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Remote vs In-home Physician Visits for Hospital-Level Care at HomeA Randomized Clinical Trial

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  When a patient receives acute hospital-level care at home (home hospital), is the use of remote physician visits noninferior to in-home physician visits in terms of safety and patient experience?

Findings  In this 2-site randomized clinical trial of 172 patients, the mean adverse event count was 6.8 per 100 patients for patients receiving remote care vs 3.9 per 100 patients for control patients, for a difference of 2.8, supporting noninferiority, although 19% of patients receiving remote care required in-home physician visits. Patient experience was noninferior.

Meaning  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 1 in 5 patients receiving remote care.


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

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Article Information

Accepted for Publication: July 9, 2022.

Published: August 30, 2022. doi:10.1001/jamanetworkopen.2022.29067

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Levine DM et al. JAMA Network Open.

Corresponding Author: David M. Levine, MD, MPH, MA, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, 1620 Tremont St, Third Floor, Boston, MA 02120 (dmlevine@bwh.harvard.edu).

Author Contributions: Dr Levine had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Levine, Morris, Schnipper.

Acquisition, analysis, or interpretation of data: Levine, Paz, Burke, Beaumont, Boxer, Britton, Orav, Schnipper.

Drafting of the manuscript: Levine.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Levine, Orav.

Administrative, technical, or material support: Levine, Paz, Burke, Beaumont, Boxer, Morris, Britton.

Supervision: Morris, Schnipper.

Conflict of Interest Disclosures: Dr Levine reported receiving grants from Biofourmis and IBM and personal fees from The MetroHealth System outside the submitted work. Dr Morris reported providing US government expert testimony outside the submitted work. Dr Schnipper reported receiving personal fees from the American Society of Health-System Pharmacists to create an online course on medication history-taking outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 3.

FastStats. Health expenditures. Accessed December 3, 2018. https://www.cdc.gov/nchs/fastats/health-expenditures.htm
Hung  WW , Ross  JS , Farber  J , Siu  AL .  Evaluation of the Mobile Acute Care of the Elderly (MACE) service.   JAMA Intern Med. 2013;173(11):990-996. doi:10.1001/jamainternmed.2013.478 PubMedGoogle ScholarCrossref
Covinsky  KE , Pierluissi  E , Johnston  CB .  Hospitalization-associated disability: “She was probably able to ambulate, but I’m not sure”.   JAMA. 2011;306(16):1782-1793. doi:10.1001/jama.2011.1556 PubMedGoogle ScholarCrossref
Loyd  C , Markland  AD , Zhang  Y ,  et al.  Prevalence of hospital-associated disability in older adults: a meta-analysis.   J Am Med Dir Assoc. 2020;21(4):455-461.e5. doi:10.1016/j.jamda.2019.09.015 PubMedGoogle ScholarCrossref
Leff  B .  Defining and disseminating the hospital-at-home model.   CMAJ. 2009;180(2):156-157. doi:10.1503/cmaj.081891 PubMedGoogle ScholarCrossref
Leff  B , Burton  L , Mader  SL ,  et al.  Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients.   Ann Intern Med. 2005;143(11):798-808. doi:10.7326/0003-4819-143-11-200512060-00008 PubMedGoogle ScholarCrossref
Cryer  L , Shannon  SB , Van Amsterdam  M , Leff  B .  Costs for ‘hospital at home’ patients were 19 percent lower, with equal or better outcomes compared to similar inpatients.   Health Aff (Millwood). 2012;31(6):1237-1243. doi:10.1377/hlthaff.2011.1132 PubMedGoogle ScholarCrossref
Tibaldi  V , Isaia  G , Scarafiotti  C ,  et al.  Hospital at home for elderly patients with acute decompensation of chronic heart failure: a prospective randomized controlled trial.   Arch Intern Med. 2009;169(17):1569-1575. doi:10.1001/archinternmed.2009.267 PubMedGoogle ScholarCrossref
Caplan  GA , Sulaiman  NS , Mangin  DA , Aimonino Ricauda  N , Wilson  AD , Barclay  L .  A meta-analysis of “hospital in the home”.   Med J Aust. 2012;197(9):512-519. doi:10.5694/mja12.10480 PubMedGoogle ScholarCrossref
Shepperd  S , Doll  H , Angus  RM ,  et al.  Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data.   CMAJ. 2009;180(2):175-182. doi:10.1503/cmaj.081491 PubMedGoogle ScholarCrossref
Shepperd  S , Iliffe  S , Doll  HA ,  et al.  Admission avoidance hospital at home.   Cochrane Database Syst Rev. 2016;9(9):CD007491. doi:10.1002/14651858.CD007491.pub2Google ScholarCrossref
Board  N , Brennan  N , Caplan  GA .  A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients.   Aust N Z J Public Health. 2000;24(3):305-311. doi:10.1111/j.1467-842X.2000.tb01573.x PubMedGoogle ScholarCrossref
Caplan  GA , Coconis  J , Board  N , Sayers  A , Woods  J .  Does home treatment affect delirium? a randomised controlled trial of rehabilitation of elderly and care at home or usual treatment (The REACH-OUT trial).   Age Ageing. 2006;35(1):53-60. doi:10.1093/ageing/afi206 PubMedGoogle ScholarCrossref
Caplan  GA , Coconis  J , Woods  J .  Effect of hospital in the home treatment on physical and cognitive function: a randomized controlled trial.   J Gerontol A Biol Sci Med Sci. 2005;60(8):1035-1038. doi:10.1093/gerona/60.8.1035 PubMedGoogle ScholarCrossref
Federman  AD , Soones  T , DeCherrie  LV , Leff  B , Siu  AL .  Association of a bundled hospital-at-home and 30-day postacute transitional care program with clinical outcomes and patient experiences.   JAMA Intern Med. 2018;178(8):1033-1040. doi:10.1001/jamainternmed.2018.2562 PubMedGoogle ScholarCrossref
Levine  DM , Ouchi  K , Blanchfield  B ,  et al.  Hospital-level care at home for acutely ill adults: a randomized controlled trial.   Ann Intern Med. 2020;172(2):77-85. doi:10.7326/M19-0600 PubMedGoogle ScholarCrossref
Cai  S , Intrator  O , Chan  C ,  et al.  Association of costs and days at home with transfer hospital in home.   JAMA Netw Open. 2021;4(6):e2114920. doi:10.1001/jamanetworkopen.2021.14920 PubMedGoogle ScholarCrossref
Arsenault-Lapierre  G , Henein  M , Gaid  D , Le Berre  M , Gore  G , Vedel  I .  Hospital-at-home interventions vs in-hospital stay for patients with chronic disease who present to the emergency department: a systematic review and meta-analysis.   JAMA Netw Open. 2021;4(6):e2111568. doi:10.1001/jamanetworkopen.2021.11568 PubMedGoogle ScholarCrossref
Levine  DM , Desai  MP , Ross  J , Como  N , Anne Gill  E .  Rural perceptions of acute care at home: a qualitative analysis.   J Rural Health. 2021;37(2):353-361. doi:10.1111/jrh.12551 PubMedGoogle ScholarCrossref
Levine  DM , Desai  MP , Ross  JB , Como  N , Holley  S .  Scoping and testing rural acute care at home: a simulation analysis.   BMJ Innov. 2021;7:539-547. doi:10.1136/bmjinnov-2020-000592 Google ScholarCrossref
Levine  DM , Ouchi  K , Blanchfield  B ,  et al.  Hospital-level care at home for acutely ill adults: a pilot randomized controlled trial.   J Gen Intern Med. 2018;33(5):729-736. doi:10.1007/s11606-018-4307-z PubMedGoogle ScholarCrossref
Levine  DM , Pian  J , Mahendrakumar  K , Patel  A , Saenz  A , Schnipper  JL .  Hospital-level care at home for acutely ill adults: a qualitative evaluation of a randomized controlled trial.   J Gen Intern Med. 2021;36(7):1965-1973. doi:10.1007/s11606-020-06416-7 PubMedGoogle ScholarCrossref
Raîche  M , Hébert  R , Dubois  MF .  PRISMA-7: a case-finding tool to identify older adults with moderate to severe disabilities.   Arch Gerontol Geriatr. 2008;47(1):9-18. doi:10.1016/j.archger.2007.06.004 PubMedGoogle ScholarCrossref
Galvin  JE , Roe  CM , Powlishta  KK ,  et al.  The AD8: a brief informant interview to detect dementia.   Neurology. 2005;65(4):559-564. doi:10.1212/01.wnl.0000172958.95282.2a PubMedGoogle ScholarCrossref
Kroenke  K , Spitzer  RL , Williams  JBW .  The Patient Health Questionnaire-2: validity of a two-item depression screener.   Med Care. 2003;41(11):1284-1292. doi:10.1097/01.MLR.0000093487.78664.3C PubMedGoogle ScholarCrossref
Ader  DN .  Developing the Patient-Reported Outcomes Measurement Information System (PROMIS).   Med Care. 2007;45(suppl 1):S1-S2. doi:10.1097/01.mlr.0000260537.45076.74 Google ScholarCrossref
Chew  LD , Bradley  KA , Boyko  EJ .  Brief questions to identify patients with inadequate health literacy.   Fam Med. 2004;36(8):588-594.https://www.ncbi.nlm.nih.gov/pubmed/15343421PubMedGoogle Scholar
van Hout  B , Janssen  MF , Feng  YS ,  et al.  Interim scoring for the EQ-5D-5L: mapping the EQ-5D-5L to EQ-5D-3L value sets.   Value Health. 2012;15(5):708-715. doi:10.1016/j.jval.2012.02.008 PubMedGoogle ScholarCrossref
Lawton  MP , Brody  EM .  Assessment of older people: self-maintaining and instrumental activities of daily living.   Gerontologist. 1969;9(3):179-186. doi:10.1093/geront/9.3_Part_1.179 PubMedGoogle ScholarCrossref
Logan  MS , Myers  LC , Salmasian  H ,  et al.  Expert consensus on currently accepted measures of harm.   J Patient Saf. 2021;17(8):e1726-e1731. doi:10.1097/PTS.0000000000000754 PubMedGoogle ScholarCrossref
Jenkinson  C , Coulter  A , Bruster  S .  The Picker Patient Experience Questionnaire: development and validation using data from in-patient surveys in five countries.   Int J Qual Health Care. 2002;14(5):353-358. doi:10.1093/intqhc/14.5.353 PubMedGoogle ScholarCrossref
Piaggio  G , Elbourne  DR , Pocock  SJ , Evans  SJW , Altman  DG ; CONSORT Group.  Reporting of noninferiority and equivalence randomized trials: extension of the CONSORT 2010 statement.   JAMA. 2012;308(24):2594-2604. doi:10.1001/jama.2012.87802 PubMedGoogle ScholarCrossref
Donzé  J , Aujesky  D , Williams  D , Schnipper  JL .  Potentially avoidable 30-day hospital readmissions in medical patients: derivation and validation of a prediction model.   JAMA Intern Med. 2013;173(8):632-638. doi:10.1001/jamainternmed.2013.3023 PubMedGoogle ScholarCrossref
Levine  DM , Paz  M , Burke  K , Schnipper  JL .  Predictors and reasons why patients decline to participate in home hospital: a mixed methods analysis of a randomized controlled trial.   J Gen Intern Med. 2022;37(2):327-331. doi:10.1007/s11606-021-06833-2 PubMedGoogle ScholarCrossref
Gutierrez  J , Moeckli  J , Holcombe  A ,  et al.  Implementing a telehospitalist program between veterans health administration hospitals: outcomes, acceptance, and barriers to implementation.   J Hosp Med. 2021;16(3):156-163. doi:10.12788/jhm.3570 PubMedGoogle ScholarCrossref
Kuperman  EF , Linson  EL , Klefstad  K , Perry  E , Glenn  K .  The virtual hospitalist: a single-site implementation bringing hospitalist coverage to critical access hospitals.   J Hosp Med. 2018;13(11):759-763. doi:10.12788/jhm.3061 PubMedGoogle ScholarCrossref
Vranas  KC , Slatore  CG , Kerlin  MP .  Telemedicine coverage of intensive care units: a narrative review.   Ann Am Thorac Soc. 2018;15(11):1256-1264. doi:10.1513/AnnalsATS.201804-225CME PubMedGoogle ScholarCrossref
Lilly  CM , Cody  S , Zhao  H ,  et al; University of Massachusetts Memorial Critical Care Operations Group.  Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes.   JAMA. 2011;305(21):2175-2183. doi:10.1001/jama.2011.697 PubMedGoogle ScholarCrossref
Fusaro  MV , Becker  C , Scurlock  C .  Evaluating tele-ICU implementation based on observed and predicted ICU mortality: a systematic review and meta-analysis.   Crit Care Med. 2019;47(4):501-507. doi:10.1097/CCM.0000000000003627 PubMedGoogle ScholarCrossref
Sitammagari  K , Murphy  S , Kowalkowski  M ,  et al.  Insights from rapid deployment of a “virtual hospital” as standard care during the COVID-19 pandemic.   Ann Intern Med. 2021;174(2):192-199. doi:10.7326/M20-4076 PubMedGoogle ScholarCrossref
Levine  DM , Mitchell  H , Rosario  N ,  et al.  Acute care at home during the COVID-19 pandemic surge in Boston.   J Gen Intern Med. 2021;36(11):3644-3646. doi:10.1007/s11606-021-07052-5 PubMedGoogle ScholarCrossref
Levine  DM , DeCherrie  LV , Siu  AL , Leff  B .  Early uptake of the acute hospital care at home waiver.   Ann Intern Med. 2021;174(12):1772-1774. doi:10.7326/M21-2516 PubMedGoogle ScholarCrossref
Leff  B , DeCherrie  LV , Montalto  M , Levine  DM .  A research agenda for hospital at home.   J Am Geriatr Soc. 2022;70(4):1060-1069. doi:10.1111/jgs.17715 PubMedGoogle ScholarCrossref
Ouchi  K , Liu  S , Tonellato  D , Keschner  YG , Kennedy  M , Levine  DM .  Home hospital as a disposition for older adults from the emergency department: benefits and opportunities.   J Am Coll Emerg Physicians Open. 2021;2(4):e12517. doi:10.1002/emp2.12517 PubMedGoogle ScholarCrossref
Bryan  AF , Levine  DM , Tsai  TC .  Home hospital for surgery.   JAMA Surg. 2021;156(7):679-680. doi:10.1001/jamasurg.2021.0597 PubMedGoogle ScholarCrossref
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