Methods

RCT (A)
(sealed envelopes)
Blinded outcome assessment

Participants

Patients referred to day hospital
Excluded: dysphasic, required nursing or occupational therapy > twice per week
163 patients eligible, (28 needed day hospital treatment, 21 refused consent, 9 operational problems at day centre)
Participants = 105
Baseline function: Median Barthel index 15 (interquartile range 12‐17) and 15 (11‐17)
Male 36%

Interventions

Day hospital care by multidisciplinary rehabilitation team, principally nursing assessment, occupational therapy and physiotherapy
vs
Day centre rehabilitation provided by a physiotherapist and two support workers

Outcomes

12 month follow up
Death
Institutional care
Barthel index
Caregiver strain index
Philadelphia Geriatric Morale scale
Costs

Notes

Total of 105 patients of whom 23 had a stroke diagnosis, 14 osteoarthritis, 13 fracture, 9 Parkinsonism
Of the 55 patients randomised to day centre attendance, 10 transferred to day hospital

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate

Methods

RCT (B)

Participants

Patients referred for inpatient rehabilitation
Inclusion: age over 15 years, disabled (not spinal injuries or head injuries), living with someone, fit to travel, 24 telephone contact, suitable residence, medicare eligible
556 patients screened, 8 patient/carers refused consent, 452 rejected from study sample.
Participants = 96
Baseline function: Kenny ADL index 21.8 and 22.1
Male 54%

Interventions

Day hospital attendance 5 days a week
Emphasis on rehabilitation with greater patient and carer involvement
A complete range of medical and therapeutic services available.
vs
Rehabilitation as an inpatient

Outcomes

3 month follow up
Death
Institutional care
ADL: i) modified Kenny, ii) subjective rating
Instrumental ADL
Checklists to measure indoor and outdoor leisure activity
Medical status
Mental state
Psychological well‐being (Kahn Mental Status Questionnaire)
Patient satisfaction
Family impact questionnaire
Costs

Notes

A total 96 patients recruited of whom 55 had a stroke diagnosis,
26 amputees
Day hospital tested as an alternative to inpatient care

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

RCT (B)
Stratified by conventional service

Participants

Patients referred from the community to 2 geriatricians or about to be discharged from hospital
Inclusion: age over 65 years, reduced function with rehabilitation potential
128 patients asked to participate, 15 refused
Participants = 113
Baseline function : Geriatric Quality of Life Questionnaire (ADL) 4.49 and 4.46
Male 40%

Interventions

Day hospital attendance 2 days a week
Treatment included multidisciplinary team assessment, programme of rehabilitation provided by physiotherapists and occupational therapists
vs
Usual elderly care (management in inpatient geriatric assessment unit for comprehensive assessment and treatment, management in the outpatient geriatric clinic, with limited diagnostic and rehabilitative opportunities, or early discharge from a medical‐surgical inpatient unit and appropriate community follow‐up services
Same professional provided treatment to both groups

Outcomes

12 month follow up
Death
Institutional care
Mental status
Geriatric Quality of Life Questionnaire
Barthel Index
Rand questionnaire
Global Health Question (GHQ)
Family rating of Barthel Index, GHQ, Rand Questionnaire
Patient rating of Barthel Index
Resource use

Notes

Total of 113 patients of whom 26 had a stroke diagnosis, 32 a diagnosis of depression and 19 a diagnosis of degenerative joint disease
Patients were stratified according to the type of conventional care specified by the participating geriatrician prior to randomisation

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

RCT (A)
(sequential sealed envelopes)
Blinded outcome assessment

Participants

Patients discharged home from hospital after acute stroke
Exclusion: discharged to residential or nursing homes, requiring respite of terminal care, receiving outpatient rehabilitation prior to the stroke, no significant disability, in hospital < 7 days
Patients discharged from elderly care, general medical wards and stroke unit were randomised separately
Participants = 155
Baseline function: Median Barthel index 17 (14‐17) and 16 (13‐17)
Male 48%

Interventions

Domiciliary rehabilitation team (2 half time physiotherapists, 1 occupational therapist)
treatment for up to 6 months (75% received treatment)
vs
Day hospital attendance
Multidisciplinary rehabilitation provided (54% received treatment)

Outcomes

12 month follow up
Death
Institutional care
Extended ADL score
Barthel Index
Nottingham Health Profile
Brief Assessment of Social Engagement
Life Satisfaction Index (Nottingham version)
Costs

Notes

All stroke patients (155)
Previous stroke 42 (27%), domiciliary group 19 (31%)

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate

Methods

RCT (A)
(central site randomisation)
Blinded outcome assessment

Participants

To be eligible for this Veterans Administration service patients had one of the following: at risk of nursing home placement, 'Service connected disability', hospital inpatient, in home care programme, in a VA domiciliary service
Entry criteria for study ‐ one of the following: living in a nursing home, need help for ADL activities, bowel incontinence, significant cognitive impairment, acceptable to day care staff
1236 patients screened,
252 not eligible
158 refused consent
826 patients recruited
Baseline status: Sickness Impact Profile (Physical) of 31.7 (SD18.8) and 33.8 (18.4)
Male 96%

Interventions

Adult day health care attendance
Therapeutically orientated programme providing health maintenance and rehabilitation services
Staff included nurses, rehabilitation therapists, recreation therapists and social worker
Mean number of 28 day attendance over 6 months
vs
'Usual care' (nursing home, inpatient care, clinic visits, home care etc)

Outcomes

12 month follow up
Death
Institutional care
Mini Mental state
Sickness Impact Profile
Survival Satisfaction Questionnaire
Self‐rated health
Social support scale
Katz Instrumental ADL
Self‐rated health
Psychological Distress Scale
Caregiver Burden Scale
Satisfaction Questionnaire
Service use and costs

Notes

No accurate information on patient diagnosis given
Evaluation of adult day health care

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

RCT (A)
(sequential sealed envelopes)
Stratified by disability

Participants

Patients admitted to a rehabilitation ward one week after acute stroke
Excluded: age<65 yrs, previous stroke, dementia, live outside catchment area, Barthel index of 20
Participants n = 120
Baseline function: Barthel index 9.9 (SD 4.9) and 10.4 (5.3)
Male 44%

Interventions

Conventional inpatient rehabilitation by a neurology team with medical clinic follow up
vs
Care under the geriatrician ‐ early discharge as able with continued care in day hospital

Outcomes

6 month follow up
Death
Institutional care
AMT score
Barthel Index
Self‐rated health scale score
Geriatric Depression Scale
Subjective satisfaction with services
Use of hospital and community services
Costs

Notes

Stroke patients only
All patients initially treated on same rehabilitation ward

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate

Methods

RCT (C)
Quasi‐randomised by year of birth

Participants

Patients receiving home care in a rural community in Finland
All 177 chronically ill patients receiving home care screened, 3 refused consent
Participants n = 174
Male 34%

Interventions

Day hospital attendance
New 10‐place day hospital provided medical and nursing assessment and care
Intensive physiotherapy and OT provided according to individual need.
Patients attended 2‐3 days a week from 8.30am‐ 4.30pm
on average 20 days treatment over 2 months
vs
Usual elderly care (included mixture of home health care and referral to a hospital or outpatient care)

Outcomes

12 month follow up
Death
Institutional care
Katz ADL
Subjective health assessment
Mood
Resource use, hospital admissions, outpatients visits, GP visits
Number of symptoms
Number of medications

Notes

Total of 174 patients of whom 40 had a stroke diagnosis, 54 a diagnosis of coronary heart disease, 53 arthrosis, 33 'moderate' or 'severe' dementia

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate

Methods

RCT (A)
Stratified by sex, ages and disability (Barthel index <10; 10‐14; >15) and catchment areas of day hospitals.

Participants

Inclusion: Patients with newly diagnosed stroke admitted to a Poole Hospital NHS Trust hospital, or community referrals.
Confirmed diagnosis of stroke
Aged over 55 years
Residents of East Dorset
Needed rehabilitation for stroke related disability
Were able to attend day hospital
No previous disability which would prevent rehabilitation
No signs of advanced dementia
Exclusions: Terminal illness
Needing day hospital care for social or medical reasons.
180 eligible
140 randomised into trial.
Baseline function:
Median Barthel Index: DH 14 (9‐17 IQR), C 14 (9‐16 IQR).
46% male

Interventions

Day hospital: 5 day hospitals with coordinated care from multidisciplinary teams, both individual and group therapies
Domiciliary care: Domiciliary stroke team comprising 1 full time physiotherapist and a half time physiotherapist and consultant geriatrician, who met with each other fortnightly to review patients. Out patient speech and language therapy provided.

In both cases therapy as provided until maximum potential for recovery reached, patients were then placed on review, and if no further therapy required, discharged.

Outcomes

6 month follow‐up:
Primary outcome, Barthel Index,
Secondary outcomes: Rivermead Mobility Index
Philadelphia Geriatric Center Morale Scale
Frenchay Activities Index
Perceived Quality of Life (SF‐36)
Health and local authority social service costs.

Notes

All stroke patients, previous stroke: DH 23 (32%),

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate

Methods

RCT (B)
Stratified by stroke or non‐stroke diagnosis

Participants

Patients over 55 years
Patients needing assessment and rehabilitation but not 24 hour institutional care
Referrals from hospital and GP's
Excluded: dementia, patients needing social care
Baseline function: 17.6 (12‐31) and 16.3 (12‐25) on Northwick Park ADL score
Male 43%

Interventions

Day hospital attendance
Day hospital provided intensive physiotherapy, occupational therapy, speech therapy and medical and nursing assessment and supervision
Patients attended 2‐3 days per week, Monday to Friday from 8.30a.m. ‐ 2.00p.m. for 6 ‐ 8 weeks
vs
Usual elderly care:
(inpatient, outpatient follow‐up with or without outpatient
physiotherapy, by referral for domiciliary services, by referral to the sole care of their GP; or by referral to a day centre as decided before randomisation)

Outcomes

5 months follow up
Death
Institutional care
Northwick Park ADL
Zung Depression Index
Service use
Costs

Notes

No information on number of patients screened for inclusion
Stroke patients randomised separately from other diagnoses (65 of 120)

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

RCT (B) (pilot study)
Randomised using sealed envelopes

Participants

Consecutive patients attending 2 day hospitals were eligible for trial if:
Required rehabilitation
Not attended day hospital in previous year
Did not require medical investigations only provided in day hospital
Not confused
270 patients screened, (83 needing maintenance ‐ had attended the day hospital in the previous year, 41 needed medical investigation, 28 confused, 10 required respite, 5 attended only once, 4 refused and 40 not recruited due to administrative problems
Participants n = 59
Baseline function: Barthel index of approximately 13
Male 32%

Interventions

Day hospital attendance
Day hospitals (2 sites) provided medical and nursing support and
physiotherapy, occupational therapy, speech therapy, chiropody, dietary, pharmaceutical and opthalmic services
vs
Home rehabilitation ‐ a newly established service, comprising two part‐time physiotherapists, three part‐time OT's, speech therapist, dietician, clinical psychologist available for referrals as appropriate
Regular team meetings
Attempt to equalise amount of therapy given to both groups

Outcomes

2 month follow up
Death
Institutional care
Barthel Index
Sickness Impact Profile

Notes

Total of 59 patients of whom 16 had a stroke diagnosis, 12 fractured neck of femur, 5 osteo‐arthritis

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate

Methods

RCT (B)

Participants

New service established and advertised
Referral from a number of sources (hospital, community etc)
Patients screened for eligibility for day care service
63% of eligible referred patients agreed to participate
Participants = 644
Male 39%

Interventions

Day care services
A programme of services including nursing, physiotherapy, patient activities provided under health leadership with physical rehabilitation as the treatment goal.
Four different sites available
Patients attended for an average of 51 days per year
vs
Control group
All patients continued to be eligible for existing services, which
included hospital and skilled nursing inpatient and outpatient
care, home health visits.

Outcomes

12 month follow up
Death
Institutional care
Katz ADL index
Kahn Mental Status Questionniare
Contentment scale
Social activity
Resource use
Costs

Notes

Little information on patient diagnosis (only circulatory disorders (225, 41% and injuries 55 (10%))
Alternative to institutional care

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

RCT (B)
(random numbers)
Stratified by age and sex

Participants

Patients (n=331) from a consecutive series of 500 former geriatric unit inpatients (169 had died, left area, or not traced)
Patients over 60 years (not psychiatric disorders)

Interventions

Day hospital attendance
Patients received a medical assessment, occupational therapy and group exercises
Individual physiotherapy provided as required.
Chiropody, bathing and hairwashing also available.
Attend 1 day a week 9am ‐ 5pm.
vs
Control group (usual elderly care with limited resources available)

Outcomes

12 month follow up
Death
Institutional care
Hospital readmission
Subjective health assessment by doctor and patient

Notes

No information on patient diagnosis
Aimed to reduce demand for hospital admission

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

RCT (B)
Stratified by disability and time since stroke

Participants

Patients discharged home from hospital after new stroke event.
Fit to travel
Age > 60 yrs
Barthel Index <20
Excluded: patients who had to attend DH for respite (n=9)
516 screened for inclusion (143 patients discharged to residential care, 160 patients Barthel score of 20, 40 patients no change in Barthel Index score, 25 lived out of area, 9 needed respite care, non‐consent 15)
Participants n = 124
Baseline function: Median Barthel index 15 (range 4‐19) and 16 (1‐19)
Male 56%

Interventions

Day hospital attendance
Focus on physical rehabilitation, staffed by a multidisciplinary team of nurses, physiotherapists and OT's.
2 days a week for 8 weeks 9.30am ‐ 3.45pm
vs
Home physiotherapy to a maximum of 20 hours in 8 weeks

Outcomes

6 months follow up
Death
Institutional care
Barthel Index
Functional Ambulatory Catagories
Motor Club Assessment
Frenchay Activities Index
Nottingham Health Profile
Carers GHQ‐28
Service use
Costs (first eight weeks only)

Notes

Stroke patients only (124)
Previous stroke 36 29%

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear