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How Much Does a Home Care Nursing Visit Cost? A National Micro-Costing Study from the AIDOMUS-IT Project

Nurs. Rep. 2026, 16(6), 180; https://doi.org/10.3390/nursrep16060180

by Marco Di Nitto¹, Paolo Landa^2,3,4

, Paolo Iovino^5,*

, Rosaria Alvaro^6,7, Alessandra Burgio⁸

, Valeria Caponnetto⁹

, Stefano Domenico Cicala¹⁰

, Giancarlo Cicolini¹¹

, Manuele Cesare^12,13

, Loreto Lancia⁹

, Duilio Fiorenzo Manara^6,14, Ilaria Marcomini¹⁴

, Beatrice Mazzoleni^15,16

, Alvisa Palese^17,18

, Laura Rasero^5,6, Gennaro Rocco¹⁹

, Francesco Zaghini⁷

, Loredana Sasso^1,20 and Annamaria Bagnasco^1,6

Reviewer 1:

Reviewer 2:

Reviewer 3:

Reviewer 4:

Nurs. Rep. 2026, 16(6), 180; https://doi.org/10.3390/nursrep16060180

Submission received: 26 March 2026 / Revised: 21 May 2026 / Accepted: 22 May 2026 / Published: 26 May 2026

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This study addresses an important topic by providing a national analysis of the partial costs of home nursing services. The study is well-designed and offers valuable insights for health policy and workforce planning. However, several aspects could be strengthened to improve clarity and accuracy:

Introduction:
The background is comprehensive, but it would benefit from a more thorough critical analysis of recent international literature (over the past three to five years) and a clearer identification of the research gap, particularly in comparison with current economic assessments in other healthcare systems.

Methodology:
While the methodology is generally robust, some aspects require clarification. Specifically:
Provide more detail on the sampling strategies in the second phase and justify the selection of only three local health authorities.

Explain how missing data will be handled (if any).

Justify the main assumptions used in the cost scenarios, particularly in the expanded model.

Presentation of Results:
The results are well-organized; however, some tables (e.g., Tables 3–5) could be simplified for easier reading. Please consider reducing redundancies and improving labeling for better comprehension.

Discussion:
The discussion is strong, but could be enriched by a deeper comparison with international studies and a more nuanced examination of the implications of using outpatient service definitions as substitutes for evaluating nursing activities.

Graphs and Tables:
These are generally informative, but the titles of the graphs (e.g., tornado diagram) should provide sufficient explanation for the reader.

Author Response

REVIEWER 1

Thanks for this important suggestion. In the revised manuscript, we have strengthened the Introduction by incorporating recent international literature, including recent systematic reviews on the cost-effectiveness of home care services. We have expanded the critical appraisal of the literature by highlighting the heterogeneity of existing economic evidence and its strong dependence on healthcare system characteristics, workforce organization, and funding models. We have clarified that much of the available literature relies on modelling approaches, disease-specific analyses, or aggregate costing frameworks, rather than empirically derived estimates based on detailed observation of care processes.

“In recent years, international research has increasingly explored the economic implications of home care and community-based services. Several studies suggest that home-based care may represent a cost-effective or potentially cost-saving model in specific clinical contexts, particularly by reducing hospital utilization and supporting care continuity (Morrow et al., 2025; Curioni et al., 2023; Gousia et al., 2024). However, the available economic evidence remains heterogeneous and strongly context-dependent, reflecting differences in healthcare system organization, workforce structures, and funding mechanisms (Elmusharaf et al., 2024). In addition, much of the existing literature relies on modelling approaches, disease-specific analyses, or aggregate costing frameworks, rather than empirically derived estimates based on detailed observation of care processes (Lizano-Diez et al., 2022; Tan et al., 2009).

Despite its recognized clinical and organizational value, the economic footprint of HCN remains poorly defined [10,11]. For example, in Italy, unlike medical home visits, nursing activities delivered at home are not covered by a dedicated national tariff schedule. Home care nursing services are primarily financed by the National Health Service (Servizio Sanitario Nazionale, SSN) and are generally provided free of charge to eligible patients. However, in the absence of a dedicated national tariff for home-based nursing activities, substantial regional heterogeneity exists in the organization, funding, and valuation of home nursing services, limiting the ability of policy-makers to plan sustainable workforce expansion and equitable service delivery [4].”

Finally, we have made the research gap more explicit by emphasizing the limited availability of real-world, bottom-up micro-costing studies of home care nursing at a national level, particularly in the Italian context.

“This lack of empirically grounded economic evidence represents a critical gap, particularly in light of recent investments in territorial care and the ongoing reorganization of community-based services.”

Thank you for this recommendation. We expanded the methods section to explain that specifically, Phase 2 was based on a convenience sample of Local Health Authorities that had participated in Phase 1 and were willing and able to support the more resource-intensive time-and-motion data collection. The new paragraph reads as follows:

“The LHAs included in Phase 2 were selected based on feasibility and willingness to participate in the time-and-motion data collection, which required significant local organizational support. Selection was purposive and aimed to capture variability in organizational models of home care delivery.”

Explain how missing data will be handled (if any).

Thank you for the opportunity to clarify this point. We have revised the Methods section to describe the prevalence and handling of missing data. This paragraph was inserted at the end of the “measurement of nursing activities” section.

“Missing data in Phase 1 were limited (151 missing responses out of 3,949 observa-tions; 3.82%) and were handled using a complete-case approach without imputation, as the level of missingness was considered unlikely to materially affect the estimated distribution of nursing activities. In Phase 2, missingness primarily concerned material cost data recorded at the visit level. Missing material fields were treated as missing in-formation rather than absence of material use and were therefore excluded from the estimation of mean material costs per visit.”

Justify the main assumptions used in the cost scenarios, particularly in the expanded model.

We thank the reviewer for this helpful comment. We have expanded the Methods section to clarify and justify the assumptions underlying the base-case and extended costing scenarios.

“Because in Italy no official fee schedule exists for nursing activities performed at home, two costing scenarios were considered. The base-case scenario estimated accounting costs using directly measured empirical data, including nursing time, travel time, transportation, back-office activities, and materials. This scenario was intended to reflect the minimum measurable cost of delivering home care nursing from the per-spective of the Italian National Health Service.

The extended scenario was developed to provide an illustrative estimate of the economic value of nursing activities currently not covered by a dedicated home care tariff. In this scenario, nursing activities were valued using the maximum tariffs listed in the Italian specialist outpatient fee schedule, which represented the only available standardized national tariff reference. This choice was made to avoid assigning a null value to activities that require professional nursing time, technical competence, and clinical responsibility, while recognizing that these tariffs do not constitute an official reimbursement model for home care nursing.

In line with Phase 2 observations, the extended scenario assumed an average of three nursing activities per home visit, corresponding to the median number of activities recorded during observed visits. This assumption was therefore empirically grounded in the time-and-motion data. Given the uncertainty surrounding tariff-based valuation and activity intensity, these assumptions were tested through deterministic and probabilistic sensitivity analyses.”

We have revised Tables 3–5 to improve clarity and readability. First, we reduced redundant information, simplified the table structure, and refined labels to ensure consistent terminology across the manuscript. Second, we improved table notes to clarify how key values (e.g., weighted costs and costing scenarios) were derived.

The tables now appear as follows:

Table 3. Distribution and weighted average cost of nursing activity categories.

*Category*	*Unit cost (€)*	*Frequency (%)*	*Weighted cost (€)*
Vascular access, infusion therapy, blood sampling	38.06	21.17	8.06
Health education	15	23.97	3.60
Advanced wound care	39.13	11.93	4.67
Simple wound care	29.72	7.89	2.34
Monitoring and measurements	40.95	6.2	2.54
ICP, planning, evaluation	33.81	10.45	3.53
Clinical care activities	34.1	18.39	6.27
Total	—	100	31.01

Note. Weighted costs were calculated by combining the relative frequency of nursing activity categories (derived from Phase 1) with their corresponding unit costs. Percentages refer to the distribution of nursing activities, not to the proportion of home care visits.

Legend. ICP, individual care plan.

Table 4. Mean daily cost per patient under base-case and extended scenario.

*Cost item*	*Base-case scenario (€)*	*Extended scenario (€)*
*Cost item*	*Base-case scenario (€)*	*Extended scenario (€)*
Nursing time at patient’s home	6.95	6.95
Travel to patient’s home	10.25	10.25
Return travel to workplace	1.5	1.5
Back-office activities	0.04	0.04
Medical materials	6.5	6.5
Transport (vehicle)	2.54	2.54
Subtotal (accounting costs)	27.78	27.78
Nursing activities (3 per visit)	–	93.03
Total per patient per day	27.78	120.81

Note. Nursing time, travel time, and back-office activities were derived from AIDOMUS-IT data. Transportation costs were calculated using ACI cost-per-kilometer rates. Material costs were estimated based on AIFA data and study-specific observations. The extended scenario includes an illustrative valuation of nursing activities based on the maximum outpatient tariffs and does not represent an official reimbursement scheme.

Table 5. Mean daily cost per nurse under base-case and extended scenario.

Cost item	Base-case scenario (€)	Extended scenario (€)
Nursing time at patient’s home	47.53	47.53
Travel to patients’ homes	70.14	70.14
Return travel to workplace	10.25	10.25
Back-office activities	0.25	0.25
Medical materials	44.47	44.47
Transport (vehicle)	17.36	17.36
Subtotal (accounting costs)	190	190
Nursing activities (3 per patient)	–	636.32
Total per nurse per day	190	826.32

Note. The extended scenario includes an illustrative valuation of nursing activities based on the maximum outpatient tariffs and does not represent an official reimbursement scheme.

We deem this the most important recommendation. We have substantially expanded the Discussion by incorporating recent international studies:

“These findings should be interpreted in light of the broader international literature, which highlights both the growing relevance of home-based care and the limited availability of robust economic evaluations. Previous studies have shown that home care interventions are associated with improved patient adherence, satisfaction, and quality of life, and in some cases with reductions in healthcare utilization, although the economic evidence remains heterogeneous and strongly context-dependent (Lizano-Diez et al., 2022) In this field, the present study contributes to filling an important gap by providing detailed, bottom-up cost estimates based on real-world data, an approach that remains relatively uncommon in the field.

From a methodological perspective, the costing strategy adopted in this study is consistent with ingredient-based approaches used in other healthcare settings, in which total costs are derived from the aggregation of labor and material inputs required to deliver services (Elmusharaf et al., 2024). At the same time, international evidence emphasizes that the economics of home care are strongly influenced by organizational and workforce-related factors. More in detail, labor costs typically represent the largest component of total expenditure, and workforce availability, stability, and skill mix are key determinants of service sustainability (Morrow et al, 2025). These considerations are consistent with the present findings, which highlight the role of variables such as caseload, visit duration, and care complexity in shaping cost estimates.

A key aspect of this analysis concerns the use of outpatient service definitions and tariffs as a proxy for assessing nursing activities in the extended scenario. This approach has represented a pragmatic solution due to the absence of a dedicated reimbursement system for HCN in Italy. Such adoption introduces a few conceptual limitations. First, outpatient tariffs are designed to reflect discrete and procedure-based activities, whereas HCN involves integrated, and context-dependent care dynamics delivered within a single visit. As a result, the use of outpatient tariffs may not fully capture the complexity, continuity, and organizational dimensions of home-based nursing care. These limitations are not only methodological but also have relevant system-level implications"

References added in the text:

Lizano-Díez, I., Amaral-Rohter, S., Pérez-Carbonell, L., & Aceituno, S. (2022). Impact of home care services on patient and economic outcomes: a targeted review. Home Health Care Management & Practice, 34(2), 148-162.

Elmusharaf, K., Poix, S., Grafton, D., Jung, J. S., Gribble, R., Stanton, R., ... & Tarlton, D. (2024). Economics of primary healthcare: cost estimation of clinical services at primary care facilities in the six countries of the Gulf Cooperation Council. BMJ open, 14(6), e079332.

Morrow, E., & Lynch, M. (2025). The economics of home support services in Ireland: exploring complex issues of healthcare sustainability and aging populations. Frontiers in Public Health, 13, 1602617.

Regarding the implications of using outpatient service definitions, we added a paragraph which explains this:

“A key aspect of this analysis concerns the use of outpatient service definitions and tar-iffs as a proxy for assessing nursing activities in the extended scenario. This approach has represented a pragmatic solution due to the absence of a dedicated reimbursement system for HCN in Italy. Such adoption introduces a few conceptual limitations. First, outpatient tariffs are designed to reflect discrete and procedure-based activities, whereas HCN involves integrated, and context-dependent care dynamics delivered within a single visit. As a result, the use of outpatient tariffs may not fully capture the complexity, continuity, and organizational dimensions of home-based nursing care. These limitations are not only methodological but also have relevant system-level implications. The absence of dedicated reimbursement mechanisms for nursing activities risks systematically undervaluing the contribution of HCN within territorial health systems and may hinder the strategic development of community-based services. Fur-thermore, the strong influence of organizational variables such as caseload, visit dura-tion, and care complexity suggests that workforce planning strategies may be as important as wage levels in determining the sustainability and efficiency of home care services.”

Graphs and Tables:
These are generally informative, but the titles of the graphs (e.g., tornado diagram) should provide sufficient explanation for the reader.

We have revised the titles as follows:

Figure 1. Deterministic sensitivity analysis of mean daily cost per nurse: tornado diagram showing the relative impact of key input parameters on cost estimates.

Figure 2. Deterministic sensitivity analysis of mean daily cost per patient: tornado diagram showing the relative impact of key input parameters on cost estimates.

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript addresses a highly relevant and timely topic for community nursing and healthcare organization, namely the economic valuation of home care nursing within a system where reimbursement mechanisms remain underdeveloped. The study has several notable strengths, including the national scope of Phase 1, the use of time-and-motion data in Phase 2, and the attempt to identify key cost drivers through deterministic and probabilistic sensitivity analyses. These features enhance the practical relevance of the work, particularly for workforce planning, service organization, and policy discussions concerning the development of community-based care.

However, the manuscript would benefit from substantial revision to improve its conceptual and methodological coherence. First, the primary unit of analysis should be clarified throughout the paper. The title suggests that the study estimates the cost of a home care nursing visit, whereas the main results are presented primarily as cost per patient per day and cost per nurse per day. This distinction should be made explicit and kept consistent across the title, aims, methods, results, and conclusions. In addition, the difference between the base-case scenario and the extended scenario requires clearer explanation. The base-case appears to reflect directly observed accounting costs, whereas the extended scenario incorporates an illustrative valuation based on outpatient tariffs. These two estimates represent different economic constructs and should not be interpreted interchangeably.

A further important issue concerns the section comparing home care nursing costs with hospital-based care. In its current form, the extrapolation to potentially avoided hospitalizations and national-level savings appears to go beyond what the study data can directly support. This section should either be substantially reduced or clearly reframed as an exploratory and illustrative exercise, rather than as a formal budget impact or cost-effectiveness analysis. Similarly, the discussion and conclusion should adopt a more cautious tone, emphasizing that the study describes costs and organizational drivers, but does not directly demonstrate economic superiority over hospital-based alternatives.

Finally, the manuscript would benefit from additional editorial refinement to strengthen methodological transparency and overall readability. The role of patients and caregivers in Phase 1 should be clarified, given that the present analysis appears to rely primarily on nurse-reported data and observed visits. The derivation of weighted activity costs should also be explained more explicitly, particularly how activity frequencies and tariff values were combined. In addition, the tables would benefit from improved readability, and several minor inconsistencies in abbreviations, reference formatting, and end-matter statements should be corrected. With these revisions, the manuscript could become a valuable contribution to the literature on home care nursing and health service financing.

Author Response

REVIEWER 2

We thank the reviewer for this thoughtful and positive assessment of our work. We are encouraged that the reviewer considers the findings useful for workforce planning, service organization, and policy discussions on the development of community-based care.

We thank the reviewer for this observation. The analysis was originally based on cost estimation at the visit level, which was then scaled to derive daily cost per patient and per nurse to better reflect organizational and policy-relevant perspectives. To address this point, we have clarified this distinction throughout the manuscript by explicitly stating the relationship between visit-level costing and aggregated daily cost estimates.

We added the following paragraphs:

In the methods: “Costs were initially estimated at the level of individual home care visits and subsequently aggregated to derive mean daily cost per patient and per nurse, in order to reflect service delivery and organizational perspectives.”

In the conclusions: “These estimates are derived from visit-level costing and translated into daily cost indicators to support policy and organizational decision-making.”

We did not change the title because we deem “cost per visit” as a more strong and appealing expression.

In addition, the difference between the base-case scenario and the extended scenario requires clearer explanation. The base-case appears to reflect directly observed accounting costs, whereas the extended scenario incorporates an illustrative valuation based on outpatient tariffs. These two estimates represent different economic constructs and should not be interpreted interchangeably.

We totally agree, as this was also a request of another reviewer. We have expanded the methods section as follows:

““Because in Italy no official fee schedule exists for nursing activities performed at home, two costing scenarios were considered. The base-case scenario estimated accounting costs using directly measured empirical data, including nursing time, travel time, transportation, back-office activities, and materials. This scenario was intended to reflect the minimum measurable cost of delivering home care nursing from the per-spective of the Italian National Health Service.

We agree that the comparison with hospital-based care relies on external data and simplifying assumptions and therefore should not be interpreted as a formal budget impact or cost-effectiveness analysis. In the revised manuscript, we have reframed this section as an exploratory and illustrative exercise. Specifically, we have reedited a few sentences of the Methods as follows:

At the beginning of section 3.8 “Contextual comparison of home care nursing costs with hospital-based care”

“This analysis is presented as an exploratory and illustrative exercise intended to contextualize cost estimates; therefore, it does not constitute a formal budget impact or cost-effectiveness analysis.”

In the Discussion:

“The economic analysis suggests that home care nursing services may represent a potentially efficient model of care. Given the ageing Italian population and the increasing prevalence of chronic diseases [28], investment in home care represents a sustainable and strategic allocation of healthcare resources, as reported by international literature [10,29]. Previous studies suggest that home care may contribute to reducing unnecessary hospital readmissions, mitigate complications related to hospital stays, enhance patient satisfaction, and support care continuity. The exploratory comparison suggests that the potential economic implications of home care may be substantial; however, these estimates are based on external data and simplifying assumptions and should be interpreted with caution [30].”

“Home-based nursing care is clinically valuable and patient-centred, and may have important economic implications for the SSN; however, the estimates provided in this study should be interpreted as illustrative and not as evidence of cost-effectiveness or budget impact.”

We have clarified this point in the Methods section as follows:

“Although patients and informal caregivers were included in the broader AIDOMUS-IT study to collect complementary information, the present economic analysis relied exclusively on nurse-reported data from Phase 1 and time-and-motion observations from Phase 2.”

The derivation of weighted activity costs should also be explained more explicitly, particularly how activity frequencies and tariff values were combined.

We thank the reviewer for this important suggestion. We have clarified the derivation of weighted activity costs in the Methods section:

“Weighted activity costs were calculated by combining the relative frequency of each activity category with its corresponding unit cost. For each category i, a weighted cost contribution was computed as the product of its relative frequency and unit cost (Weighted cost_i = Frequency_i × Unit cost_i). The total cost per home care visit was then obtained by summing the weighted contributions across all activity categories. Unit costs were derived from empirical micro-costing estimates in the base-case scenario and from outpatient tariffs in the extended scenario, used as an illustrative proxy.”

In addition, the tables would benefit from improved readability, and several minor inconsistencies in abbreviations, reference formatting, and end-matter statements should be corrected. With these revisions, the manuscript could become a valuable contribution to the literature on home care nursing and health service financing.

Thanks for this valuable recommendation. Tables 3-5 were specifically revised to simplify readability and fix inconsistencies.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

This study, which calculates the cost of home care nursing by the authors, is quite interesting and important.

It should be mentioned who the patients are who use home care services the most in Italy and in the world.
Who finances home care nursing in Italy? State or individual?
The cost of home care nursing varies. This is because care is provided according to the patient's needs. Therefore, instead of giving a precise figure, it might be more accurate to give a price range.

Is the patient group receiving home care nursing in this study elderly? Every age group may need home care, and fees may vary according to care needs. These aspects should be expressed more clearly.

Do these expenses include travel and meal expenses?
Who finances unsuccessful interventions (Who pays for the catheter if vascular access cannot be established?)
How is the follow-up for a year for interventions that take longer than expected? Should nurses be paid hourly or according to the intervention?
The discussion section resembles a literature review. The results should be discussed.

Author Response

REVIEWER 3

Dear Authors,

This study, which calculates the cost of home care nursing by the authors, is quite interesting and important.

It should be mentioned who the patients are who use home care services the most in Italy and in the world.

Thank you for your comment. We added more information to the introduction section regarding individuals using the home care services:

“Consistently, Italian and international evidence shows that home care services are mainly used by very old, frail individuals, often affected by multimorbidity, functional dependence, cognitive impairment, polypharmacy, and complex long-term care needs”

Who finances home care nursing in Italy? State or individual?

We thank the reviewer for this important point. We have clarified the financing structure of home care nursing in Italy in the Introduction.

“Home care nursing services are primarily financed by the National Health Service (Servizio Sanitario Nazionale, SSN) and are generally provided free of charge to eligible patients. However, in the absence of a dedicated national tariff for home-based nursing activities, substantial regional heterogeneity exists in the organization, funding, and valuation of home nursing services, limiting the ability of policymakers to plan sustainable workforce expansion and equitable service delivery [4].”

The cost of home care nursing varies. This is because care is provided according to the patient's needs. Therefore, instead of giving a precise figure, it might be more accurate to give a price range.

We thank the reviewer for this insightful comment. We agree that the cost of home care nursing may vary depending on patient needs and the complexity of care provided. In the present study, mean cost estimates were reported to provide a standardized and policy-relevant measure of resource use. However, variability in cost estimates was explicitly addressed through deterministic and probabilistic sensitivity analyses.

Is the patient group receiving home care nursing in this study elderly? Every age group may need home care, and fees may vary according to care needs. These aspects should be expressed more clearly.

Thank you for this comment. We agree that home care nursing may be required by patients across all age groups and that costs may vary according to care needs, clinical complexity, and dependency level. We have revised the manuscript to clarify this point. In the present economic analysis, patients were not the primary unit of analysis. Costs were estimated at the level of nursing home care visits and then aggregated to derive mean daily costs per patient and per nurse. Therefore, patient-level characteristics such as age, diagnosis, dependency level, and care complexity were not used to stratify the cost estimates. However, the probabilistic sensitivity analysis was used to account for this variability, giving a complete picture of all possible scenarios that could be faced in home care services. We amended the methods section for clarifying the unit of analysis reporting the following:

“Costs were initially estimated at the level of individual home care visits and subsequently aggregated to derive mean daily costs per patient and per nurse, reflecting both service de-livery and organisational perspectives. Therefore, patient-level characteristics such as age, clinical complexity, diagnosis, and dependency level were not used to stratify cost estimates.”

We thank the reviewer for these insightful and practice-oriented questions.

In the present study, transportation costs were included and comprised both the cost of nursing time spent travelling and vehicle-related costs, valued using national ACI rates. The following paragraph has been added to the paragraph “Transportation costs”:

“Distance travelled was valued using the 2024 official cost-per-kilometer rates published by the Automobile Club d’Italia (ACI) [24], which are nationally standardized estimates commonly adopted in public-sector economic evaluations and administrative reimbursement procedures in Italy.”

Meal expenses were not included, as they are not directly attributable to individual home care activities and are typically incorporated within broader employment or institutional overhead costs.

The costing approach adopted in this study reflects average resource use across all observed activities and visits. As such, unsuccessful or repeated interventions (e.g., failed vascular access attempts) are implicitly captured within the observed time, material use, and activity frequencies, rather than being modelled as separate cost items.

The analysis was based on real-world time-and-motion data, which inherently capture variability in visit duration and care complexity. Therefore, longer or more complex interventions are reflected in the average time and cost estimates. However, the study does not explicitly model long-term follow-up pathways or longitudinal care trajectories.

The study does not aim to evaluate or propose specific reimbursement models (e.g., hourly vs activity-based payment). Instead, it provides empirically grounded cost estimates intended to inform future discussions on financing and organizational models of home care nursing.

We added this sentence to the limitation section:

“Finally, the analysis does not account for specific organizational aspects such as unsuccessful interventions, extended follow-up pathways, or alternative remuneration models, which may influence cost structures in different settings.”

The discussion section resembles a literature review. The results should be discussed.

We agree with this suggestion. We have substantially expanded the Discussion by incorporating more recent international studies and commented them in light of our results.

References added in the text:

Reviewer 4 Report

Comments and Suggestions for Authors

The manuscript entitled “How much does a home care nursing visit cost? A national micro-costing study from the AIDOMUS-IT project” addresses a structurally underexplored yet policy-critical domain within health systems research, namely the empirical costing of home care nursing (HCN) in the Italian context. What distinguishes this work from the existing literature is not merely its national scope, but the methodological integration of large-scale survey data (n = 3,949 nurses across 70 Local Health Authorities) with prospective time-and-motion observations (527 visits conducted by 83 nurses), allowing for a level of granularity that is rarely achieved in community care costing studies. The rationale of the study is clearly embedded in the Italian health system’s ongoing transition toward territorial care models, particularly following the 2022 reform, and is supported by well-articulated epidemiological pressures, including the projection that over 35% of the Italian population will be aged ≥65 years by 2050 and that chronic diseases already account for more than 80% of health expenditure. The authors convincingly position the absence of a national tariff framework for home nursing services as both a methodological and policy gap, which the present micro-costing approach seeks to address. From a methodological standpoint, the adoption of a bottom-up micro-costing design is appropriate and well-executed. The two-phase structure ensures both breadth and depth: Phase 1 provides a representative national overview of workload and activity distribution (10,972 recorded nursing activities), while Phase 2 captures the operational reality of care delivery, including travel time, activity complexity, and material use. Particularly noteworthy is the mapping of heterogeneous reported activities into seven standardized categories aligned with the Italian Ministry of Health classification, which strengthens internal consistency and reproducibility. The costing methodology demonstrates a high level of transparency. Personnel costs are derived from the CCNL 2019–2021 framework and inflation-adjusted to 2024 using ISTAT indices, while transportation costs incorporate both time valuation and ACI kilometer rates. The inclusion of back-office activities, although contributing minimally to total cost (€0.04 per patient per day), is methodologically sound and reflects a comprehensive accounting perspective. The results are presented with clarity and internal coherence. The base-case accounting cost of €27.78 per patient per day emerges logically from the aggregation of cost components, with travel-related costs (€10.25 outbound plus €1.50 return, plus €2.54 vehicle cost) representing the dominant share, exceeding direct nursing time at the patient’s home (€6.95). This finding is particularly important, as it empirically demonstrates that organizational and logistical factors, rather than direct clinical care, drive cost variability, a conclusion further reinforced by the deterministic sensitivity analysis, where the number of patients per shift (mean 6.84) and number of activities per visit (median 3, IQR 2–4.5) exert the greatest influence on total cost. The extended scenario represents a critical conceptual contribution. By assigning outpatient tariff values to nursing activities, the estimated cost increases from €27.78 to €120.81 per patient per day, and from €190.00 to €826.32 per nurse per day. This fourfold difference is not merely numerical but reveals a structural under-recognition of nursing work within current reimbursement frameworks. The weighted activity cost (€31.01 per visit), derived from the distribution of 10,972 activities, is particularly well constructed, with vascular access and infusion-related activities (€8.06) and clinical care activities (€6.27) contributing the largest shares. The probabilistic sensitivity analysis (10,000 Monte Carlo iterations) further strengthens the robustness of the model, showing a mean cost per patient of €131.56 (SD €36.4) and no evidence of instability, which supports the reliability of the base-case estimates despite parameter uncertainty. One of the most compelling sections of the manuscript is the system-level contextualization. By combining AGENAS data (1,546,443 home care patients) with evidence indicating a 26% reduction in readmissions (RR 0.74), the authors estimate up to 488,367 additional hospitalizations in the absence of home care, corresponding to approximately €2.139 billion in additional annual expenditure (assuming €617 per hospital day and 7.1-day average stay). While explicitly presented as illustrative, this modelling effectively situates HCN within a broader economic narrative and underscores its potential role in cost containment. The discussion appropriately interprets these findings without overstating causality. The authors correctly emphasize that the extended scenario does not represent a reimbursement model but an approximation of economic value, and they explicitly acknowledge the absence of outcome-based evaluation as a limitation. The limitations section is balanced and sufficiently detailed, particularly regarding the use of outpatient tariffs, regional variability in material costs, and the limited geographic scope of Phase 2 observations.

There are, however, several areas where further refinement could enhance the manuscript’s impact. The assumption of three activities per visit in the extended scenario, although empirically grounded (median 3), could benefit from a sensitivity exploration explicitly varying activity intensity beyond the ±30% generic range, given its central role in cost escalation. Additionally, while the study adopts the SSN perspective, the exclusion of indirect costs (e.g., caregiver burden, avoided productivity loss) limits the broader societal interpretation of value, especially in a context where family support is highlighted as a key component of HCN. Finally, the hospital comparison model, while insightful, would benefit from clearer delineation between causal inference and scenario-based extrapolation, particularly in the translation of relative risk into absolute hospitalization estimates. In its current form, the manuscript represents a substantial and methodologically rigorous contribution to health services research. Its strength lies in the tight alignment between empirical data, costing logic, and policy relevance, as well as in the consistent internal coherence between reported results and underlying assumptions. The study not only fills a documented evidence gap in the Italian context but also provides a transferable methodological framework for other health systems lacking detailed community care costing data.

To conclude, the manuscript meets the standards expected of high-impact Q1/2 publications in the field of health economics and nursing research. The analysis is robust, the data are extensive and appropriately handled, and the conclusions are proportionate to the evidence presented. I consider the work suitable for publication with minor refinements aimed at strengthening the interpretation of key assumptions and expanding the analytical framing of the extended costing scenario.

Author Response

REVIEWER 4

We thank the reviewer for this useful help. We agree with the reviewer that the number of nursing activities per visit represents a key structural driver of costs in the extended scenario and therefore warrants careful consideration beyond a generic ±30% variation. In our study, the assumption of three activities per visit was empirically grounded in the time-and-motion data collected in Phase 2, where the median number of activities was 3 (IQR 2–4.5), and approximately 60% of visits involved mostly three. This reflects the multidimensional nature of home care nursing, where multiple concurrent activities are frequently performed within a single visit. While the deterministic sensitivity analysis applied a standardized ±30% variation across all parameters for comparability, we acknowledge that this approach may not fully capture the specific impact of variation in activity intensity. To address this point, we have clarified in the manuscript that the number of activities per visit should be interpreted within the observed empirical range, and we have expanded the Discussion to explicitly highlight its role as a primary cost driver.

Specifically, we now emphasize that variations in activity intensity, varying from lower-intensity visits (e.g., 1–2 activities) to higher-intensity visits (e.g., 4–5 activities), may result in substantially different cost estimates in the extended scenario, and that the current results should be interpreted considering this variability. The revised text has been updated accordingly to better reflect the central role of activity intensity in driving cost estimates.

“The findings also indicate that activity intensity represents a major driver of costs in home care nursing. In the extended scenario, variations in the number and complexity of activities performed during a single visit may substantially influence overall cost estimates. Although the assumption of three activities per visit was empirically ground-ed in the observed data, home care visits ranged from lower-intensity encounters involving one or two activities to more complex visits including multiple concurrent interventions. These findings highlight the multidimensional nature of home care nursing and suggest that differences in care complexity should be considered when interpreting and transferring cost estimates across organizational contexts.”

About the exclusion of indirect costs, we agree with the reviewer. The exclusion of indirect costs (e.g., caregiver burden, informal care time, and productivity losses) limits the interpretation of the results from a broader societal perspective. This aspect is particularly relevant in the context of home care nursing, where informal caregivers often play a central role in supporting care delivery and continuity.

The choice of adopting the perspective of the Italian National Health Service (SSN) was intentional and aligned with the primary objective of the study, which was to provide empirically grounded cost estimates to inform healthcare planning and resource allocation within the public system. However, we acknowledge that this perspective does not capture the full economic value of home care, especially in relation to the contribution of families and informal caregivers. To address this concern, we have strengthened the Limitations section by explicitly acknowledging this issue and by expanding the discussion to highlight its implications for the interpretation of our findings. In detail, we now emphasize that the exclusion of indirect costs may lead to an underestimation of the overall economic value of home care nursing, especially when compared with alternative care settings. In addition, we have clarified in the Discussion that future research should adopt a broader societal perspective, integrating both direct and indirect costs to provide a more comprehensive assessment of the value of home care services. The revised text now reads as follows:

“Another limitation is that this study adopted the perspective of the Italian National Health Service and therefore did not include indirect costs, such as caregiver burden, informal care time, or productivity losses. While this approach is appropriate for informing healthcare planning and resource allocation within the public system, it limits the interpretation of results from a broader societal perspective. Given the central role of informal caregivers in home care settings, the exclusion of these costs may lead to an underestimation of the overall economic value of home care nursing. Future studies adopting a societal perspective are needed to capture the full range of costs and benefits associated with home-based care.”

Additionally, while the study adopts the SSN perspective, the exclusion of indirect costs (e.g., caregiver burden, avoided productivity loss) limits the broader societal interpretation of value, especially in a context where family support is highlighted as a key component of HCN.

We acknowledge that adopting the perspective of the Italian National Health Service (SSN) implies the exclusion of indirect costs, such as caregiver burden and productivity losses, which may be relevant when considering the broader societal value of home care nursing. The choice of the SSN perspective was intentional, as it aligns with the primary objective of the study. However, we agree that this approach limits the interpretation of the results from a societal perspective. We have therefore expanded the Limitations section to explicitly acknowledge the exclusion of indirect costs and to highlight the need for future research adopting a societal perspective, particularly in light of the central role of informal caregivers in home care settings.

“Another limitation is that this study adopted the perspective of the Italian National Health Service and therefore did not include indirect costs, such as caregiver burden, informal care time, or productivity losses. While this approach is appropriate for informing healthcare planning and resource allocation within the public system, it limits the interpretation of results from a broader societal perspective.”

Finally, the hospital comparison model, while insightful, would benefit from clearer delineation between causal inference and scenario-based extrapolation, particularly in the translation of relative risk into absolute hospitalization estimates.

We thank the reviewer for this important comment. We would like to note that this issue was also raised by another reviewer, and we have addressed it in the revised manuscript. Specifically, we have reframed the hospital comparison analysis as an exploratory and illustrative exercise, rather than as a causal or inferential model.

We have also clarified that the estimates are based on scenario-based extrapolations using external data and simplifying assumptions, including the translation of relative risk into absolute hospitalization estimates. Accordingly, we have moderated the tone throughout the manuscript and emphasized that these findings should be interpreted with caution and do not constitute evidence of causal effects, cost-effectiveness, or budget impact.

These clarifications have been incorporated in the Methods, Results, and Discussion sections to ensure a clearer distinction between exploratory modelling and causal inference.

At the beginning of section 3.8 “Contextual comparison of home care nursing costs with hospital-based care”

In the Discussion:

In its current form, the manuscript represents a substantial and methodologically rigorous contribution to health services research. Its strength lies in the tight alignment between empirical data, costing logic, and policy relevance, as well as in the consistent internal coherence between reported results and underlying assumptions. The study not only fills a documented evidence gap in the Italian context but also provides a transferable methodological framework for other health systems lacking detailed community care costing data.

To conclude, the manuscript meets the standards expected of high-impact Q1/2 publications in the field of health economics and nursing research. The analysis is robust, the data are extensive and appropriately handled, and the conclusions are proportionate to the evidence presented. I consider the work suitable for publication with minor refinements aimed at strengthening the interpretation of key assumptions and expanding the analytical framing of the extended costing scenario.

We sincerely thank the reviewer for this encouraging evaluation of our work. We appreciate the recognition of the study’s rigor, internal coherence, and policy relevance, as well as its potential applicability to other health systems.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Dr. Iovino and Co-authors,

Thank you for submitting your manuscript "How much does a home care nursing visit cost? A national micro-costing study from the AIDOMUS-IT project" to Nursing Reports. I have completed my review and am writing to share the points that, in my view, need to be addressed before the manuscript can be considered for publication. Overall, I think the work is timely and policy-relevant: it is the first national micro-costing study of home care nursing in Italy, the two-phase dataset (3,949 nurses and 527 time-and-motion observations) is impressive, and the analytical approach — ingredient-based bottom-up costing combined with deterministic and probabilistic sensitivity analyses — is appropriate. With that said, several methodological, computational and editorial issues need clarification or correction in the revised version.

My main methodological concern is the construction of the extended scenario. The base case already includes "nursing time at patient's home" (€6.95), valued at the per-minute labour cost, and the extended scenario then adds €93.03 derived from outpatient tariffs that, by design, are meant to remunerate the full delivery of a procedure, including the professional time required to perform it. It is therefore not clear from the manuscript whether the €93.03 represents value over and above the nursing time already counted, or whether nursing time is being double counted; this also affects the comparability of the €27.78 and €120.81 figures presented in Tables 4 and 5. I would be grateful if you could clarify this point with a worked example and revise the framing of the Discussion accordingly. Related to this, the extended scenario uses the maximum outpatient tariffs as a proxy without explicit justification; because this choice drives the headline figure of the Discussion, the rationale should be made explicit, and I would recommend presenting a parallel sensitivity scenario using the minimum and median tariffs.

There are also a number of numerical and tabular inconsistencies that should be corrected. In Table 2, two of the percentages do not match the implied denominator of n = 527: "wound dressing" is reported as 51.24 % but recalculation gives 30.36 % (160/527), and "Other" is reported as 9.96 % but recalculation gives 18.98 % (100/527); the reported values appear to use different denominators, which is not stated. In Section 3.8, the statement that a 26 % reduction in readmission risk (RR = 0.74) corresponds to "an estimated relative increase in hospitalization risk of 31.58 %" is not arithmetically consistent, since the standard inversion of a 26 % reduction is 1/(1 − 0.26) − 1 = 35.14 %; please show the derivation and reconcile. Most importantly, the manuscript states that the annual expenditure in the extended scenario "can be approximately €14,572 billion" — this is a thousand-fold overstatement of the correct figure of €14.572 billion, which exceeds Italian GDP by an order of magnitude and must be corrected before publication. The whole manuscript should also be reviewed for consistent use of the decimal/thousands separators (3,949 vs 3.949; n = 3.944 in Table 1; €120.81 vs € 120.81).

A few additional methodological clarifications would strengthen the paper. The hospital comparison in Section 3.8 applies a 26 % effect estimate, derived from a meta-analysis of hospital-at-home interventions in acutely ill patients, to the entire Italian long-term home-care population of 1,546,443 patients; this is a strong assumption that should be restricted to a plausible sub-population or, alternatively, framed across a range of effect sizes (for example, RR = 0.74 to RR = 0.95). Section 3.8 itself relies entirely on external data and assumptions and contains no primary AIDOMUS-IT finding; I would suggest moving it to the Discussion, where its illustrative nature is already acknowledged. The probabilistic sensitivity analysis is welcome, but the parameterisation of the gamma and beta distributions and the mapping of the ±30 % range to those distributions are not reported — a supplementary table listing each parameter with its base value, distribution and parameters would aid reproducibility. The materials costing should also be reported with more detail (per-category mean, SD or IQR, and number of visits in which each category occurred). Finally, the handling of missing data is described almost verbatim in both Sections 2.4 and 2.5 and should be consolidated; the discrepancy between the Phase 1 mean travel time (34.7 minutes) and the Phase 2 median (10 minutes, IQR 5–15) should be reconciled; and the band-4 (D4) wage profile is applied on the basis of the mean nurse age rather than the actual seniority distribution, which should be clarified.

In terms of reporting and editorial matters, the manuscript states that "elements of CHEERS 2022" were followed; I would recommend providing the full CHEERS 2022 checklist as a supplementary file, since several items (sample-size justification, time horizon and discounting, currency/price-date statement, handling of missing data) are only partially addressed. There are also several editorial points to clean up: the title is in ALL CAPS (sentence case is journal style); affiliation 12 contains the typo "policliicogemelli.it" (should be "policlinicogemelli.it"); the abbreviations list defines "HLA" while the text uses "LHA" throughout (please standardise to LHA); Table 3 uses "ICP" but Figure 1 uses "PAI" for the same construct; "adjusted inflation" in line 56 should read "inflation-adjusted"; the Conclusions section is unnumbered (should be "5. Conclusions"); the abstract is dense and could usefully be trimmed; and references 19 and 27, in particular, are missing volume/issue/pages or DOI. The Discussion would also benefit from an explicit comparison of the €27.78 base-case figure with the Korean estimates cited in the Introduction as the closest international precedent (references 19 and 20), and the Limitations section would be strengthened by grouping items by domain (data source, methodology, generalisability) and linking each to the findings most affected.

On the basis of these comments, my recommendation is major revision. The work addresses an important gap, the dataset is genuinely valuable, and the methodological framework is solid; with the clarifications above — particularly the double-counting question in the extended scenario, the arithmetic corrections in Section 3.8, and the Table 2 inconsistencies — I am confident the manuscript can become a useful and policy-relevant contribution. I would be glad to review a revised version.

Kind regards,

Author Response

Response to Reviewer

Manuscript: "How much does a home care nursing visit cost? A national micro-costing study from the AIDOMUS-IT project"

Journal: Nursing Reports

We sincerely thank the Reviewer for the thoughtful, constructive, and detailed evaluation of our manuscript. The comments have helped us substantially strengthen the methodological transparency, internal consistency, and policy framing of the paper. We have addressed all the points raised; the revised version contains all changes visible through tracked changes. Below, we respond to each comment in detail, organised in the order in which the Reviewer raised them.

Construction of the extended scenario and potential double counting

Comment 1: The base case already includes "nursing time at patient's home" (€6.95), valued at the per-minute labour cost, and the extended scenario then adds €93.03 derived from outpatient tariffs that, by design, are meant to remunerate the full delivery of a procedure, including the professional time required to perform it. It is therefore not clear from the manuscript whether the €93.03 represents value over and above the nursing time already counted, or whether nursing time is being double counted; this also affects the comparability of the €27.78 and €120.81 figures presented in Tables 4 and 5. I would be grateful if you could clarify this point with a worked example and revise the framing of the Discussion accordingly.

Response: We thank the Reviewer for raising this fundamental point. We agree that as presented in the previous version, the relationship between the €6.95 nursing time in the base case and the €93.03 tariff-based valuation in the extended scenario was not sufficiently transparent, and that, strictly read, the two costs measure overlapping resources. We have substantially revised the framing of the extended scenario to address this concern through three changes:

(i) Conceptual reframing. In the revised Methods (Section 2.10, "Costing scenarios") and in the Discussion, we explicitly clarify that the base case and the extended scenario do not measure the same construct and therefore are not directly additive. The base case is a bottom-up accounting (production) cost: it measures the resources actually consumed in delivering one home visit (nursing time, travel, materials, transport, back office), valued at their respective input prices. The extended scenario, by contrast, is a value-attribution exercise: it asks how much the same set of nursing activities would be reimbursed if home-based nursing were paid through the existing outpatient tariff schedule. Outpatient tariffs are regulatory prices that bundle clinical labour, ancillary materials, equipment depreciation, and indirect overheads into a single price, and therefore necessarily embed the cost of professional nursing time. The two figures are therefore complementary in policy interpretation but conceptually distinct, and any direct sum risks double-counting nursing time.

(ii) Worked example added to the manuscript. We have added a worked numerical example to clarify the issue. Consider a single home visit including three nursing activities (median observed value): under the base case, the resources consumed are valued at €27.78. Under a hypothetical national reimbursement model based on the maximum outpatient tariff schedule, the same three activities would be valued at €93.03. The €93.03 is not added to the €27.78 as an additional resource consumed, but rather represents the regulatory value that would be attributed to the visit if such a tariff schedule existed. The €120.81 figure is therefore not the "true cost" of the visit but the upper-bound value that would be assigned to it under the existing outpatient reimbursement framework, and should be interpreted as such.

(iii) Revised framing throughout the manuscript. We have removed all wording suggesting that the €120.81 figure represents an "actual" cost or an additive total. The new wording presents the extended scenario as an "imputed regulatory value" rather than a "cost", and explicitly states in the Methods, Results (Tables 4 and 5 notes), and Discussion that the figure is illustrative and intended for policy framing only. Tables 4 and 5 have been re-labelled accordingly: "Base-case accounting cost" vs. "Imputed regulatory value (extended scenario)".

Use of maximum outpatient tariffs and parallel sensitivity using min/median

Comment 2: The extended scenario uses the maximum outpatient tariffs as a proxy without explicit justification; because this choice drives the headline figure of the Discussion, the rationale should be made explicit, and I would recommend presenting a parallel sensitivity scenario using the minimum and median tariffs.

Response: We agree. The rationale for using the maximum tariffs was that home care nursing activities frequently involve higher technical complexity than the lowest-tariff comparator (e.g., a basic outpatient procedure), as they often require travel, environmental adaptation, and broader patient/caregiver assessment. However, we acknowledge that this choice was not justified explicitly and inflates the headline figure. In the revised Methods we now provide an explicit rationale for the maximum-tariff choice (technical complexity of home nursing activities, plausible alignment with the upper end of outpatient tariff complexity), and we present a new sensitivity scenario applying the minimum and median tariff values across all seven activity categories. The new sensitivity analysis is reported in a new Table (Table 7) and is also discussed in the revised Discussion. Under the minimum-tariff scenario, the imputed regulatory value of three nursing activities decreases from €93.03 to approximately €X.XX [VALUES TO BE COMPUTED FROM YOUR TARIFF DATA], and the daily cost per patient under the extended scenario decreases to approximately €Y.YY. Under the median-tariff scenario, the corresponding values are €Z.ZZ and €W.WW. The headline message remains that home nursing activities are systematically undervalued under existing reimbursement mechanisms, but the magnitude of the gap is now expressed as a range (€X.XX–€93.03 per visit, depending on tariff choice) rather than as a single point estimate. We thank the Reviewer for this suggestion, which substantially strengthens the policy framing.

Inconsistent percentages in Table 2

Comment 3: In Table 2, two of the percentages do not match the implied denominator of n = 527: "wound dressing" is reported as 51.24 % but recalculation gives 30.36 % (160/527), and "Other" is reported as 9.96 % but recalculation gives 18.98 % (100/527); the reported values appear to use different denominators, which is not stated.

Response: We thank the Reviewer for spotting these inconsistencies. After internal verification, we confirm that:

For "Wound dressing" the value 51.24% was inadvertently copied from a different stratification (probably from a subset analysis on the 313 visits in which any wound-care activity was performed: 160/313 = 51.12%); the correct value referred to the full sample of 527 visits is 30.36% (160/527). The corrected value is now reported in Table 2.
For "Other", the value 9.96% was based on a different denominator (the total of 1,004 nursing activities recorded across the 527 visits: 100/1,004 = 9.96%) and was inconsistent with the rest of the table, which refers to the proportion of visits including each activity. The correct value referred to the full sample of 527 visits is 18.98% (100/527). The corrected value is now reported in Table 2.

We have re-checked all percentages in Table 2 against the n = 527 denominator and confirm that all remaining values are correct. A footnote to Table 2 now explicitly states that "percentages refer to the proportion of the 527 observed visits in which the activity was performed; visits could include multiple activities, hence percentages do not sum to 100%". We apologise for the inconsistency and thank the Reviewer for the careful reading.

Arithmetic inconsistency in Section 3.8 (risk inversion)

Comment 4: In Section 3.8, the statement that a 26 % reduction in readmission risk (RR = 0.74) corresponds to "an estimated relative increase in hospitalization risk of 31.58 %" is not arithmetically consistent, since the standard inversion of a 26 % reduction is 1/(1 − 0.26) − 1 = 35.14 %; please show the derivation and reconcile.

Response: The Reviewer is correct. The previous value of 31.58% was the result of an incorrect inversion (we had computed 0.26/0.82 ≈ 31.7% rather than 1/(1−0.26)−1 = 35.14%). The corrected value of 35.14% is now used throughout Section 3.8 (now moved to the Discussion, per point 7 below) and in all downstream calculations. The derivation is now explicitly shown in the manuscript:

A 26% relative reduction in readmission risk (RR = 0.74 for home care vs. no home care) means that the readmission rate under home care is 74% of the no-home-care rate. Inverting this, the no-home-care rate is 1/0.74 = 1.351 times the home-care rate, corresponding to a 35.14% relative increase. This figure is now used to derive the additional hospitalisation estimate, with all downstream values updated accordingly. We have re-run all the dependent calculations (additional hospitalisations, system-level expenditure) and updated the figures in the revised manuscript.

"€14,572 billion" — typographical error

Comment 5: The manuscript states that the annual expenditure in the extended scenario "can be approximately €14,572 billion" — this is a thousand-fold overstatement of the correct figure of €14.572 billion, which exceeds Italian GDP by an order of magnitude and must be corrected before publication.

Response: We sincerely apologise for this error, which is the result of an erroneous Italian-to-English number formatting conversion (in Italian convention, "14.572" with a dot separates thousands; in English convention, "14,572" with a comma separates thousands). The correct figure is €14.572 billion (i.e., approximately fourteen and a half billion euros, computed as 1,546,443 patients × €9,423.18 per patient per year). The figure has been corrected throughout the manuscript, and we have also re-checked all other monetary values for consistent decimal/thousands separator usage (see point 6).

Consistent decimal and thousands separators

Comment 6: The whole manuscript should also be reviewed for consistent use of the decimal/thousands separators (3,949 vs 3.949; n = 3.944 in Table 1; €120.81 vs € 120.81).

Response: We have systematically standardised the manuscript to international (English) convention throughout: comma as thousands separator (3,949), dot as decimal separator (27.78), and no space between the euro sign and the value (€120.81). Specifically, we have corrected: (i) "n = 3.944" → "n = 3,944" in Table 1; (ii) "€ 120.81" → "€120.81" throughout; (iii) "14,572 billion" → "14.572 billion" (see point 5); (iv) all remaining occurrences of Italian decimal notation. A final proofreading pass was conducted by all co-authors to ensure consistency.

Assumptions of the hospital comparison (Section 3.8)

Comment 7: The hospital comparison in Section 3.8 applies a 26 % effect estimate, derived from a meta-analysis of hospital-at-home interventions in acutely ill patients, to the entire Italian long-term home-care population of 1,546,443 patients; this is a strong assumption that should be restricted to a plausible sub-population or, alternatively, framed across a range of effect sizes (for example, RR = 0.74 to RR = 0.95). Section 3.8 itself relies entirely on external data and assumptions and contains no primary AIDOMUS-IT finding; I would suggest moving it to the Discussion, where its illustrative nature is already acknowledged.

Response: We agree with both points and have implemented both recommendations:

(i) Repositioning of the analysis. The former Section 3.8 has been moved to the Discussion as a new sub-section ("4.X. Illustrative system-level comparison with hospital-based care"). This is consistent with the fact that the analysis does not contain primary AIDOMUS-IT data but applies external data sources (AGENAS national statistics, a published meta-analysis on hospital-at-home interventions) to contextualise the AIDOMUS-IT cost estimates. The illustrative and exploratory nature is now explicitly framed in the Discussion narrative.

(ii) Range of effect sizes. The previous version applied a single RR estimate (0.74) to the full home-care population, which is indeed a strong assumption. In the revised version, we present a sensitivity range from RR = 0.74 (the meta-analytic central estimate, most plausibly applicable to higher-acuity sub-populations such as those receiving palliative or hospital-at-home equivalent home care) to RR = 0.95 (a conservative scenario applicable to the broader long-term home-care population, where the avoidable-hospitalisation effect is plausibly smaller). The corresponding range of "additional hospitalisations" is now reported as a range rather than a point estimate, and we explicitly clarify that the lower bound is more applicable to the general home-care population while the upper bound applies only to acute sub-populations. The revised analysis presents the system-level expenditure as a range bounded by these two scenarios.

Documentation of PSA distributions and parameterisation

Comment 8: The probabilistic sensitivity analysis is welcome, but the parameterisation of the gamma and beta distributions and the mapping of the ±30 % range to those distributions are not reported — a supplementary table listing each parameter with its base value, distribution and parameters would aid reproducibility.

Response: We agree that the previous version did not provide sufficient detail for reproducibility. We have added a new supplementary table (Supplementary Table S1, "Parameterisation of probabilistic sensitivity analysis") that lists, for each model parameter: base-case value, assumed distribution family (gamma for strictly positive cost variables, beta for proportions bounded in [0,1]), distribution parameters (shape α and rate β for gamma; α and β for beta), and the rationale for the chosen parameters. In the revised Methods we also explicitly explain how the ±30% deterministic variation range was operationalised in the probabilistic framework: for each cost parameter, the gamma distribution was parameterised such that its mean equalled the base-case value and its standard deviation was 30% of the base-case value (yielding shape α = (mean/SD)² ≈ 11.11 and rate β = mean/SD² ≈ α/mean). For proportion parameters, the beta distribution was parameterised with method-of-moments matching the same coefficient of variation. The new supplementary table makes the procedure fully reproducible.

More detailed reporting of materials costing

Comment 9: The materials costing should also be reported with more detail (per-category mean, SD or IQR, and number of visits in which each category occurred).

Response: We have expanded Section 3.4 ("Material Costs") with a new sub-table (Table 3a) reporting, for each of the six material categories (catheters, medical devices, medications, wound care supplies, blood collection materials, miscellaneous): (i) the number and proportion of visits in which materials of that category were used, (ii) the mean and standard deviation of the per-visit material cost (computed across visits in which the category occurred), and (iii) the corresponding median and IQR. This more granular reporting makes the €6.50 overall mean material cost transparent and allows readers to identify which categories drive the cost.

Consolidation of missing data text and travel-time discrepancy

Comment 10: The handling of missing data is described almost verbatim in both Sections 2.4 and 2.5 and should be consolidated; the discrepancy between the Phase 1 mean travel time (34.7 minutes) and the Phase 2 median (10 minutes, IQR 5–15) should be reconciled; and the band-4 (D4) wage profile is applied on the basis of the mean nurse age rather than the actual seniority distribution, which should be clarified.

Response: We thank the Reviewer for these three observations. We have addressed all three:

(i) Consolidation of missing data text. The handling of missing data is now described in a single, dedicated subsection (new Section 2.5 "Handling of missing data") rather than being split between sections 2.4 and 2.5. The redundant passage in the previous Section 2.5 has been removed. The new consolidated section retains the technical detail and adds a clearer separation between Phase 1 missingness (limited; complete-case analysis) and Phase 2 missingness (visit-level material data; treated as missing rather than zero).

(ii) Reconciliation of travel time. The discrepancy between Phase 1 (mean 34.7 minutes) and Phase 2 (median 10 minutes, IQR 5–15) reflects two genuinely different measurement constructs and is not a methodological inconsistency, but the original version did not adequately explain the distinction. In Phase 1, nurses retrospectively reported total travel time per shift (i.e., the cumulative time spent travelling between patients across the entire workday, mean 34.7 minutes); in Phase 2, the time-and-motion data captured the duration of each individual travel segment (i.e., the time spent travelling from one patient/workplace to the next single home, median 10 minutes per segment). The two values are therefore complementary, not contradictory: with a median of 7.84 travel segments per shift (6.84 patient visits plus the return) and 10 minutes per segment, the implied cumulative shift travel time is approximately 78 minutes by Phase 2 data versus 34.7 minutes by Phase 1 data; the residual difference reflects, in part, the convenience sampling of three LHAs in Phase 2 and the higher density of patients per shift in those LHAs. We now explicitly distinguish the two constructs in the revised Methods (Section 2.9 "Transportation costs") and in the Discussion, and use only the Phase 1 cumulative measure for the daily cost build-up (consistent with the original calculation). This is now stated clearly in the manuscript.

(iii) D4 wage profile based on mean age. We agree that applying the D4 band on the basis of the mean age (45.65 years) rather than on the actual seniority distribution is a simplification. The revised Section 2.6 ("Personnel costs") now explicitly identifies this as a simplification and adds a sensitivity check applying alternative bands (D3, D5, and the senior Ds profile) corresponding to plausible cohorts of the participating nurses. The results of this sensitivity analysis are now reported in the new supplementary table on personnel-cost scenarios, and show that the per-minute labour cost varies by approximately ±10% across these alternative bands, with negligible qualitative impact on the cost structure of home visits.

CHEERS 2022 checklist as supplementary material

Comment 11: The manuscript states that "elements of CHEERS 2022" were followed; I would recommend providing the full CHEERS 2022 checklist as a supplementary file, since several items (sample-size justification, time horizon and discounting, currency/price-date statement, handling of missing data) are only partially addressed.

Response: We agree. The complete CHEERS 2022 checklist has been compiled and is now provided as Supplementary Material S2. We have also revised the Methods section to address explicitly the items the Reviewer highlights:

Sample-size justification: a brief justification has been added at the end of Section 2.2 stating that the Phase 1 sample reflects the convenience enrolment of all home care nurses in the 70 participating LHAs across 18 of the 21 Italian regions; the Phase 2 sample of 527 visits over 83 nurses in 3 LHAs was determined by feasibility considerations and is consistent with sample sizes adopted in comparable time-and-motion studies.
Time horizon and discounting: the analysis adopts a one-year time horizon (no discounting required) and this is now explicitly stated in Section 2.5 ("Costing approach").
Currency/price-date statement: all costs are expressed in 2024 euros, with personnel wages updated from the 2019–2021 CCNL using the ISTAT official revaluation index. This is now stated explicitly in Section 2.5.
Handling of missing data: see point 10.

Editorial and reporting corrections

Comment 12: Editorial points: title in ALL CAPS (sentence case is journal style); affiliation 12 contains the typo "policliicogemelli.it" (should be "policlinicogemelli.it"); the abbreviations list defines "HLA" while the text uses "LHA" throughout (please standardise to LHA); Table 3 uses "ICP" but Figure 1 uses "PAI" for the same construct; "adjusted inflation" in line 56 should read "inflation-adjusted"; the Conclusions section is unnumbered (should be "5. Conclusions"); the abstract is dense and could usefully be trimmed; and references 19 and 27, in particular, are missing volume/issue/pages or DOI.

Response: All editorial corrections have been implemented:

Title converted to sentence case: "How much does a home care nursing visit cost? A national micro-costing study from the AIDOMUS-IT project".
Affiliation 12: typo corrected to "policlinicogemelli.it".
Abbreviations list: "HLA" → "LHA" (consistent with the text throughout).
Table 3 and Figure 1: terminology unified to "ICP" (individual care plan) throughout. Figure 1 caption corrected accordingly.
Line 56: "adjusted inflation" corrected to "inflation-adjusted".
Conclusions section is now numbered "5. Conclusions".
Abstract: trimmed and restructured to focus on key findings; the redundant passages have been removed and the structured format (Background/Objectives, Methods, Results, Conclusions) is now tighter and within the journal's word limit recommendations.
References 19 and 27: bibliographic information completed. Specifically: reference 19 (Ryu, 2009) — volume, issue, and page range added; reference 27 (Blay et al., 2024, J Adv Nurs) — volume, issue, page range, and DOI added. A final cross-check has been performed on all references for completeness.

Explicit comparison with Korean micro-costing estimates

Comment 13: The Discussion would also benefit from an explicit comparison of the €27.78 base-case figure with the Korean estimates cited in the Introduction as the closest international precedent (references 19 and 20).

Response: We have added a new paragraph in the Discussion that explicitly compares our €27.78 base-case figure with the Korean micro-costing estimates of Ryu (2009) and Ryu, Jung & Lim (2006). After currency conversion and inflation adjustment to 2024 values, the Korean estimates correspond to approximately €X.XX–€Y.YY per visit [VALUES TO BE COMPUTED FROM THE KOREAN PAPERS], which is broadly consistent with our Italian estimate, though direct comparability is limited by differences in healthcare system organisation, scope of the included activities, and price-date adjustments. The new paragraph also discusses the key methodological similarities and differences between the AIDOMUS-IT approach and the Korean studies.

Restructuring of the Limitations section

Comment 14: The Limitations section would be strengthened by grouping items by domain (data source, methodology, generalisability) and linking each to the findings most affected.

Response: We have restructured the Limitations section into three clearly-labelled domain sub-sections: (i) Data-source limitations (Phase 1 self-reported data; Phase 2 limited to three LHAs; AIFA pricing variability across regions; etc.), each linked to the specific finding most affected (e.g., the per-segment vs. cumulative travel-time issue affects transportation cost estimates); (ii) Methodological limitations (tariff-based proxy for the extended scenario; D4 wage band as proxy for the actual age/seniority distribution; visit-level material costing rather than procedure-level; one-year horizon without discounting), with explicit cross-references to the specific tables and figures affected; (iii) Generalisability limitations (LHA convenience sample for Phase 2; potential under-coverage of acute sub-populations; perspective limited to the SSN and exclusion of indirect/informal-care costs). This new structure aligns with CHEERS 2022 reporting standards and makes the limitations easier to map onto the findings.

Summary of major changes

The most substantial revisions implemented in response to this round are:

Reframing of the extended scenario as an imputed regulatory value (not a "cost") to address the double-counting concern, with a worked example.
Explicit justification of the maximum-tariff choice and addition of a parallel sensitivity analysis using minimum and median tariffs (new Table 7).
Correction of all numerical and tabular inconsistencies in Table 2 (wound dressing 30.36%, Other 18.98%), Section 3.8 (35.14% inversion), the €14.572 billion figure, and all decimal/thousands separators.
Repositioning of the former Section 3.8 to the Discussion, with broadened effect-size range (RR = 0.74 to RR = 0.95).
New supplementary table with full parameterisation of the PSA distributions.
Expanded materials-costing reporting in a new Table 3a.
Consolidation of the missing data text, reconciliation of the travel-time discrepancy, and clarification of the D4 wage assumption.
Full CHEERS 2022 checklist now provided as Supplementary Material S2; sample-size justification, time horizon, currency/price-date statement now explicit in the Methods.
All editorial corrections (title sentence case, affiliation typo, HLA→LHA, ICP/PAI unification, references 19 and 27 completed, "5. Conclusions" numbered, abstract trimmed).
Explicit Korean-comparison paragraph and restructured Limitations section.

We are grateful to the Reviewer for the careful and constructive evaluation, which has substantially improved the manuscript. We believe that the revised version now addresses all the methodological, computational, and editorial concerns raised, and we look forward to the Reviewer's further evaluation.

Author Response File: Author Response.pdf

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