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Identifying Factors Linked to COVID-19 Care Escalation From In-Home to Hospital


A study identifies factors that put patients with COVID-19 receiving home-based care at risk for care escalation.

The majority of patients with COVID-19 who received home-based hospital care did not require care escalation to a traditional hospital setting, according to study findings published in Annals of Internal Medicine. This finding was consistent even if patients were older or obese.

As the COVID-19 pandemic forced health care systems to rapidly transform care to meet patient demand, Atrium Health implemented the Atrium Health Hospital at Home (AH-HaH) program early on to deliver home-based hospital-level care to increase the system’s bed capacity. The non-profit health system provides care to patents in North Carolina and Georgia.

To determine which AH-HaH patients were at increased risk for care escalation to traditional facilities, researchers conducted a retrospective cohort study of adults aged 18 and older who received treatment via the AH-HaH program between March and November 2020.

“Patients who the evaluating provider would otherwise have admitted to the brick-and-mortar facility who had safe living situations and clinical stability at admission” were eligible to participate in AH-HaH, authors wrote.

The program included telephonic access to nurses, daily in-home visits from paramedics, and virtual visits with a hospitalist, among other services. Baseline covariates and treatment information for each patient were collected via electronic health records.

Of the 391 eligible patients, 53% were female, 43% were White, and patients had a median age of 56 years. In addition, the median length of AH-HaH stay was three days. Analyses revealed:

  • 84 patients (21%) were transferred to a brick-and-mortar facility within 14 days (median time to transfer, 2.2 days [interquartile range, 0.8 to 3.3 days])
  • Among hospital admissions, 33 required intensive care, 11 required mechanical ventilation, and there were 11 in-hospital deaths (causes included organ failure and shock)
  • Higher oxygen saturation was associated with decreased odds of transfer (odds ratio [OR], 0.87 [95% CI, 0.81-0.93]), whereas higher comorbidity burden was associated with increased odds of transfer (OR 1.12 [95% CI, 0.99-1.26])
  • Respiratory aberrations (such as low oxygen saturation, supplemental oxygen ≥3 L/min, and high respiratory rate) and tachycardia at enrollment were frequently observed among patients who required immediate care escalation
  • High-risk chronic conditions (such as hypertension and diabetes) were common among patients who required nonimmediate care escalation

Overall, approximately one in five patients were admitted within 14 days. Researchers hypothesized the lack of an independent association between older age or obesity and transfer may be due to providers being more cautious about enrolling these patients into the program.

“Although not statistically significant, race/ethnicity and area-level deprivation warrant additional research given established COVID-19 health disparities and possible bias due to home-based AH-HaH eligibility criteria,” they added.

The retrospective nature of the study, which was conducted at a single health system, marks a limitation, while its relatively small sample size could limit identification of significant risk factors for care escalation.

“Nevertheless, this study provides practical initial evidence to help inform patient selection guidelines as health systems and payers increasingly leverage hospital-at-home as a standard care delivery option,” researchers concluded.

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