A randomized controlled trial of day hospital and day centre therapy

Organization of rehabilitation services in randomized controlled trials - which factors influence functional outcome? A systematic review

Objective

To identify factors related to the organization of rehabilitation services that may influence patients’ functional outcome and make recommendations for categories to be used in the reporting of rehabilitation interventions.

Data Sources

A systematic review based on a search in MEDLINE indexed journals (MEDLINE [OVID], Cumulative Index of Nursing and Allied Health Literature, PsycINFO, Cochrane Central Register of Controlled Trials) until June 2019.

Study Selection

In total 8587 candidate randomized controlled trials reporting on organizational factors of multidisciplinary rehabilitation interventions and their associations with functional outcome. An additional 1534 trials were identified from June 2019 to March 2021. Data Extraction: Quality evaluation was conducted by 2 independent researchers. The organizational factors were classified according to the International Classification for Service Organization in Health-related Rehabilitation 2.0.

Data Synthesis

In total 80 articles fulfilled the inclusion criteria. There was a great heterogeneity in the terminology and reporting of service organization across all studies. Aspects of Settings including the Mode of Service Delivery was the most explicitly analyzed organizational category (44 studies). The importance of the integration of rehabilitation in the inpatient services was supported. Furthermore, several studies documented a lack of difference in outcome between outpatient vs inpatient service delivery. Patient Centeredness, Integration of Care, and Time and Intensity factors were also analyzed, but heterogeneity of interventions in these studies prohibited aggregation of results.

Conclusions

Settings and in particular the way the services were delivered to the users influenced functional outcome. Hence, it should be compulsory to include a standardized reporting of aspects of service delivery in clinical trials. We would also advise further standardization in the description of organizational factors in rehabilitation interventions to build knowledge of effective service organization.

Interventions to Prevent or Delay Long-Term Nursing Home Placement for Adults with Impairments-a Systematic Review of Reviews

BACKGROUND

With continued growth in the older adult population, US federal and state costs for long-term care services are projected to increase. Recent policy changes have shifted funding to home and community-based services (HCBS), but it remains unclear whether HCBS can prevent or delay long-term nursing home placement (NHP).

METHODS

We searched MEDLINE (OVID), Sociological Abstracts, PsycINFO, CINAHL, and Embase (from inception through September 2018); and Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database, AHRQ Evidence-based Practice Center, and VA Evidence Synthesis Program reports (from inception through November 2018) for English-language systematic reviews. We also sought expert referrals. Eligible reviews addressed HCBS for community-dwelling adults with, or at risk of developing, physical and/or cognitive impairments. Two individuals rated quality (using modified AMSTAR 2) and abstracted review characteristics, including definition of NHP and interventions. From a prioritized subset of the highest-quality and most recent reviews, we abstracted intervention effects and strength of evidence (as reported by review authors).

RESULTS

Of 47 eligible reviews, most focused on caregiver support (n = 10), respite care and adult day programs (n = 9), case management (n = 8), and preventive home visits (n = 6). Among 20 prioritized reviews, 12 exclusively included randomized controlled trials, while the rest also included observational studies. Prioritized reviews found no overall benefit or inconsistent effects for caregiver support (n = 2), respite care and adult day programs (n = 3), case management (n = 4), and preventive home visits (n = 2). For caregiver support, case management, and preventive home visits, some reviews highlighted that a few studies of higher-intensity models reduced NHP. Reviews on other interventions (n = 9) generally found a lack of evidence examining NHP.

DISCUSSION

Evidence indicated no benefit or inconsistent effects of HCBS in preventing or delaying NHP. Demonstration of substantial impacts on NHP may require longer-term studies of higher-intensity interventions that can be adapted for a variety of settings. Registration PROSPERO # CRD42018116198.

Programme evaluation of a geriatric rehabilitation day hospital

Objective: To evaluate the rehabilitation programme in a geriatric day hospital.

Design: An observational study.

Setting: An urban geriatric rehabilitation day hospital.

Subjects: Three hundred and fifty-three older patients admitted to a rehabilitation day hospital during 2000: 163 post stroke, 113 with deconditioning and 77 post orthopaedic surgery (hip fracture and joint replacement).

Main outcome measures: Functional Independence Measure (FIM), Nottingham Extended ADL Index, timed ‘get up and go’ test.

Results: The mean discharge scores of all FIM items were significantly higher than the mean admission scores. Mean score change, however, for each item was less than one point. Most of the patients (70%) improved by less than 5 points, regardless of main admission diagnoses. Patients with a lower admission FIM score improved more than those with a higher admission score. The majority of the enrolled patients (92%) showed an improvement in their Nottingham Extended ADL Index score. The mean (SD) score on admission was 21 (11.9) and at discharge 31 (14.6). In all but three items (self-feeding, using a telephone and driving a car), mean scores at discharge were significantly higher than admission scores ( p < 0.001). A significant improvement in timed ‘get up and go’ score was found for all patients regardless of main diagnosis. Performance time decreased by 33% and discharge scores for all patient groups were approximately 20 seconds.

Conclusions: The notable improvement in mobility and instrumental activities of daily living on the one hand, and the minor improvements achieved in basic activities of daily living on the other, suggests a need to revise treatment goals of day hospitals.

Medical day hospital care for older people versus alternative forms of care

BACKGROUND

The proportion of the world's population aged over 60 years is increasing. Therefore, there is a need to examine different methods of healthcare provision for this population. Medical day hospitals provide multidisciplinary health services to older people in one location.

OBJECTIVES

To examine the effectiveness of medical day hospitals for older people in preventing death, disability, institutionalisation and improving subjective health status.

SEARCH METHODS

Our search included the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register of Studies, CENTRAL (2013, Issue 7), MEDLINE via Ovid (1950-2013 ), EMBASE via Ovid (1947-2013) and CINAHL via EbscoHost (1980-2013). We also conducted cited reference searches, searched conference proceedings and trial registries, hand searched select journals, and contacted relevant authors and researchers to inquire about additional data.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing medical day hospitals with alternative care for older people (mean/median > 60 years of age).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and risk of bias and extracted data from included trials. We used standard methodological procedures expected by the Cochrane Collaboration. Trials were sub-categorised as comprehensive care, domiciliary care or no comprehensive care.

MAIN RESULTS

Sixteen trials (3689 participants) compared day hospitals with comprehensive care (five trials), domiciliary care (seven trials) or no comprehensive care (four trials). Overall there was low quality evidence from these trials for the following results.For the outcome of death, there was no strong evidence for or against day hospitals compared to other treatments overall (odds ratio (OR) 1.05; 95% CI 0.85 to 1.28; P = 0.66), or to comprehensive care (OR 1.26; 95% CI 0.87 to 1.82; P = 0.22), domiciliary care (OR 0.97; 95% CI 0.61 to 1.55; P = 0.89), or no comprehensive care (OR 0.88; 95% CI 0.63 to 1.22; P = 0.43).For the outcome of death or deterioration in activities of daily living (ADL), there was no strong evidence for day hospital attendance compared to other treatments (OR 1.07; 95% CI 0.76 to 1.49; P = 0.70), or to comprehensive care (OR 1.18; 95% CI 0.63 to 2.18; P = 0.61), domiciliary care (OR 1.41; 95% CI 0.82 to 2.42; P = 0.21) or no comprehensive care (OR 0.76; 95% CI 0.56 to 1.05; P = 0.09).For the outcome of death or poor outcome (institutional care, dependency, deterioration in physical function), there was no strong evidence for day hospitals compared to other treatments (OR 0.92; 95% CI 0.74 to 1.15; P = 0.49), or compared to comprehensive care (OR 1.05; 95% CI 0.79 to 1.40; P = 0.74) or domiciliary care (OR 1.08; 95% CI 0.67 to 1.74; P = 0.75). However, compared with no comprehensive care there was a difference in favour of day hospitals (OR 0.72; 95% CI 0.53 to 0.99; P = 0.04).For the outcome of death or institutional care, there was no strong evidence for day hospitals compared to other treatments overall (OR 0.85; 95% CI 0.63 to 1.14; P = 0.28), or to comprehensive care (OR 1.00; 95% CI 0.69 to 1.44; P = 0.99), domiciliary care (OR 1.05; 95% CI 0.57 to1.92; P = 0. 88) or no comprehensive care (OR 0.63; 95% CI 0.40 to 1.00; P = 0.05).For the outcome of deterioration in ADL, there was no strong evidence that day hospital attendance had a different effect than other treatments overall (OR 1.11; 95% CI 0.68 to 1.80; P = 0.67) or compared with comprehensive care (OR 1.21; 0.58 to 2.52; P = 0.61), or domiciliary care (OR 1.59; 95% CI 0.87 to 2.90; P = 0.13). However, day hospital patients showed a reduced odds of deterioration compared with those receiving no comprehensive care (OR 0.61; 95% CI 0.38 to 0.97; P = 0.04) and significant subgroup differences (P = 0.04).For the outcome of requiring institutional care, there was no strong evidence for day hospitals compared to other treatments (OR 0.84; 95% CI 0.58 to 1.21; P = 0.35), or to comprehensive care (OR 0.91; 95% CI 0.70 to 1.19; P = 0.49), domiciliary care (OR 1.49; 95% CI 0.53 to 4.25; P = 0.45), or no comprehensive care (OR 0.58; 95% CI 0.28 to 1.20; P = 0.14).

AUTHORS' CONCLUSIONS

There is low quality evidence that medical day hospitals appear effective compared to no comprehensive care for the combined outcome of death or poor outcome, and for deterioration in ADL. There is no clear evidence for other outcomes, or an advantage over other medical care provision.

The impact of an integrated care service on service users: the service users’ perspective

Purpose

– The purpose of this paper is to examine the effects of an integration programme on service users from users’ own perspective.

Design/methodology/approach

– Multi-method approach was used. Both quantitative and qualitative data collection and analysis were employed to uncover and examine service users’ views of the impact of the integration programme.

Findings

– An improvement in the physical functioning of one in three occupational equipment users; a rise in the level of satisfaction of 85 per cent of occupational health and 82 per cent of physiotherapy users; older people with complex problems and high-level needs were able to be helped to live at home; and waiting times for both assessment and for services within two weeks and four weeks were below the national achievement and ministerial targets. The impact of the integration programme on users was complex. Positive outcomes were achieved for some user groups and individuals but not for others. A lack of change outcomes in social care, and service users’ low level of satisfaction with social care services appears to be associated with the impact of agency work and the predominant aim in social work of achieving maintenance and prevention outcomes.

Originality/value

– This paper contributes to knowledge on what and how the total integration in Cambridgeshire has benefited users.

Changes in everyday life after discharge from day care rehabilitation

Community-based day care that provides rehabilitation (DCR) targets elderly people with physical disabilities. The goal of these programmes is mainly to improve physical ability in order to enable participants to remain in their ordinary homes. Knowledge of the outcomes of DCR is limited as well as knowledge of what it is that makes a difference for the individual. The aim of this study was to describe what changes in everyday life elderly persons experienced after discharge from a community-based day care rehabilitation centre and to give possible explanations for these changes. Fifteen elderly people were interviewed after that they had been discharged from DCR. A narrative approach was used for analysing the interview data. Four case stories constitute the findings, each of them with unique descriptions of changes in everyday life as well as possible explanations for these changes. The first case story described resumption of daily activities that made the days more eventful and meaningful. The second described how everyday life became an arena for exercising, which create confidence for the future. The third described how an increased sense of certainty and security in the movements led to an increased appetite for life. Finally, the fourth case story described both the stay at the DCR centre and the promise of a new period there as uplifting that made the days easier. Concerning possible explanations for these changes, the findings indicate that it was a combination of several events that together contributed to the changes. Examples were physical training, counselling about how to live in an active and healthy lifestyle, and socialisation with other patients in formal as well as in informal sessions.

Effectiveness of the geriatric day hospital – a realist review

This research paper is a realist review on the effectiveness of medical care for older people in the geriatric day hospital (GDH), based on trial data from a Cochrane review published in 2008. The Cochrane review indicated no overall difference between GDH care and alternative services. However, health care management and policy interventions are quite complex and methodologically more diverse than clinical treatments. Hence a ‘realist review’ is a more suitable explanatory analysis, aimed at discerning what works for whom, in what circumstances, in what respect, and how. This realist review on GDH care provides an explanatory analysis and has aimed to identify where GDH care is and is not effective.

Modernising social care services for older people: scoping the United Kingdom evidence base

In common with other developed countries at the end of the 20th century, modernising public services was a priority of the United Kingdom (UK) Labour administration after its election in 1997. The modernisation reforms in health and social care exemplified their approach to public policy. The authors were commissioned to examine the evidence base for the modernisation of social care services for older people, and for this purpose conducted a systematic review of the relevant peer-reviewed UK research literature published from 1990 to 2001. Publications that reported descriptive, analytical, evaluative, quantitative and qualitative studies were identified and critically appraised under six key themes of modernisation: integration, independence, consistency, support for carers, meeting individuals' needs, and the workforce. This paper lists the principal features of each study, provides an overview of the literature, and presents substantive findings relating to three of the modernisation themes (integration, independence and individuals' needs). The account provides a systematic portrayal both of the state of social care for older people prior to the modernisation process and of the relative strengths and weaknesses of the evidence base. It suggests that, for evidence-based practice and policy to become a reality in social care for older people, there is a general need for higher quality studies in this area.

The training and education of nurses working in stroke care

The National Clinical Guidelines for Stroke (2004) recommend that patients are cared for by staff who have expertise in stroke rehabilitation and access to relevant educational programmes. However, they provide only limited information as to the content and delivery of such programmes and recommend that such decisions are made at a local level. This must inevitably lead to the duplication of efforts and variations in standards and content across national services. This literature review hopes to identify how the content and delivery of educational programmes for nurses on stroke units meet the needs of their role, impact on their practice and influence patient outcomes. It is expected that the findings will be valuable in the development of ongoing training programmes and may contribute to a cohesive approach at national level.

Effects of a stroke rehabilitation education programme for nurses

AIMS

This paper reports a study which aimed to explore the effects of education on the practice of nurses working in stroke rehabilitation units.

BACKGROUND

It has been suggested that a key component of the success of stroke units in reducing mortality and disability is the contribution made by nurses, but debate continues around their specific role. Literature has concentrated on nurses' perceptions of their role rather than their actual activities with patients. In studying the effects of education on nurses' practice with stroke patients there is a need to identify what nurses actually do, rather than what they say they do.

METHODS

A quasi-experimental, non-equivalent control group design was used to study two stroke rehabilitation units. Non-participant observation was conducted during morning care sessions, focusing on styles of physical interaction. Base-line observations were recorded in each unit, after which the staff in the intervention unit received 7 hours' education, specifically focused on therapeutic handling in relation to morning care activities. Following this, postintervention observations were conducted and comparisons of interaction styles made between units.

RESULTS

Twenty-six staff and 37 patients took part in the study. Following the education, staff in the intervention unit showed a change in physical interaction style more in line with therapeutic practice, with the proportion of 'doing for' interventions reducing (45.4% vs. 33.2%; P < 0.05). The proportion of facilitatory interventions increased (3.9% vs. 6.1%) however, this difference was not statistically significant (P = 0.098). The change in styles of practice was achieved with no increased demand on nurses' time.

CONCLUSION

Education for nurses which aims to change styles of interaction with stroke patients can be effective. However, further research is required to identify the effect of nursing interventions on patient outcomes following stroke.

Adult day care for the frail elderly: outcomes, satisfaction, and cost

OBJECTIVES

To assess outcomes and satisfaction among frail elderly day care clients and their informal caregivers and the impact of adult day care on the cost of health services.

METHODS

One-hundred eight elderly participants were randomly assigned to the experimental group (immediate admission to an adult day care center) and 104 participants to the control group (3 months on a waiting list).

RESULTS

Participants' and caregivers' subjective perceptions of the day center's effects were positive. However, using standard research instruments, there was no evidence of an effect of day center attendance on the client's anxiety, depression, or functional status; on caregiver burden; or on the cost of health services.

DISCUSSION

It is difficult to demonstrate objectively the benefits of programs and interventions that are perceived by clients, caregivers, and staff to have positive effects. In future studies, maintenance of high levels of participation should be incorporated as an explicit program goal.

Collaboration, facilities and communities in day care services for older people

Collaborative working in care for older people is often seen as a desirable goal. However, there can be problems with this approach. This paper reports on a single blind randomized controlled trial which was carried out to compare outcomes of rehabilitation in two settings: a day hospital and social services day centres augmented by visiting therapists. The subjects were 105 older patients. Principal outcome measures were the Barthel Index, Philadelphia Geriatric Centre Morale Scale and the Caregiver Strain Index. Two aspects of the trial are examined here. Firstly, we investigated whether trial patients were more disabled than regular day centre attendees. Levels of health and well being amongst trial patients were compared with those of a random sample of 20 regular attendees from both of the participating day centres and an additional voluntary sector day centre. Secondly, key staff from the different settings were interviewed to assess how well the day centre model had worked in practice. Trial patients were significantly more disabled than regular day centre attendees according to the Barthel Index (P < 0.001), but this difference was no longer significant after three months of treatment. The day centre model had several problems, principally discharge policy, acceptability, facilities and attitudes of staff and regular attendees. Positive aspects of the day centre model, as well as successful rehabilitation, included shared skills, knowledge and resources. This paper suggests that collaborative working in day centres requires multipurpose facilities. If health staff maintain a permanent presence, benefits can include improved joint working, easier access to health care and the use of rehabilitative therapy as a preventative strategy. Day care settings can be analyzed as representing different types of communities. Allowing older users a greater degree of choice in facilities may increase the acceptability of care.

Rhetoric and reality in stroke patient care

The aim of this study was to identify aspects of the process of care that might help explain the improved outcomes associated with stroke units. Three different care settings for stroke patients, an elderly care unit and general medical ward in an inner-city teaching hospital and a stroke unit in another teaching hospital in the same city, were compared using non-participant observational methods. Nurses on the stroke unit and general medical ward usually engaged in standardised and functional interaction with patients, while nurses on the elderly care unit were observed to adopt a more personal and attentive approach with patients. Rehabilitation nursing was rarely observed on the stroke unit, never on the general medical ward but always on the elderly care unit. There was evidence of effective communication between nurses and therapists on the elderly care unit but this was not observed on the stroke unit. On the elderly care unit the team appeared divided, with therapists and nurses on one side and medicine on the other, while on the stroke unit the divide was between doctors and therapists on one hand and nurses the other. On the general medical ward there was no team working. The observed lack of rehabilitation nursing, nurses' disengagement from the team and nurses' observed lack of warmth towards patients on the stroke unit were all surprising findings. Further research needs to examine whether such findings would be reproduced in stroke units elsewhere. If so, it might be that the better outcomes achieved on stroke units are despite rather than because of the nursing they receive there.

The Huntingdon Day Hospital Trial: secondary outcome measures

OBJECTIVE

To compare day hospital to day centre rehabilitation using scales to measure mobility, activities of daily living and quality of life.

DESIGN

Single blind randomized controlled trial with home assessments at baseline (twice), six weeks and three months.

SETTING

Mainly rural health district. Day hospital and social services day centres in market towns.

INTERVENTIONS

Day hospital treatment or day centre rehabilitation by a physiotherapist and two health support workers.

MAIN OUTCOME MEASURES

World Health Organization mobility scale scored with and without aid, Nottingham Extended Activities of Daily Living Scale and Nottingham Health Profile.

SUBJECTS

One hundred and five physically disabled older patients living at home referred for day hospital rehabilitation or maintenance before discharge from hospital (66) or referred as outpatients (39).

RESULTS

At three months there were no statistically significant differences between rehabilitation at day hospital and day centre for any of the outcome measurements. However, there were significant improvements between baseline and three months for the following subscales [mean change per six-week period (95% confidence interval) ]: WHO mobility subscale (with aid) -0.67 (-0.99,-0.35); Nottingham Health Profile mobility subscale -10 (-15.5,-4.5) Nottingham extended ADL mobility subscale +3.08 (1.78,4.37); Nottingham extended ADL leisure subscale +1.66 (0.96,2.36).

CONCLUSION

There were no differences between day hospital and day centre in the outcomes measured. Day rehabilitation appeared to improve functional ability and mobility and scales reflecting these domains deserve further evaluation as outcome measures in this patient group. However, no improvement in quality of life was observed.

Medical day hospital care for the elderly versus alternative forms of care

BACKGROUND

Geriatric day hospitals provide multi-disciplinary rehabilitation in an outpatient setting. Concern has been expressed that evidence for effectiveness is equivocal and that day hospital care is expensive.

OBJECTIVES

To assess the effects of medical day hospitals for elderly people.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, Sigle, Bids, and Cinahl up to January 1997, and reference lists of articles. We also searched Index Medicus and International Dissertation Abstracts up to January 1997. We contacted authors of previous studies of day hospital care.

SELECTION CRITERIA

Randomised trials comparing geriatric medical day hospitals with alternative forms of care. The participants were elderly medical patients. The outcomes were death, place of residence, dependency, global 'poor' outcome (death, institutionalisation or dependency), activities of daily (ADL) score, subjective health status, patient satisfaction, and resource use.

DATA COLLECTION AND ANALYSIS

Three reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Twelve studies were included involving 22 day hospitals and 2867 patients. Five studies compared day hospital with comprehensive elderly care, four compared day hospital with domiciliary care and three compared day hospital with no comprehensive elderly care. There were no significant differences between day hospital attendance and comparison treatments for the outcomes of death, death or requiring institutional care, death or deterioration in ADL. When death or a 'poor' outcome at follow up was examined there was a significant difference in favour of day hospital attendance when compared to no comprehensive elderly care (odds ratio 0.73; 95% confidence interval 0.53-1.00; P < 0.05). Dependency was measured in 11 studies using a variety of ADL measures; two described short-term improvement for the day hospital group, one reported improved outcome for the comparison group, while in the remainder there was no statistically significant difference. Using the outcome of deterioration in ADL among survivors, day hospital patients showed reduced odds of deterioration compared with those receiving no comprehensive elderly care (0.60; 0.38-0.97; P <0.05). When resource use was examined the day hospital group showed trends towards reductions in hospital bed use and placement of survivors in institutional care. Nine studies comparing treatment costs indicated that day hospital attendance was a more expensive option, although only two analyses took into account long-term care costs.

REVIEWER'S CONCLUSIONS

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.

Systematic review of day hospital care for elderly people. The Day Hospital Group

OBJECTIVE

To examine the effectiveness of day hospital attendance in prolonging independent living for elderly people.

DESIGN

Systematic review of 12 controlled clinical trials (available by January 1997) comparing day hospital care with comprehensive care (five trials), domiciliary care (four trials), or no comprehensive care (three trials).

SUBJECTS

2867 elderly people.

MAIN OUTCOME MEASURES

Death, institutionalisation, disability, global "poor outcome," and use of resources.

RESULTS

Overall, there was no significant difference between day hospitals and alternative services for death, disability, or use of resources. However, compared with subjects receiving no comprehensive care, patients attending day hospitals had a lower odds of death or "poor" outcome (0.72, 95% confidence interval 0.53 to 0.99; P<0.05) and functional deterioration (0.61, 0.38 to 0.97; P<0.05). The day hospital group showed trends towards reductions in hospital bed use and placement in institutional care. Eight trials reported treatment costs, six of which reported that day hospital attendance was more expensive than other care, although only two analyses took into account cost of long term care.

CONCLUSIONS

Day hospital care seems to be an effective service for elderly people who need rehabilitation but may have no clear advantage over other comprehensive care. Methodological problems limit these conclusions, and further randomised trials are justifiable.