Volume 198 - Issue 4
A meta-analysis of “hospital in the home”
Author: Gideon A Caplan
Med J Aust 2013; 198 (4): 195-196. || doi: 10.5694/mja12.11841
Published online: 4 March 2013
Published online: 4 March 2013
In reply: Dickson argues for exclusion of randomised controlled trials (RCTs) if treatments have changed, but treatments are constantly changing so, following
this rule, meta-analysis would be impossible. Similarly, diagnosis
has changed - stroke was
a clinical diagnosis, then computed tomography was required, and
now magnetic resonance imaging
is needed. Equipoise is not a requirement for inclusion in a
meta-analysis.
Complaints about research being simplistic because ...
In reply: Dickson argues for exclusion of randomised controlled trials (RCTs) if treatments have changed, but treatments are constantly changing so, following this rule, meta-analysis would be impossible. Similarly, diagnosis has changed — stroke was a clinical diagnosis, then computed tomography was required, and now magnetic resonance imaging is needed. Equipoise is not a requirement for inclusion in a meta-analysis.
Complaints about research being simplistic because it aggregates patients and groups demonstrates a misconception of research, which is designed to aggregate one factor while other factors differ — for example, study arms may have different mixtures of ages but similar average ages. The meta-analysis studied effects of two systems of care — hospital and hospital in the home (HITH) — not a particular diagnosis or treatment.1,2 Therefore it is legitimate to aggregate hospital patients and compare them with HITH patients.
Location and heterogeneity were mathematically defined, there was no heterogeneity for mortality data, and other outcomes were adjusted appropriately.
Results from the study by Indredavik et al were published in several reports, but (due to space limitations) only the primary report was cited. The data that Dickson refers to are in a report by Fjaertoft et al.3
Although the prevailing opinions of the Royal College of Physicians of London and the British Cardiac Society criticised the study by Mather et al in the 1970s, no contradictory facts or trials were cited at the time.4 Considering that other prevailing practices that were initially not examined by adequate RCTs led to many iatrogenic deaths (eg, prophylactic use of antiarrhythmic drugs5), such practices should be examined and evidence of patient harm taken seriously, rather than simply dismissing evidence as obsolete.
Competing interests
I work in a hospital and a HITH unit.
References
- Caplan GA, Sulaiman NS, Mangin DA, et al. A meta-analysis of “hospital in the home”. Med J Aust 2012; 197: 512-519.
- Caplan GA, Brown A. Post acute care: can hospitals do better with less? Aust Health Rev 1997; 20: 43-54. 0_i1142868
- Fjaertoft H, Indredavik B, Johnson R, Lydersen S. Acute stroke unit care combined with early supported discharge. Long term effects on quality of life. A randomized controlled trial. Clin Rehabil 2004; 18: 580-586. 0_CBBCGIGB
- The care of the patient with coronary heart disease. Report of a joint working party of the Royal College of Physicians of London and the British Cardiac Society. J R Coll Physicians Lond 1975; 10: 5-46. 0_CBBEGIDD
- Teo KK, Yusuf S, Furberg CD. Effects of prophylactic antiarrhythmic drug therapy in acute myocardial infarction. JAMA 1993; 270: 1589-1595. 0_CBBHHFED