“Hospital in the home” a lot's in a name 2012 Michael Montalto.pdf

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Editorials
“Hospitalinthehome”:alot’sinaname
Betterdefinitioninindividualstudieswillenablemeaningfulsynthesisofresearch
MichaelMontaltoomeasuretheeffectivenessofinnovationsinImprovingtheimpactoffutureHITHmeta-analysis
MBBS,PhD,
Director,healthcare,itiscriticallyimportanttodefinetherequiresimprovingthestandardsofindividualHITHstud-
1,2
,,humbleresearchresources,
BruceALeff
MD,oftenlackinginhealthservicesresearch:definitionsarepoordefinitions,patientandhospitalunwillingnesstobe
ProfessorofMedicine3ofteninadequateforreproducibility,andoutcomesattrib-randomlyassignedtonon-HITHarms,andtheintricaciesof
utedtotheinterventionareconsequentlydifficulttoadjustnegotiatingHITHaccesshavebeenmountainousbarriers
1RoyalMelbourneHospital,-
Melbourne,
2EpworthHospital,
Melbourne,-
3DivisionofGeriatricorevolving.“Hospitalinthehome”(HITH)isanexampleoftion(likeHITH)intoreproduciblebite-sizednuggetswhere
Medicine,
UniversitySchoolthecontextofthesurroundinghealthcaredeliveryenviron-
ofMedicine,topatientsathome:withouttheHITHservice,,
Baltimore,Md,USA.
,theoutcomeofacomplexarrayof
michael.******@yearssincetheconceptfirstappearedinthepagesofthe
,safety,technology,expertise,
Journal,andtherehasbeenenormousprogressinthatmercy,patientacceptanceandreimbursement.
1,2
doi:.TherehasalsobeenconfusingheterogeneityintheInanotherarticleinthisissue,Sarodeandcolleagues
definitionandprogramstructureofHITH—
argumentaroundtheglobe,
notidentifyit,theinterventiontheydescribemeetsour
beenconsideredaseverythingfromhigh-technologyacute
definitionofHITH:theytookintensivecaretechnology
hospitalmedicinethroughtooutpatienttherapyandpost-
andexpertisehomewithapatientwhowouldhaveother-
,
-
organisationalandculturalinvestmentrequiredtoestablisha

fully-fledgedHITHservicearestillkeentoleveragetheHITH
provided,adaptedtofitthecontext,andprotocolsthat
labeltodeliveranaltogetherdifferentservice.

However,inameta-analysisofHITHinthisissueofthe

Journal,CaplanandcolleaguesfollowPRISMA(Preferred
offersaclinicalandfinancialstructurefordeliveringinno-
ReportingItemsforSystematicReviewsandMeta-Analyses)
vativecareinthissituation,andmanysimilarclinical
guidelinesandacceptonlyrandomisedcontrolledtrialsfor
-examiningthisbodyofwork,theyconcen-situationsthatoccurinhospitals.
trateonresearchwhereHITHcareinvolvesasubstitutionforTheprinciplesofapplyingthecaredescribedbySarodeet
partoralloftheepisodeofcareinhospital:substitutingforatalareverysimilartotheprinciplesofapplyingcareinother
least7daysinhospitalorHITHcarethatreplacesatleast25%situationsinwhichHITHisregularlyinvolved,suchas:
-stageheartfailure;
excludingresearchthatdoesnotmeetthisarbitrarystandard,caringforselectedpatientswhopresenttotheemergency
previouslyequivalentornegativemeta-outcomesmightdepartmentwithpulmonaryemboli;caringforolderpatients
,thisisthecase,-
Whilethegoalofclinicalequivalenceshouldbeenough,theytialcare;administeringintravenousantibiotics,antiviralsand
showthatHITHcarereducesmortalityandreadmissionsbyantifungalsforcommunity-andhospital-acquired(sensitive
about20%)infections;andgivingbloodorintrave-

fourstudieswereexcludedonthegroundsofnotmeetinginterestingandinnovativecasereportsanddescriptiveout-
the7-dayor25%,andmanyhavefallenintoroutinehigh-quality
TheMedicalJournalofAustraliaISSN:0025-
—generallybeforetheavailablilityof,orin
729X5November20121979479-480
studiesaresmallanddonotcompletelydescribetheirtheabsenceof,thehighestgradesofevidence.
©TheMedicalJournalofAustralia2012
,manydescribenon-acuteHITHresearchcouldbesignificantlyadvancedbyestab-
careorinterventionsthatthatwepersonallywouldnolishinganinternationalexpertconsensusstatementto

readmissionaredefinedvariably;inmostcases,,reimbursementitselfhasdrivenasharper
Systematicreviewp512to“post-discharge”
MJA197(9)·5November2012479
Editorials
ThedefinitionneedsanagreedstructureandprocessCompetinginterests:Norelevantdisclosures.
forHITH,notjustamissionstatement,astheplatformProvenance:Commissioned;externallypeerreviewed.
onwhichclinicalinterventionscanoccur,befurther1MontaltoM,
;159:263-265.

’;193:598-601.
HITHservicebecomesalegalandclinicalextension
3ChengJ,MontaltoM,;25:79-91.
,itmustaddressmedical4CaplanGA,SulaimanNS,ManginDA,-analysisof“hospitalinthe
care:specifically,whetherahospital-affiliated,for-home”.MedJAust2012;197:512-519.
mal,separate,;299:1182-1184.
,ReevesJ,BarrettJ,?MedJAust2012;197:
Caplanetal’smeta-analysischipsawayalittlefurther524-525.
intothefutureformofhospitalsandHITH,.
Melbourne:VictorianGovernment,:///
sculptorchiselsatamarbleblocktorevealimportantnew3F753BB75D5077D4CA257949007FA85F/$FILE/110702_DoH%20HITH
aspectsoftheimagethatlieswithin.%20guidelines%(accessedOct2012).❏
TheAustralasianColorectalCancer
FamilyRegistry
Reducingtheimpactofcolorectalcancer
IngridWinshipolorectalcancer(CRC)isoneofthemostcommonroll(270controlfamilies).MaintenanceoftheACCFR
MBChB,MD,FRACP,
ProfessorofAdultClinicalcancersinAustralia,withariskinpeopleundertheincludesconductingfollow-upsurveysevery5yearsto
Genetics,1andExecutiveageof75yearsofonein18formenandonein26updatedataregardingpersonalandfamilycancerhistory,
DirectorofResearch2C
,about15000Australiansarediag-CRCscreening(byfaecaloccultbloodtestorcolonoscopy),
AungKoWin1
MBBS,MPH,nosedwithCRC,-yearcolonoscopicpolypectomyandotherbowelsurgeries.
ResearchFellow
(Epidemiologist)3survivalfromCRCis62%,whichisconsiderablyworseTheACCFRactsasaresearchenabler,withaccessto
than,forexample,breastcancer,whichhasa5-yeardataandbiospecimensprovidedequitablytointernaland
survivalof88%.2
1UniversityofMelbourne,
Melbourne,
3
2RoyalMelbourneHospital,,only5%ofCRCsareknowninformedconsentisobtainedfromallstudyparticipants,
Melbourne,
3CentreforMolecular,withprotocolsapprovedbytherelevantinstitutional
Environmental,GeneticandSubstantialadvancementinunderstandingtheaetiology,,moststudies
AnalyticEpidemiology,preventionandtreatmentofCRC,aswellasreducing

mortality,requirescomprehensivepersonal,familyand
PopulationHealth,casesthroughfamilycancerclinicshavedeliberatelybeen
UniversityofMelbourne,epidemiologicaldataandbiospecimens(DNAandtumour
Melbourne,,theACCFRdiffersfromother
tissue)forlargenumbersofpeopleacrossthefullspectrum
Ingrid.******@,unaffected


(ACCFR)
affectedfamilymembers,andcanbeusedascontrols.
TheACCFRwasestablishedforcollaborativeresearch
doi:
intothepreventionandtreatmentofCRCandisour
asCRCcasesfromtheVictorianCancerRegistry,whoare
region’slargestandbestcharacterisedfamily-based
selectedirrespectiveofCRCfamilyhistory,areusefulfor

VictorianCancerFamilyStudy,,notonly
1997,theACCFRhasbeenpartoftheColonCancerthosethatareinherited.
FamilyRegistry(CCFR),aninternationalconsortiumGenotypedataintheACCFRenablestudiesoftherisk-
acrossAustralia,NewZealand,theUnitedStatesandmodifyingeffectsofgeneticandnon-
CanadathatisfundedbytheUSNationalInstitutesofhavebeenusedforarangeofgene-discoveryresearch,
-basedworldwideincludingclassiclinkagestudies,genome-wideassociation
resourceforstudiesofCRCandassociatedcancers,andstudies,andwhole-exomeandwhole-genomestudies
-,partici-
peoplefrom1800familiesinAustraliaandNewZealandpantswithCRCatrecruitmentareprospectivelyfollowed
havebeenrecruitedtotheACCFR,throughtheVictorianuptoprovideinformationaboutpotentialriskfactorsfor
CancerRegistry(960casefamilies),-
Brisbane,Sydney,Melbourne,Adelaide,PerthandAuck-tatesnovelbehaviouralandpsychosocialresearchto
land(580multiple-casefamilies),ortheVictorianelectoralunderstandparticipants’healthcareutilisation.
480MJA197(9)·5November2012