Stroke rehabilitation after hospital discharge: a randomized trial comparing domiciliary and day-hospital care

Objectives: to compare the effectiveness and costs of a new domiciliary reh abilitation service for elderly stroke patients with geriatric day-hospital care. Design: randomized controlled trial. Participants: stroke patients aged 55 + who required further rehabilitation after hospital discharge or after referral to geriatricians from the commu nity. Setting: Poole area, East Dorset, a mixed urban/rural area on the south coa st of England. Main outcomes: primary-changes between hospital discharge and 6-month follo w-up in physical function as measured by Barthel index. Secondary-changes o ver this period in Rivermead Mobility Index and mental state (Philadelphia Geriatric Centre Morale Scale) and differences in social activity (Frenchay Activities Index) and generic health status (SF-36). Health service and so cial service cost per patient were compared for the two groups. Results: 180 patients were eligible and 140 (78%) were randomized. The grou ps were well balanced for age, sex, social class and initial Barthel index. We achieved follow-up in of subjects,who were alive at 6 months. We detect ed no significant differences in patient outcomes, although there was a non -significant improvement in measures of physical function and social activi ty in the domiciliary group. Domiciliary patients had more physiotherapy ti me per session and more district nurse time, and made greater use of social service da, centres and home helps. Total cost per patient did not differ significantly between the two groups, with reduced health service costs in the domiciliary arm offset by higher social service costs. Conclusion: no significant differences were detected in the effectiveness o f the two services. Neither service influenced patients' mental state, and their social activity remained low. Total costs were similar. A mixed model of day-hospital and domiciliary care may be most cost-effective for commun ity stroke rehabilitation, but this requires further evaluation.