Introduction
Many major diseases and conditions are more common in older people, resulting in disabilities that reduce their ability to look after themselves and to manage their activities of daily living. The essence of modern geriatric medicine is to assess and treat the medical and rehabilitative needs of the older patient. The evidence base demonstrates that multidisciplinary team management improves outcomes for older people with multiple pathologies and functional problems.1
Health and social services sometimes fail to meet older peoples’ needs, at times by failing to treat them with dignity and respect, by discriminating against them and by not applying best evidence-based practice across important clinical areas.2 The NHS Plan3 argued that older people tend to have a much greater need for health and social care services, so the majority of resources should be directed at older peoples’ needs. The National Service Framework (NSF) for Older People2 mapped out health care policy in relation to older people.
The concept of intermediate care became policy as a result of the NHS Plan3 and was implemented in England through the NSF for Older People.2 The aim of intermediate care is to prevent unnecessary acute hospital admissions, support early discharge, prevent unnecessary or premature admission to long-term residential or nursing care, promote faster recovery from illness, and maximize independent living in the older patient, through integrated services. The geriatric day hospital (GDH) is one of many service models that come under the umbrella of intermediate care that offer comprehensive geriatric assessment and care to older people in the community. They are out-patient health care facilities for older people and provide multi-professional treatment on a full or part basis to those who attend.4
Despite their varied functions, GDHs have in the past come under the spotlight for lack of a good evidence base for clinical and cost-effectiveness. The Cochrane reviewReference Forster, Young, Lambley and Langhorne5 indicated no overall significant difference between GDH care and alternative services. However, there was a significant difference in favour of GDH care compared with no comprehensive elderly care.
Methodology
The literature on health care management and policy interventions is quite complex and methodologically much more diverse compared with clinical treatments. Hence it is argued that a ‘realist review’ is a more suitable approach to assessment than a randomized controlled trial.Reference Pawson, Greenhalgh, Harvey and Walshe6 The realist approach differs from the traditional methods of review, as it provides an explanatory analysis aimed at discerning what works for whom, in what respect, how and in what circumstances.
The process of developing a ‘realist review’ using trial data from a systematic (Cochrane) review was illustrated by Greenhalgh et al. in 2007.Reference Greenhalgh, Kristjansson and Robinson7 The present paper is a ‘realist review’ of GDH, which aims to determine the circumstances where GDH is effective in providing care for older people. The review re-analyses previously published trial data and includes those trials identified by the Cochrane review.Reference Forster, Young, Lambley and Langhorne5
Results of realist review on geriatric day hospitals
The review identified a number of programme theories where GDH care was found to be effective, as well as some circumstances where it was found to be ineffective
The GDH has been shown to improve patient survival,Reference Weissert, Wan, Liviertos and Katz8 physical functional ability,Reference Weissert, Wan, Liviertos and Katz8–Reference Hui, Lum, Woo, Or and Kay11 patient's mood,Reference Hedrick and Branch10, Reference Tucker, Davison and Ogle12, Reference Woodford-Williams, McKeon, Trotter, Watson and Bushby13 patient satisfactionReference Hedrick and Branch10 and treatment compliance.Reference Burch, Longbottom, MacKay, Borland and Prevost14 Better patient selection,Reference Hedrick and Branch10 increased and sustained service utilization,Reference Weissert, Wan, Liviertos and Katz8, Reference Wan, Weissert and Liviertos15 access to multi-professional services,Reference Hedrick and Branch10 increased social interactionReference Tucker, Davison and Ogle12, Reference Woodford-Williams, McKeon, Trotter, Watson and Bushby13 and delivery of structured care plansReference Burch, Longbottom, MacKay, Borland and Prevost14 were some of the reasons identified to explain the above outcomes supporting the clinical effectiveness of GDH.
Trial data reported cost savings where there was patient selectionReference Hedrick and Branch10 and increased service utilization.Reference Cummings, Kerner, Arones and Steinbock9 In addition, they identified outcomes that supported cost savings by reduction in general hospital bed use,Reference Forster, Young, Lambley and Langhorne5 institutionalization in skilled nursing facilities,Reference Weissert, Wan, Liviertos and Katz8 out-patient visitsReference Hui, Lum, Woo, Or and Kay11 and social services use.Reference Roderick, Low, Day, Peasgood, Mullee, Turnbull, Villar and Raftery16 Better patient selection,Reference Hedrick and Branch10 increased service utilizationReference Weissert, Wan, Liviertos and Katz8 and access to medical services in the communityReference Hui, Lum, Woo, Or and Kay11 were suggested explanations for cost-effectiveness.
Poorer clinical outcomes, including reduction in emotional well-being,Reference Eagle, Guyatt, Patterson, Turpie, Sackett and Singer17 were reported in the trials where other community-based services were strong and where patient selection was poor.Reference Hedrick and Branch10 GDH care was not cost-effective when there were low service utilization rates,Reference Tucker, Davison and Ogle12 poor patient selection,Reference Hedrick and Branch10 general hospital services were in close proximity to the GDH,Reference Crotty, Giles, Halbert, Harding and Miller18 service infrastructure was lacking and service goals were poorly defined.Reference Weissert, Wan, Liviertos and Katz8
Recommendations
The analysis and conclusions of a realist review is far from a final judgement on what works and what doesn't.Reference Pawson, Greenhalgh, Harvey and Walshe6 However, the literature suggests a number of possible situations where GDH care may be useful – in communities where primary care is difficult for older people to access, and where medication management or providing social support is required in addition to physical rehabilitation.Reference Eagle, Guyatt, Patterson, Turpie, Sackett and Singer17, Reference Crotty, Giles, Halbert, Harding and Miller18 The GDH provides a base for co-ordinated multi-disciplinary care and appears to benefit patients with ongoing medical and nursing needs and patients with moderate to severe disability. They also provide respite care to the carers of patients.
Conflicts of interest
The author reports no conflicts of interest related to this paper.
