Hospital at home for older frequent hospital users: present and future of a healthcare challenge

BACKGROUND: Frequent hospital users (FHUs) show high risk of clinical instability. A hospital-at-home (HaH) service (“GIROT”) was created in Florence, Italy, to reduce hospitalizations in older adults vulnerable to hospital-related complications. AIM: To investigate the association of frequent hospital use with all-cause mortality and hospitalization among HaH patients. METHODS: patients referred to GIROT between January 2022 and March 2024, participated in a prospective longitudinal study. Participants were stratified by prior-year hospital admissions (0–1, 2, and 3+) and FHUs were defined based on the association between admissions and risks of subsequent hospitalization and mortality. Multivariate Cox regression assessed the independent association between FHU status and outcomes. RESULTS: Among 219 patients (mean age 85.9, 55% female, 44% with severe disability), the median number of hospitalizations in the previous year was 2. Over a 6-month follow-up, mortality risk was 43% and hospitalization risk was 39%. Six-month mortality was higher in subjects with 2 (58%) and 3 + admissions (48%) versus 0–1 admissions (32%), with similar patterns for hospitalization. These findings led to defining FHUs as individuals with 2 + prior hospitalizations. Shorter time-to-death was independently associated with weight loss, severe disability, heart failure with reduced ejection fraction (HFrEF), and FHU status (adjHR 1.49, 95%CI 1.00-2.21). Time-to-hospitalization was independently predicted by HFrEF and FHU status (adjHR 1.80, 95%CI 1.08–3.01). CONCLUSIONS: FHUs (i.e., 2 + hospitalizations in the previous year) showed an increased risk of re-admission and mortality among older adults receiving HaH. Extra-hospital care pathways, including HaH and palliative care, may help reduce admissions in this population.