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As you or perhaps your parents get older, would you want to be at home when recovering from an illness? Would the choice between home rehabilitation or visits to a day hospital make a difference to your recovery and health? Which is cheaper for the healthcare services? A recent study published in the journal Health Technology Assessment (HTA) shows that home-based care in the United Kingdom is no worse than attendance at a day hospital for older adults .
Under any nationally funded healthcare system, there is always an enormous pressure on resources. As such, it is vital to explore the outcomes of different types of care, keeping in mind the cost-effectiveness. Rehabilitation after illness is a vital part of healthcare, but is enormously costly. As the U.S. and European populations age, there is increasing pressure on the health services to deliver cost-effective rehabilitation for older patients . Older patients often present with more complications following illness and take longer to recover, so this push to reduce costs must always take into account how well each intervention or mode of care works. With the emphasis on “quality of life” in healthcare (that simply being physically “healthy” is not the sole goal of healthcare, but that the experienced quality of ones life is highly important), rehabilitation care is further emphasised.
U.K. researchers conducted a randomised controlled trial, where patients were randomised to receive either day hospital care or home-based rehabilitation . Eighty-nine older adults receiving rehabilitation care for a range of health conditions took part in the study; 90% of the participants were over 70 years of age. Measures of daily living activities (normal daily life tasks eg bathing, preparing food), quality of life, anxiety, depression and general health were taken. The scientists also collected data about health outcome and number of hospital admissions. The patients and their carers (informal carers in this case, such as spouse or friends) were followed for up to 12 months. Data were collected at 3 months, 6 months and 12 months following the start of the rehabilitation program. The home-based rehabilitation program and the day hospital both included services such as physiotherapy and occupational therapy, stroke rehabilitation and falls assessment — the key difference between the two types of care then being the venue.
Results of both patient outcomes and carer wellbeing showed that home-based rehabilitation “confers no particular disadvantage for patients and carers.” However, in this case, the cost of the home-based rehabilitation provision was not significantly different to that of day hospital rehabilitation. This suggests that although home-based care may appear on the surface to be more cost-effective, this is not always the case. This study then has important implications practice, most importantly perhaps is that rehabilitation providers must consider the local needs and characteristics of their population when providing care. Indeed, given there is no difference found in outcomes or costs, patients could potentially be given the choice. Local issues are clearly important, for example in a rural community home-based care may be vital if patients are restricted in access to transport.
This study did conclude that the two types of care are equivalent: rather they explored non-inferiority. This just establishes that one treatment is not worse than the other. This does not mean the two types of care are equivalent, indeed, this is impossible to show as there will always be differences . Non-inferiority trials tell us if there are differences that are clinically important, i.e. if the treatment results in worse outcomes.
This study illustrates some of the complex issues around choice of services to be delivered through healthcare systems. As healthcare systems are increasingly scrutinised and reforms are planned, it is important to have a grasp of some of these issues to understand debates. On an individual level, this study shows that despite personal preferences and preconceived ideas, care in a day hospital is not superior to care within the home. Evaluating evidence may lead you then to choose a different type of care.
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