One in Ten Home Hospital Patients With Heart Failure Requires Escalation of Care
Key findings
- This retrospective, observational study examined 437 home hospitalizations of patients with heart failure (HF; 46 unique patients) between February 2020 and October 2022 at Massachusetts General Hospital or Brigham and Women's Hospital
- In 10% of hospitalizations, patients required transfer for at least one overnight inpatient stay; the main predictor of this escalated care was low mean arterial pressure at home hospital admission
- The 30-day rate of readmission to home hospital was 15%, the 90-day readmission rate was 34%, and the six-month mortality rate was 11.5%
- Overall length of stay (home hospital care followed by time in a traditional hospital) was significantly longer for patients who required escalation (median 19 days vs. 7.5 days for other patients; P<0.001)
- It is important to attempt to identify patients at high risk of escalation of care, who should be followed closely and may benefit from invasive therapies, early involvement of HF specialists, and early recognition of refractoriness to diuretics
Heart failure (HF) is a common indication for admission to the home hospital model of care. In other disease states, home hospital has been found to reduce costs and readmissions compared with traditional hospitalization. In general, it improves patient and caregiver satisfaction.
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To expand on the limited contemporary data about home hospital for HF, researchers at Massachusetts General Hospital and Brigham and Women's Hospital reviewed data on patient demographics, clinical characteristics, and outcomes from their two home hospital programs. In Circulation: Cardiovascular Quality and Outcomes, they report important safety data for selecting which patients are good candidates.
The authors are Aditya Achanta, MD, a resident physician in the Department of Medicine at Mass General, David Michael Levine, MD, MPH, MA, an internist in the Division of General Internal Medicine and Primary Care at Brigham and Women's Hospital and director of its home hospital program, Rory B. Weiner, MD, a cardiologist in the Corrigan Minehan Heart Center at Mass General, and colleagues.
Methods
The researchers analyzed data on 437 home hospitalizations for acute decompensated HF (346 unique patients) between February 2020 and October 2022. The median patient age was 80 and 71% had an ejection fraction ≥50%.
The primary outcome was an escalation of care, defined as a transfer to an emergency department or inpatient medical unit for at least one overnight stay, regardless of eventual disposition.
Escalation of Care
45 hospitalizations (10%) required escalation, most commonly because of progressive renal dysfunction (36%) or cardiac symptoms (31%). The most significant predictor of escalation was low mean arterial pressure. 9% of patients who required escalation had MAP <70 mmHg on admission, compared with 1% of patients who remained in home hospital.
Including their time spent in a brick-and-mortar hospital after home hospital care, patients who required escalation had a median length of stay of 19 days versus 7.5 days for other patients (P<0.001).
Readmission and Mortality
Secondary outcomes were:
- 30-day readmission rate—15%
- 90-day readmission rate—34%
- 6-month mortality rate—11.5%
There was no mortality during a home hospital stay, excluding two patients who were transitioned to hospice and one patient who chose to pass away at home under the care of home hospital.
No significant differences in escalation rates, readmission rates, or mortality were detected based on the source of admission (from home, an ED, or a traditional hospital).
Putting the Results in Context
The escalation rate in this study (10%) is higher than the escalation rate of 7% reported by the Centers for Medicare and Medicaid Services in October 2021 for all conditions treated in home hospital. The most likely explanation is the prevalence of multiorgan failure in HF.
Because home hospital was associated with significantly increased length of stay and substantial overall morbidity, it is important to attempt to identify patients at high risk of requiring escalation of care. They should be followed closely and may benefit from invasive therapies, early involvement of HF specialists, and early recognition of refractoriness to diuretics.
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