Predictors and Reasons Why Patients Decline to Participate in Home Hospital: a Mixed Methods Analysis of a Randomized Controlled Trial

Abstract

Background

Acute care at home (“home hospital”) compared to traditional hospital care has been shown to lower cost, utilization, and readmission and improve patient experience and physical activity. Despite these benefits, many patients decline to enroll in home hospital.

Objective

Describe predictors and reasons why patients decline home hospital.

Design

Mixed methods evaluation of a randomized controlled trial.

Participants

Patients in the emergency department who required admission and were accepted for home hospital by the home hospital attending, but ultimately declined to enroll.

Intervention

Home hospital care, including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing.

Approach

We conducted a thematic content analysis of verbatim reasons for decline. We performed bivariate comparisons then multivariable logistic regression to identify patient characteristics associated with declining participation.

Key Results

Two hundred forty-eight patients were eligible to enroll, and 157 (63%) declined enrollment. Patients who declined and enrolled were of similar age (median age, 74 vs 75 years old; p = 0.27), sex (32% vs 36% female; p = 0.49), and race/ethnicity (p = 0.26). In multivariable analysis, patients were significantly more likely to decline if they initially presented at the community hospital compared to the academic medical center (53% vs 42%; adjusted OR, 2.2 [95% CI, 1.2 to 4.2]) and if single (37% v 24%; adjusted OR, 2.5 [95% CI, 1.2 to 5.1]). We formulated 10 qualitative categories describing reasons patients ultimately declined. Many patients declined because they felt it was easier to remain in the hospital (20%) or felt safer in the hospital than in their home (20%).

Conclusions

Patients who declined to enroll in a home hospital intervention had similar sociodemographic characteristics as enrollees except partner status and declined most often for perceptions surrounding safety at home and the ease of remaining in the hospital.

Trial Registration

NCT03203759

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Acknowledgements

The authors would like to acknowledge the clinicians who cared for all of the patients in this study during their time of need. The authors also graciously acknowledge the various departments at Brigham Health who were instrumental to the success of the home hospital program: Cardiology, Emergency Medicine, General Internal Medicine and Primary Care, Hospital Medicine Unit, Pharmacy, Laboratory, and Population Health.

Funding

Brigham and Women’s Hospital President’s Fund.

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Corresponding author

Correspondence to David M Levine MD MPH MA.

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Conflict of Interest

None of the study’s commercial vendors participated in design, analysis, interpretation, preparation, review, or approval. Dr. Levine is the recipient of funding from Biofourmis for an investigator-initiated study of machine learning warning scores for acutely ill patients, both traditionally and home hospitalized. Dr. Schnipper was the recipient of funding from Mallinckrodt Pharmaceuticals for an investigator-initiated study of opioid related adverse drug events in post-operative hospitalized patients. Otherwise, the authors declare that they do not have a conflict of interest.

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Prior Presentations

Society of General Internal Medicine - National conference; Washington, DC, 2019.

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Levine, D.M., Paz, M., Burke, K. et al. Predictors and Reasons Why Patients Decline to Participate in Home Hospital: a Mixed Methods Analysis of a Randomized Controlled Trial. J GEN INTERN MED (2021). https://doi.org/10.1007/s11606-021-06833-2

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KEY WORDS

  • home hospital
  • hospital at home
  • refusal