[The authors respond:]
In our review of the research evidence regarding the health and cost effects of substituting home care services for some inpatient acute care, [1] we drew 2 conclusions. First, although the evidence indicates that such home care has no notable effects on patients' or caregivers' health, it does not establish that this home care reduces health care costs. Second, the available, internally valid evidence is very limited, so well-designed evaluations of this home care are urgently needed. Michael Montalto's comments are consistent with our conclusions.
He argues that "genuine acute home care programs" were not evaluated in the 4 most valid studies we reviewed. We disagree. Those studies involved health conditions for which home care is thought appropriate clinically, and, in the programs evaluated, health professionals provided services in patients' homes that were substituted for inpatient care.
Montalto also argues that we should have considered 3 other studies. Two of them [2, 3] evaluated programs in which patients with venous thrombosis self-injected heparin at home, not programs involving health professionals providing services in patients' homes. Moreover, had we included these 2 studies, there would still be no evidence that home care was cost-effective for most health conditions for which it was being used. The third study [4] concluded that home care was cost-effective. However, the cost-effect estimate is questionable. Inappropriate cost calculations were made by using hospital revenue data (i.e., diagnostic-related group reimbursement rates). The researchers did not estimate the change, caused by the use of home care, in the value of the hospital resources used to manage the patients' health problems.
Lee Soderstrom, PhD
McGill University; Montreal, Que.
Pierre Tousignant, MD
Montreal-Centre Regional Council for Health and Social Services; Montreal, Que.
Terry Kaufman, LLB
Centre local des Services communautaires; Notre Dame de Grace-Montreal West; Montreal, Que.