TY - JOUR
T1 - The effect of adapting Hospital at Home to facilitate implementation and sustainment on program drift or voltage drop
AU - Siu, Albert L.
AU - Zimbroff, Robert M.
AU - Federman, Alex D.
AU - Decherrie, Linda V.
AU - Garrido, Melissa
AU - Morano, Barbara
AU - Lubetsky, Sara
AU - Catalan, Elisse
AU - Leff, Bruce
N1 - Funding Information:
Research reported in this publication was supported by the Department of Health and Human Services, Centers for Medicare & Medicaid Services (1C1CMS331334–01-00), the National Institute on Aging Claude D. Pepper Older Americans Independence Center (TS, 3P30AG028741), and The John A. Hartford Foundation. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented was conducted by the awardee. Findings may or may not be consistent with or confirmed by the findings of the independent evaluation contractor.
Publisher Copyright:
© 2019 The Author(s).
PY - 2019/4/29
Y1 - 2019/4/29
N2 - Background: Translating evidence-based interventions from study conditions to actual practice necessarily requires adaptation. We implemented an evidence-based Hospital at Home (HaH) intervention and evaluated whether adaptations could avoid diminished benefit from "voltage drop" (decreased benefit when interventions are applied under more heterogeneous conditions than existing in studies) or "program drift." (decreased benefit arising from deviations from study protocols). Methods: Patients were enrolled in HaH over a 6-month pilot period followed by nine quarters of implementation activity. The program retained core components of the original evidence-based HaH model, but adaptations were made at inception and throughout the implementation. These adaptations were coded as to who made them, what was modified, for whom the adaptations were made, and the nature of the adaptations. We collected information on length of stay (LOS), 30-day readmissions and emergency department (ED) visits, escalations to the hospital, and patient ratings of care. Outcomes were assessed by quarter of admission. Selected outcomes were tracked and fed back to the program leadership. We used logistic or linear regression with an independent variable included for the numerical quarter of enrollment after the initial 6-month pilot phase. Models controlled for season and for patient characteristics. Results: Adaptations were made throughout the implementation period. The nature of adaptations was most commonly to add or to substitute new program elements. HaH services substituting for a hospital stay were received by 295 patients (a mean of 33, range 11-44, per quarter). A small effect of quarter from program inception was seen for escalations (OR 1.09, 95% CI 1.01 to 1.18, p = 0.03), but no effect was observed for LOS (- 0.007 days/quarter; SE 0.02, p = 0.75), 30 day ED visit (OR 0.93, 95% CI 0.86 to 1.01, p = 0.09), 30-day readmission (OR 1.00, 95% CI 0.93 to 1.08, p = 0.99), or patient rating of overall hospital care (OR for highest overall rating 0.99, 95% CI 0.93 to 1.05, p = 0.66). Conclusions: We made adaptations to HaH at inception and over the course of implementation. Our findings indicate that adaptations to evidence-based programs may avoid diminished benefits due to potential 'program drift' or 'voltage drop.' Trial registration: Not applicable. This study is not a clinical trial by the International Committee of Medical Journal Editors (ICMJE) definition because it is an observational study "in which the assignment of the medical intervention is not at the discretion of the investigator.
AB - Background: Translating evidence-based interventions from study conditions to actual practice necessarily requires adaptation. We implemented an evidence-based Hospital at Home (HaH) intervention and evaluated whether adaptations could avoid diminished benefit from "voltage drop" (decreased benefit when interventions are applied under more heterogeneous conditions than existing in studies) or "program drift." (decreased benefit arising from deviations from study protocols). Methods: Patients were enrolled in HaH over a 6-month pilot period followed by nine quarters of implementation activity. The program retained core components of the original evidence-based HaH model, but adaptations were made at inception and throughout the implementation. These adaptations were coded as to who made them, what was modified, for whom the adaptations were made, and the nature of the adaptations. We collected information on length of stay (LOS), 30-day readmissions and emergency department (ED) visits, escalations to the hospital, and patient ratings of care. Outcomes were assessed by quarter of admission. Selected outcomes were tracked and fed back to the program leadership. We used logistic or linear regression with an independent variable included for the numerical quarter of enrollment after the initial 6-month pilot phase. Models controlled for season and for patient characteristics. Results: Adaptations were made throughout the implementation period. The nature of adaptations was most commonly to add or to substitute new program elements. HaH services substituting for a hospital stay were received by 295 patients (a mean of 33, range 11-44, per quarter). A small effect of quarter from program inception was seen for escalations (OR 1.09, 95% CI 1.01 to 1.18, p = 0.03), but no effect was observed for LOS (- 0.007 days/quarter; SE 0.02, p = 0.75), 30 day ED visit (OR 0.93, 95% CI 0.86 to 1.01, p = 0.09), 30-day readmission (OR 1.00, 95% CI 0.93 to 1.08, p = 0.99), or patient rating of overall hospital care (OR for highest overall rating 0.99, 95% CI 0.93 to 1.05, p = 0.66). Conclusions: We made adaptations to HaH at inception and over the course of implementation. Our findings indicate that adaptations to evidence-based programs may avoid diminished benefits due to potential 'program drift' or 'voltage drop.' Trial registration: Not applicable. This study is not a clinical trial by the International Committee of Medical Journal Editors (ICMJE) definition because it is an observational study "in which the assignment of the medical intervention is not at the discretion of the investigator.
KW - Adaptation
KW - Health outcome assessment
KW - Implementation
KW - Quality of care
UR - http://www.scopus.com/inward/record.url?scp=85065241435&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85065241435&partnerID=8YFLogxK
U2 - 10.1186/s12913-019-4063-8
DO - 10.1186/s12913-019-4063-8
M3 - Article
C2 - 31035973
AN - SCOPUS:85065241435
SN - 1472-6963
VL - 19
JO - BMC health services research
JF - BMC health services research
IS - 1
M1 - 264
ER -