Hilda Parker

Economic evaluation of hospital at home versus hospital care: cost minimisation analysis of data from randomised controlled trial

Abstract Objectives: To compare the costs of admission to a hospital at home scheme with those of acute hospital admission. Design: Cost minimisation analysis within a pragmatic randomised controlled trial. Setting: Hospital at home scheme in Leicester and the citys three acute hospitals. Participants: 199 consecutive patients assessed as being suitable for admission to hospital at home for acute care during the 18 month trial period (median age 84 years). Intervention: Hospital at home or hospital inpatient care. Main outcome measures: Costs to NHS, social services, patients, and families during the initial episode of treatment and the three months after admission. Results: Mean (median) costs per episode (including any transfer from hospital at home to hospital) were similar when analysed by intention to treat—hospital at home £2569 (£1655), hospital ward £2881 (£2031), bootstrap mean difference −305 (95% confidence interval −1112 to 448). When analysis was restricted to those who accepted their allocated place of care, hospital at home was significantly cheaper—hospital at home £2557 (£1710), hospital ward £3660 (£2903), bootstrap mean difference −1071 (−1843 to −246). At three months the cost differences were sustained. Costs with all cases included were hospital at home £3671 (£2491), hospital ward £3877 (£3405), bootstrap mean difference −210 (−1025 to 635). When only those accepting allocated care were included the costs were hospital at home £3698 (£2493), hospital ward £4761 (£3940), bootstrap mean difference −1063 (−2044 to −163); P=0.009. About 25% of the costs for episodes of hospital at home were incurred through transfer to hospital. Costs per day of care were higher in the hospital at home arm (mean £207 v £134 in the hospital arm, excluding refusers, P<0.001). Conclusions: Hospital at home can deliver care at similar or lower cost than an equivalent admission to an acute hospital.

Beyond ethnic categories: why racism should be a variable in health services research.

Racism can affect health by making people ill, exacerbating existing illness, and by inequality in access to and utilisation of health services. Recent British publications assessing the methods used in studies of ethnicity primarily considered the status of the variables ‘ethnicity’ and ‘race’ and advised on the use of appropriate categories. Such scrutiny of ethnicity research is welcomed, yet authors rarely emphasise the importance of racism as a variable. This paper discusses why racism matters as a variable and poses suggestions for its absence from British health services research. Reference is made to US research to demonstrate that this focus is important and feasible. Health services research that considers ethnicity and excludes the effect of racism may result, at best, in an incomplete understanding. At worst, this omission could itself be perceived as a racist practice.

Performance of hospital-at-home after a randomised controlled trial.

Objective: To compare the performance of an admission-avoidance hospital-at-home scheme one year after the end of a randomised trial with its performance during the trial. Methods: Observational study of patients admitted to the scheme during a period of 12-19 months after the trial ended. In addition to routine data from service records, patients were interviewed at three days, two weeks and three months after admission, using the same instruments as used in the trial. Results: All 78 patients admitted to hospital-at-home during the follow-up period were included, and compared with the 95 patients admitted during the trial. The referral rate to hospital-at-home was the same (11 per month) as during the trial. During the trial, patients were randomised to hospital-at-home or hospital, meaning that hospital-at-home worked at about double the trial volume in the post-trial period. Baseline characteristics showed no statistically significant differences except that post-trial patients were less cognitively impaired. There were no statistically significant differences between the groups in survival at two weeks and three months, or in Barthel index, Sickness Impact Profile 68 and Philadelphia Geriatric Morale Scale. Length of stay in hospital-at-home was significantly shorter in the post-trial period (median of five days versus seven, P < 0.001), and more patients received a visit from their general practitioner during the period of admission (54% versus 38%, P = 0.04); otherwise there were no significant differences in process measures. Conclusion: Apart from working at higher volume and achieving a shorter length of stay, performance of the hospital-at-home scheme a year after the trial ended was little different from that reported during the trial. This is an example of an observational study providing evidence to support the generalisability of trial findings.