Retrospective Comparison of Pneumonia Complications in Older Adults: Acute Hospital Admission versus Hospital at Home

Retrospective Comparison of Pneumonia Complications in Older Adults: Acute Hospital Admission versus Hospital at Home | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Retrospective Comparison of Pneumonia Complications in Older Adults: Acute Hospital Admission versus Hospital at Home Dr Ruqaiyah Behranwala, Dr Kyaw Myat Thu, Dr Michelle Carr This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8622467/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Community acquired pneumonia (CAP) is a common cause of hospital admission among older adults and is associated with significant morbidity, particularly in frail populations. Hospital at Home (HAH) services have emerged as an alternative model of acute care delivery, aiming to reduce hospital-related complications while maintaining clinical effectiveness. Methods We conducted a retrospective comparative study within a single NHS trust over one year, comparing outcomes of older adults treated for CAP or lower respiratory tract infection (LRTI) with intravenous antibiotics either through a HAH service or on an elderly care ward. Data were extracted from electronic health records. Outcomes included length of stay, rates of delirium, acute kidney injury and 12-month mortality. Nonparametric and categorical statistical comparisons were performed as appropriate. Results A total of 172 patients were included (64 HAH, 108 inpatients). Length of stay was significantly shorter in the HAH cohort (median 4 vs 10 days; p < 0.001). Delirium occurred less frequently in HAH patients (9% vs 37%; p < 0.001). Rates of acute kidney injury were lower in HAH but did not reach statistical significance (17% vs 25%; p = 0.22). A greater proportion of HAH patients were receiving palliative care (33% vs 12%; p = 0.002). Twelve-month mortality was higher in the HAH cohort (59% vs 34%; p = 0.004). Conclusions In selected frail older adults with CAP or LRTI, management through a Hospital at Home service was associated with shorter length of stay and fewer in-hospital complications, despite higher baseline frailty and greater palliative care needs. Hospital at Home Community acquired pneumonia Frailty Older adults Introduction Hospital at home (HAH) is increasingly used internationally as an alternative model of healthcare delivery [ 1 , 2 ]. By providing acute hospital-level care in the home environment, HAH offers a flexible approach that may reduce exposure to hospital-associated harms while supporting patient preferences to remain at home [ 3 ]. Service models vary across healthcare systems according to patient selection, staffing and the intensity of clinical input provided. Broadly, two models are recognised. Admission avoidance, whereby patients are treated entirely at home instead of hospital admission, and early supported discharge, which facilitates earlier discharge from hospital with ongoing treatment delivered by a HAH team [ 4 ]. In England, HAH services currently manage approximately 35,000 patients each month [ 4 ]. Recent national policy initiatives have supported further expansion of these services reflecting a broader shift towards care models that prioritise person-centred outcomes, optimise time spent at home, and reduce pressure on acute hospital services [ 5 ]. Existing evidence suggests that HAH is associated with lower healthcare costs and high levels of patient satisfaction [ 6 , 7 ]. Regular clinical review and the use of remote monitoring have shown to enhance patient reassurance, safety, and autonomy. Community-acquired pneumonia (CAP) remains a significant cause of morbidity and mortality among older adults. It accounts for approximately 5 to 12% of lower respiratory tract infections (LRTI) managed in primary care, with between 22% and 42% of affected individuals requiring hospital admission [ 8 ]. Mortality among hospitalised patients ranges from 5% to 14%, contributing to more than 25,000 deaths annually in the UK [ 9 ]. Outcomes are particularly poor among frail older adults, who are at increased risk of functional decline, delirium, and other hospital-associated complications [ 10 ]. As demand for acute hospital care continues to rise, there is growing interest in alternative models that enable the safe and effective management of selected patients with CAP outside the traditional inpatient setting. Methods Study Design and Setting A retrospective comparative study was conducted at Frimley Health NHS Foundation Trust. The study examined outcomes for older adults treated for CAP or LRTI across two care settings: the HAH service and an elderly care ward at Frimley Park Hospital. The study period was January to December 2024. Study Population Patients were included if they were diagnosed with CAP or LRTI and treated with IV antibiotics. Patients managed through the HAH service received once daily IV ceftriaxone at home. Patients admitted to the elderly care ward received IV antibiotic therapy according to local hospital guidelines. Exclusion criteria included infective exacerbation of chronic obstructive pulmonary disease (IECOPD), aspiration pneumonia, hospital-acquired pneumonia (HAP), COVID-19 pneumonia, influenza or COVID-19 infection with superadded bacterial infection, an unclear source of infection and subsequent admission to an acute hospital following initial assessment by the HAH service. Patients referred to HAH from hospital for continuation of treatment as part of an early supported discharge pathway were also excluded from analysis. Data Collection Data was retrospectively extracted from electronic health records and included demographic characteristics, Clinical Frailty Scale (CFS) scores, National Early Warning Scores (NEWS) at presentation, duration of IV antibiotic therapy, length of stay, and clinical outcomes. Outcome Measures The primary outcome measures were length of stay, development of delirium and development of acute kidney injury (AKI). Secondary outcomes were hospital readmission within 4 weeks with CAP and all-cause mortality within 6 months. Statistical Analysis Continuous variables were assessed for distribution using summary statistics and visual inspection. Variables demonstrating skewed distributions, including CFS scores, NEWS at presentation, duration of IV antibiotic therapy and length of stay, were analysed using non-parametric methods and are presented as medians where appropriate. Comparisons between groups for continuous variables were performed using the Mann–Whitney U test. Categorical variables, including the development of AKI, delirium, palliative care status, readmission and 12-month mortality, were compared using the χ² test. Statistical significance was defined as a two-sided p value of < 0.05. Given the exploratory nature of this retrospective study, no adjustment was made for multiple comparisons. Results During the study period, 64 patients managed through the HAH service and 108 patients admitted to an elderly care ward met the inclusion criteria. The mean age was 85 years in both cohorts. Baseline frailty, as measured by the Clinical Frailty Scale (CFS), was significantly higher in the HAH cohort compared with hospital inpatients (median 7 vs 5, p < 0.001). The median National Early Warning Score (NEWS) on presentation was lower in the HAH cohort compared with hospital inpatients (4 vs 5, p = 0.01), indicating less acute physiological derangement among patients treated under HAH. The median duration of intravenous antibiotic therapy was shorter in the HAH cohort (4 days vs 5 days, p = 0.29) however not statistically significant, demonstrating similar treatment intensity across care settings. Length of stay was significantly shorter for patients managed through HAH compared with hospital inpatients (median 4 vs 10 days; p < 0.001). 17% of HAH patients developed acute kidney injury compared with 25% of hospital inpatients (p = 0.22). Delirium occurred less frequently in the HAH cohort, affecting 9% of patients compared with 37% of hospital inpatients (p < 0.001). A higher proportion of HAH patients were receiving palliative care (33% vs 12%; p = 0.002). Hospital readmission within 4 weeks occurred in 8% of HAH patients versus 12% of inpatients (p = 0.42), with no statistically significant difference. 12-month all-cause mortality was higher among HAH patients compared with hospital inpatients (59% vs 34%; p = 0.004). Variable HAH (n = 64) Hospital Inpatients (n = 108) Statistical Test p-value Age (years) 85 ± 6 85 ± 7 Mann–Whitney U 0.99 Clinical Frailty Score, median (IQR) 7 (6,7) 5 (5,6) Mann–Whitney U < 0.001* NEWS on admission, median (IQR) 4 (3,6) 5 (3,7) Mann–Whitney U 0.01* IV antibiotics duration in days, median (IQR) 4 (3,6) 5 (4,7) Mann–Whitney U 0.29 Length of stay in days, median 4 (3,6) 10 (7,17) Mann–Whitney U < 0.001* AKI (%) 17% 25% χ² test 0.22 Delirium (%) 9% 37% χ² test < 0.001* Palliative care (%) 33% 12% χ² test 0.002* Readmission (%) 8% 12% χ² test 0.42 12-month mortality (%) 59% 34% χ² test 0.004* *Statistically significant at α = 0.05 Table 1. Baseline characteristics, treatment, and outcomes of patients with community-acquired pneumonia or lower respiratory tract infection managed through Hospital at Home (HAH) or admitted to an elderly care ward. Abbreviations: HAH, Hospital at Home; NEWS, National Early Warning Score; IV, intravenous; LOS, length of stay; AKI, acute kidney injury. Notes: Continuous variables are presented as mean ± standard deviation or median (for skewed distributions). Categorical variables are presented as number (%). Mann–Whitney U test was used for non-parametric continuous variables (CFS, NEWS, IV antibiotic duration, LOS). χ² test was used for categorical variables (AKI, delirium, palliative care, 12-month mortality). *p < 0.05 was considered statistically significant. Length of stay reflects the total duration of care under HAH or hospital admission. Discussion Overall, despite higher baseline frailty and palliative care needs, HAH patients had significantly shorter lengths of stayand lower rates of delirium compared with hospital inpatients. Duration of IV antibiotic therapy was comparable between groups and rates of acute kidney injury were lower in the HAH cohort, although this difference did not reach statistical significance. A key finding of this study was the significant reduction in length of stay among HAH patients. Delivering acute treatment in a familiar home environment may contribute to earlier clinical stability and better preservation of functional status. Additionally, inpatient admissions are frequently prolonged by discharge planning requirements even after patients are deemed medically fit, particularly among older adults with social care needs. Home-based care may also enable earlier alignment of treatment with patient goals, including timely decisions to prioritise comfort and palliative management, avoiding prolonged admission and active treatment. The significantly lower incidence of delirium observed in the HAH cohort was notable and aligns with existing evidence highlighting hospital admission as a major risk factor for delirium in frail older adults. Environmental factors, sleep disruption, immobility, and exposure to unfamiliar surroundings are well recognised contributors to delirium risk and management in the home setting mitigates several of these factors [11]. Although rates of acute kidney injury were lower in the HAH cohort, this difference did not reach statistical significance. This trend may reflect differences in treatment delivery and care context, including reduced frequency of IV antibiotic administration and greater opportunity for oral fluid intake in the home environment. Twelve-month mortality was higher in the HAH cohort which may be explained by the greater baseline frailty and higher proportion of patients receiving palliative care in this group. This highlights the importance of interpreting mortality outcomes within the context of patient characteristics and care goals, particularly in geriatric populations where survival may not be the primary outcome of interest. Strengths and Limitations Strengths This study provides data on a geriatric population often underrepresented in clinical trials. Inclusion of geriatric-relevant variables and outcomes, including frailty, delirium, AKI and palliative care status, strengthens the applicability of the findings to routine practice. The results support HAH as a viable alternative to inpatient care for selected older adults with CAP which may help inform service planning across similar healthcare settings. The use of non-parametric statistical methods appropriately accounts for the advanced age, frailty and skewed distributions common in this population. Limitations The retrospective, non-randomised design introduces the potential for selection bias and unmeasured confounding, limiting causal inference. The study was conducted within a single NHS trust, which may limit generalisability to other settings with different HAH structures or patient populations. Sample size may have limited the ability to detect statistically significant differences in less frequent outcomes such as AKI. Additionally, data on patient reported outcomes were not captured, which may be relevant for future evaluations of HAH services. Conclusion This study suggests that HAH is a feasible and potentially advantageous model for the management of selected older adults with CAP or LRTI, offering shorter lengths of stay and reduced rates of delirium despite higher baseline frailty. Prospective, multi-centre studies are needed to further assess the safety, efficacy, and cost-effectiveness of HAH in frail older populations across diverse healthcare systems. Inclusion of quality of life and caregiver experience would provide a more comprehensive assessment of the impact of HAH. Abbreviations HAH Hospital at Home NEWS National Early Warning Score IV intravenous LOS length of stay AKI acute kidney injury. References Corrado OJ (2001) Hospital-at-home. Age Ageing 30(Suppl 3):11–14. 10.1093/ageing/30.suppl_3.11 Nikmanesh P, Arabloo J, Gorji HA (2024) Dimensions and components of hospital-at-home care: a systematic review. BMC Health Serv Res 24(1):1458. 10.1186/s12913-024-11970-5 Denecke K, Reichenpfader D (2024) Preparing for hospital at home: a review of the current landscape of training practices. Stud Health Technol Inf 321:48–52. 10.3233/SHTI241060 British Geriatrics Society, UK Hospital at Home Society. Hospital at Home for frailty: current situation and future potential [Internet] (2025) Aug 8. Available from: https://www.bgs.org.uk/HospitalAtHomeFrailty Department of Health and Social Care, Prime Minister’s Office 10 Downing Street. Fit for the future: 10 Year Health Plan for England (accessible version) [Internet]. London: GOV.UK (2025) Jul 3. Available from: https://www.gov.uk/government/publications/10-year-health-plan-for-england-fit-for-the-future/fit-for-the-future-10-year-health-plan-for-england-accessible-version\ Coast J, Richards SH, Peters TJ, Gunnell D, Darlow MA, Pounsford J et al (1998) Hospital at home or acute hospital care? A cost minimisation analysis. BMJ 316(7147):1802–1806. 10.1136/bmj.316.7147.1802 Shepperd S, Doll H, Angus RM et al (2009) Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data. CMAJ 180(2):175–182. 10.1503/cmaj.081491 National Institute for Health and Care Excellence. Pneumonia: diagnosis and management (NICE guideline NG250) [Internet]. London: NICE (2025) Sep 02. Available from: https://www.nice.org.uk/guidance/ng250 British Thoracic Society. National adult community acquired pneumonia audit 2018/19 [Internet]. London: British Thoracic Society (2019) Available from: https://www.brit-thoracic.org.uk/quality-improvement/clinical-audit/national-adult-community-acquired-pneumonia-audit-201819/ Zhao H, Tu J, She Q, Li M, Wang K, Zhao W et al (2023) Prognostic significance of frailty in hospitalized elderly patients with community-acquired pneumonia: a retrospective cohort study. BMC Geriatr 23:308. 10.1186/s12877-023-04029-3 Marcantonio ER (2017) Delirium in hospitalized older adults. N Engl J Med 377(15):1456–1466 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Home\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHospital at home (HAH) is increasingly used internationally as an alternative model of healthcare delivery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. By providing acute hospital-level care in the home environment, HAH offers a flexible approach that may reduce exposure to hospital-associated harms while supporting patient preferences to remain at home [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Service models vary across healthcare systems according to patient selection, staffing and the intensity of clinical input provided. Broadly, two models are recognised. Admission avoidance, whereby patients are treated entirely at home instead of hospital admission, and early supported discharge, which facilitates earlier discharge from hospital with ongoing treatment delivered by a HAH team [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn England, HAH services currently manage approximately 35,000 patients each month [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Recent national policy initiatives have supported further expansion of these services reflecting a broader shift towards care models that prioritise person-centred outcomes, optimise time spent at home, and reduce pressure on acute hospital services [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Existing evidence suggests that HAH is associated with lower healthcare costs and high levels of patient satisfaction [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Regular clinical review and the use of remote monitoring have shown to enhance patient reassurance, safety, and autonomy.\u003c/p\u003e \u003cp\u003eCommunity-acquired pneumonia (CAP) remains a significant cause of morbidity and mortality among older adults. It accounts for approximately 5 to 12% of lower respiratory tract infections (LRTI) managed in primary care, with between 22% and 42% of affected individuals requiring hospital admission [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Mortality among hospitalised patients ranges from 5% to 14%, contributing to more than 25,000 deaths annually in the UK [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Outcomes are particularly poor among frail older adults, who are at increased risk of functional decline, delirium, and other hospital-associated complications [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. As demand for acute hospital care continues to rise, there is growing interest in alternative models that enable the safe and effective management of selected patients with CAP outside the traditional inpatient setting.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eA retrospective comparative study was conducted at Frimley Health NHS Foundation Trust. The study examined outcomes for older adults treated for CAP or LRTI across two care settings: the HAH service and an elderly care ward at Frimley Park Hospital. The study period was January to December 2024.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003ePatients were included if they were diagnosed with CAP or LRTI and treated with IV antibiotics. Patients managed through the HAH service received once daily IV ceftriaxone at home. Patients admitted to the elderly care ward received IV antibiotic therapy according to local hospital guidelines.\u003c/p\u003e \u003cp\u003eExclusion criteria included infective exacerbation of chronic obstructive pulmonary disease (IECOPD), aspiration pneumonia, hospital-acquired pneumonia (HAP), COVID-19 pneumonia, influenza or COVID-19 infection with superadded bacterial infection, an unclear source of infection and subsequent admission to an acute hospital following initial assessment by the HAH service. Patients referred to HAH from hospital for continuation of treatment as part of an early supported discharge pathway were also excluded from analysis.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData was retrospectively extracted from electronic health records and included demographic characteristics, Clinical Frailty Scale (CFS) scores, National Early Warning Scores (NEWS) at presentation, duration of IV antibiotic therapy, length of stay, and clinical outcomes.\u003c/p\u003e\n\u003ch3\u003eOutcome Measures\u003c/h3\u003e\n\u003cp\u003eThe primary outcome measures were length of stay, development of delirium and development of acute kidney injury (AKI). Secondary outcomes were hospital readmission within 4 weeks with CAP and all-cause mortality within 6 months.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were assessed for distribution using summary statistics and visual inspection. Variables demonstrating skewed distributions, including CFS scores, NEWS at presentation, duration of IV antibiotic therapy and length of stay, were analysed using non-parametric methods and are presented as medians where appropriate. Comparisons between groups for continuous variables were performed using the Mann\u0026ndash;Whitney U test.\u003c/p\u003e \u003cp\u003eCategorical variables, including the development of AKI, delirium, palliative care status, readmission and 12-month mortality, were compared using the χ\u0026sup2; test. Statistical significance was defined as a two-sided p value of \u0026lt;\u0026thinsp;0.05. Given the exploratory nature of this retrospective study, no adjustment was made for multiple comparisons.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the study period, 64 patients managed through the HAH service and 108 patients admitted to an elderly care ward met the inclusion criteria. The mean age was 85 years in both cohorts. Baseline frailty, as measured by the Clinical Frailty Scale (CFS), was significantly higher in the HAH cohort compared with hospital inpatients (median 7 vs 5, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The median National Early Warning Score (NEWS) on presentation was lower in the HAH cohort compared with hospital inpatients (4 vs 5, p\u0026thinsp;=\u0026thinsp;0.01), indicating less acute physiological derangement among patients treated under HAH. The median duration of intravenous antibiotic therapy was shorter in the HAH cohort (4 days vs 5 days, p\u0026thinsp;=\u0026thinsp;0.29) however not statistically significant, demonstrating similar treatment intensity across care settings.\u003c/p\u003e \u003cp\u003eLength of stay was significantly shorter for patients managed through HAH compared with hospital inpatients (median 4 vs 10 days; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). 17% of HAH patients developed acute kidney injury compared with 25% of hospital inpatients (p\u0026thinsp;=\u0026thinsp;0.22). Delirium occurred less frequently in the HAH cohort, affecting 9% of patients compared with 37% of hospital inpatients (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A higher proportion of HAH patients were receiving palliative care (33% vs 12%; p\u0026thinsp;=\u0026thinsp;0.002). Hospital readmission within 4 weeks occurred in 8% of HAH patients versus 12% of inpatients (p\u0026thinsp;=\u0026thinsp;0.42), with no statistically significant difference. 12-month all-cause mortality was higher among HAH patients compared with hospital inpatients (59% vs 34%; p\u0026thinsp;=\u0026thinsp;0.004).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHAH (n\u0026thinsp;=\u0026thinsp;64)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHospital Inpatients (n\u0026thinsp;=\u0026thinsp;108)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistical Test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u0026thinsp;\u0026plusmn;\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85\u0026thinsp;\u0026plusmn;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMann\u0026ndash;Whitney U\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical Frailty Score, median (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (6,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (5,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMann\u0026ndash;Whitney U\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNEWS on admission, median (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMann\u0026ndash;Whitney U\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.01*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIV antibiotics duration in days, median (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (4,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMann\u0026ndash;Whitney U\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of stay in days, median\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (7,17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMann\u0026ndash;Whitney U\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAKI (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDelirium (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePalliative care (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReadmission (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e12-month mortality (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u0026sup2; test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.004*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Statistically significant at α\u0026thinsp;=\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;1. Baseline characteristics, treatment, and outcomes of patients with community-acquired pneumonia or lower respiratory tract infection managed through Hospital at Home (HAH) or admitted to an elderly care ward.\u003c/b\u003e \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e HAH, Hospital at Home; NEWS, National Early Warning Score; IV, intravenous; LOS, length of stay; AKI, acute kidney injury.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNotes:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eContinuous variables are presented as mean ± standard deviation or median (for skewed distributions).\u003c/li\u003e\n \u003cli\u003eCategorical variables are presented as number (%).\u003c/li\u003e\n \u003cli\u003eMann–Whitney U test was used for non-parametric continuous variables (CFS, NEWS, IV antibiotic duration, LOS).\u003c/li\u003e\n \u003cli\u003eχ² test was used for categorical variables (AKI, delirium, palliative care, 12-month mortality).\u003c/li\u003e\n \u003cli\u003e*p \u0026lt; 0.05 was considered statistically significant.\u003c/li\u003e\n \u003cli\u003eLength of stay reflects the total duration of care under HAH or hospital admission.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Discussion","content":"\u003cp\u003eOverall, despite higher baseline frailty and palliative care needs, HAH patients had significantly shorter lengths of stayand\u0026nbsp;lower rates of delirium\u0026nbsp;compared with hospital inpatients. Duration of IV antibiotic therapy was comparable between groups and rates of acute kidney injury were lower in the HAH cohort, although this difference did not reach statistical significance.\u003c/p\u003e\n\u003cp\u003eA key finding of this study was the significant reduction in length of stay among HAH patients. Delivering acute treatment in a familiar home environment may contribute to earlier clinical stability and better preservation of functional status. Additionally, inpatient admissions are frequently prolonged by discharge planning requirements even after patients are deemed medically fit, particularly among older adults with social care needs. Home-based care may also enable earlier alignment of treatment with patient goals, including timely decisions to prioritise comfort and palliative management, avoiding prolonged admission and active treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe significantly lower incidence of delirium observed in the HAH cohort was notable and aligns with existing evidence highlighting hospital admission as a major risk factor for delirium in frail older adults. Environmental factors, sleep disruption, immobility, and exposure to unfamiliar surroundings are well recognised contributors to delirium risk and management in the home setting mitigates several of these factors [11]. Although rates of acute kidney injury were lower in the HAH cohort, this difference did not reach statistical significance. This trend may reflect differences in treatment delivery and care context, including reduced frequency of IV antibiotic administration and greater opportunity for oral fluid intake in the home environment.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwelve-month mortality was higher in the HAH cohort which may be explained by the greater baseline frailty and higher proportion of patients receiving palliative care in this group. This highlights the importance of interpreting mortality outcomes within the context of patient characteristics and care goals, particularly in geriatric populations where survival may not be the primary outcome of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStrengths\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study provides data on a geriatric population often underrepresented in clinical trials. Inclusion of geriatric-relevant variables and outcomes, including frailty, delirium, AKI and palliative care status, strengthens the applicability of the findings to routine practice. The results support HAH as a viable alternative to inpatient care for selected older adults with CAP which may help inform service planning across similar healthcare settings. The use of non-parametric statistical methods appropriately accounts for the advanced age, frailty and skewed distributions common in this population.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLimitations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe retrospective, non-randomised design introduces the potential for selection bias and unmeasured confounding, limiting causal inference. The study was conducted within a single NHS trust, which may limit generalisability to other settings with different HAH structures or patient populations. Sample size may have limited the ability to detect statistically significant differences in less frequent outcomes such as AKI. Additionally, data on patient reported outcomes were not captured, which may be relevant for future evaluations of HAH services.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study suggests that HAH is a feasible and potentially advantageous model for the management of selected older adults with CAP or LRTI, offering shorter lengths of stay and reduced rates of delirium despite higher baseline frailty. Prospective, multi-centre studies are needed to further assess the safety, efficacy, and cost-effectiveness of HAH in frail older populations across diverse healthcare systems. Inclusion of quality of life and caregiver experience would provide a more comprehensive assessment of the impact of HAH.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHAH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHospital at Home\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNEWS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Early Warning Score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eintravenous\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLOS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elength of stay\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAKI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eacute kidney injury.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCorrado OJ (2001) Hospital-at-home. 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Stud Health Technol Inf 321:48\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3233/SHTI241060\u003c/span\u003e\u003cspan address=\"10.3233/SHTI241060\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBritish Geriatrics Society, UK Hospital at Home Society. Hospital at Home for frailty: current situation and future potential [Internet] (2025) Aug 8. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bgs.org.uk/HospitalAtHomeFrailty\u003c/span\u003e\u003cspan address=\"https://www.bgs.org.uk/HospitalAtHomeFrailty\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDepartment of Health and Social Care, Prime Minister\u0026rsquo;s Office 10 Downing Street. 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London: British Thoracic Society (2019) Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.brit-thoracic.org.uk/quality-improvement/clinical-audit/national-adult-community-acquired-pneumonia-audit-201819/\u003c/span\u003e\u003cspan address=\"https://www.brit-thoracic.org.uk/quality-improvement/clinical-audit/national-adult-community-acquired-pneumonia-audit-201819/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao H, Tu J, She Q, Li M, Wang K, Zhao W et al (2023) Prognostic significance of frailty in hospitalized elderly patients with community-acquired pneumonia: a retrospective cohort study. BMC Geriatr 23:308. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12877-023-04029-3\u003c/span\u003e\u003cspan address=\"10.1186/s12877-023-04029-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarcantonio ER (2017) Delirium in hospitalized older adults. N Engl J Med 377(15):1456\u0026ndash;1466\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Frimley Park Hospital NHS Foundation Trust","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hospital at Home, Community acquired pneumonia, Frailty, Older adults ","lastPublishedDoi":"10.21203/rs.3.rs-8622467/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8622467/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCommunity acquired pneumonia (CAP) is a common cause of hospital admission among older adults and is associated with significant morbidity, particularly in frail populations. Hospital at Home (HAH) services have emerged as an alternative model of acute care delivery, aiming to reduce hospital-related complications while maintaining clinical effectiveness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a retrospective comparative study within a single NHS trust over one year, comparing outcomes of older adults treated for CAP or lower respiratory tract infection (LRTI) with intravenous antibiotics either through a HAH service or on an elderly care ward. Data were extracted from electronic health records. Outcomes included length of stay, rates of delirium, acute kidney injury and 12-month mortality. Nonparametric and categorical statistical comparisons were performed as appropriate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 172 patients were included (64 HAH, 108 inpatients). Length of stay was significantly shorter in the HAH cohort (median 4 vs 10 days; p \u0026lt; 0.001). Delirium occurred less frequently in HAH patients (9% vs 37%; p \u0026lt; 0.001). Rates of acute kidney injury were lower in HAH but did not reach statistical significance (17% vs 25%; p = 0.22). A greater proportion of HAH patients were receiving palliative care (33% vs 12%; p = 0.002). Twelve-month mortality was higher in the HAH cohort (59% vs 34%; p = 0.004).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn selected frail older adults with CAP or LRTI, management through a Hospital at Home service was associated with shorter length of stay and fewer in-hospital complications, despite higher baseline frailty and greater palliative care needs.\u003c/p\u003e","manuscriptTitle":"Retrospective Comparison of Pneumonia Complications in Older Adults: Acute Hospital Admission versus Hospital at Home","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-20 07:56:19","doi":"10.21203/rs.3.rs-8622467/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"56e5d89d-5dc5-4c27-9b4b-a69b7a5746e6","owner":[],"postedDate":"January 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-20T07:56:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-20 07:56:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8622467","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8622467","identity":"rs-8622467","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}