Hospital care at home benefits medically complex, socially vulnerable patients
Current acute hospital care at home waiver expires December 2024
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Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.
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1. Hospital care at home benefits medically complex, socially vulnerable patients
Current acute hospital care at home waiver expires December 2024
Abstract: https://www.acpjournals.org/doi/10.7326/M23-2264
URL goes live when the embargo lifts
A study of more than 5,000 adults found that acute hospital care at home (AHCaH) may provide important benefits to a diverse group of medically complex and socially vulnerable patients. Hospital care at home also was associated with low mortality, escalation, and readmission rates. However, the current AHCaH waiver issued by the Centers for Medicare & Medicaid Services (CMS) is set to expire in December 2024. The report is published in Annals of Internal Medicine.
Hospitalization is the standard of care for acute illness, but hospital care is often expensive, unsafe, and uncomfortable. Prior research has shown that compared with traditional inpatient hospital care, patients cared for in AHCaH have improved experiences and physical activity levels, with lower rates of mortality, readmission, and discharge to skilled-nursing facilities. In November 2020, the Centers for Medicare & Medicaid Services issued the AHCaH waiver, creating a regulatory and payment pathway for hospitals to deliver AHCaH. However, this waiver is set to expire in December 2024.
Researchers from Brigham and Women’s Hospital and Harvard Medical School analyzed data for 5,132 patients receiving AHCaH between July 2022 and June 2023. Of the patients studied, 42.5 percent had heart failure, 43.3 percent had chronic obstructive pulmonary disease, 22.1 percent had cancer, and 16.1 percent had dementia. AHCaH was associated with low rates of mortality, escalation, skilled nursing facility use, and readmission. According to the authors, their data provide preliminary evidence on national uptake and suggest that AHCaH is an important care model to manage acute illness, including among socially vulnerable and medically complex patients. They suggest that these data should help inform ongoing policy deliberations.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, David M. Levine, MD, MPH, MA, please email Haley Bridger at hbridger@mgb.org.
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2. In real world study, BNT162b2 bivalent vaccine provides substantial protection against severe illness from Delta and Omicron variants in pediatric patients
Abstract: https://www.acpjournals.org/doi/10.7326/M23-1754
URL goes live when the embargo lifts
In a real-world study, the BNT162b2 bivalent vaccine proved to be highly effective against COVID-19 during the Delta period. There was a moderate decline in effectiveness against the Omicron variant after 4 months, but the vaccine still provided significant protection against severe outcomes, including hospital admissions. The vaccine was safe, with no indication of heart-related complications. The findings are published in Annals of Internal Medicine.
Researchers from the University of Pennsylvania Perelman School of Medicine used electronic health record data from a national network of U.S. pediatric medical centers to assess the real-world effectiveness of BNT162b2 among children and adolescents during the periods when the Delta and Omicron variants of SARS-CoV-2 were predominant. The researchers used a novel comparative effectiveness research method and adjusted for underreporting issues in vaccination status.
The researchers found that during the Delta variant period, the BNT162b2 vaccine showed an estimated effectiveness of 98.4 percent against getting infected with COVID-19 among adolescents. The effectiveness didn't significantly decrease after receiving the first vaccine dose. During the Omicron variant period, the effectiveness against documented infection among children dropped to 74.3 percent. However, the vaccine seemed to provide significant protection against more severe infection and hospital admission due to COVID-19. Among adolescents, the effectiveness against Omicron infection was 85.5 percent, with higher effectiveness against more severe outcomes. The effectiveness of the vaccine against the Omicron variant declined four months after the first dose but then stabilized. An analysis did not find an increased risk of heart-related complications after vaccination.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Yong Chen, PhD, please email ychen123@pennmedicine.upenn.edu.
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3. Two doses of the herpes zoster vaccine provides strong and lasting protection against shingles
Abstract: https://www.acpjournals.org/doi/10.7326/M23-2023
URL goes live when the embargo lifts
A real-world study of the recombinant zoster vaccine (RZV) found that two doses provided strong and lasting protection against herpes zoster , or shingles, even in patients at higher risk for the disease , such as those taking corticosteroids. The findings are published in Annals of Internal Medicine.
Shingles is a painful rash with complications that include persistent burning pain at the site of the initial rash, known as postherpetic neuralgia. The incidence and severity of shingles increase markedly with age and immunocompromising conditions. A 2-dose series of RZV has been shown to be very effective in clinical trials, but the long-term effectiveness has not been extensively studied in real-world settings.
Researchers from Kaiser Permanente Northern California studied data from the Vaccine Safety Datalink to evaluate the real-world effectiveness of RZV against acquiring shingles. The outcome was incident shingles defined by a diagnosis with an antiviral prescription. The researchers used a Cox regression model to compare the risk of getting shingles in people who were vaccinated versus those who were not. Other factors that could affect the risk, such as age or other health conditions were accounted for in the model. The researchers found that the RZV vaccine provided a high level of protection that didn't decrease much over 4 years. Among people taking corticosteroids, medications that can weaken the immune system, the vaccine still showed substantial effectiveness. According to the authors, this is important because people on corticosteroids are at a higher risk of getting shingles. The study also revealed that the effectiveness of just one dose of the vaccine decreased after a year, supporting the current recommendation for people to get a second dose. These findings support the existing guideline recommending a two-dose regimen for optimal protection.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Ousseny Zerbo, PhD, please e-mail ousseny.x.zerbo@kp.org.
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JOURNAL
Annals of Internal Medicine
METHOD OF RESEARCH
News article
SUBJECT OF RESEARCH
People
ARTICLE TITLE
Acute Hospital Care at Home in the United States: The Early National Experience
ARTICLE PUBLICATION DATE
9-Jan-2024
Study of national data demonstrates the value of acute hospital care at home
Mass General Brigham researchers found low rates of mortality, less use of skilled nursing facilities, and less need for escalation in patient care for patients taken care of at home instead of in the hospital
Since the Centers for Medicare and Medicaid Services launched the Acute Hospital Care at Home (AHCaH) Waiver in 2020, thousands of patients from across 300 hospitals in 37 states have been treated in their homes. Yet little is understood about these patients’ outcomes on a national level, and the waiver will end in December 2024 unless there is an act from Congress. A new study by investigators from Mass General Brigham analyzed outcomes from AHCaH for a diverse group of patients across America. The study provides preliminary evidence suggesting that home hospital is an important care model for managing acute illness, including among socially vulnerable and medically complex patients. Results are published in a research letter in Annals of Internal Medicine.
“For hundreds of years, since the inception of hospitals, we’ve told patients to go to a hospital to get acute medical care. But in the last 40 years, there’s been a global movement to bring care back to the home,” said corresponding author David Michael Levine, MD, MPH, MA, clinical director for research and development for Mass General Brigham’s Healthcare at Home. “We wanted to conduct this national analysis so there would be more data for policymakers and clinicians to make an informed decision about extending or even permanently approving the waiver to extend opportunities for patients to receive care in the comfort of home.”
Advances in healthcare technology have made it more possible than ever to offer treatment options to patients in their home rather than requiring office or hospital visits. Mass General Brigham is a recognized leader in acute hospital care at home, with a Home Hospital program that serves 66 neighborhoods across greater Boston. In addition, Levine and other investigators from across Mass General Brigham are conducting rigorous, national-level research to present data relevant to clinicians, patients, caregivers and policymakers to inform decisions about the acute hospital care at home model.
Levine and colleagues looked at clinical characteristics and outcomes from all of the 5,858 patients from across the U.S. who were cared for under the AHCaH Waiver, using Medicare fee-for-service Part A claims filed between July 1 2022 and June 30 2023. Then they studied whether these clinical characteristics varied across different demographic groups.
Fifty-four percent of the patients were female, 85.2 percent were white, 61.8 percent were over 75 years old, and 18.1 percent were disabled. The mean household income was $83,932.
When the team studied hospitalizations among all these patients, they found a 0.5 percent mortality rate and 6.2 percent escalation rate (returning to the hospital for at least 24 hours). In addition, within 30 days of discharge, 2.6 percent of patients used a skilled nursing facility, 3.2 percent died, and 15.6 percent were readmitted.
“Home hospital care appears quite safe and of high quality from decades of research — you live longer, get readmitted less often, and have fewer adverse events.” Levine says. “If people had the opportunity to give this to their mom, their dad, their brother, their sister … they should.”
The patients included in the current study had medically complex conditions, including 42.5 percent with heart failure, 43.3 percent with chronic obstructive pulmonary disease, 22.1 percent with cancer, and 16.1 percent with dementia. The five most common discharge diagnoses were heart failure, respiratory infection (including COVID), sepsis, kidney/urinary tract infections, and cellulitis.
“There are a number of reasons we think hospital-level care is better at home,” Levine said. “For one, the discharge process is smoother since we show patients how to take care of themselves right in their homes, where they are also more likely to be upright and move more. In addition, the clinical team has a greater ability to educate and act on the social determinants of health that we see in the home. For example, we can discuss a patient’s diet right in the kitchen or link a patient with resources when we see the cupboards are bare.”
The outcomes were also stratified by patients of Black and Latine race and ethnicity, dual-eligible status, and by disability status. The findings were consistent across all groups.
“It was reassuring to see that there were not clinically meaningful differences in outcomes across marginalized populations, because we know that there are massive disparities in outcomes for traditional hospitalization,” Levine said. “This suggests home hospital can really reach a diverse group of patients and families.”
Still, the findings are limited to observational data, and additional research is necessary to compare the measured outcomes to those at brick-and-mortar hospitals. Levine’s team is also currently studying home hospital care for rural patients, who were not well represented in the current study.
"For decades, home hospital care has been offered all around the world,” Levine said. “This is an important moment in the United States where we might see a paradigm shift in how we deliver a sizeable portion of health care.”
Authorship: Additional authors include Jeffrey Souza, Jeffrey Schnipper (BWH), Thomas Tsai (BWH), Bruce Leff, and Bruce Landon.
Disclosures: Levine reports a PI-initiated grant and co-development from Biofourmis as well as fees from The MetroHealth System. Leff reports affiliations with Medically Home, Dispatch Health, Chartis Health and Kenes. Landon reports grants from the Agency for Healthcare Research and Quality (AHRQ) and the National Institute on Aging (NIA).
Funding: NIH Funding 5P01AG032952-13.
Paper cited: Levine, DM et al. “Acute Hospital Care at Home in The United States: The Early National Experience” Annals DOI: 10.7326/M23-2264
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About Mass General Brigham
Mass General Brigham is an integrated academic health care system, uniting great minds to solve the hardest problems in medicine for our communities and the world. Mass General Brigham connects a full continuum of care across a system of academic medical centers, community and specialty hospitals, a health insurance plan, physician networks, community health centers, home care, and long-term care services. Mass General Brigham is a nonprofit organization committed to patient care, research, teaching, and service to the community. In addition, Mass General Brigham is one of the nation’s leading biomedical research organizations with several Harvard Medical School teaching hospitals. For more information, please visit massgeneralbrigham.org.
JOURNAL
Annals of Internal Medicine
METHOD OF RESEARCH
Observational study
SUBJECT OF RESEARCH
People
ARTICLE TITLE
Acute Hospital Care at Home in The United States: The Early National Experience
ARTICLE PUBLICATION DATE
9-Jan-2024
COI STATEMENT
Levine reports a PI-initiated grant and co-development from Biofourmis as well as fees from The MetroHealth System. Leff reports affiliations with Medically Home, Dispatch Health, Chartis Health and Kenes. Landon reports grants from the Agency for Healthcare Research and Quality (AHRQ) and the National Institute on Aging (NIA). Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum¼M23-2264.
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