A Cochrane review suggests that while day hospitals offer an effective service for older people, they are no more effective than other, less expensive forms of care
Citation: Andrews L (2016) Are day hospitals effective for older people’s care? Nursing Times; 112: 11, 23.
Author: Lesley Andrews is a teaching fellow at the School of Health Sciences, University of Stirling, and a member of the Cochrane Nursing Care Field.
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Day hospitals were first developed in the 1960s to provide multidisciplinary assessment and rehabilitation for older patients in an outpatient setting, bridging the gap between primary and secondary care. However, since their inception, there have been many changes to the design of healthcare services in an attempt to meet the needs of an ageing population.
The day hospital has not been immune to these changes and is now required to offer specialised treatment, such as sub-acute care and clinical investigations. In this context, day hospitals are increasingly being viewed as an alternative to community-based or hospital inpatient care for older people. However, the evidence for their effectiveness in terms of clinical outcomes and cost effectiveness, as compared with alternative forms of care, has been unclear.
The aim of the Cochrane review was to examine the effectiveness of medical day hospitals for older people in preventing death, disability, institutionalisation and improving subjective health status. It included 16 studies based in 37 day hospitals in several countries including eight in the UK, three in the US and one each in Australia, Canada, Hong Kong, Finland, and New Zealand.
All day hospitals provided multidisciplinary outpatient rehabilitation and were compared with three key subgroups:
- Comprehensive care, where patients had access to a range of medical services (five trials);
- Domiciliary care, where patients were provided a similar rehabilitation programme within their own home or social day centre (seven trials);
- No comprehensive care, where patients did not routinely have access to outpatient rehabilitation services (four trials).
Participants (n=3689) had a mean age of >65yrs, a mixture of diagnoses and a degree of dependency based on their assessed activities of daily living (ADL) scores. The primary outcomes examined included: death, need for institutional care, dependency and global “poor outcome” (comprising death or one of the following: resident in institutional care, severe dependency at the end of follow-up, or deterioration in physical function during follow-up).
Nine studies provided final outcome data at 12 months, four studies at six months, one at five months, one at three months and one at two months. Pooled results suggested that there was no significance difference at the end of scheduled follow-up between day-hospital attendance and comparison interventions overall for the following outcomes:
- Death (16 trials);
- Death or institutional care (13 trials);
- Death or deterioration in activities of daily living (ADL) (7 trials);
- Death or poor outcome (13 trials).
Comparison with no comprehensive care demonstrated a significant difference in favour of day hospitals.
The results of this review support the notion that day hospitals offer an effective outpatient service for older people. However, they are no more effective than other potentially less expensive forms of comprehensive care. Day hospitals offer some key benefits when compared with no treatment, including a reduction in the risk of death, being institutionalised or becoming more dependent on others for assistance with ADLs.
The authors caution that any conclusions drawn from this review are limited by the relatively small amount of low-quality evidence available, suggesting that there is a need for further research that explores alternative services that aim to provide similar or better forms of comprehensive care to that of day hospitals. In the meantime, the authors conclude, day-hospital attendance needs to be carefully monitored and the staff and facilities used as flexibly and efficiently as possible.
Implications for practice
The results of this review failed to find any significant differences in the selected outcomes between day hospitals and alternative forms of comprehensive care. However, it is reassuring to know that there are clear benefits for those receiving some form of comprehensive care, no matter the environment. The main issue is perhaps increasing availability and accessibility to these services in the current climate of austerity.
Brown L et al (2015) Medical day hospital care for older people versus alternative forms of care. Cochrane Database of Systematic Reviews. CD001730. DOI: 10.1002/14651858.CD001730.pub3