Letters · Correspondance

CMAJ 1999;161:365-8

• Considering the cost of CABG M.J. Walsh;
  response: G. Naglie, et al
• Home is where the health care is M. Montalto;
  response: L. Soderstrom, et al
• A straw-man argument? R. Patterson;
  response: M.T. Schechter, M.V. O'Shaughnessy
• Smoking out the economics of tobacco use W.R. Harris;
  response: J. Hoey
• Whiplash cultures R. Ferrari

It is evident to me that one of the consequences of the article by Gary Naglie and colleagues [abstract / résumé]¹ on the age difference in the cost of coronary artery bypass grafting (CABG) will be an attempt by the cost managers to reduce the numbers of seniors who have this procedure. This is ageism at its worst.

Considering that half of the cost of health care for an individual occurs in the last year of life (when he or she is sickest, unto death), it should have been self-evident that it costs more to treat older people. The need to put a figure on this escapes me. However, it will not, you can be sure, escape the cost-cutters. There will be a push to limit this procedure to those under 65 years of age, even though the "research" does not demonstrate that the outcome is different among those who are younger, or that the postoperative life span is longer or more productive.

This appears to me to be a nasty article, which serves no good purpose, but will, I fear, produce bad consequences.

Michael J. Walsh, MD
Barrie, Ont.
walshm@rvh.on.ca

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1. Naglie G, Tansey C, Krahn MD, O'Rourke K, Detsky AS, Bolley H. Direct costs of coronary artery bypass grafting in patients aged 65 years or more and those under age 65. CMAJ 1999;160(6):805-11.

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We are chagrined by Michael Walsh's perception that we have been authors of a "nasty" article, but we are not unaware of the irony of this accusation. As practitioners who primarily care for seniors, we routinely advocate that CABG be performed in patients over 65 years of age, both for our own patients and at a policy level. What particularly concerns us about Walsh's comments is the potential for misunderstanding and misuse of descriptive costing information. We wish to emphasize most strongly that clinical policy is only indirectly related to descriptive costing information. Whether CABG should be performed in seniors depends primarily on 3 things: efficacy, effectiveness and cost-effectiveness.^1,2 Cost-effectiveness expresses the relation between the cost and the clinical value of an intervention. Transplants, for example, are very costly, but they are usually cost-effective because they are extremely effective. A cost-effectiveness model that we are working on suggests that the same is likely to be true for CABG in seniors.³ It is quite expensive but probably worth doing because it is very effective in prolonging life (for selected indications) and relieving angina.

So what is descriptive costing information good for? Costing studies allow us to identify categories of heavy resource utilization (e.g., drugs, investigations, inpatient care) and to direct future research efforts to areas in which the potential gain would be greatest. Our results indicate that the majority of the cost difference between older and younger patients was accounted for by the difference in the length of stay in the intensive care unit and on the ward. Identification of modifiable factors that contribute to longer stays for older patients may lead to interventions that decrease costs and also potentially improve clinical outcomes.

We strongly discourage the misuse of costing data alone to guide clinical policy. We hope that this descriptive costing study will not be fodder for the "cost-cutters," rather that it will promote further research that will lead to improvements in CABG for patients over 65.

Gary Naglie, MD
Murray Krahn, MD, MSc
Allan Detsky, MD, PhD
University Health Network and Mount Sinai Hospital
University of Toronto
Toronto, Ont.

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1. Detsky AS, Naglie IG. A clinician's guide to cost-effectiveness analysis. Ann Intern Med 1990;113:147-54.
2. Laupacis A, Feeny D, Detsky AS, Tugwell PX. How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. CMAJ 1992;146:473-81.
3. Naglie G, Krahn M, Tansey C, Detsky A, Bolley H. Is coronary artery bypass surgery cost-effective in the elderly? [abstract]. Clin Invest Med 1997;20(Suppl):S23.

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None of the 4 selected class 1 studies in the review paper by Lee Soderstrom and colleagues [full article]¹ reported genuine acute home care programs. In the selected studies, the definitions of acute home-based care were problematic. Richards and colleagues² described hospital in the home (HIH) as "a generic term, referring to a package of home based nursing and rehabilitation services," whereas Shepperd and colleagues³ restricted the eligibility to patients older than 60 years with 5 broadly defined conditions. These studies included patients selected on the basis of their clinical condition and its burden on the hospital, rather than on the basis that they had definite acute care needs and that this care could be appropriately delivered at home. The presence of validated research instruments seemed to influence the conditions chosen for inclusion in some trials. Data on the length of stay presented in these trials suggest strongly that the programs were additive to hospital stays and not substitutive.

The appropriate definition of HIH is one in which the patient requires treatment that, without the presence of the HIH, would otherwise require care in hospital. Substitution is the critical component of HIH care; it can be demonstrated through the use of hospital technologies or drugs not usually associated with community care (e.g., intravenous therapy and pumps, low molecular weight heparin), by the delivery of 24-hour care to patients or by the fact that hospitals retain the legal and financial responsibility for care provision. None of these preconditions is apparent in the selected class 1 studies. Valid selections would have included the randomized controlled trials by Levine and colleagues⁴ and Koopman and colleagues⁵ in the management of deep venous thrombosis and by Wolter and colleagues⁶ in the management of cystic fibrosis at home.

Without firm definitions and consistent clinical applications with which to define the interventions, cost comparisons are as problematic as assessments of the clinical outcomes of such trials. In an assessment of the cost of HIH care for the delivery of intravenous therapy to patients with cellulitis,⁷ HIH admissions were approximately 40% less costly for patients admitted to the HIH directly from the emergency department and approximately 30% less costly for patients who required a stay within the hospital itself. The greatest savings were found in hospital overhead costs and nursing salaries, while HIH was more costly in the provision of pharmaceuticals and procedures. The results concurred with my clinical experience in the delivery of acute care to over 1200 patients at home.^8,9

Systematic reviews of complex health service interventions such as HIH should be used with great care and usually resist efforts at reductionism. The results of the article by Soderstrom and colleagues¹ must be scrutinized in that light. The challenge is to establish high-quality HIH programs and then test their efficiency in a randomized controlled trial for a variety of clinical conditions and therapeutic interventions. To do otherwise is, to borrow from the biomedical vocabulary, to skip phases 1 and 2 and go straight to phase 3 trials.

Michael Montalto, MD, PhD
Director
Hospital in the Home
Frankston Hospital
Frankston, Victoria
Australia
m.montalto@gpph.unimelb.edu.au

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1. Soderstrom L, Tousignant P, Kaufman T. The health and cost effects of substituting home care for inpatient acute care: a review of the evidence. CMAJ 1999;160(8):1151-5.
2. Richards SH, Coast J, Gunnell DJ, Peters TJ, Pounsford J, Darlow MA. Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care. BMJ 1998;316:1796-801.
3. Shepperd S, Harwood D, Jenkinson C, Gray A, Vessey M, Morgan P. Randomised controlled trial comparing hospital at home care with inpatient hospital care. 1: Three month follow up of health outcomes. BMJ 1998;316:1786-91.
4. Levine M, Gent M, Hirsch J, Leclerc J, Anderson D, Weitz J, et al. A comparison of low molecular weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep vein thrombosis. N Engl J Med 1996;334:677-81.
5. Koopman MM, Prandoni P, Piovella F, Ockelford PA, Brandjes DP, van der Meer J, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low molecular weight heparin administered at home. N Engl J Med 1996;334:682-7.
6. Wolter JM, Bowler S, Nolan P, McCormack J. Home intravenous therapy in cystic fibrosis: a prospective randomized trial examining clinical, quality of life and cost aspects. Eur Respir J 1997;10:896-900.
7. Montalto M, Watts J. Considering the cost of hospital in the the home care. Melbourne: Centre for Health Program Evaluation; 1998.
8. Montalto M. How safe is hospital in the home? Med J Aust 1998;168:277-80.
9. Montalto M. Hospital in the home: take the evidence and run. Med J Aust 1999;170:148-9.

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In our review of the research evidence regarding the health and cost effects of substituting home care services for some inpatient acute care (full article),¹ we drew 2 conclusions. First, although the evidence indicates that such home care has no notable effects on patients' or caregivers' health, it does not establish that this home care reduces health care costs. Second, the available, internally valid evidence is very limited, so well-designed evaluations of this home care are urgently needed. Michael Montalto's comments are consistent with our conclusions.

He argues that "genuine acute home care programs" were not evaluated in the 4 most valid studies we reviewed. We disagree. Those studies involved health conditions for which home care is thought appropriate clinically, and, in the programs evaluated, health professionals provided services in patients' homes that were substituted for inpatient care.

Montalto also argues that we should have considered 3 other studies. Two of them^2,3 evaluated programs in which patients with venous thrombosis self-injected heparin at home, not programs involving health professionals providing services in patients' homes. Moreover, had we included these 2 studies, there would still be no evidence that home care was cost-effective for most health conditions for which it was being used. The third study⁴ concluded that home care was cost-effective. However, the cost-effect estimate is questionable. Inappropriate cost calculations were made by using hospital revenue data (i.e., diagnostic-related group reimbursement rates). The researchers did not estimate the change, caused by the use of home care, in the value of the hospital resources used to manage the patients' health problems.

Lee Soderstrom, PhD
McGill University
Montreal, Que.
Pierre Tousignant, MD
Montreal-Centre Regional Council for
  Health and Social Services
Montreal, Que.
Terry Kaufman, LLB
Centre local des Services communautaires
Notre Dame de Grace­Montreal West
Montreal, Que.

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1. Soderstrom L, Tousignant P, Kaufman T. The health and costs effects of substituting home care for inpatient acute care: a review of the evidence. CMAJ 1999;160(8):1151-5.
2. Levine M, Gent M, Hirsch J, Leclerc J, Anderson D, Weitz J, et al. A comparison of low molecular weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep vein thrombosis. N Engl J Med 1996;334:677-81.
3. Koopman MM, Prandoni P, Piovella F, Ockelford PA, Brandjes DP, van der Meer J, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low molecular weight heparin administered at home. N Engl J Med 1996;334:682-7.
4. Wolter JM, Bowler S, Nolan P, McCormack J. Home intravenous therapy in cystic fibrosis: a prospective randomized trial examining clinical, quality of life and cost aspects. Eur Respir J 1997;10:896-900.

[Contents]

A recent article by Martin Schechter and Michael O'Shaughnessy, "Krever 2008," (full article)¹ is a hypothetical transcript set in the future in which the authors present the testimony of an "expert witness" who purportedly represents the collective wisdom of today's political policy-makers. The witness' arguments are neatly demolished by the fictitious commissioner, and the witness and his position are made to look foolish and weak.

In doing this the authors have set up a "straw-man" argument, so called because it is easier to knock down a man of straw than a real opponent. Another explanation is that, in the 19th century, witnesses-for-hire would hang about law courts, willing to say whatever was requested. These untrustworthy characters were identified by a straw in their shoe.²

Schechter and O'Shaughnessy create the impression that their opponents' point of view has been properly represented and justly defeated, but in fact no debate has taken place. An opponent of needle-exchange programs could easily write a similar script that would have a very different and equally unsubstantiated verdict. The authors may or may not be correct in their conclusions, but we won't know until a full and proper deliberation has occurred and each side has advanced its own arguments instead of relying on partisan interpretation of each other's views.

Robert Patterson, MD
Leamington, Ont.
robpatterson@attcanada.net

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1. Schechter MT, O'Shaughnessy MV. Krever 2008. CMAJ 1999;160(8):1179-80.
2. Brewer EC. The dictionary of phrase and fable. New York: Harpercollins; 1995.

[Contents]

We did not write a technical article but rather a dramatic piece whose purpose was to raise the following point: If questions of civil and criminal negligence can be raised with regard to bureaucrats and politicians who knowingly did not provide the means to protect the blood supply, then cannot the same questions be raised about those who knowingly did not provide the means for injection drug users to protect themselves from lethal harm? We do not know the answer, but the question is legitimate.

As to whether the opinions of our decision-makers were properly represented, if only this were not so. Since 1986 both of us have sat on a number of national and provincial ministerial advisory panels, where we have discussed this subject with a host of federal and provincial bureaucrats and ministers of health. Sadly, the statements of our "witness" are virtual quotations from those discussions. If our witness was made to look foolish and weak, then we are better playwrights than we thought, for this is precisely how we believe decision-makers have acted.

Robert Patterson quite rightly asks for a full and proper deliberation. We invite him to read the report of the National Task Force on HIV, AIDS and Injection Drug Use,¹ which brought together national and international experts and evidence in 1997. He might also read the Le Dain Royal Commission report,² which was written more than 25 years ago. Unfortunately, these reports have been neglected, not discussed.

Patterson correctly notes that opponents of harm reduction could write a similar script to ours but with a different verdict. We would look forward to reading the testimony of their "witness" about his or her accomplishments over the last 30 years, including the overwhelming success of the war on drugs, the wonderful state of affairs in our inner cities and the tens of thousands of cases of hepatitis C and HIV infection that could have been prevented.

Martin T. Schechter, MD, PhD
University of British Columbia
Michael V. O'Shaughnessy, PhD
BC Centre for Excellence in HIV/AIDS
Vancouver, BC

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1. National Task Force on HIV, AIDS and Injection Drug Use. HIV/AIDS and injection drug use: a national action plan. Available: www.cfdp.ca/hivaids.html (accessed 1999 July 23).
2. Commission of Inquiry into the Non-Medical Use of Drugs. Final Report. Ottawa: Queen's Printer; 1973.

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I read with interest the editor's preface on global tobacco use in a recent issue of CMAJ (full article).¹ Whenever I see figures like these I can't help wondering what would happen if all smokers miraculously quit overnight. Presumably they would live longer, healthier lives. But what would be the cost of their health care as they fade into senility? Greater, less than or the same as the $14.5 billion you quoted as the maximum amount to look after smoking-related illnesses?

Finally, where did you get the statistics you quoted? Are there comparable figures for ordinary age-related morbidity?

W.R. Harris, MD
Toronto, Ont.
bobs.harris@utoronto.ca

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1. Editor's preface. CMAJ 1999;160(11):1537.

[Contents]

Most smokers we know would like to quit and live longer lives. We know how to help people quit smoking and it doesn't cost much. The funds saved could be applied to preventing other illnesses or perhaps to improving health care for conditions that we don't know how to prevent, such as degenerative hip disease, to mention something of interest to Dr. Harris.

As for the figures, they are widely available. We found them at www.who.org/toh/worldnotobacco99/teaser.htm (last accessed 1999 July 6).

John Hoey, MD
Editor-in-Chief

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[Contents]

The recent CMAJ piece on the increase in the cost of seat-belt-related injuries (full article)¹ reveals the seriousness of the whiplash problem in the United Kingdom. It is a medicolegal and social problem in many other countries as well.

There is a stark contrast, however, between the experience of whiplash in areas such as the United Kingdom and North America and that in Lithuania, Greece and Germany. In the latter countries, acute whiplash injury does occur frequently, but despite the use of seat belts, whiplash patients do not appear to have an increased risk of chronic pain compared with the uninjured population.² The acute whiplash injury is not even associated, in most cases, with short-term disability; time off work (if any) is usually 2 weeks or less. This is despite the fact that in both Greece and Germany, for example, accident victims have full insurance and disability coverage and are fully entitled to and do (especially in Germany) engage in litigation if they so desire. Yet in these same countries, recovery routinely occurs in 6 weeks or less, and treatment costs are usually less than Can$100-200. It has been shown that this profoundly different outcome is not due to a failure to report symptoms or cultural stoicism.²

The reasons for these cross-cultural differences are many and complex, but their elucidation is the basis for new paradigms for the management of this problem in "whiplash cultures."³ The problem may not be, as Charles Galasko suggests, a lack of attention to whiplash in countries where it is epidemic,¹ but rather our lack of attention to whiplash in countries in which it is not.

Robert Ferrari, MD
Edmonton, Alta.
rferrari@home.com

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1. LeBourdais E. Cost of seat-belt-related whiplash injuries rising. CMAJ 1999;160(10):1425.
2. Obelieniene D, Schrader H, Bovim G, Miseviciene I, Sand T. Pain after whiplash — a prospective controlled inception cohort study. J Neurol Neurosurg Psychiatry 1999;66:279-83.
3. Ferrari R, Kwan O, Russell AS, Schrader H, Pearce JMS. The best approach to the problem of whiplash? One ticket to Lithuania, please. Clin Exp Rheumatol 1999;17:321-6.