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LETTER - A home-based intervention reduced out-of-hospital deaths and hospitalizations in CHF

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To the editor. I was dismayed to read the commentary by Farmer (1) on the effectiveness of house calls after hospital discharge. Several excellent randomized controlled trials (RCTs), similar to the reviewed study, have appeared in major medical journals, and the results of these studies are consistent (2­4). The commentary is dated; the first article cited (5) predates most RCTs in this area.

The commentary also appears to be unduly influenced by noncomparable health services research; the second article cited in the commentary (6) reports a study of the home-hospital method of care compared with routine hospital care, not simple follow-up visits after discharge. This study, and the commentary in general, seems flavored by the U.K. National Health Service. Studies done within U.S. health care systems have shown that follow-up visits after discharge consistently reduce overall utilization and costs (2­7). Consequently, many mature managed care organizations liberally use physicians and nurse practitioners to visit high-risk patients at home after discharge. The commentary misses the mark, at least for American readers.

Wayne C. McCormick, MD, MPH

Harborview Medical Center

Seattle, Washington, USA

References

1. ACP J Club. 1999 Jul-Aug;131:6. Evidence-Based Medicine. 1999 Jul-Aug;4:115. Abstract of: Arch Intern Med. 1999;159:257-61.

2. Naylor MD, Brooten D, Campbell R, et al. JAMA. 1999;281:613-20.

3. Stuck AE, Aronow HU, Steiner A, et al. N Engl J Med. 1995;333:1184-9.

4. Rich MW, Beckham V, Wittenberg C, et al. N Engl J Med. 1995;333:1190-5.

5. Gladman JR, Lincoln NB. Age Ageing. 1994;23:9-13.

6. Shepperd S, Harwood D, Gray A, Vessey M, Morgan P. BMJ. 1998;316:1791-6.

7. Stewart S, Vandenbroek AJ, Pearson S, Horowitz JD. Arch Intern Med. 1999; 159:257-61.

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