Effect of hospital-at-home vs. traditional brick-and-mortar hospital care in acutely ill adults: study protocol for a pragmatic randomized controlled trial

BACKGROUND

Delivering acute hospital care to patients at home might reduce costs and improve patient experience. Mayo Clinic's Advanced Care at Home (ACH) program is a novel virtual hybrid model of "Hospital at Home." This pragmatic randomized controlled non-inferiority trial aims to compare two acute care delivery models: ACH vs. traditional brick-and-mortar hospital care in acutely ill patients.

METHODS

We aim to enroll 360 acutely ill adult patients (≥18 years) who are admitted to three hospitals in Arizona, Florida, and Wisconsin, two of which are academic medical centers and one is a community-based practice. The eligibility criteria will follow what is used in routine practice determined by local clinical teams, including clinical stability, social stability, health insurance plans, and zip codes. Patients will be randomized 1:1 to ACH or traditional inpatient care, stratified by site. The primary outcome is a composite outcome of all-cause mortality and 30-day readmission. Secondary outcomes include individual outcomes in the composite endpoint, fall with injury, medication errors, emergency room visit, transfer to intensive care unit (ICU), cost, the number of days alive out of hospital, and patient-reported quality of life. A mixed-methods study will be conducted with patients, clinicians, and other staff to investigate their experience.

DISCUSSION

The pragmatic trial will examine a novel virtual hybrid model for delivering high-acuity medical care at home. The findings will inform patient selection and future large-scale implementation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05212077. Registered on 27 January 2022.

Trends in antihypertensive drug therapy of ambulatory patients by US office-based physicians

This study assessed trends from 1980 to 1995 in ambulatory patients' antihypertensive drug therapy by US office-based physicians for visits in which hypertension was the principal diagnosis and compared these trends with the respective guidelines given in 5 Joint National Committee (JNC) Reports on Detection, Evaluation, and Treatment of High Blood Pressure published around the same time period. Data from the National Center for Health Statistics' National Ambulatory Medical Care Surveys for 1980, 1985, 1990, and 1995 were used. From 1980 to 1995, there was no significant trend in the percentage of hypertension visits that did not mention any antihypertensive drug (20% to 27%). Further analyses focused on those hypertension visits in which at least 1 antihypertensive drug was used. Across the years, antihypertensive drug visits mentioning calcium channel blockers or ACE inhibitors significantly increased; those noting diuretics significantly decreased. However, in 1995, antihypertensive drug visits that included a diuretic and/or a beta-adrenergic blocker equalled 53%; these are the antihypertensive drug classes preferred by the JNC V. Physician antihypertensive drug prescribing was generally consistent with the basic antihypertensive drug guidelines of the JNC reports.

State-space modeling of the relationship between air quality and mortality

A portion of a population is assumed to be at risk, with the mortality hazard varying with atmospheric conditions including total suspended particulates (TSP). This at-risk population is not observed and the hazard function is unknown; we wish to estimate these from mortality count and atmospheric variables. Consideration of population dynamics leads to a state-space representation, allowing the Kalman Filter (KF) to be used for estimation. A harvesting effect is thus implied; high mortality is followed by lower mortality until the population is replenished by new arrivals. The model is applied to daily data for Philadelphia, PA, 1973-1990. The estimated hazard function rises with the level of TSP and at extremes of temperature and also reflects a positive interaction between TSP and temperature. The estimated at-risk population averages about 480 and varies seasonally. We find that lags of TSP are statistically significant, but the presence of negative coefficients suggests their role may be partially statistical rather than biological. In the population dynamics framework, the natural metric for health damage from air pollution is its impact on life expectancy. The range of hazard rates over the sample period is 0.07 to 0.085, corresponding to life expectancies of 14.3 and 11.8 days, respectively.

The genome sequence of Drosophila melanogaster

The fly Drosophila melanogaster is one of the most intensively studied organisms in biology and serves as a model system for the investigation of many developmental and cellular processes common to higher eukaryotes, including humans. We have determined the nucleotide sequence of nearly all of the approximately 120-megabase euchromatic portion of the Drosophila genome using a whole-genome shotgun sequencing strategy supported by extensive clone-based sequence and a high-quality bacterial artificial chromosome physical map. Efforts are under way to close the remaining gaps; however, the sequence is of sufficient accuracy and contiguity to be declared substantially complete and to support an initial analysis of genome structure and preliminary gene annotation and interpretation. The genome encodes approximately 13,600 genes, somewhat fewer than the smaller Caenorhabditis elegans genome, but with comparable functional diversity.

A BAC-based physical map of the major autosomes of Drosophila melanogaster

We constructed a bacterial artificial chromosome (BAC)-based physical map of chromosomes 2 and 3 of Drosophila melanogaster, which constitute 81% of the genome. Sequence tagged site (STS) content, restriction fingerprinting, and polytene chromosome in situ hybridization approaches were integrated to produce a map spanning the euchromatin. Three of five remaining gaps are in repeat-rich regions near the centromeres. A tiling path of clones spanning this map and STS maps of chromosomes X and 4 was sequenced to low coverage; the maps and tiling path sequence were used to support and verify the whole-genome sequence assembly, and tiling path BACs were used as templates in sequence finishing.

Comparative genomics of the eukaryotes

A comparative analysis of the genomes of Drosophila melanogaster, Caenorhabditis elegans, and Saccharomyces cerevisiae-and the proteins they are predicted to encode-was undertaken in the context of cellular, developmental, and evolutionary processes. The nonredundant protein sets of flies and worms are similar in size and are only twice that of yeast, but different gene families are expanded in each genome, and the multidomain proteins and signaling pathways of the fly and worm are far more complex than those of yeast. The fly has orthologs to 177 of the 289 human disease genes examined and provides the foundation for rapid analysis of some of the basic processes involved in human disease.

Medication therapy in ambulatory medical care. National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 1992

OBJECTIVES

This report describes medications provided or prescribed during ambulatory medical care visits in 1992. Total ambulatory care medication therapy combines data from office-based physicians, hospital outpatient departments (OPD's), and hospital emergency departments (ED's). Drug therapy is described along three dimensions: number of drugs provided or prescribed (drug mention), whether a visit had any drugs mentioned (drug visit), and average number of drugs mentioned per 100 visits (drug mention rate). Utilization in ambulatory care settings is compared in terms of patient, drug, provider, and visit characteristics.

METHODS

Annual use of medication therapy was determined using data collected in the 1992 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS). NAMCS includes office visits to nonfederal physicians principally engaged in office practice. The target universe of NHAMCS includes visits to ED's and OPD's of non-Federal, short-stay, or general hospitals. Sample data were weighted to produce annual estimates. Drug mentions are defined as the number of drugs mentioned on the patient record from.

RESULTS

An estimated 1.1 billion medications were provided or prescribed at ambulatory care visits in 1992. The setting with the greatest percent of visits with medication therapy was the ED; OPD's had the lowest percent with medications. Patients at the ED were provided more pain relief type drugs. The rate of drug mentions and percent of visits with medications were significantly higher in OPD clinics of general medicine and pediatrics compared with other types of OPD clinics. In office-based settings, physicians specializing in cardiovascular diseases were most likely to prescribe medications. Also, cardiovascular-renal type drugs accounted for the largest percent of office-based drug mentions. Visits with illness diagnoses are most likely to receive medication therapy. Trend data comparing 1980 to 1992 office-based mentions showed significant changes on several characteristics: single-ingredient drug status, physician specialty, and patient age.

CONCLUSIONS

The profile of patients using office- and hospital-based ambulatory care settings are quite different as is the case-mix of conditions. These differences play an important role in medications utilized. The aging of the U.S. population from 1980 to 1992 appeared to have significant effects on several drug mention characteristics.

Cytogenetic analysis of chromosome region 89A of Drosophila melanogaster: isolation of deficiencies and mapping of Po, Aldox-1 and transposon insertions

We have initiated a cytogenetic analysis of chromosome region 89A of Drosophila melanogaster by isolating a set of radiation-induced mutations causing loss of function of P[(w)B]1-1, a transposon bearing the white locus inserted in 89A. Complementation tests and cytological examination of these chromosomes identified four new deficiencies (Df(3R)Po2, Df(3R)Po3, Df(3R)Po4 and Df(3R)c(3)G2). The new deficiencies and three previously identified deficiencies (Df(3R)sbd26, Df(3R)sbd45 and Df(3R)sbd105) were tested for the ability to complement mutations in the enzyme loci Po and Aldox-1, the indirect flight muscle genes Tm2 and act88F, the morphological mutations jvl, sbd2 and Sb, the vital loci srp, pnr and mor, and a newly described vital locus l(3)89Aa. We also used linkage analysis to determine the order and relative positions of P[(w)B]1-1 and an independent transposon insertion, P[w+]21, with respect to cv-c, Po, Aldox-1 and sbd2. Cytological examination of the deficiencies and analysis of the transformed lines by in situ hybridization permits the correlation of genetically defined regions with specific polytene chromosome bands. A revised cytogenetic map of the 88F-89B region is presented.

Timing of mitotic chromosome loss caused by the ncd mutation of Drosophila melanogaster

We studied the timing of mitotic loss of maternally and paternally derived chromosomes among the progeny of Drosophila melanogaster females homozygous for an amorphic mutation in ncd, a gene encoding a kinesin-like protein. In order to determine the division at which chromosome loss occurs, we estimated the fraction of XO nuclei resulting from X chromosome loss by scoring the phenotype of 47 adult cuticular landmarks in 160 XX-XO mosaics (gynandromorphs) derived from maternal X chromosome loss, and 33 gynandromorphs derived from paternal X chromosome loss. The results show that while most of the mitotic loss of maternally derived chromosomes occurs at the first cleavage division, the mitotic loss of paternally derived chromosomes occurs only at the second and later divisions. This means that paternally derived chromosomes are immune from the effects of ncd prior to karyogamy, which occurs after the first cleavage division. We discuss the implications of these results for the function of the ncd gene product and for other kinesin-like proteins in Drosophila.

Genetic analysis of the claret locus of Drosophila melanogaster

The claret (ca) locus of Drosophila melanogaster comprises two separately mutable domains, one responsible for eye color and one responsible for proper disjunction of chromosomes in meiosis and early cleavage divisions. Previously isolated alleles are of three types: (1) alleles of the claret (ca) type that affect eye color only, (2) alleles of the claret-nondisjunctional (cand) type that affect eye color and chromosome behavior, and (3) a meiotic mutation, non-claret disjunctional (ncd), that affects chromosome behavior only. In order to investigate the genetic structure of the claret locus, we have isolated 19 radiation-induced alleles of claret on the basis of the eye color phenotype. Two of these 19 new alleles are of the cand type, while 17 are of the ca type, demonstrating that the two domains do not often act as a single target for mutagenesis. This suggests that the two separately mutable functions are likely to be encoded by separate or overlapping genes rather than by a single gene. One of the new alleles of the cand type is a chromosome rearrangement with a breakpoint at the position of the claret locus. If this breakpoint is the cause of the mutant phenotype and there are no other mutations associated with the rearrangement, the two functions must be encoded by overlapping genes.

Assimilation of cholesterol by Lactobacillus acidophilus

Considerable variation was found among strains of Lactobacillus acidophilus isolated from the fecal flora of pigs with regard to the ability to grow well in the presence of bile and to assimilate cholesterol from a laboratory growth medium. The uptake of cholesterol occurred only when the culture(s) was growing in the presence of bile under anaerobic conditions. Consumption of L. acidophilus RP32, which was selected for its ability to grow well in the presence of bile and to assimilate cholesterol from the laboratory medium, significantly inhibited increases in serum cholesterol levels of pigs (P less than 0.05) fed a high-cholesterol diet. Consumption of L. acidophilus P47, which was selected for its ability to grow in the presence of bile and lack of ability to remove cholesterol from the growth medium, failed to have a similar effect. This indicates that certain strains of L. acidophilus act directly on cholesterol in the gastrointestinal tract, and thus may be beneficial in reducing serum cholesterol levels.