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They Make Another Comment Further On In The Paper Which Suggests That Care ...



They make another comment further on in the paper which suggests that care givers, in total, provided an average of 33 mins. per day with patients in the intervention group more than they did with the usual treatment group. This actually underlines another major cause of concern with regard to the statistical validity of the study. There was no attempt made to equate the amount of patient contact time with healthcare professionals in the study. One could argue that it was not necessarily the regime that was responsible for the improved figures but simply that healthcare professionals ended up spending more professional time with the patients in the intervention group and this could equate with the reasons why this group spent less time in hospital. (Schulz K F et al. 1999)

In terms of the thrust of this particular essay, we should note that another shortcoming of this study was the fact that no attempt was made to try to determine which of the interventions offered were particularly important in reducing the admission rates for the intervention group and equally they could not point to which elements were important in improving the quality of life of the remaining patients. The authors correctly and properly point out that it is entirely likely that some of the interventions may have had no overall effect and therefore could have been omitted on the grounds of both expediency and cost, but the study only considered the overall effect of the whole package without considering any subdivisions of individual components of treatment. (Moher D et al. 1999)

We have already commented on the short length of patient follow up in this study (90 days). The authors suggest that this was chosen as the first 90 days after an initial admission is the time of greatest risk for further hospitalisation. Curiously that is not borne out by the data from the Strömberg trial which, despite the shortcomings already outlined above, appeared to suggest that there was an apparent latent period directly after the first discharge in which the patients were less likely to be admitted. One can hypothesise that this may be because directly after hospitalisation, the patient could be expected to be well stabilised and not likely to have developed any untreated significant co-morbidity. Such factors would be more likely to occur some time after the patients had been seen and assessed. Clearly this is conjecture and we cannot find any evidence base to support it in the literature.

The Stewart paper is similar but places a specific emphasis of the provision of home visits in order to ensure that the pharmacological regime is optimal.

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