Hospital‐At‐Home for Respiratory Diseases—Opportunities and Challenges

Respiratory diseases impose a staggering global health burden, accounting for more than 4 million deaths annually [1], with COPD, lower respiratory tract infections, and lung cancer among the top causes of mortality worldwide. The Asia Pacific region accounts for 70 million cases [2], exacerbated by air pollution and high prevalence of tuberculosis (TB). These conditions create a substantial burden on acute hospital care across all health systems. As populations age and health workers are in shortage, health systems globally are shifting focus from hospital-based to community-based care [3]. For acute care shifts, hospital-at-home has emerged as a compelling model to supplement traditionally brick-and-mortar (BAM) hospital-focused care. Hospital-at-home (HaH) is an acute substitutive clinical service that provides care typically delivered in hospital wards to selected patients in the comfort of their home [4]. Patients may be admitted to HaH through three routes: (A) from the BAM ward to complete their admission at home; (B) admitted directly from the Emergency Department (ED) to HaH without an initial stay in the BAM ward; and (C) referred directly from primary care or community care providers to HaH, bypassing both the ED and the BAM ward (Figure 1). In all routes, HaH substitutes BAM bed days, with advantages including: recovery in a familiar setting, reduced risk of hospital-acquired infections and functional decline, and expanded capacity without investing in new hospital infrastructure. Originating in Europe in the 1960s and gaining momentum in Australia (1990s) and the United States (2000s), HaH has surged globally in the past 5 years, catalysed by the COVID-19 pandemic. Several meta-analyses have demonstrated that for well-selected patients [5, 6], HaH treatment outcomes are similar to BAM, may be delivered at lower cost, and with high levels of patient satisfaction. In Asia, HaH units in Singapore [7] and Taiwan developed in the past 5 years have shown that HaH can be effective and scale within diverse health systems. Across the broad spectrum of conditions that HaH has been applied to—including general medical conditions, geriatric, heart failure, oncology—respiratory conditions like COPD and lower respiratory tract infections feature dominantly. The most well-studied condition is the management of selected COPD patients with acute exacerbations (AECOPD) [8]. Echevarria et al. [9] suggested that the cost of HaH in AECOPD could be lower than in BAM in addition to a trend towards lower mortality. Unsurprisingly, selected lower-risk-acquired pneumonia patients can be safely managed with HaH with daily nursing assessment, careful pulse oximetry monitoring, and early switch from intravenous to oral antibiotics. In a small study in New Zealand, Richards et al. [10] showed that home treatment of mild to moderately severe pneumonia, assessed using the CURB-65 scoring system, is an effective alternative to hospital treatment. The selection of patients to be admitted to the HaH care model is key. A low ‘DECAF’ score [9] has been suggested as a safe triaging tool to select those AECOPD patients for HaH with resultant cost savings (due to reduced hospital bed-days) and no deaths recorded in the acute period. More broadly, in a RCT reported by Levine et al. [11], the mean cost of the acute episode was shown to be 38% lower for patients cared for at home versus usual inpatient care. Of the acute medical episodes examined, COPD, asthma, and pneumonia featured prominently. Fewer laboratory and imaging studies and a reduction in specialist consults were similarly reported. Similarly, Hernandez et al. [12] showed that in HaH for COPD, asthma, and pneumonia, there was less healthcare resource utilisation, concurring with the earlier findings. There was no difference in readmissions and mortality in the HaH group versus the usual hospital care group. In summary, across the major respiratory diseases which contribute to inpatient care burden, the adoption of HaH for selected COPD exacerbations, asthma, and pneumonia patients has been shown to be safe with cost savings. More recently, as the general population has become familiar with the use of pulse oximetry measurement during and after the COVID-19 pandemic, HaH for respiratory diseases is even more feasible than before. For Asian health systems with existing HaH programmes, strengthening capabilities to manage respiratory diseases should be a strategic priority. This includes integrating HaH with chronic disease programmes (e.g., COPD) for early identification and treatment of acute exacerbations, and ensuring capabilities to rapidly initiate oxygen therapy, nebulised medications, and early diagnostics at home. The COVID-19 pandemic offered a large-scale proof of concept, where home-based oxygen monitoring and telemedicine were deployed at speed and scale. In a recent qualitative evidence synthesis, Wallis et al. [13] summarised factors influencing implementation of HaH. Specifically for Asian health systems yet to adopt HaH, adoption in Asia faces three key barriers. First, Asia's heterogeneous geography, hospital admission practices and treatment protocols demand tailored local models that balance rural and urban needs, adapt to island geographies and align with existing care pathways. Second, health system financing for HaH admissions must be similar to BAM admissions, to ensure that patients are not denied access due to higher out-of-pocket expenses. Policy shifts in Singapore and Taiwan in 2024 to extend hospitalisation subsidies and insurance coverage to HaH have been a critical enabler. Third, multi-generational households are common in Asian communities with high involvement of family caregivers [14]. Their active involvement as partners and stakeholders can accelerate implementation of HaH. To advance respiratory HaH in Asia, three areas merit focused research and innovation. First, pushing clinical boundaries with technology and innovation [15], including exploring the use of non-invasive ventilation, continuous vital signs monitoring, remote digital auscultation, Point of Care Ultrasound and mobile chest radiography. Second, adapting respiratory HaH for rural and resource-limited settings. Third, investigating how living conditions (e.g., smoking, overcrowding) may weigh against the benefits of HaH care and developing mitigation strategies. Given the global burden of respiratory hospitalisations, HaH in respiratory care has the potential to deliver substantial benefits for patients and health systems. The model's capacity to absorb surges in demand, as demonstrated during the COVID-19 pandemic, also positions HaH as a key strategy in pandemic preparedness. Therein lies a present opportunity for HaH to meet Asia's rising demands for respiratory admissions with a model that is patient-centred, scalable and resilient. The authors declare no conflicts of interest.