Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Obtaining evidence: A job worth doing?
- Hilda Parker (13 December 1999)
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GPs abusers or abused?
- Paul N Moore (14 December 1999)
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Recruitment and randomisation to Leicester hospital at home scheme.
- Mark Cotton (14 December 1999)
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Re: GPs abusers or abused?
- Andrew Wilson (18 December 1999)
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Re: Recruitment and randomisation to Leicester hospital at home scheme.
- Andrew Wilson (18 December 1999)
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Baseline differences were not fully taken into account
- Flora Hodman, Alison Massey, Carmel Rice, Francisca Scott (7 January 2000)
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Hilda Parker, Self-employed
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Colleague: "Two papers in the BMJ on one day, wow, congratulations!" Me: "Mmm ... pity the service that took part in the trial is struggling to survive..." I am the researcher who managed the RCT of the Leicester HAH scheme that is published in this week's BMJ.(Ref 1,2) Perhaps the following details will explain why I did not experience a sense of achievement when observing that the results of our study were finally in print. For eighteen months a team of dedicated nurses co-operated with a research protocol demanding that access to their unique service would be random. They, and I, persevered because we believed (and were told) that the continuation of the service depended on "evidence". Poorly, frail people who preferred to be nursed at home, were randomised to hospital. At times, when successive referrals were randomised to hospital, the staff had to cope with the frustration of being on duty and having no patients. Results from the trial suggest a safe and cost-effective alternative to hospital. Despite these encouraging findings, the Leicester Hospital at Home scheme is currently faced with financial constraints that do not support realistic development and expansion of this scheme. The result? Staff numbers have been reduced, contracts are being amended, morale is low and many have left. This letter reflects my personal views. Yours faithfully, Hilda Parker
Andrew Wilson, et al. Randomised controlled trial of effectiveness of Leicester hospital at home scheme compared with hospital care. BMJ, 319:1542-1546 Jeremy Jones, et al. Economic evaluation of hospital at home versus hospital care: cost minimisation analysis of data from randomised controlled trial. BMJ, 319:1547-1550 |
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Paul N Moore, GP Newhaven
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The Leicester Hospital at Home team were quite clear that "GPs were not abusing the system" by enrolling their patients into the scheme in the hope of securing more intensive care for their patients at home. It is less clear whether GPs were being abused by apparently retaining responsibility for usually hospitalised patients in the community. The GP team costs were not clearly represented, and may have been ignored. GP visits may have been reimbursed, although it looks like the cost of each was £20. Cheap at the price. The cost effectiveness calculation is undermined by this omission, in an otherwise thorough study. |
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Mark Cotton, Senior Registrar Dept. Respiratory Medicine, Glasgow Royal Infirmary
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The article on the Leicester hospital at home scheme by Wilson et al. contains a great deal of information. While one obviously cannot include all information from a study in a paper I wonder whether the authors could clarify some points. How many patients were referred to the hospital at home team via the bed bureau between November 95 and May 97? What proportion of these were assessed, and of those assessed what proportion were suitable for hospital at home? Were any patients suitable but not included in the trial becuase the hospital at home team were full (already managing 5 patients)? As randomisation occured prior to obtaining informed consent did the patients know the allocation prior to giving consent, and how many refused consent? Assuming each block of 10 in the randomisation process would result in an equal number being allocated to each arm of the study, out of 199 randomised patients one would expect 100 in one arm, and 99 in the other. If some randomised patients declined to take part in the study, then this might explain the disparity, assuming the 199 refers to eligible and consenting patients. It is important to know if there was a significant number of randomised patients who refused to take part, and if this occured to a greater extent in one arm than the other. |
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Andrew Wilson, senior lecturer in general practice University of Leicester
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The Leicester scheme, unlike some others, does not include any incentive payment to GPs to use the scheme, nor payment for visits made to patients on the scheme. However in the economics paper we did cost GP inputs using data from the PSSRU, University of Kent, and so our finding that costs were equivalent or cheaper does not ignore GP inputs. |
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Andrew Wilson, senior lecturer in general practice University of Leicester
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As stated in our results section, 96 of the 102 patients randomised to hospital at home received care there and 74 of the 99 patients randomised to hospital agreed to admission after randomisation. These 'refusers' were included in the study and in the accompanying economics comparison. Our aim was to compare how patients assessed as being eligible for hospital at home fared in the two environments, rather than the effect of the scheme on the whole system of care. We therefore did not record patients who may have been eligible if the service was not full, or those thought not suitable after assessment by the hospital at home scheme. In fact the number in the latter group was very small. |
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Flora Hodman, Medical students Department of Epidemiology and Public Health, Newcastle University Medical School, Alison Massey, Carmel Rice, Francisca Scott
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Editor-In response to Wilson’s et al’s(1)paper regarding the Leicester hospital at home scheme, we agree with the authors that their evidence suggests such schemes are a promising development in health care delivery and warrant further evaluation. Whilst recognising that the study was generally well designed, we have some concerns. The authors highlight certain baseline characteristics as comparable in both groups, however, we think that others have been overlooked. More patients in the hospital group lived alone compared with patients in the hospital at home scheme (56% v 48%, excluding missing data), and fewer lived with others (38% v 48%).Before admission more patients received nursing and home care in the hospital group (20% and 45%, excluding missing data) compared with patients in the hospital at home scheme (15% and 31%). This suggests those randomised to hospital care may have been a group for which early discharge was more difficult and readmission more likely. We feel that adjustment for these should have been made in the analysis and could find no evidence that this had been done. This casts doubt on the authors conclusion that the hospital at home scheme results in shorter lengths of stay and equivalent emergency admission rates. In addition, there are large areas of missing data which the authors attribute to working with an elderly and frail population. However, these omissions detract from the validity of the study. One must be cautious in drawing firm conclusions from this study in view of the points outlined above. We look forward to the publication of the economic evaluation and patient satisfaction report, which should provide useful additional information. Flora Hodman
We would like to acknowledge the assistance of Dr Richard Edwards. 3rd Year Medical Students
1. Wilson, A. Parker, H., Wynn, A., Jagger, C., Spiers, N., Jones, J., Parker, G., Randomised controlled trial of effectiveness of Leicester hospital at home scheme compared with hospital care.BMJ 1999;319:1542-6. |
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