• David M Levine, Kei Ouchi, Bonnie Blanchfield, Keren Diamond, Adam Licurse, Charles T Pu, and Jeffrey L Schnipper.
• Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA. dmlevine@bwh.harvard.edu.
• J Gen Intern Med. 2018 May 1; 33 (5): 729736729-736.

BackgroundHospitals are standard of care for acute illness, but hospitals can be unsafe, uncomfortable, and expensive. Providing substitutive hospital-level care in a patient's home potentially reduces cost while maintaining or improving quality, safety, and patient experience, although evidence from randomized controlled trials in the US is lacking.ObjectiveDetermine if home hospital care reduces cost while maintaining quality, safety, and patient experience.DesignRandomized controlled trial.ParticipantsAdults admitted via the emergency department with any infection or exacerbation of heart failure, chronic obstructive pulmonary disease, or asthma.InterventionHome hospital care, including nurse and physician home visits, intravenous medications, continuous monitoring, video communication, and point-of-care testing.Main MeasuresPrimary outcome was direct cost of the acute care episode. Secondary outcomes included utilization, 30-day cost, physical activity, and patient experience.Key ResultsNine patients were randomized to home, 11 to usual care. Median direct cost of the acute care episode for home patients was 52% (IQR, 28%; p = 0.05) lower than for control patients. During the care episode, home patients had fewer laboratory orders (median per admission: 6 vs. 19; p < 0.01) and less often received consultations (0% vs. 27%; p = 0.04). Home patients were more physically active (median minutes, 209 vs. 78; p < 0.01), with a trend toward more sleep. No adverse events occurred in home patients, one occurred in control patients. Median direct cost for the acute care plus 30-day post-discharge period for home patients was 67% (IQR, 77%; p < 0.01) lower, with trends toward less use of home-care services (22% vs. 55%; p = 0.08) and fewer readmissions (11% vs. 36%; p = 0.32). Patient experience was similar in both groups.ConclusionsThe use of substitutive home-hospitalization compared to in-hospital usual care reduced cost and utilization and improved physical activity. No significant differences in quality, safety, and patient experience were noted, with more definitive results awaiting a larger trial. Trial Registration NCT02864420.

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