Year: 2025
Type: article
Abstract: Editorial to accompany: Comprehensive Geriatric Hospital-at-Home increases the days at home in older adults compared to bed-based intermediate care. Comprehensive geriatric assessment can be delivered using a hospital-at-home model. Assessing time spent at home can be a useful outcome measure in older adult research. Questions remain about the feasibility and efficacy of hospital at home for important groups, e.g. those in care homes. Inpatient hospital stays have become a cornerstone of medical care. The traditional hospital model was designed to provide reactive treatment during times of acute, reversible deteriorations in health. However, changes in societal demographics, clinical interventions and service user expectations have combined to create a context where the traditional hospital-bed-based model of care may no longer be fit for purpose. While the intention is therapeutic, admission to the acute hospital can be associated with multiple potential iatrogenic harms, including hospital-acquired infection, deconditioning and delirium [1]. As older adults are frequent users of acute healthcare and at high risk of iatrogenic harm, home-delivered care seems especially attractive. The ‘gold standard’ intervention for older adults living with frailty is comprehensive geriatric assessment (CGA) and seminal reviews of hospital-based CGA have shown it can reduce mortality and long-term care placement [2]. While the benefits of traditional CGA are well established, trials describing the clinical and cost effectiveness of CGA in other settings have given mixed results. Given the importance that older adults ascribe to staying at home and the risks of a hospital stay, research assessing the efficacy of the CGA package in the home environment, often described as hospital at home (H@H), seems highly relevant [3]. The largest UK trial of geriatrician-led, multidisciplinary H@H-based CGA found equivalence with standard hospital-delivered services on a primary outcome of living at home at 6 months, and a reduction in care home admission [4]. Overall, H@H-based CGA was cost-effective when NHS, social care and informal care costs were accounted for [5]. Having large, robust studies describing the efficacy of H@H for older adults is encouraging, but there is heterogeneity in the various offerings that are included under the auspices of the H@H label, and questions remain around optimal delivery and selection of recipients [6]. For this reason, robust comparative evaluations of H@H interventions, in real-world practice, remain important contributions to the evidence base. Such an evaluation is provided by Mazzarone and colleagues [7] who compared H@H based rehabilitation/reablement (average length of intervention 4–6 weeks) with traditional hospital-based intermediate care services. The Catalan region has been a pioneer of H@H for older adults, and their service offers multidisciplinary input, with access to services 12 h a day, 7 days a week for both admission avoidance (step-up) and facilitating early discharge (step down). Linking admission data to other datasets, the team were able to offer follow-up of all users of their H@H service from 2018 to 2023, matching them to equivalent patients receiving secondary care-based CGA. Across 961 patients in either group, with a mean follow-up of 705 days, the efficacy of H@H was demonstrated, with no increase in adverse events. These data are encouraging but come with certain caveats. This was not a randomised trial, and even with the best propensity matching, it is impossible to fully account for the complex and nuanced decision-making that will inform the choice of H@H or standard secondary care. It is worth noting that over the duration of the study, 10 times more patients received standard hospital care than H@H, and the diagnoses and demographics of the two groups differed in many respects. An important demographic difference between the groups, which is fully acknowledged by the authors, is socioeconomic, with a higher socioeconomic status in the group receiving care at home. Reasons for this difference will be clear to clinicians who offer home visits. Housing in certain areas may not be appropriate, or even safe, for providing care at home. This imbalance creates potential bias in the analysis, as people living in socioeconomically deprived areas often have poorer outcomes following illness regardless of the care setting [8]. The imbalance also points to an important consideration for those services looking to increase their H@H offering. Equity in access is a key consideration for healthcare providers, and it is important that structural differences around housing, including the impact of deprivation and poverty, do not create barriers to equitable care. A further consideration, and strength of the study, is around the outcome measure used. The article and the motivation behind the study are based on a recognition of the importance of staying at home for older adults [9]. Indeed, it has been argued that remaining independent at home is more important to older adults than traditional trial outcomes such as death [10]. If the home setting is important as part of an intervention package, it may equally be useful as a measure of the efficacy of an intervention in this population. Here, the authors were able to include both efficacy (length of stay, care home admission) and safety (death, readmission) measures in one combined outcome by calculating the proportional time spent at home over the duration of the follow-up. This ‘home-time’ measure offers time and cost efficiencies, as it can be derived from data collected routinely. However, unlike measures such as length of hospital stay, it is less prone to biases from early mortality or transfers to other settings [11]. Assessing time spent at home as an outcome is not entirely novel. The approach has been used in conditions such as dementia and stroke, where it is now incorporated into national audit data [12, 13]. The measure seems ideally suited to studies of older adults. Older adults prioritise staying at home, and so a quantification of time spent at home is a highly relevant and person-centred outcome measure [14]. It is reassuring that home-time has strong correlations with other traditional health, functional and quality of life measures assessed in trials [11, 15]. Time at home is not the only outcome of interest when assessing H@H, and other aspects may be important, for example, the burden placed on care partners. However, unlike home-time, such metrics require direct assessment and do not lend themselves to retrospective derivation from existing data. While this study adds to a compelling evidence base supporting H@H, some questions remain, for example does the H@H models deliver the same benefits in a care home environment. It is encouraging that, unlike in some other H@H research studies, the intervention in this study was also offered to those living in a care home environment. This population remain a priority for inclusion in research about models of care and ‘care at home’ studies. Overall, this study strengthens the case for offering home-based care to older adults, highlights potential equality issues around the delivery of H@H, and emphasises the importance of staying at home as a measure of success for any acute care intervention in older adults. Thus, the clinical, policy and research importance of time spent at home is clear, and time at home should be a consideration for all future older adult interventions. None declared. None declared.
Source: Age and Ageing
Language: English
Topic: Frailty in Older Adults
Subfield: Geriatrics and Gerontology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W4413105249