Table 1 An assessment of the local applicability of a systematic review about home care (from the perspective of a Canadian policymaker)

Policymakers assessing the applicability of a 2005 review of home care could apply the series of questions discussed earlier as follows [24]:

1. Were the studies included in the systematic review conducted in the same setting or were the findings consistent across settings or time periods?

   • 22 studies were included in the review

◦ 9 from the United Kingdom (UK)

◦ 3 from Australia

◦ 1 each from Italy, Norway, and the United States

◦ 7 were not described in a way that identified the country in which the study was conducted

   • Findings were not consistent across settings

   • Two studies were published in 1978 while the others were published from 1992 onwards. Many did not specify a time period, making it difficult to support the contention that the findings were consistent over time periods

2. Are there important differences in on-the-ground realities and constraints that might substantially alter the feasibility and acceptability of an option?

   • In Canada, nurses are in tremendous demand (particularly in hospitals) and many are not used to the scope of practice required in home care settings. This means that many nurses might not embrace career opportunities in home care settings

   • In Canada, unlike in the UK where 9 of 13 identifiable studies were conducted, citizens differ in whether they have supplementary coverage permitting more intensive home care. This means that relatively more wealthy people may get access to home care than the less well off

   • In Canada, unlike in the UK, home care recipients and their families may have to travel very long distances if they have to seek acute care. Some may therefore delay their discharge from hospital; others may suffer if a hospital transfer is difficult

   • In Canada, nurses may face a drop in pay if they move from hospitals to the community. Many of them may therefore actively oppose a shift from hospital care to home care

   • In Canada, there is even more of a separation between health and social services (at least outside the province of Quebec) than there is in the UK, which means that caregivers may face a greater burden that is not covered by social services

3. Are there important differences in health system arrangements that may mean an option could not work in the same way?

   • In Canada, as suggested earlier, home care recipients and their families cannot rely on the same breadth of services available to those in the UK (at least outside the province of Quebec)

   • In Canada, unlike in the UK, there is a governmental commitment to first-dollar coverage for hospital-based and physician-provided care but not for home care, which means that Canadian home care recipients and their families may face significant financial barriers to accessing home care

   • In Canada, unlike in the UK, most Canadians are not 'attached' to a multi-disciplinary primary healthcare practice, and some Canadian home care recipients would not even have a regular primary healthcare provider

4. Are there important differences in the baseline conditions that might yield different absolute effects - even if relative effectiveness was the same?

   • In Canada, home care is already well established for most types of care, which means that the benefits may be small in absolute terms, at least for those not facing financial barriers

5. What insights can be drawn about options, implementation, and monitoring and evaluation?

   • In Canada, admission-avoidance schemes may be a relatively unknown option compared to well-established schemes, such as the early discharge of elderly medical patients, or patients following surgery, or care of terminally ill patients

The review has now been updated and divided into two separate reviews, one of which deals specifically with admission-avoidance schemes and would be particularly relevant to Canada [25].