Outcomes of Elderly Stroke Patients
Day Hospital Versus Conventional Medical Management
Background and Purpose 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.
Methods 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.
Results 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.
Conclusions 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.
Geriatric day hospitals have developed since the 1950s as a form of multidisciplinary health care for the elderly, encompassing medical, nursing, remedial, and psychological support, as well as input from social services and chiropodists.1 However, this type of care is expensive,2 and its advantages over conventional forms of health care have not been conclusively demonstrated, with a great deal of controversy arising from various studies carried out previously.2 3 4 5 6 7 8 9 10 In a randomized controlled study from New Zealand, Tucker et al demonstrated that the day hospital care improved patients’ mental and physical function but at significantly higher costs than alternative means using outpatient rehabilitation without the team approach adopted by geriatricians.2 Similarly, in the United Kingdom, Gladman et al found that care through the GDH hastened recovery and prevent institutionalization and death in a group of elderly patients with stroke compared with domiciliary rehabilitation.3 4 On the other hand, studies in North America have found no significant benefit in functional status and quality of life in day hospital patients compared with conventional outpatient care.5 6 Moreover, many existing studies have only concentrated on limited aspects of GDH care, such as cost and functional recovery, with little information on parameters such as clinical, social, and psychological outcome or consumer satisfaction.7
The New Territories East region in Hong Kong has an estimated elderly (over 65 years of age) population of 100,000. It is served by a large district general hospital with a GDH that has been in operation since 1985, with a capacity of 40 patients per day. Over half of the day hospital patients have a diagnosis of cerebrovascular accident; therefore, it is important to examine the cost-effectiveness of the GDH versus conventional medical management of patients with stroke.
Subjects and Methods
All patients admitted to a district general hospital with a catchment population of over one million between December 1992 and October 1993 with the clinical diagnosis of cerebrovascular accident were identified. Those with the following features were excluded from the study: age under 65 years, previous history of stroke or dementia, residence outside our catchment area, and a Barthel Index11 score of 20 (score ranges from 0 to 20).
Patients who could not be discharged after the initial week were transferred to a stroke rehabilitation ward. Those who met our study criteria were stratified into two groups according to their BI score: group A, ≤15, and group B, 16 to 19. They were then randomized to receive conventional inpatient rehabilitation under a neurology team or care under the geriatricians. Both teams had equal accessibility to rehabilitation facilities on the ward. Conventional care consisted of inpatient rehabilitation until patients were considered by the attending neurologist to have reached full potential before they were discharged to their own homes or institutions for the elderly, and then medical follow-up as outpatients. Patients under the care of the geriatric team were also treated on the same rehabilitation ward, with an equivalent number of sessions of physiotherapy and occupational therapy as the conventional group. However, as soon as they were considered able to cope at home, they were discharged with continued treatment at the day hospital. Family or community services support was arranged wherever necessary before discharge in both treatment groups.
Information was collected at the time of recruitment on patient demographics (age, sex, and social history), medical history, clinical features of stroke (motor and/or sensory deficits), bladder function, and mental state (using an AMT12 score ranging from 0 to 10) as well as functional state (using the BI). On discharge from the hospital, the duration of stay on the acute and rehabilitation wards was noted. Follow-up assessment was performed by a research nurse at 3 and 6 months after ictus. Data collected at each assessment included details of hospital services received (number of visits to the GDH where applicable, new hospital admissions, and outpatient visits); use of general practitioner services; use of community services (eg, community nurse, health visitor, and home help); functional evaluation (BI); information on well-being, consisting of a self-rated health scale score of 1 (very poor) to 5 (excellent); problems with sleeping; and assessment of mood by the GDS.13 14 Patients and their caregivers were also asked to indicate their degree of satisfaction with services received on a scale of 1 (not satisfied) to 4 (very satisfied).
Costs (in Hong Kong dollars) were derived from our local data15 : acute bed, $2105 per day; rehabilitation bed, $910 per day; GDH, $677 per attendance; outpatient clinic, $313 per visit. The total cost for each type of treatment was therefore calculated as follows:
Conventional group: Total inpatient stay (acute+rehabilitation ward)±outpatient clinic attendances±hospital readmissions.
GDH group: Total inpatient stay (acute+rehabilitation ward)±GDH attendances±outpatient clinic attendances± hospital readmissions.
Statistical analysis was performed using the spss, version 3.1. The χ2 test was calculated for comparison of categorical variables. Mean (±SEM) and probability values were calculated with the one-way ANOVA for continuous variables. A paired t test was performed for comparison within groups.
On entry into the study, the two treatment groups were comparable in terms of neurological deficits and bladder dysfunction (Table 1⇓) as well as coexisting diseases, of which the eight most common were coded, including those affecting the cardiovascular, respiratory, central nervous, musculoskeletal, endocrine, gastrointestinal, and other systems.
Table 2⇓ shows similar baseline characteristics (age, sex ratio, AMT, and number of patients in groups A and B according to BI score) and duration of stay in the hospital of the two treatment groups.
Table 3⇓ shows the follow-up status of patients by group at 3 and 6 months. The numbers of patients attending follow-up, deaths, and defaults were similar in both treatment groups.
The mean±SD of BI scores for the two treatment groups were recorded. At baseline, mean BI of the conventional group was 10.4±5.3 versus 9.9±4.9 in the GDH group. At 3 months, mean BI was 14.6±5.8 in the conventional group and 16.1±3.9 in the GDH group. By 6 months, the scores were 15.6±5.6 and 17.1±3.6 for the conventional and GDH groups, respectively. There was no significant difference in overall mean BI scores between the two groups at each assessment.
At 3 months, both treatment groups showed an improvement in BI scores, but more patients in the GDH group were in a higher BI category compared with baseline (Table 4⇓). In particular, subgroup analysis of patients in group A (BI score of ≤15 at baseline) showed a significantly higher mean BI score in the GDH group compared with the conventional group (13.4±0.9 versus 15.7±0.6; P=.04) at 3 months. By 6 months, there was no significant difference in the number of cases in each BI category for the two treatment groups. The mean BI scores of patients overall, as well as in subgroup A, also increased significantly (P<.0005) within each treatment group between baseline and 3 months, but not between 3 and 6 months after ictus (Table 5⇓). The number of cases in subgroup B (BI scores of 16 to 19 at baseline) were too small (11 in conventional and 8 in GDH group at baseline) for statistical analysis, and the BI may also have a ceiling effect in its higher ranges, hence the data for these cases has not been presented.
At 3 months, the mean±SEM cost per course of treatment for the GDH group was greater than that for the conventional group ($53,891±28,835 versus $44,960±17,954), although it did not quite reach statistical significance (P=.055). The number of readmissions (7 episodes for GDH versus 6 for the conventional group) and mean duration (and range) of stay in acute±rehabilitation wards (9.86 (range, 2 to 23) days for GDH versus 4.75 (range, 1 to 14) for conventional group) were too small for statistical analysis. There was no significant difference in the mean number of outpatient attendances (0.26±0.7 for GDH versus 0.38±0.8 for conventional care; P=.39). By 6 months, there was no significant difference in mean costs for the two treatment groups ($58,168±25,898 for GDH versus $51,809±30,480 for conventional treatment; P=.29), although patients in the GDH group had significantly fewer outpatient visits (0.26±0.7 versus 0.74±1.5 for the conventional group; P=.03). There were 11 episodes of readmission in the GDH group, with a mean duration of stay of 7.36 (range, 1 to 45) days, while the conventional treatment group had 17 readmission episodes, with a mean duration of stay of 9.7 (range, 2 to 47) days (numbers were too small for analysis). For patients in the GDH group, the mean number of day hospital visits were 6.4±6.8 at 3 months and 12.2±10.9 at 6 months. Other parameters assessed, such as patient well-being (self-perceived health, sleep problems, GDS score), use of community services, and financial support, were all comparable between the two treatment groups at each follow-up (data not shown).
Consumer satisfaction was assessed by asking patients and their caregivers about their degree of satisfaction with treatment. At 3 months, response rate was almost 100% (104/105) for patients, and 92% (97/105) for carers. By 6 months, patient and carer response rates were 95% (83/87) and 76% (66/87). No significant difference in patient and caregiver satisfaction was found between the two groups.
This study showed that functional improvement, using the BI as a marker, occurred in both treatment groups. Although the final outcome appeared to be the same for both teams at 6 months, improvement was more marked in the group under the care of geriatricians at 3 months, particularly those who were more disabled initially (subgroup A, with BI score of ≤15 at baseline), while those managed by the medical team appeared to catch up in terms of progress between 3 to 6 months. This finding was consistent with those of Tucker et al2 and Gladman et al.3 4 Thus, it appears that elderly stroke patients looked after by a geriatric team with day hospital facilities and a multidisciplinary approach may be able to achieve full rehabilitation potential earlier than those receiving conventional treatment.
With the GDH group, we expected the patients to receive better general health care, which should be reflected in a shorter total duration of stay on rehabilitation wards, fewer readmissions to the hospital and outpatient or general practitioner visits, better patient morale and perceived well-being.2 16 However, such differences were not observed in this study except for significantly fewer attendances at outpatient clinics. The lack of difference between the two groups may be explained by the relatively similar duration of stay on a rehabilitation ward, where intensive physiotherapy and occupational therapy was equally accessible to both specialist teams. In addition, apart from the GDS (which has been validated as a screening instrument for depression in local Chinese),14 the assessment instruments we used were quite crude, with a yes/no response (eg, sleep problems, financial assistance, community services), or 5-point scale (eg, perceived well-being). With a small sample size of 120, which diminished further with patients lost to follow-up at 3 and 6 months, the instruments may not have been sensitive enough to detect any small differences between the two groups. In particular, it was not possible to carry out statistical analysis on the change in BI score for subgroup B (BI score of 16 to 19) due to small numbers. There is also the potential problem with ceiling effects of the BI score. It is also possible that the duration of study was not long enough to demonstrate such differences. No significant difference was found in costs between the two groups by 6 months, which suggests that the conventional care group was using more resources with time and that the GDH may prove to be more cost-effective in the long term by reducing readmission rate and outpatient attendances.
We also attempted to assess consumer satisfaction by asking patients and their caregivers about their degree of satisfaction with their treatment at 3 and 6 months. Response rates were similar in the two treatment groups. The lower response rate of caregivers may reflect the fact that a considerable number of elderly patients live alone. The further fall in the caregiver response rate at 6 months may be due to a higher default rate among caregivers, which may be explained by either a decline in their interest in the patients or the fact that more patients had become independent with time.
Cost-effective studies for stroke care have so far failed to demonstrate conclusively any advantages in GDH treatment over conventional therapy.17 18 However, such studies from the developed world cannot be extrapolated to reflect the situation in our locality. In this study, the costs shown were derived from a cost analysis of our day hospital,15 using information from the Hospital Authority of Hong Kong, on costs of hospital beds, ambulance transportation, and median salaries of various grades of staff in 1993. Costs at 3 and 6 months were not statistically different between the two groups. Costs of the day hospital treatment group can probably be reduced with the introduction of nonemergency transport and better use of resources, such as optimizing occupancy rate and use of manpower. Initial costs of inpatient rehabilitation could also be reduced if subjects in the GDH group could be discharged sooner from hospital to be followed up at the day hospital.
Recent studies have examined the value of home physiotherapy for stroke patients.3 4 17 18 19 The Bradford community stroke trial18 showed that home physiotherapy was more cost-effective than day hospital for aftercare of stroke patients. The DOMINO study3 4 found that the day hospital did have some advantage in preventing death or institutionalization in a more elderly group. However, the cost of the day hospital service was also greater than that of the domiciliary team.17 Currently, because domiciliary services are not yet available in Hong Kong and our day hospital therapist-to-patient ratio is probably lower compared with many overseas centers, thus it is not possible to compare our findings directly with studies from the developed world. Further local studies on domiciliary rehabilitation, comparing cost-effectiveness with our day hospitals, will have to be carried out before any recommendations can be made.
In conclusion, we have demonstrated that compared with conventional medical management, a geriatric team approach with a day hospital facility hastened functional recovery, as measured by the BI, in a group of elderly patients with cerebrovascular accidents, without significant additional cost. General well-being and consumer satisfaction appeared to be similar in the two groups at 3 and 6 months, while the day hospital group had significantly fewer outpatient visits at 6 months.
Selected Abbreviations and Acronyms
|AMT||=||Abbreviated Mental Test|
|GDH||=||geriatric day hospital|
|GDS||=||Geriatric Depression Scale|
- Received December 13, 1994.
- Revision received May 4, 1995.
- Accepted May 4, 1995.
- Copyright © 1995 by American Heart Association
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