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Rapid Responses: Rapid Responses published:
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“home AFTER hospital” or “hospital AT home”.
- Uday Gupta (11 August 2004)
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The place of end of life care
- James Watts, BB102PQ (17 August 2004)
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Acute exacerbations of chronic obstructive pulmonary disease: Comparative efficacy of hospital at home schemes versus inpatient hospital care
- Daniel K C Lee, Graeme P Currie, Kean C Khoo (20 August 2004)
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Cochrane review
- Felix S F Ram (6 September 2004)
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Selective reporting of results
- Sasha Shepperd (29 October 2004)
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Uday Gupta, Junior Resident VP Chest Institute, University of Delhi, India
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To The Editor: It is important that efforts aimed at cutting costs and giving choices to the patients are evaluated. In the present review [1] following points merit more consideration. 1. In the criteria for patient selection, patients with concomitant medical conditions and those admitted for social reasons are omitted. However the authors conclude that “Many admissions for COPD do not occur because of severe exacerbations but because of comorbidities and social circumstances; these patients could safely be managed at home.” Although it may be a logical and clinical extension but there is no data analysis in the present review to support this statement. 2. Home management plans/home care schemes/hospital at home (you can call it whatever you like) are increasingly being made available and are prevalent especially for asthma [2]. In this context home care scheme imply recognition and management of exacerbation by the patient entirely at home under certain conditions. These are truly “home care” avoiding even a visit to the hospital. In the present study “home care” starts after up to 72 hours of hospital care, hence mostly after receiving initial hospital treatment; the authors have rightly stressed that all exacerbations should be first evaluated at hospital and then triage can happen. Hence the present study is more about “home AFTER hospital” rather than “hospital AT home”. In no circumstance should a confusion between the two entities need happen. In the same vein, this review perhaps paves the way to explore just that – a true “hospital at home”. After all in asthma also although Peak Expiratory Flow Meter based home based asthma exacerbation plans are only “ideal” to have [2] and severity of symptoms is more sensitive than PEF monitoring for exacerbation of asthma [3]. Similarly, for COPD an exacerbation is defined clinically with symptoms only [4], something that patients can easily recognize. Using the criteria for readmission [4], or obligatory criteria for admission [5] caveats may be incorporated in the home based algorithm. There will be problems for a “hospital at home” algorithm, like the differential diagnosis of left ventricular failure in this chronic smoker. Hopefully, truly home based management action plans will be developed for COPD also. References: 1. Ram FSF, Wedzicha JA, Wright J, Greenstone M. Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: systematic review of evidence. BMJ 2004;329:315 2. Global Initiative against Asthma. Workshop report 2002. Available at http://www.ginasthma.com/workshop.pdf Last accessed 10 Aug 2004. 3. Turner MO, Taylor D, Bennett R, FitzGerald JM. A Randomized trial comparing peak expiratory flow and symptom self-management plans for patients with asthma attending a primary care clinic. Am J Respir Crit Care Med 1998;157:540-6. 4. National Collaborating Centre for Chronic Diseases. NICE guidelines for COPD. Available at www.nice.org.uk/CG012niceguideline. Last accessed 10 Aug, 2004. 5. British Thoracic Society. British Thoracic Society guidelines for the management of chronic obstructive pulmonary disease. Thorax 1997;52(suppl 5): S1-28. Competing interests: None declared |
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James Watts, Consultant in Anaesthesia and intensive Care Medicine East Lanacshire Trust, BB102PQ
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Editor The article by Ram and colleagues (1) concernng the management of patients with COPD is timely, being followed as it is by the publication of NICE guidance on the same subject. Disappointingly, Ram’s article does not mention at all the role of the multidisciplinary team in approaching end of life care decisions in the chronically sick. It has been suggested at least since 1998 that there is a specific need for specialist palliative care in non malignanat disease ( 2), and yet still, all too often, the decision as to whether to institute invasive treatment or palliative care in patients with chronic illnesses who may be in the terminal rather than reversible stages of disease, is left until the crisis admission in the early hours of the morning when neither relatives nor patient are in a fit state to participate in such planning. The American Thoracic society guidelines, for example, specifically stress the importance of targeted early planning of so called “living wills” (3) The Leslie Burke case (4) illustrates how clearly patients wish to be autonomously involved in these decisions. It is up to health care professionals to ensure that their future care pathways address these issues. 1. Hospital at home for patients with acute exacerbations of COPD Ram FS Wedzicha JA Wright J Greenstone BMJ 2004 329 315 2. Addlington Hall J Fakhoury W McCarthy M Palliat Med 1998 12 (6) 417-27 3. (www.thoracic.org/COPD). 4. “Man wins battle to keep receiving life support” BMJ 2004 Competing interests: None declared |
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Daniel K C Lee, Respiratory Physician Department of Respiratory Medicine, Ipswich Hospital, Heath Road, Ipswich IP4 5PD, Suffolk, England, Graeme P Currie, Kean C Khoo
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We thank Ram and colleagues [1] for an informative meta-analysis on the comparative efficacy of hospital at home schemes versus inpatient hospital care for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD). Such schemes are to be commended as there are so many unnecessary admissions to hospitals, further burdening the already stretched National Health Service in the United Kingdom. It is especially pertinent in light of the current struggles facing many National Health Service Trusts in trying to be compliant with the mandatory European Union directive on limiting junior doctors' working hours. Hospital physicians must welcome the evidence demonstrating the non- inferiority of home schemes compared to inpatient care of patients with COPD. Nevertheless, it is important to stress that not all patients are suitable for hospital at home schemes. Indeed, it is in this area that most guidance is urgently needed with regards to patient selection and risk stratification, which unfortunately is clearly lacking at present. Notably, suitable patients are in a select group, having already being assessed initially by a hospital medical team. There is at present no national standard for selection of such patients and currently suitability is based on local rather than national protocols. Current National Institute for Clinical Excellence guideline on COPD [2] do not offer specific criterion, but merely suggest factors to consider when deciding where to treat patients. We agree with the authors for the need to further assess certain areas of hospital at home schemes. For example, knowledge of patient and carer satisfaction is important. The current study demonstrates no significant effect upon mortality but gain in financial saving; indeed it is important to be aware that ethical issues surround implications of saving money at the expense of quality of life. The authors have also illustrated several weaknesses that are inherent to meta-analysis where data from different trials are gathered together and patients are treated as means rather than individuals. Finally, it would be of interest to see whether such schemes could be extended to other chronic respiratory conditions such as interstitial lung diseases, chronic asthma and bronchiectasis. Daniel K C Lee MB BCh MRCP MD, Department of Respiratory Medicine, Ipswich Hospital, Heath Road, Ipswich IP4 5PD, Suffolk, England, United Kingdom Graeme P Currie MB ChB DCH MRCP MD, Department of Respiratory Medicine, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, Scotland, United Kingdom Kean C Khoo MB BCh MRCP, Department of Respiratory Medicine, Llandough Hospital, Penlan Road, Penarth, Cardiff CF64 2XX, Wales, United Kingdom References 1. Ram FS, Wedzicha JA, Wright J, Greenstone M. Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: systematic review of evidence. BMJ 2004;329:315. 2. National Collaborating Centre for Chronic Conditions. Chronic obstructive pulmonary disease. National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax 2004;59(Suppl 1):1-232. Competing interests: None declared |
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Felix S F Ram, Senior Research Fellow (Respiratory Medicine) National Collaborating Centre
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Dear Editor, We failed to make it explicit in our manuscript that prior to publication in the BMJ our systematic review was available on the Cochrane Library in electronic form only (Ram FSF, Wedzicha JA, Wright J, Greenstone M. Hospital at home for acute exacerbations of chronic obstructive pulmonary disease (Cochrane Review). In: The Cochrane Library, Issue 3, 2004). Sincerely Felix Ram Competing interests: None declared |
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Sasha Shepperd, Associate Director Health Sciences Department of Continuing Education, University of Oxford, Littlegate House, Oxford OX1 1PT
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The systematic review of hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease published in the BMJ in July this year(1) risks misleading decision makers due to the selective reporting of trial results. This systematic review has also been published as a Cochrane Review.(2) The message in the BMJ paper that cost analysis data suggests considerable financial savings is not supported by the available evidence cited in the Cochrane Review. In the BMJ paper the authors report that four trials present cost analysis data, however as described in their Cochrane review cost data is available from 3 trials. Confusingly the authors omit from the cost analysis data in the BMJ paper one of the studies included in the Cochrane review which reports the results of a formal economic evaluation showing a significant increase in cost to the health service for those allocated to hospital at home,(3) and yet include a trial which only reports length of stay with no cost data.(4) Differences in the methodology for the economic evaluations have also not been taken into account. Finally the lack of a significant difference in patient outcomes is interpreted by the authors that patients with acute exacerbation of COPD can be as safely and successfully treated at home as they would as inpatients. This is not correct as the null value is included within the 95% confidence intervals. Sasha Shepperd
(1) Ram, FSF., Wedzicha, JA., Wright, J. and Greenstone, M. Hospital at home for patients with acute exacerbations of chronic obstructive pulmonary disease: systematic review of evidence. BMJ, 2004 329: 315-19. (2) Ram FSF., Wedzicha, JA, Wright, J, Greenstone, M. Hospital at home for acute exacerbations of chronic obstructive pulmonary disease (Cochrane Review). In: The Cochrane Library, issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd. (3) Shepperd, S, Harwood, D, Gray, A, Vessey, M, Morgan, P. Randomised controlled trial comparing hospital at home care with inpatient hospital care. II: cost minimisation analysis BMJ 1998; 316:1791-1796. (4) Cotton, MM, Bucknall, CE, Dagg, KD, Johnson, MK, MacGregor, G, Stewart, C et al. Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Thorax, 2000; 55: 902-6. Competing interests: None declared |
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