A Hospital-at-Home Pilot in Singapore

NCT04330378 | Completed

• 1 other identifier: 2020/00345
• Study Type: observational
• Target: 378
• Locations: 1 country
• Sites: 2

Brief Summary

Hospital-at-home models seek to address the impending shortage of hospital beds by reimagining the way we deliver acute hospital-level care - substituting the ward for a patient's home. Such programmes have been well established in other countries such as Australia, Europe and USA to be a less costly way to provide inpatient care as a result of a reduction of fixed costs of building and running hospitals, with equivalent variable costs and comparable clinical outcomes. Acute services are provided at home, including regular visits by doctors, nurses and therapists, intravenous therapy, simple investigations and 24/7 access to doctors. The clinical service is tech-enabled, by remote monitoring and telecommunication technologies. Although overseas experience suggests that hospital-at-home programmes are an effective, safe and scalable substitute for inpatient beds, and promising strategy to meet the bed demands of our ageing population, the outcomes in the local environment is unclear. Singapore has a unique healthcare system compared to primarily insurance driven (USA) or publicly funded (UK and Australia), which favours subsidies of inpatient care compared to community-based care. In addition, cultural beliefs of hospitals as a source of comfort and healing and unfamiliarity with healthcare providers performing home visits may provide unique challenges which may affect outcomes of a hospital-at-home programme in Singapore. In an Asian setting, family and informal caregivers are heavily involved in the care of patients and may pose unique barriers and facilitators to such care at home that may not be evident in similar models in Western countries. This study aims to evaluate the effectiveness, feasibility and processes of a new hospital-at-home programme in Singapore.

Conditions

Hospital-at-home

Keywords

Home Care; Hospital-in-the-home; Home Hospital

Outcome Measures

Primary Outcomes (1)

• Cost of care

  The primary outcome is cost of care which the sum of the following: 1. Itemised consumables 2. Labour cost of physicians, estimated by the average time spent delivering care multiplied by standard salary (plus benefits) estimates of physicians' respective paygrades. 3. Labour cost of nurses, estimated by the average time spent delivering care multiplied by standard salary (plus benefits) estimates of nurses' respective paygrades 4. Labour cost of allied health (e.g. phlebotomists, physiotherapists) will be estimated by the average time spent delivering care multiplied by standard salary (plus benefits) estimates of their respective paygrades. 5. Any additional costs incurred by the intervention group (e.g. telemonitoring, transport of blood tests) will be itemised as well.

  At completion of intervention (an average of 7 days)

Secondary Outcomes (14)

• 30-day readmission rate and attendance rate to emergency department

  30 days from completion of intervention (an average of 7 days)

• Death during treatment

  At completion of intervention (an average of 7 days)

• 30-day mortality

  30 days from enrolment

• Iatrogenic events during treatment period

  At completion of intervention (an average of 7 days)

• Number of bed days in hospital

  At completion of intervention (an average of 7 days)

Study Arms (3)

Hospital-at-home

All patients who are enrolled into the NUHS@Home Programme will be recruited into this arm. Patients will be sent home via ambulance, where they will be reviewed by a NUHS@Home nurse. Intravenous therapies, pillboxes for medication, remote monitoring software, and telecommunication tools will be set up as indicated. NUHS@Home doctors will visit at least once daily, and nurses at least twice daily as required. Therapists will conduct home visits as necessary. The NUHS@Home team is available 24/7. When conventional discharge criteria are met, the patient will be discharged. The NUHS@Home clinical team will be under clinical governance of Division of Advanced Internal Medicine at NUH and patients will be considered 'inpatients' throughout the treatment period.

Other: Hospital-at-home

Usual in-hospital care

Patients who would otherwise be eligible for NUHS@Home but are not able to be enrolled due to capacity will be recruited into this arm. They will receive usual care in the wards that they are already in until they are discharged.

Other: Usual in-hospital care

Rejected cohort

Patients who were offered but declined enrolments inot the NUHS@Home programme will be approached for consent to be in the rejected cohort. There will be no change to the patient's clinical management.

Other: Usual in-hospital care

Interventions

Hospital-at-home OTHER

As per experimental arm

Also known as: Home Hospitalisation, Home Hospital, Hospital-in-the-home

Hospital-at-home

Usual in-hospital care OTHER

As per control arm

Rejected cohort; Usual in-hospital care

Eligibility Criteria

• Age: 21 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)
• Sampling Method: Non-Probability Sample

Study Population

Patients who are enrolled into the NUHS@Home programme will be approached for consent to be in the hospital-at-home cohort. Patients who are suitable for NUHS@Home programme but the programme has no bed capacity will be approached for consent to be in the control cohort. There will be no change to the patient's clinical management. Patients who were offered but declined enrolments into the NUHS@Home programme will be approached for consent to be in the rejected cohort. There will be no change to the patient's clinical management.

You may qualify if:

• Admitted to one of the following wards:
• Episodic short stay patients
• NUH Extended Diagnosis and Treatment Unit (EDTU)
• AH Extended Diagnosis and Treatment Unit (EDTU)
• NUH Acute Medical Unit (AMU)
• Long stay patients requiring ongoing treatment or monitoring
• NUH general medicine wards
• AH general medicine wards
• Speciality specific treatment and monitoring with a protocolised approach
• Fluid overload admissions from NUH cardiology service
• Fluid overload admissions from NUH nephrology service
• ≥ 21 years old
• Lives within the Western Cluster of Singapore (pre-specified list of postcodes)
• Requires continued hospitalisation
• The EDTU is a ward within the emergency department that patients can stay for up to 24hours for diagnosis and treatment and meant for discharge after. Some of these patients subsequently require hospital admission, which would be the target group for the pilot. The AMU is a short-stay ward at NUH which aims to discharge patients within 72 hours of stay.

You may not qualify if:

• Lives in nursing home
• Suitable for discharge to other community programmes
• Planned for discharge the next day (D-1)
• Haemodynamic instability defined as NEWScore \>2 at time of recruitment (a NEWScore ≤2 in a local setting showed very low rates of transfer to intensive care and death in 24 hours )
• Requires oxygen (long term oxygen therapy is acceptable)
• Acute psychosis or suicidal intent
• Need for negative pressure isolation
• Anticipated to deteriorate
• Planned for imaging, endoscopy, blood transfusion, cardiac stress test, surgery, interventional radiology procedures or ongoing non-medical specialist review
• Need for intravenous controlled drugs (e.g. morphine)
• Unable to establish venous access in emergency department
• Current or former intravenous drug user
• History of violence towards healthcare workers
• Cannot provide meals at home
• Does not have a bed, table and fridge at home

Sponsors & Collaborators

• National University Health System, Singapore: lead
• National University of Singapore: collaborator

Study Sites (2)

Alexandra Hospital

Singapore, Singapore

Location

National University Hospital

Singapore, Singapore

Location

Related Publications (10)

• Goncalves-Bradley DC, Iliffe S, Doll HA, Broad J, Gladman J, Langhorne P, Richards SH, Shepperd S. Early discharge hospital at home. Cochrane Database Syst Rev. 2017 Jun 26;6(6):CD000356. doi: 10.1002/14651858.CD000356.pub4.

  PMID: 28651296 BACKGROUND

• Caplan GA, Sulaiman NS, Mangin DA, Aimonino Ricauda N, Wilson AD, Barclay L. A meta-analysis of "hospital in the home". Med J Aust. 2012 Nov 5;197(9):512-9. doi: 10.5694/mja12.10480.

  PMID: 23121588 BACKGROUND

• Shepperd S, Iliffe S, Doll HA, Clarke MJ, Kalra L, Wilson AD, Goncalves-Bradley DC. Admission avoidance hospital at home. Cochrane Database Syst Rev. 2016 Sep 1;9(9):CD007491. doi: 10.1002/14651858.CD007491.pub2.

  PMID: 27583824 BACKGROUND

• Qaddoura A, Yazdan-Ashoori P, Kabali C, Thabane L, Haynes RB, Connolly SJ, Van Spall HG. Efficacy of Hospital at Home in Patients with Heart Failure: A Systematic Review and Meta-Analysis. PLoS One. 2015 Jun 8;10(6):e0129282. doi: 10.1371/journal.pone.0129282. eCollection 2015.

  PMID: 26052944 BACKGROUND

• Jeppesen E, Brurberg KG, Vist GE, Wedzicha JA, Wright JJ, Greenstone M, Walters JA. Hospital at home for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 May 16;2012(5):CD003573. doi: 10.1002/14651858.CD003573.pub2.

  PMID: 22592692 BACKGROUND

• Federman AD, Soones T, DeCherrie LV, Leff B, Siu AL. Association of a Bundled Hospital-at-Home and 30-Day Postacute Transitional Care Program With Clinical Outcomes and Patient Experiences. JAMA Intern Med. 2018 Aug 1;178(8):1033-1040. doi: 10.1001/jamainternmed.2018.2562.

  PMID: 29946693 BACKGROUND

• Echevarria C, Gray J, Hartley T, Steer J, Miller J, Simpson AJ, Gibson GJ, Bourke SC. Home treatment of COPD exacerbation selected by DECAF score: a non-inferiority, randomised controlled trial and economic evaluation. Thorax. 2018 Aug;73(8):713-722. doi: 10.1136/thoraxjnl-2017-211197. Epub 2018 Apr 21.

  PMID: 29680821 BACKGROUND

• Levine DM, Ouchi K, Blanchfield B, Saenz A, Burke K, Paz M, Diamond K, Pu CT, Schnipper JL. Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Ann Intern Med. 2020 Jan 21;172(2):77-85. doi: 10.7326/M19-0600. Epub 2019 Dec 17.

  PMID: 31842232 BACKGROUND

• Montalto M. The 500-bed hospital that isn't there: the Victorian Department of Health review of the Hospital in the Home program. Med J Aust. 2010 Nov 15;193(10):598-601. doi: 10.5694/j.1326-5377.2010.tb04070.x.

  PMID: 21077817 BACKGROUND

• Ko SQ, Rahman N, Chai JH, Goh J, Luo N, Shi L, Lai YF, Soong JTY, Chan DKW, Peh ALT, Kuan WS, Lim YW. Hospital-at-home versus hospital admission for acute care in Singapore: a prospective quasi-experimental study on cost, utilisation and clinical outcomes. BMC Health Serv Res. 2026 Jan 20. doi: 10.1186/s12913-025-13938-5. Online ahead of print.

  PMID: 41559634 DERIVED

Study Officials

• Stephanie Q Ko, MBBS MPH

  National University Health Systems

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: observational
• Observational Model: COHORT
• Time Perspective: PROSPECTIVE
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Associate Consultant

Study Record Dates

• First Submitted: March 27, 2020
• First Posted: April 1, 2020
• Study Start: January 18, 2021
• Primary Completion: May 18, 2023
• Study Completion: June 18, 2023
• Last Updated: January 9, 2024

Record last verified: 2024-01

Data Sharing

• IPD Sharing: Will not share

Locations

SG (2)