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. 1998 Dec 12;317(7173):1652.
Acceptability of early discharge, hospital at home schemes
Treatments that can be safely and acceptably managed at home need to be defined
Editor—Richards et al’s and Shepperd et al’s definitions of what constitutes hospital in the home care are problematic.1,2 Richards et al described hospital in the home as “a generic term, referring to a package of home based nursing and rehabilitation services,” while Shepperd et al restricted the eligible groups of patient to patients older than 60 with five broadly defined conditions.
Our concern with these studies is that patients seem to have been selected on the basis of their clinical condition and its burden on the hospital rather than on the basis that their acute hospital based treatment could be appropriately delivered at home. We also wonder whether the selection of conditions for study was determined by the presence of validated research instruments
The appropriate definition of hospital in the home is one in which the patient requires treatment that, without the presence of a hospital in the home delivery system, would otherwise require care in hospital. Substitution of hospital in the home care for acute hospital care is the critical element. In the above papers, the length of stay data showed that the hospital in the home component was additional to the hospital stay rather than a substitute for it.
It is a pity that both papers chose not to consider non-British publications in their discussions, since considerable activity has occurred outside Britain. In Australia hospital in the home programmes provide acute treatment such as intravenous treatment (giving antibiotics, chemotherapy, inotropes, blood products), giving dalteparin for deep venous thrombosis, and complex postoperative wound care.3–5 Increasingly, patients are admitted to hospital in the home care directly from the emergency department and are considered inpatients in every sense other than that their care is provided at home.5 The hospital retains clinical, fiscal, and legal responsibility for the pharmaceutical input, medical supervision, and nursing care of hospital in the home patients.
Without firm clinical definitions to ensure substitution, cost comparisons are of little value. Most descriptive studies, however, have found cost savings with hospital in the home care if patients are selected carefully.5
The challenge for the future of hospital in the home is to determine which types of treatment in which patient groups can be safely, effectively, and acceptably managed at home and which are the best models for delivering quality outcomes. Trials will need to be clear about the nature of the intervention if they are to be helpful in the future.
References
1.Richards SH, Coast J, Gunnell DJ, Peters TJ, Pounsford J, Darlow M-A. Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care. BMJ. 1998;316:1796–1801. doi: 10.1136/bmj.316.7147.1796. . (13 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Shepperd S, Harwood D, Jenkinson C, Gray A, Vessey M, Morgan P. Randomised controlled trial comparing hospital at home care with inpatient hospital care. 1. Three month follow up of health outcomes. BMJ. 1998;316:1786–1790. doi: 10.1136/bmj.316.7147.1786. . (13 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Montalto M. How safe is hospital in the home care? Med J Aust. 1998;168:277–280. doi: 10.5694/j.1326-5377.1998.tb140161.x. [DOI] [PubMed] [Google Scholar]
4.Ting S, Ziegenbein R, Eng Gan T, Catalano JV, Monagle P, Silvers J, et al. Dalteparin for deep venous thrombosis: a hospital in the home program. Med J Aust. 1998;168:272–276. doi: 10.5694/j.1326-5377.1998.tb140160.x. [DOI] [PubMed] [Google Scholar]
5.Grayson ML. Hospital-in-the-home care: is it worth the hassle? Med J Aust. 1998;168:262–263. doi: 10.5694/j.1326-5377.1998.tb140157.x. [DOI] [PubMed] [Google Scholar]
BMJ. 1998 Dec 12;317(7173):1652.
Care in community hospitals is another alternative
Editor—Two useful papers comparing hospital at home with inpatient hospital care1-1,1-2 did not consider another possible lower cost alternative to acute care in a district general hospital—namely, care in a community hospital.
There are roughly 450 community hospitals in the United Kingdom, with most beds being general practitioner led (data on file, Community Hospitals Association). The recognised roles of such hospitals include general medical care and rehabilitation after falls, strokes, and orthopaedic and general surgery. Seamark et al have reported evidence of good quality care in community hospitals and satisfaction with these hospitals among carers,1-3 and a cost analysis indicated that a community hospital bed cost between a third and a half of a bed in a district general hospital.1-4 The advantages of community hospitals are the proximity to the patients’ homes1-5; the low technology environment, which patients find less intimidating; the continuity of care provided by their own general practitioner and primary healthcare team; and hospital staff who are often known to both the patients and the carers.1-5
Given the uncertainties over effectiveness (albeit for certain clinical groups), costs, and probable increased burden on the primary healthcare team, before extensive investment is made in new hospital at home schemes it would be wise to run comparative studies with community hospital facilities; they have a long track record in the type of medicine targeted for hospital at home schemes.
Footnotes
DASEAMARK@msn.com
References
1-1.Shepperd S, Harwood D, Jenkinson C, Gray A, Vessey M, Morgan P. Randomised controlled trial comparing hospital at home care with inpatient hospital care. I. Three month follow up of health outcomes. BMJ. 1998;316:1786–1791. doi: 10.1136/bmj.316.7147.1786. . (13 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
1-2.Richards SH, Coast J, Gunnell DJ, Peters TJ, Pounsford J, Darlow M-A. Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care. BMJ. 1998;316:1796–1801. doi: 10.1136/bmj.316.7147.1796. . (13 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
1-3.Seamark DA, Williams S, Hall M, Lawrence CJ, Gilbert J. Dying from cancer in community hospitals or a hospice: closest lay carers’ perceptions. Br J Gen Pract. 1998;48:1317–1321. [PMC free article] [PubMed] [Google Scholar]
1-4.Tucker H. Financial management and strategy in community hospitals. Report to the Department of Health. London: HACAS; 1991. [Google Scholar]
1-5.Seamark DA, Williams S, Hall M, Lawrence CJ, Gilbert J. Palliative terminal cancer care in community hospitals and a hospice: a comparative study. Br J Gen Pract. 1998;48:1312–1316. [PMC free article] [PubMed] [Google Scholar]
Editor—Montalto and Grayson raise important points that must be considered when home care is substituted for acute inpatient hospital care. The first point they make concerns the definition of hospital at home. The hospital at home scheme that we evaluated “provided hospital at home as a direct alternative to inpatient care for patients who were clinically stable and did not require immediate access to diagnostic or specialist medical care.” Without the presence of hospital at home these patients would have required inpatient hospital care.
As Montalto and Grayson point out, “without firm clinical definitions to ensure substitution, cost comparisons are of little value.” We took this argument further by hypothesising that “both outcomes and costs would differ according to diagnosis and age.” We therefore set out to identify suitable groups of patients defined by their clinical condition. After discussions with clinicians and service providers and a review of the published experience of other hospital at home schemes,2-1 we considered five groups of patients to be suitable for the trial. A major issue was to identify groups of patients who were eligible for hospital at home but who would also be recruited in sufficient numbers to provide the study with adequate power.
A second point raised by Montalto and Grayson concerns non-British publications. We did not exclude these. The three articles that they cite were published after our papers were submitted for publication. We do, however, cite the results of a trial conducted in the United States.2-2
Finally, we agree that trials will need to be clear about the nature of the intervention. Indeed, in the discussion of the first paper we write that “one of the most important issues in designing the trial was to define the service provided, and the population to be studied.” We did not intend to include all the groups of patients who could receive hospital at home or all the types of treatment that could be delivered by this form of care. We would be delighted to see well designed studies on other groups and treatments.
References
2-1.Shepperd S, Iliffe S. Hospital at home compared with in-patient hospital care [review] In: Bero L, Grilli R, Grimshaw J, Oxman A, editors. The Cochrane Library. 1998. Update Software. [Google Scholar]
2-2.Hughes SL, Cummings J, Weaver F, Manheim L, Braun B, Conrad K. A randomized trial of the cost effectiveness of VA hospital-based home care for the terminally ill. Health Serv Res. 1992;26:801–817. [PMC free article] [PubMed] [Google Scholar]
