Patients need choices
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
Rothschild House Surgery
Herts HP23 6PU
General Practitioner, Aston Clinton Surgery
General Practitioner, Wendover Health Centre
General Practitioner, Bedgrove Surgery
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