 2 consecutive 11-month phases. In the first (observation) phase, Hospital at Home–eligible patients were followed up through usual acute hospital care. In the second (intervention) phase, all Hospital at Home–eligible patients were offered Hospital at Home care. A randomized controlled trial was precluded because of regulations related to Medicare managed care.

The study was conducted at 3 sites. Univera Health and Independent Health, in Buffalo, New York (hereafter, Buffalo), are Medicare managed care plans that operate in an independent practice association model. The Fallon Health Care System, in Worcester, Massachusetts (hereafter, Fallon), operates a not-for-profit Medicare managed care plan and the Fallon Clinic, a for-profit multispecialty physician group that provides care on a capitated basis to Medicare managed care beneficiaries. The Portland Veterans Affairs Medical Center, in Oregon (hereafter, PVAMC), is a quaternary care and teaching facility.

Patients and the Hospital at Home Model of Care
Eligible patients were community-dwelling persons 65 years and older residing within a specific catchment area who required acute hospital admission for an exacerbation of chronic obstructive pulmonary disease (COPD) or chronic heart failure (CHF), for community-acquired pneumonia, or for cellulitis. Patients requiring acute hospital admission for one of the target conditions and who met previously validated Hospital at Home eligibility criteria were included.¹¹ The most common reasons for medical ineligibility were uncorrectable hypoxemia, suspected myocardial ischemia, and the presence of an acute illness that required hospital admission other than the target illness. Patients were identified in an emergency department or at an ambulatory site at times when Hospital at Home could admit patients (usually between 6 am and 8 pm). After informed consent was obtained, patients were transported home via ambulance. Patients were evaluated by a Hospital at Home physician in the emergency department or shortly after arrival at home. A Hospital at Home nurse met the ambulance at home and provided initial direct one-on-one care for a mean of 16.9 hours. After direct nursing supervision, the patient had intermittent nursing visits at least daily. Patients were not required to have a caregiver in the home, and if a caregiver was available, there was no requirement that the caregiver provide assistance or care to the patient. A Lifeline medical alert device (Philips Electronics North America Corporation, Andover, MA) was placed in the home of any patient who did not have a caregiver present in the home. The Hospital at Home physician made at least daily home visits and was available at all times for urgent visits. Nursing and other care components such as durable medical equipment, oxygen therapy, skilled therapies, and pharmacy support were provided by a partner Medicarecertified home health agency and for some services (eg, home radiology) by independent contractors. Diagnostic studies such as electrocardiography, radiology, intravenous fluids, intravenous antimicrobial agents and other medicines, oxygen, and other respiratory therapies were provided at home.

Cost Data
Third-party payer cost data were obtained from each of the 3 study sites. The PVAMC provided costs based on a standard Veterans Affairs stepdown cost accounting approach. Buffalo provided charges, as well as a cost-to-charge ratio for hospital facility costs. Fallon provided allowable hospital charges at the level of the admission. Data from all sites include all resources used for patient care for inpatient settings and for Hospital at Home care. There is no reason to suspect that any single costing method would systematically favor the intervention.

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