Julia Lowe, Director of General Medicine, Department of Endocrinology, John Hunter Hospital, Newcastle, New South Wales
Michael Montalto is the director of the Hospital in the Home at Edgeworth Hospital in Melbourne. It must be recognised that he is an advocate of a certain model of hospital in the home. For reasons that he briefly alludes to in this book, substitution of domestic for hospital care for patients who would otherwise 'require inpatient care by the nature of their medical or social condition', is far more advanced in Victoria than in other parts of Australia. For clinicians from these other areas, his book provides a short introduction to the topic, and a source of references for further reading. As I practise outside Victoria, I found the first two chapters the most interesting. These discuss factors supporting the emergence of alternatives to hospitalisation, the difficulties of organising randomised controlled clinical trials in this area, and organisational models of hospital in the home.
Chapters 3, 4 and 6 outline the frequently asked questions about hospital in the home - general clinical principles, patient selection and management, and the drugs and devices used. I may have missed something, but as a clinician in New South Wales the description of conditions that could be managed at home merely confirmed my suspicion that many of these programs deal with patients who would not be admitted to hospital in other areas. Many general practitioners will manage uncomplicated deep venous thrombosis, pyelonephritis or pneumonia in the community. The Diabetes Education Centre in Newcastle, New South Wales, demonstrated more than 25 years ago that it is not necessary to admit people to hospital to start treatment with insulin, and in Leicester in the UK, even young children have been started on insulin as outpatients, for over forty years. The true advances have been the technological ones that allow long-term intravenous antibiotic therapy of conditions such as septic arthritis and bacterial endocarditis to take place outside the conventional hospital setting.
Chapters 5, 7 and 8 deal with cost, quality and ethical issues. It is always easy to criticise a non-expert writing in these areas, but I thought the chapter on ethics was lightweight and superficial. The final section in this chapter on identifying poor hospital in the home care was interesting, but for those who skim books it would have been better placed in the chapter on quality. I was also surprised that there was no recognition of the major criticism of cost analyses of hospital in the home, namely that while there may be some savings, these are only achieved if hospital in the home is substituted for hospital beds that are then closed. Publicity associated with the publication of the book suggested that hospital in the home was an alternative (less costly) way of meeting the need for increased hospital beds without building more hospitals. I could only find one sentence alluding to this, and those who like me were looking for some discussion of this idea will be disappointed.
These criticisms aside, this is a slim, readable introduction to an important development in health care.
