Assignment task: Annals of Internal Medicine
Abstract:
Background:
Substitutive hospital-level care in a patient's home may reduce cost, health care use, and readmissions while improving patient experience, although evidence from randomized controlled trials in the United States is lacking.
Objective:
To compare outcomes of home hospital versus usual hospital care for patients requiring admission.
Design:
Randomized controlled trial. (ClinicalTrials.gov: NCT03203759)
Setting: Academic medical center and community hospital.
Patients: 91 adults (43 home and 48 control) admitted via the emergency department with selected acute conditions.
Intervention:
Acute care at home, including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing.
Measurements: The primary outcome was the total direct cost of the acute care episode (sum of costs for nonphysician labor, supplies, medications, and diagnostic tests). Secondary outcomes included health care use and physical activity during the acute care episode and at 30 days.
Results:
The adjusted mean cost of the acute care episode was 38% (95% CI, 24% to 49%) lower for home patients than control patients. Compared with usual care patients, home patients had fewer laboratory orders (median per admission, 3 vs. 15), imaging studies (median, 14% vs. 44%), and consultations (median, 2% vs. 31%). Home patients spent a smaller proportion of the day sedentary (median, 12% vs. 23%) or lying down (median, 18% vs. 55%) and were readmitted less frequently within 30 days (7% vs. 23%).
Limitation:
The study involved 2 sites, a small number of home physicians, and a small sample of highly selected patients (with a 63% refusal rate among potentially eligible patients); these factors may limit generalizability.
Conclusion:
Substitutive home hospitalization reduced cost, health care use, and readmissions while increasing physical activity compared with usual hospital care.
Primary Funding Source:
Partners HealthCare Center for Population Health and internal departmental funds.
Question 1: Provide a very brief summary (3-4 sentences) of what the study was about and purpose if stated. Include the research question(s) if available.
Question 2: Define the target population to which the statistical analysis can be generalized. Describe the sampling approach and note whether it is representative.
Question 3: What was the hypothesis advanced by the researchers / authors?
Question 4: Provide a clear definition of the outcome/dependent variables and a short description of the instrument used to measure them. What was the level of measurement?
Question 5: Provide a clear definition of the independent/predictor variables and a short description of the instrument(s) used to measure them. What was the level of measurement for each variable?
Question 6: Describe the type of study design used. How many groups were included? How many subjects were included overall?
Question 7: Describe the statistical tests used. List each and explain why used. What was the level of significance assigned? Was the test chosen appropriate based on the research question and procedures?
Question 8: Report the results with significance levels (p values) and identify hypothesis decisions. What do the results mean? Are there any clinical implications for nurse practitioners given the results?
Question 9: Describe one ethical implication that pertains to the overall research design or data analysis in your article.
Question 10: Describe how the aggregate data in your article would guide population-based disease prevention. What level of prevention is applicable if any all?