Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Geriatric day hospital did not improve functional status or quality of life in elderly persons

ACP J Club. 1991 Sept-Oct;115:40. doi:10.7326/ACPJC-1991-115-2-040


Source Citation

Eagle DJ, Guyatt GH, Patterson C, et al. Effectiveness of a geriatric day hospital. Can Med Assoc J. 1991 Mar 15;144:699-704.


Abstract

Objective

To compare quality of life and functional status between patients attending a geriatric day hospital with those receiving conventional care.

Design

12-month, randomized controlled trial.

Setting

Geriatric day hospital at a secondary- to tertiary-care teaching hospital.

Patients

113 of 128 consecutive patients aged > 65 years agreed to participate. 78% were from the community and 22% from hospitals. Patients had impaired functioning, no acute illness, and a positive prognosis for long-term improvement. Patients with a life expectancy of less than 6 months or a disability requiring 24-hour monitoring were excluded. All patients (mean age 79 y, 39% men) were followed for 1 year.

Intervention

Study patients (n = 55) attended the geriatric day hospital 2 d/wk, 4 to 5 h/d. Staff included a general practitioner, nurses, occupational, physical and speech therapists, a nutritionist, and a pharmacist. Control patients (n = 58) were seen by equivalent staff in an outpatient setting every 4 to 6 weeks or as needed.

Main outcome measures

Mental status, quality of life (Geriatric Quality of Life Questionnaire [GQLQ]), functional status (Barthel Index, Rand Questionnaire), and health status (Global Health Questionnaire) assessments were completed by patients and patient care providers at baseline and at 3, 6, and 12 months.

Main results

8 of 55 study patients (14%) and 4 of 58 control patients (7%) died {Absolute risk difference 7%, CI -4% to 20%}.*(P > 0.2). Decreases were seen in both groups in functional status (Barthel, P = 0.002) and in the ability to perform activities of daily living (ADL) (P = 0.05). The differences between the groups were not significant (P = 0.2 for functional status, P = 0.3 for ADL). Based on the 60 patients who could fill out the GQLQ questionnaire, both groups showed reduced symptoms (P = 0.009), again with no differences between groups (P = 0.2). A treatment effect was seen in favor of the control group on the emotions dimension of the GQLQ (P = 0.02). Use of health care resources was similar, with study group patients hospitalized for 1388 days and control group patients for 1351 days. The power of the study was sufficient to exclude an important effect of the day hospital in comparison with conventional care.

Conclusion

Geriatric day-hospital care compared with geriatric outpatient care did not improve functional status or quality of life in elderly persons.

Source of funding: Ontario Ministry of Health.

Address for article reprint: Ms. D.J. Eagle, School of Nursing, Room 2J40E, Faculty of Health Sciences, McMaster University, Hamilton, Ontario L8N 3Z5, Canada.

*Numbers calculated from data in article.


Commentary

This randomized controlled trial comparing a geriatric day hospital to conventional care did not show a benefit as measured by decreased resource utilization or improved quality of life and functional status. The lack of a measurable beneficial effect is not surprising. The only studies of global geriatric programs to show a benefit have either restricted entry to patients judged likely to benefit (as was the case in this study) or have involved a control group receiving a "usual care" alternative of questionable adequacy, or both. 1 of the most influential of the positive randomized controlled trials showed a benefit in terms of both survival and resource consumption (1).

The negative findings suggest that care in the community (even though of less intensity and not as organized) is as effective as day-hospital care. Whether these findings are generalizable to other settings is unclear: The investigators indicate that patients in the control group received more specialized care and community support than did those in previous studies. The authors ascribe the statistically significant control group gains on the emotional scale of the GQLQ to chance. An alternative explanation, however, might be that more frequent care can cause patients to feel sicker and less well emotionally (2).

This study supports the use of community-based care for older patients. It may be that geriatric day hospitals benefit only certain types of patients. Innovative research is needed to determine which patients are most likely to benefit and which components of care are most important for improved outcomes among the geriatric population.

Eric B. Larson, MD, MPH
University of Washington School of MedicineSeattle, Washington, USA


References

1. Rubinstein L. Effectiveness of a geriatric evaluation unit: a randomized clinical trial. N Engl J Med. 1984;311:1664-70.

2. Avorn J, Langer E. Induced disability in nursing home patients: a controlled trial. J Am Geriatr Soc. 1982;3:397-400.