Geriatric assessment via home hospital care yields similar outcomes as hospitalization

Among patients referred from a short-stay acute medical unit, those receiving a comprehensive geriatric assessment at home had similar clinical outcomes as those who received the same assessment in the hospital, data show.

Providing a comprehensive geriatric assessment (CGA) in a patient’s home through an admission avoidance hospital-at-home (HAH) model “is equivalent to bed-based hospital care for older persons with frailty who are medically unwell and physiologically stable,” Sasha Shepperd, MSc, DPhil, a professor of health services research at the Nuffield Department of Population Health in the United Kingdom, and colleagues wrote in Annals of Internal Medicine.

HAH with CGA is a rapid response service that provides care to patients at home within about 2 hours of referral and for a limited amount of time, according to the researchers. Patients who receive HAH CGA, like those in bed-based hospital care, are “treated in the context of physical, psychological, social and functional issues” to maximize their recovery, the researchers wrote. During HAH CGAs, patients are treated by physicians from multiple specialties and “radiologic investigations are prioritized as if in hospital, with CGA HAH organizing transport.”

With previous research in this area “limited ... imprecise and inconsistent,” Shepperd and colleagues randomly assigned 1,055 patients (mean age, 83.3 years) in a 2:1 ratio to receive either an HAH CGA or receive the CGA during a hospital admission. The study population had “health problems and diagnoses that are typically associated with hospital admission for this population,” according to the researchers. Among the patients, 72.3% had some cognitive impairment, 6.8% had delirium, more than 60% had moderate or severe problems with mobility and 38% reported problems performing daily activities.

Shepperd and colleagues reported that after a 6-month follow-up period, 78.6% of those in the HAH CGA group and 75.3% in the hospital admission group were living at home (RR = 1.05; 95% CI, 0.95-1.15), while 5.7% of those in the HAH CGA group and 8.7% in the hospital admission group were in long-term residential care (RR = 0.58; 95% CI, 0.45-0.76). During the study, 16.9% of patients in the HAH CGA group and 17.7% in the hospital admission group had died (RR = 0.98; 95% CI, 0.65-1.47). Results also showed that patient satisfaction scores were higher among those in the HAH CGA group, according to the researchers.

In light of the findings, Shepperd and colleagues wrote that implementing the HAH model in other health care systems could “create additional acute health care capacity for older persons referred for a hospital admission.”

In a related editorial, Karen Titchener, MS, APRN, RN, an adjunct professor at the Huntsman Cancer Institute at the University of Utah, wrote that the findings are “consistent” with other studies in this area.

However, Titchener also pointed out that about one in five of the study patients randomly assigned to hospitalization either refused to be admitted to the hospital or were unable to find a hospital bed and thus, had no choice but to receive the CGA at home. This “tempers confidence in the study's findings because it represents more of a real-world evaluation than a controlled experiment,” she wrote.

Titchener added that the high percentage of patients living at home after 6 months may be a reflection of the assessment itself, rather than where it was performed.

References:

Shepperd S, et al. Ann Intern Med. 2021;doi:10.7326/M20-5688.

Titchener K. Ann Intern Med. 2021;doi:10.7326/M21-1373.