Day hospital and home physiotherapy for stroke patients: a comparative cost-effectiveness study. Day hospital rehabilitation--effectiveness and cost in the elderly: a randomised controlled trial. Effectiveness of a geriatric day hospital. Geriatric day care and homemaker services: an experimental study. Adult Day Health Care Evaluation Study. Stroke rehabilitation after hospital discharge: a randomized trial comparing domiciliary and day-hospital care. Cost comparison of domiciliary and hospital-based stroke rehabilitation. DOMINO Study Group. The day hospital in the community care of the elderly. Outcomes of elderly stroke patients. Day hospital versus conventional medical management.
The financial cost of stroke rehabilitation is considerable but few cost-effectiveness studies are available to guide clinical practice. The Bradford community stroke trial was a randomised trial comparing day hospital attendance with home physiotherapy for elderly stroke patients leaving hospital. The outcome measurements used indicated a consistent modest advantage in favour of home physiotherapy. This advantage is now re-examined in conjunction with the quantified costs of the rehabilitation services and community support received by the two patient groups. The results show that the median cost for the day hospital patients over the first eight weeks was 620.00 pounds (interquartile range 555.00-730.00 pounds) and 385.00 pounds for the home physiotherapy group (interquartile range 240.00-510.00 pounds). These costs were significantly different (median difference 265.00 pounds, 95% confidence interval 190.00-340.00 pounds; p < 0.01). There were no significant differences between the two groups for the indirect costs. This cost-effectiveness study supports the clinical trial result that home physiotherapy should be the treatment of choice for stroke aftercare. The effectiveness and cost of day hospital care in rehabilitation were studied in a randomised controlled trial in 120 elderly patients who were assessed at referral and six weeks and five months later in activities of daily living skills and mood. Day hospital patients were compared with a control group, who were managed as they would have been before the availability of day hospital care. Day hospital patients showed a significant improvement in performance of activities of daily living at six weeks but not at five months; however, they had a sustained improvement in mood. The cost of day hospital rehabilitation was one third greater than that of rehabilitation by alternative means. In its current form the geriatric day hospital is not a cheap alternative to other means of rehabilitation. Expensive components of the day hospital should be critically re-examined and renewed emphasis placed on sufficient inpatient beds, domiciliary services, and day care centres. To determine whether there is a difference in the quality of life between elderly patients managed in a day hospital and those receiving conventional care.
                Randomized controlled trial; assessment upon entry to study and at 3, 6 and 12 months afterward.
                Geriatrician referral-based secondary care.
                A total of 113 consecutively referred elderly patients with deteriorating functional status believed to have rehabilitation potential; 55 were assessed and treated by an interdisciplinary team in a day hospital (treatment group), and 58 were assessed in an inpatient unit or an outpatient clinic or were discharged early with appropriate community services (control group).
                Barthel Index, Rand Questionnaire, Global Health Question and Geriatric Quality of Life Questionnaire (GQLQ).
                Eight study subjects and four control subjects died; the difference was insignificant. Functional status deteriorated over time in the two groups; although the difference was not significant there was less deterioration in the control group. The GQLQ scores indicated no significant difference between the two groups in the ability to perform daily living activities and in the alleviation of symptoms over time but did show a trend favouring the control group. The GQLQ scores did indicate a significant difference in favour of the control group in the effect of treatment on emotions (p = 0.009).
                The care received at the day hospital did not improve functional status or quality of life of elderly patients as compared with the otherwise excellent geriatric outpatient care. The purpose of this study was to examine the impact of geriatric day care and homemaker services on patient outcomes. Patients were randomly assigned to receive the experimental services in three study samples. In comparing outcomes between the experimental and control groups, it was found that there were significant differences in physical functioning and activity level for the day care samples, in physical functioning and contentment level for the homemaker study sample, and in all of these outcome measures for the combined services group. Among users of the experimental services, increased use of the services was associated with improved outcomes of care. Multivariate analysis of data showed that factors other than the use of the experimental services were more effective in explaining variation in outcomes. Significant factors that affected all four outcome measures in both the day care and homemaker study were primary diagnosis, impairment prognosis, and number of inpatient hospital days. nan To compare the effectiveness and costs of a new domiciliary rehabilitation service for elderly stroke patients with geriatric day-hospital care.
                Randomized controlled trial.
                Stroke patients aged 55+ who required further rehabilitation after hospital discharge or after referral to geriatricians from the community.
                Poole area, East Dorset, a mixed urban/rural area on the south coast of England.
                Primary-changes between hospital discharge and 6-month follow-up in physical function as measured by Barthel index. Secondary-changes over this period in Rivermead Mobility Index and mental state (Philadelphia Geriatric Centre Morale Scale) and differences in social activity (Frenchay Activities Index) and generic health status (SF-36). Health service and social service cost per patient were compared for the two groups.
                180 patients were eligible and 140 (78%) were randomized. The groups were well balanced for age, sex, social class and initial Barthel index. We achieved follow-up in 88% of subjects who were alive at 6 months. We detected no significant differences in patient outcomes, although there was a non-significant improvement in measures of physical function and social activity in the domiciliary group. Domiciliary patients had more physiotherapy time per session and more district nurse time, and made greater use of social service day centres and home helps. Total cost per patient did not differ significantly between the two groups, with reduced health service costs in the domiciliary arm offset by higher social service costs.
                No significant differences were detected in the effectiveness of the two services. Neither service influenced patients' mental state, and their social activity remained low. Total costs were similar. A mixed model of day-hospital and domiciliary care may be most cost-effective for community stroke rehabilitation, but this requires further evaluation. The DOMINO study (DOMiciliary rehabilitation In NOttingham) was a randomized controlled trial comparing domiciliary and hospital-based rehabilitation for stroke patients after discharge from hospital, stratified according to the ward at hospital discharge. The outcomes of these patients have been reported previously. In this paper, we present estimates of health service costs of care. No difference in outcome had been found between the overall services, but we have found the hospital-based costs to be 27% cheaper. However, different cost-effectiveness patterns are observable when the strata are analysed. Patients from geriatric wards had been shown to be 2.4 times less likely to die or become institutionalized by 6 months if allocated to a day hospital service, although the cost of this service was 25% more than that of the domiciliary service. Patients from the Stroke Unit who had received domiciliary rehabilitation had been shown to have greater household and leisure abilities at 6 months than those treated in outpatient departments, but the domiciliary service was found to cost 2.6 times more. Patients from general medical wards had similar outcomes whether treated at home or in outpatient departments, but the cost of the latter service was 56% of the former. Some patients may be best cared for in day hospitals and others may do better if treated at home, but for these groups the clinical advantages are achieved at an expense greater than that incurred by the alternative services. Other patients may do as well if treated in outpatient departments as at home, but the former approach is cheaper. A range of services is required for stroke patients leaving hospital. nan Much controversy exists over the value of geriatric day hospitals in the rehabilitation of elderly patients, and cerebrovascular accident is a particularly common diagnosis among patients referred to these day hospitals. We carried out a prospective, randomized study to compare the outcomes of elderly stroke patients managed by a geriatric team using a day hospital facility versus conventional medical management.
                One hundred twenty elderly patients with acute stroke were randomized to inpatient care on a stroke ward under the care of either a neurologist or a geriatric team. Those under the care of neurologists were hospitalized until the attending physician felt that the patients had reached full rehabilitation potential. Patients under the care of the geriatric team were discharged home as soon as the team felt they were able to cope and given follow-up rehabilitation at the day hospital. Family or community support was arranged when necessary for both treatment groups. On recruitment, patient demographics, medical history, clinical features related to stroke, and functional ability as measured by the Barthel Index were noted. Subjects were reviewed at 3 and 6 months to assess functional level, hospital and outpatient services received, general well-being, mood, and level of satisfaction. Costs of treatment of the two groups were also compared.
                Functional improvement (Barthel Index score) was greater in the group managed by the geriatricians with a day hospital facility compared with the conventional group at 3 months (P = .03). There were also fewer outpatient visits among the day hospital patients at 6 months (P = .03). No significant difference was found in costs between the two treatment groups.
                Compared with conventional medical management, care in the geriatric day hospital hastened functional recovery and reduced outpatient visits in elderly stroke patients without additional cost.
Medical day hospital care for the elderly appears to be more effective than no intervention but may have no clear advantage over other forms of comprehensive elderly medical services.