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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.

Abstract

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.

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