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Director; Hospital in the Home; Frankston Hospital; Frankston, Victoria; Australia
None of the 4 selected class 1 studies in the review paper by Lee Soderstrom and colleagues [1] reported genuine acute home care programs. In the selected studies, the definitions of acute home-based care were problematic. Richards and colleagues [2] described hospital in the home (HIH) as "a generic term, referring to a package of home based nursing and rehabilitation services," whereas Shepperd and colleagues [3] restricted the eligibility to patients older than 60 years with 5 broadly defined conditions. These studies included patients selected on the basis of their clinical condition and its burden on the hospital, rather than on the basis that they had definite acute care needs and that this care could be appropriately delivered at home. The presence of validated research instruments seemed to influence the conditions chosen for inclusion in some trials. Data on the length of stay presented in these trials suggest strongly that the programs were additive to hospital stays and not substitutive.
The appropriate definition of HIH is one in which the patient requires treatment that, without the presence of the HIH, would otherwise require care in hospital. Substitution is the critical component of HIH care; it can be demonstrated through the use of hospital technologies or drugs not usually associated with community care (e.g., intravenous therapy and pumps, low molecular weight heparin), by the delivery of 24-hour care to patients or by the fact that hospitals retain the legal and financial responsibility for care provision. None of these preconditions is apparent in the selected class 1 studies. Valid selections would have included the randomized controlled trials by Levine and colleagues [4] and Koopman and colleagues [5] in the management of deep venous thrombosis and by Wolter and colleagues [6] in the management of cystic fibrosis at home.
Without firm definitions and consistent clinical applications with which to define the interventions, cost comparisons are as problematic as assessments of the clinical outcomes of such trials. In an assessment of the cost of HIH care for the delivery of intravenous therapy to patients with cellulitis, [7] HIH admissions were approximately 40% less costly for patients admitted to the HIH directly from the emergency department and approximately 30% less costly for patients who required a stay within the hospital itself. The greatest savings were found in hospital overhead costs and nursing salaries, while HIH was more costly in the provision of pharmaceuticals and procedures. The results concurred with my clinical experience in the delivery of acute care to over 1200 patients at home. [8,9]
Systematic reviews of complex health service interventions such as HIH should be used with great care and usually resist efforts at reductionism. The results of the article by Soderstrom and colleagues [1] must be scrutinized in that light. The challenge is to establish high-quality HIH programs and then test their efficiency in a randomized controlled trial for a variety of clinical conditions and therapeutic interventions. To do otherwise is, to borrow from the biomedical vocabulary, to skip phases 1 and 2 and go straight to phase 3 trials.
Michael Montalto, MD, PhD
Director; Hospital in the Home; Frankston Hospital; Frankston, Victoria; Australia
References
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Copyright 1995-1999, Canadian Medical Association. All rights reserved. ISSN 1488-2329
(e) 0820-3946 (p)
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association. |
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