A meta-analysis of “hospital in the home”

To the Editor: Caplan et al1 include in their meta-analysis a trial by Mather et al that compared home care with intensive care management of patients with acute myocardial infarction (AMI) between 1966 and 1968.2 A joint working party of the Royal College of Physicians and British Cardiac Society dismissed the results of this study because of design defects.3,4

Kalra et al5 performed a randomised trial with three arms for patients with acute stroke: stroke unit care, general ward care with stroke team support, and domiciliary care. Stroke units achieved a significantly lower mortality than general ward or domiciliary care. Caplan et al ignore the heterogeneity of the hospital arms, and sum their mortalities, creating a non-existent advantage for domiciliary care over hospital care. This meta-analytic technique is simplistic and invalid.

Hill et al describe home versus hospital management for patients with suspected AMI,2 as do Mather et al.2 Studies of obsolete treatments, such as home management of patients with AMI, should have been excluded from the meta-analysis.

Rudd et al studied the effect of early discharge after stroke using a 1976 clinical definition of stroke.6 No details of imaging or comorbidities were given. The assumption of equipoise in the trial arms regarding morbidity is not met, and the study is not suitable for inclusion in the meta-analysis.

Indredavik et al7 studied the effect of early supported discharge versus ordinary care in patients with stroke, with 13 deaths at 26 weeks in the experimental group against 15 deaths in the control group. However, Caplan et al incorrectly report this as 21 and 26 deaths, respectively.

If these five most heavily weighted studies are excluded, no significant difference in mortality is seen (243 hospital-in-the-home deaths [n = 2747] v 245 hospital deaths [n = 2435], two-sided P = 0.14). Moreover, meta-analysis of the effect of location on mortality where the circumstances of the location are not defined and not expected to be homogenous is invalid and makes the mathematical exercise futile.