Is caregiving by family members superior to paid home health caregiving? According to a paper by Coe et al. (2019), the answer is ‘yes’.
We find that some family involvement in home‐based care significantly decreases health‐care utilization: lower likelihood of emergency room use, Medicaid‐financed inpatient days, any Medicaid hospital expenditures, and fewer months with Medicaid‐paid inpatient use. We find that individuals who have some family involved in home‐based care are less likely to have several adverse health outcomes within the first 9 months of the trial, including lower prevalence of infections, bedsores, or shortness of breath, suggesting that the lower utilization may be due to better health outcomes.
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This is an interesting question but unfortunately the study does not answer it. The are methodologic flaws that limit the conclusions. The most important is no fault of the authors but of the design of the Medicaid demonstration project. This is obvious from the baseline demographics: at baseline 87% of patients were receiving family care. That’s a high baseline to improve on–in fact, after randomization, the difference between control and treatment groups was only 5% (89.5% vs. 94.3%). Not surprising since only 45% of treatment families used the cash they were given to pay for help in the home. Other problems include exclusion of 12% of subjects due to loss of eligibility or failure to complete all or part of survey (compromising randomization), failure to indicate the method of randomization, lack of blinded assessment (e.g., of claims data), subjective health outcomes survey that could be influenced by bias, reporting of results with little statistical validity (P>.01, given a study this large), use of multiple, logistic models with contradictory results, without explaining divergence, reporting multiple dependent results (e.g., multiple measures of inpatient spending). In the final analysis, the only reliable results would be any ER use (not statistically significant) and total Medicaid inpatient spending (not statistically significant). Even if one accepts the survey data of significant decrease in bedsores and shortness of breath (each only on one of three analyses) the study does not differentiate between decrease due to family involvement and decrease due to increased number of caregivers (which has been shown to decrease the risk of bedsores in at-risk individuals). This is an important reminder of the need to examine methodology carefully. The most likely answer about home care is that families want to be involved and a combination of family involvement and trained caregivers may offer the best care. Whether this can be proven in a study remains to be seen.