Rehabilitation of Older Patients: Day Hospital Compared to Rehabilitation at Home. A Randomized Controlled Trial
Aim: To test the hypotheses: a) Older people and their informal carers are not disadvantaged by home-based rehabilitation (HBR) relative to day-hospital rehabilitation (DHR); and b) Home-based rehabilitation is less costly.
Conclusions and results: We found no new published randomized controlled trials (RCT) since 1999, and the review conclusions provide justification for a further RCT. Of 480 NHS Trusts in England at the time of the survey, 368 (77%) completed an initial questionnaire. Of these, 322 (87.5%) trusts reported providing rehabilitation services; 181 (46.2%) provided both HBR and DHR; 80 (20.5%) provided HBR but not DHR; and 61 (15.6%) provided DHR but not HBR. Comparison with a previous survey from 1998 suggested recent increase in home-based rehabilitation teams. Originally, a sample of 460 subjects (230 in each participating site) was proposed for the RCT. However, as well as time consuming difficulties in recruiting participating sites and implementing research processes, we experienced lower than anticipated rates of recruiting subjects into the trial in participating sites. We developed an exit strategy and stopped recruiting after 89 subjects had been randomized between the services.
Recommendations: Statistical analyses of the trial outcomes do not provide sufficient evidence to conclude that patients receiving home-based rehabilitation were disadvantaged compared to those receiving day-hospital rehabilitation. This finding is complemented by the observation that the cost of providing HBR is not markedly different from providing rehabilitation in hospital. Neither the new evidence provided by this RCT, nor the existing evidence from previous trials, suggests any advantage or disadvantage from providing rehabilitation in a day hospital versus providing it in the patient’s home.
Methods: A systematic literature review and a national survey of NHS Trusts were followed by a two-arm RCT conducted in 4 trusts in England that provide both HBR and DHR. In each setting, clinical staff reviewed consecutive referrals to identify subjects who were potentially suitable for randomization according to the defined inclusion criteria. Patients were randomized to receive either HBR or DHR. The primary outcome measure was the Nottingham Extended Activities of Daily Living (NEADL) scale. Secondary outcome measures included the EuroQol 5 dimensions (EQ-5D), Hospital Anxiety and Depression Scale (HADS), Therapy Outcome Measures (TOMs), hospital admissions, and the General Health Questionnaire (GHQ-30) for carers.
Further research/reviews required: Future research, rather than comparing these settings for efficacy, might focus on identifying those services that are better provided in one or other setting and will take account of the current commissioning environment in the UK, which explicitly supports choice in the provision of health services for patients.
Written by: Professor Stuart Parker, University of Sheffield, NETSCC, United Kingdom