At what cost?

EDITOR—Crotty et al show that off-site “transitional care” facilities for elderly patients already assessed as needing residential care placement, only reduce length of hospital stay at the expense of delaying eventual transfer to a long term care facility.1 However, their assertion that such transfer resulted in no difference in mortality, rates of readmission, or the proportion of patients who eventually returned to their own homes is potentially misleading, as the study was not powered to detect such differences. Sample size was calculated only to detect “a mean reduction in length of stay of 10 days (SD 25) in the treatment group”—that is, to test the hypothesis that opening a new off-site facility and transferring inpatients to this facility would reduce length of stay (arguably a “given”).

Over the four month follow-up, patients in the treatment group had a 12% relative increase in readmissions (28% in treatment group v 25% in the control group), a 22% relative reduction in chances of returning to their own home (7% treatment v 9% controls) and nearly 4% relative “excess” mortality (28% treatment v 27% controls). As these (and other) potentially adverse outcomes are the basis of much of the controversy that surrounds this area, the results by Crotty et al contribute to the debate in terms of the design, and powering, of future studies.