BMJ 1998;316:1791-1796 ( 13 June )

General Practice

Randomised controlled trial comparing hospital at home care with inpatient hospital care. II: cost minimisation analysis

Editorial by IliffeGeneral practice p 1786, 1796, 1802

Sasha Shepperd, research officer, a Diana Harwood, research assistant, b Alastair Gray, director, c Martin Vessey, professor of public health and head of department, a Patrick Morgan, consultant in public health medicine. d

a Division of Public Health and Primary Health Care, University of Oxford, Institute of Health Sciences, Headington, Oxford OX3 7LF, b Health Services Research Unit, Division of Public Health and Primary Health Care, University of Oxford, Institute of Health Sciences, c Health Economics Research Centre, Division of Public Health and Primary Health Care, University of Oxford, Institute of Health Sciences, d Northamptonshire Health Authority, Northampton NN1 5DN

Correspondence to: Sasha Shepperd Sasha.Shepperd{at}dphpc.ox.ac.uk

Objectives: To examine the cost of providing hospital at home in place of some forms of inpatient hospital care.
Design: Cost minimisation study within a randomised controlled trial.
Setting: District general hospital and catchment area of neighbouring community trust.
Subjects: Patients recovering from hip replacement (n=86), knee replacement (n=86), and hysterectomy (n=238); elderly medical patients (n=96); and patients with chronic obstructive airways disease (n=32).
Interventions: Hospital at home or inpatient hospital care.
Main outcome measures: Cost of hospital at home scheme to health service, to general practitioners, and to patients and their families compared with hospital care.
Results: No difference was detected in total healthcare costs between hospital at home and hospital care for patients recovering from a hip or knee replacement, or elderly medical patients. Hospital at home significantly increased healthcare costs for patients recovering from a hysterectomy (ratio of geometrical means 1.15, 95% confidence interval 1.04 to 1.29, P=0.009) and for those with chronic obstructive airways disease (Mann-Whitney U test, P=0.01). Hospital at home significantly increased general practitioners' costs for elderly medical patients (Mann-Whitney U test, P<0.01) and for those with chronic obstructive airways disease (P=0.02). Patient and carer expenditure made up a small proportion of total costs.
Conclusion: Hospital at home care did not reduce total healthcare costs for the conditions studied in this trial, and costs were significantly increased for patients recovering from a hysterectomy and those with chronic obstructive airways disease. There was some evidence that costs were shifted to primary care for elderly medical patients and those with chronic obstructive airways disease.

Key messages

  • Hospital at home schemes are a popular alternative to standard hospital care, but there is uncertainty about their cost effectiveness

  • In our randomised controlled trial we compared the cost of hospital at home care with that of inpatient hospital care for patients recovering from hip replacement, knee replacement, and hysterectomy; elderly medical patients; and those with chronic obstructive airways disease

  • There were no major differences in health service costs between the two arms of the trial for patients recovering from hip or knee replacement and elderly medical patients

  • Hospital at home care increased healthcare costs for patients recovering from hysterectomy and for those with chronic obstructive airways disease

  • Hospital at home care resulted in some costs shifting to general practitioners for elderly medical patients and those with chronic obstructive airways disease



© BMJ 1998
Add to CiteULike CiteULike   Add to Complore Complore   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to StumbleUpon StumbleUpon   Add to Technorati Technorati    What's this?

Relevant Articles

Hospital at home is effective and acceptable but it's not clear whether it is cheaper
BMJ 1998 316: 0. [Full Text]

Hospital at home: from red to amber?
Steve Iliffe
BMJ 1998 316: 1761-1762. [Extract] [Full Text]

Randomised controlled trial comparing hospital at home care with inpatient hospital care. I: three month follow up of health outcomes
Sasha Shepperd, Diana Harwood, Crispin Jenkinson, Alastair Gray, Martin Vessey, and Patrick Morgan
BMJ 1998 316: 1786-1791. [Abstract] [Full Text] [PDF]

Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care
Suzanne H Richards, Joanna Coast, David J Gunnell, Tim J Peters, John Pounsford, and Mary-Anne Darlow
BMJ 1998 316: 1796-1801. [Abstract] [Full Text]

Hospital at home or acute hospital care? A cost minimisation analysis
Joanna Coast, Suzanne H Richards, Tim J Peters, David J Gunnell, Mary-Anne Darlow, and John Pounsford
BMJ 1998 316: 1802-1806. [Abstract] [Full Text]

This article has been cited by other articles:

  • Mahomed, N. N., Davis, A. M., Hawker, G., Badley, E., Davey, J. R., Syed, K. A., Coyte, P. C., Gandhi, R., Wright, J. G. (2008). Inpatient Compared with Home-Based Rehabilitation Following Primary Unilateral Total Hip or Knee Replacement: A Randomized Controlled Trial. JBJS 90: 1673-1680 [Abstract] [Full text]  
  • Armstrong, C. D., Hogg, W. E., Lemelin, J., Dahrouge, S., Martin, C., Viner, G. S., Saginur, R. (2008). Home-based intermediate care program vs hospitalization: Cost comparison study. cfp 54: 66-73 [Abstract] [Full text]  
  • Rabe, K. F., Hurd, S., Anzueto, A., Barnes, P. J., Buist, S. A., Calverley, P., Fukuchi, Y., Jenkins, C., Rodriguez-Roisin, R., van Weel, C., Zielinski, J. (2007). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: GOLD Executive Summary. Am. J. Respir. Crit. Care Med. 176: 532-555 [Abstract] [Full text]  
  • Seemungal, T. A. R., Wedzicha, J. A. (2006). Integrated care: a new model for COPD management?. Eur Respir J 28: 4-6 [Full text]  
  • Rodriguez-Roisin, R (2006). COPD exacerbations {middle dot} 5: Management.. Thorax 61: 535-544 [Abstract] [Full text]  
  • Caplan, G. A., Coconis, J., Board, N., Sayers, A., Woods, J. (2006). Does home treatment affect delirium? A randomised controlled trial of rehabilitation of elderly and care at home or usual treatment (The REACH-OUT trial). Age Ageing 35: 53-60 [Abstract] [Full text]  
  • (2005). Statement on Home Care for Patients with Respiratory Disorders. Am. J. Respir. Crit. Care Med. 171: 1443-1464 [Full text]  
  • Weinrich, M., Stuart, M., Hoyer, T. (2005). Rules for Rehabilitation: An Agenda for Research. Neurorehabil Neural Repair 19: 72-83 [Abstract]  
  • Ram, F. S F, Wedzicha, J. A, Wright, J., Greenstone, M. (2004). Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: systematic review of evidence. BMJ 329: 315- [Abstract] [Full text]  
  • Hernandez, C., Casas, A., Escarrabill, J., Alonso, J., Puig-Junoy, J., Farrero, E., Vilagut, G., Collvinent, B., Rodriguez-Roisin, R., Roca, J., and partners of the CHRONIC project, (2003). Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients. Eur Respir J 21: 58-67 [Abstract] [Full text]  
  • Bagust, A, Haycox, A, Sartain, S A, Maxwell, M J, Todd, P (2002). Economic evaluation of an acute paediatric hospital at home clinical trial. Arch. Dis. Child. 87: 489-492 [Abstract] [Full text]  
  • Depalma, J. (2002). Substitution of Care Innovations in the Nursing Care of the Chronically Ill Internationally. Home Health Care Management Practice 14: 475-476  
  • MACINTYRE, C. R., RUTH, D., ANSARI, Z. (2002). Hospital in the home is cost saving for appropriately selected patients: a comparison with in-hospital care. Int J Qual Health Care 14: 285-293 [Abstract] [Full text]  
  • Roberts, C M, Lowe, D, Bucknall, C E, Ryland, I, Kelly, Y, Pearson, M G (2002). Clinical audit indicators of outcome following admission to hospital with acute exacerbation of chronic obstructive pulmonary disease. Thorax 57: 137-141 [Abstract] [Full text]  
  • Hardy, C, Whitwell, D, Sarsfield, B, Maimaris, C (2001). Admission avoidance and early discharge of acute hospital admissions: an accident and emergency based scheme. Emerg. Med. J. 18: 435-440 [Abstract] [Full text]  
  • PAUWELS, R. A., BUIST, A. S., CALVERLEY, P. M. A., JENKINS, C. R., HURD, S. S. (2001). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease . NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop Summary. Am. J. Respir. Crit. Care Med. 163: 1256-1276 [Full text]  
  • Dubois, A., Santos-Eggimann, B. (2001). Evaluation of Patients' Satisfaction with Hospital-At-Home Care. Eval Health Prof 24: 84-98 [Abstract]  
  • Sutcliffe, N., Clarke, A. E., Taylor, R., Frost, C., Isenberg, D. A. (2001). Total costs and predictors of costs in patients with systemic lupus erythematosus. Rheumatology (Oxford) 40: 37-47 [Abstract] [Full text]  
  • KILLEN, J, ELLIS, H (2000). Assisted discharge for patients with exacerbations of chronic obstructive pulmonary disease: safe and effective. Thorax 55: 885-885 [Full text]  
  • Cotton, M M, Bucknall, C E, Dagg, K D, Johnson, M K, MacGregor, G, Stewart, C, Stevenson, R D (2000). Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomised controlled trial. Thorax 55: 902-906 [Abstract] [Full text]  
  • Grande, G E, Todd, C J, Barclay, S I G, Farquhar, M C (2000). A randomized controlled trial of a hospital at home service for the terminally ill. Palliat Med 14: 375-385 [Abstract]  
  • Thompson, S. G, Barber, J. A (2000). How should cost data in pragmatic randomised trials be analysed?. BMJ 320: 1197-1200 [Full text]  
  • Jones, J., Wilson, A., Parker, H., Wynn, A., Jagger, C., Spiers, N., Parker, G. (1999). Economic evaluation of hospital at home versus hospital care: cost minimisation analysis of data from randomised controlled trial. BMJ 319: 1547-1550 [Abstract] [Full text]  
  • Hensher, M., Fulop, N., Coast, J., Jefferys, E. (1999). The hospital of the future: Better out than in? Alternatives to acute hospital care. BMJ 319: 1127-1130 [Full text]  
  • Messecar, D. (1999). "Hospital at home" care was generally as effective as routine hospital care for older adults. Evid. Based Nurs. 2: 51-51 [Full text]  
  • Shepperd, S., Harwood, D., Jenkinson, C., Gray, A., Vessey, M., Morgan, P. (1998). Randomised controlled trial comparing hospital at home care with inpatient hospital care. I: three month follow up of health outcomes. BMJ 316: 1786-1791 [Abstract] [Full text]  
Access jobs at BMJ Careers
Whats new online at Student BMJ