Randomised controlled trial comparing hospital at home care with inpatient hospital care. I: three month follow up of health outcomes
BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7147.1786 (Published 13 June 1998) Cite this as: BMJ 1998;316:1786
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The useful papers comparing hospital at home with inpatient hospital care published in 13 June journal1-4 did not consider another possible lower cost option to acute District General Hospital (DGH) care; namely that of community hospital care. There are approximately 450 community hospitals in the UK with the majority of beds being General Practitioner (GP) led (data on file, Community Hospitals Association). The recognised roles of such hospitals include general medical care, rehabilitation following falls, strokes and orthopaedic and general surgery. There is evidence of good quality care and carer satisfaction in community hospitals5 and a cost analysis performed indicated that community hospital beds cost between 1/3 and ½ of that of a DGH bed6. The advantages of community hospitals are the proximity to the patients home7, the low technology environment which patients find less intimidating, the continuity of care provided by their own general practitioner and Primary Health Care Team (PHCT) and hospital staff who are often known to the patients and carers alike5. Before extensive investment in new hospital at home schemes, with the present uncertainties over effectiveness (albeit for certain clinical groups), costs and probable increase burden on the PHCT, it would be wise to run comparative studies using community hospital facilities that are already present and have a long-standing track record in the type of medicine targeted for hospital at home schemes.
David A Seamark
Clare J Seamark
General Practitioners, and Committee Members of the Community Hospitals Association.
The Honiton Group Practice, Marlpits Road, Honiton EX14 8DD.
1) Shepperd S, Harwood D, Jenkinson C, Gray A, Vessey M, Morgan P. Randomised controlled trial comparing hospital at home with inpatient hospital care. I: three month follow up of health outcomes. BMJ 1998;316:1786-91.
2) Shepperd S, Harwood D, Gray A, Vessey M, Morgan P. Randomised controlled trial comparing hospital at home with inpatient hospital care II: cost minimisation analysis. BMJ 1998;316:1791-6.
3) 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;316:1796-801.
4) Coast J, Richards SH, Peters TJ, Gunnell DJ, Darlow M-A, Pounsford J. Hospital at home or acute hospital care? A cost minimisation analysis. BMJ 1998;316:1802-6.
5) 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;48:1317-21.
6) HACAS Financial management and strategy in community hospitals. Report to the Department of Health. May 1991.
7) 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;48:1312-6.
Competing interests: No competing interests
Patients need choices
Dear Sir,
We congratulate Shepperd et al for designing an RCT to compare similar patients undergoing either hospital at home or inpatient treatment,1,2 We agree that purchasers should insist on evaluation as a condition of funding new community services, but we hope that RCTs will not become the gold-standard for evaluation, because such trials depend on patients being prepared to be randomised into either the hospital at home group or the inpatient hospital group, thereby excluding patients with a very strong preference for either locus of treatment.
The evidence from these papers is that for three out of the five groups studied, (hip and knee replacements and elderly medical patients), patients preferred hospital at home care,1,and that there were no major differences in health outcomes or carer burdens or health service costs,2.. Although the criteria for discharge from the hospital at home scheme are not reported, the number of care days are used as a comparison measure, and the sensitivity analysis shows how crucial this is to costing. Furthermore, the short follow-up of this study does not permit any measure of long-term dependency.
We believe in offering a choice of services to patients where outcomes are likely to be similar, and the costs not dissimilar. A new community support scheme, The Weston Project, which has been set up locally as a result of co-operation between our four practices and a local community trust, is offered specifically to patients who prefer to stay in their own homes, or to return early from hospital. We are currently commissioning an evaluation of the scheme. Preference for home treatment defines our group under study, not their medical condition, and the challenge is to undertake meaningful cost and outcome analysis without insisting that patients enter an RCT where they may be randomised to receive the treatment they least prefer. It is entirely possible that harnessing the patient’s commitment to home treatment may enable providers to offer focussed services in the community at lower costs, for as Shepperd points out "only a small proportion of hospital at home costs are fixed".
We agree with Illiffe that "Descriptive studies of the organisational culture and practice of innovative services are needed to place their findings in context, and might be useful components of future studies, since pragmatic randomised controlled trials alone seem to be necessary but insufficent guides for service development"3
Weston Project,
Rothschild House Surgery
Chapel Street,
Tring,
Herts HP23 6PU
Ed Peile
General Practitioner, Aston Clinton Surgery
Philippa Moreton
General Practitioner, Wendover Health Centre
Martin Paul
General Practitioner, Bedgrove Surgery
Ralph Roberts
General Practitioner, Rothschild House Surgery
1) Shepperd S, Harwood D, Jenkinson C, Gray A, Vessey M, Morgan P. Randomised controlled trial comparing hospital at home with inpatient hospital care. I: three month follow up of health outcomes. BMJ 1998;316:1786-91.
2) Shepperd S, Harwood D, Gray A, Vessey M, Morgan P. Randomised controlled trial comparing hospital at home with inpatient hospital care II: cost minimisation analysis. BMJ 1998; 316:1791-6.
3) Iliffe S. Hospital at home: from red to amber? BMJ 1998;316:1761-2.
Competing interests: No competing interests