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


Therapeutics

Review: Day hospitals for elderly patients do not prolong independence compared with other types of comprehensive care

ACP J Club. 1999 Sept-Oct;131:33. doi:10.7326/ACPJC-1999-131-2-033


Source Citation

Forster A, Young J, Langhorne P, for the Day Hospital Group. Systematic review of day hospital care for elderly people. BMJ. 1999 Mar 27;318:837-41. [PubMed ID: 99192484]


Abstract

Question

In elderly patients, is day hospital attendance more effective than other forms of care for prolonging independent living?

Data sources

Studies were identified by searching MEDLINE, the System for Information on Grey Literature, Bath Information and Data Services, CINAHL, and the Cochrane Library (to January 1997) with the terms day hospital, day care, ambulatory care, and outpatient clinic; Index Medicus; British and international dissertation abstracts; conference abstracts; bibliographies of known trials; and books. Authors were contacted.

Study selection

Studies were selected if they were controlled clinical trials of geriatric, day-hospital care that patients attended for a full (or nearly full) day. Trials evaluating social day centers, day hospitals for patients with dementia or psychiatric conditions, or single-condition day hospitals were excluded.

Data extraction

3 reviewers independently extracted data on study characteristics and outcomes: death, need for institutional care, disability, hospital use, resource use, and poor outcome (need for institutional care, severe disability at the end of follow-up, or deterioration in physical function during follow-up).

Main results

12 trials involving 2867 patients were included in the meta-analysis. Follow-up ranged from 8 weeks to 12 months (mean 8.9 mo). Day hospitals were compared with comprehensive elderly care (inpatient, outpatient, and domiciliary geriatric medical services), domiciliary care (therapy in patients' homes or in day centers), and no comprehensive care. The groups did not differ for death (12 studies), death or poor outcome (12 studies), deterioration in activities of daily living (ADLs) (7 studies), or institutional care (11 studies) (Table). In the subgroup of studies that compared day hospitals with no comprehensive care, patients who attended day hospitals were less likely to die or have a poor outcome {weighted relative risk reduction [RRR] 19%, 95% CI 3% to 32%, P = 0.025}*, to deteriorate in ADLs {weighted RRR 31%, CI 3% to 52%, P = 0.04}*, or to be institutionalized {weighted RRR 45%, CI 20% to 62%, P = 0.002}† than were those who received no comprehensive care.

Conclusion

In elderly patients, day hospitals do not prolong independence compared with other types of comprehensive care.

Sources of funding: NHS Executive Northern and Yorkshire Region and Stroke Association.

For correspondence: Dr. A. Forster, Department of Health Care for the Elderly, St. Luke's Hospital, Bradford BD5 0NA, England, UK. FAX 44-1274-365-260; e-mail a.forster@leeds.ac.uk.

*Numbers calculated from data in article.

†Numbers calculated from data supplied by author.


Table. Day hospitals vs other forms of comprehensive care in elderly patients†

Outcomes at a mean 9 mo Weighted event rates Weighted RRI (95% CI) NNH
Day hospital Control
Death 15% 15% 1% (-15 to 21) Not significant
Deterioration in ADLs 27% 25% 8% (-54 to 24) Not significant
Weighted RRR (CI) NNT
Death or poor outcome 34% 37% 5% (-4 to 14) Not significant
Institutional care 18% 20% Not significant

†ADLs = activities of daily living. Other abbreviations defined in Glossary; RRI, NNH, RRR, NNT, and CI calculated from data in article.
‡Numbers calculated from data supplied by author.


Commentary

Day hospitals provide multidisciplinary assessment and rehabilitation services. They differ in staffing complements and backgrounds, physical environments, and transportation and funding arrangements. The populations served by day hospitals also differ in personal values, education, socioeconomic status, and the availability of personal and caregiver support. Thus, analyzing the effectiveness of day hospitals is a mammoth undertaking.

Studies included in the review by Forster and colleagues took place in urban and large rural centers in English-, Chinese-, and Finnish-speaking countries. The original studies had limited descriptions of the term day hospital, which prevented the review authors from comparing models of care and disability outcome. Functional disability, use of home care services, and rates of absenteeism of the primary caregiver would be more appropriate outcome measures than mortality or institutional care, which were the main components of the "poor outcome" described in the review. The Barthel Index was commonly used to evaluate function in the studies; this is a fatal flaw because of the index's limited response to change in patient abilities (1).

After reviewing 30 years of literature on day hospitals, the central question remains unanswered. Although the reader is left with the understanding that any form of comprehensive care for senior citizens is probably better than usual care, whether such care should be provided in a day hospital, in a multidisciplinary clinic, or through domiciliary care remains to be determined.

Albert J. Kirshen, MD, MSc
Baycrest Centre for Geriatric CareNorth York, Ontario, Canada


Reference

1. Wellwood I, Dennis MS, Warlow CP. A comparison of the Barthel Index and the OPCS disability instrument used to measure outcome after acute stroke. Age Ageing. 1995;24:54-7.