Care home versus hospital and own home environments for rehabilitation of older people

BACKGROUND: Rehabilitation for older people has acquired an increasingly important profile for both policy-makers and service providers within health and social care agencies. This growing demand for rehabilitation services has generated an increased interest in the use of alternative care environments, for example care home environments, for older persons' rehabilitation. At a time when there is pressure for policy decision-makers and service providers to explore the use of such care settings for the provision of rehabilitation for older people, there appears limited evidence on which to base decisions.

OBJECTIVES: The objective of this review is to compare the effects of care home environments (e.g. nursing home, residential care home and nursing facilities) versus hospital environments and own home environments in the rehabilitation of older people.

SEARCH STRATEGY: The following databases were searched. The Cochrane Effective Practice and Organisation of Care Specialised Register, the Cochrane Rehabilitation Specialist Register; Cochrane Controlled Trials Register (CCTR); MEDLINE (1966-2000); EMBASE (1980-2000), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982-2000): Science Citation Index (1982-2000); Social Science Citation Index (1982-2000); Best Evidence (1991-2000); HMIC (1979-2000); PsycINFO(1967-2000); ASSIA (1987-2000); Ageline (1978-2000); AgeInfo (1971-2000); Sociological Abstracts (1963-2000); System for Information on Grey Literature (SIGLE) (1980-2000); UK National Research Registers Project Database( Issue 1 2001); Architecture Publication Index (1977-2000). The following Journals were hand searched: Disability and Rehabilitation (1992-2000); Disability and Society (1986-2000); Archives of Physical Medicine and Rehabilitation (1985-2000); Journal of the American Geriatric Society (1980-2000); International Journal of Rehabilitation Research (1980-2000); American Journal of Physical Medicine and Rehabilitation (1980-2000) and: Clinical Rehabilitation (1992-2000). The reviewers also consulted subject area experts and obtained full text review articles and forward tracked any references from these sources.

SELECTION CRITERIA: Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) that compared rehabilitation outcomes for persons 60 years or older who received rehabilitation whilst residing in a care home with those for persons 60 years or older who received rehabilitation in hospital or own home environments. Primary outcomes included functional outcomes using activities of daily living measurement (both personal and instrumental). Secondary outcomes included subjective health status; quality of life measures; return to place of usual residency; all cause mortality; adverse effects; readmission to an acute care facility; patient and carer satisfaction; number of days in facility and number of days receiving rehabilitation.

DATA COLLECTION AND ANALYSIS: One reviewer (DW) completed the initial search and identified potential papers for inclusion. Abstracts for these papers were independently scrutinised by two reviewers (DW/MS) to assess their eligibility. Full text versions of potentially eligible papers were independently assessed by two reviewers (DW/MS). Papers that fulfilled the comparison inclusion criteria were then independently scrutinised by all reviewers to assess whether they met EPOC methodological criteria for inclusion.

MAIN RESULTS: The total yield from the initial search strategy was 19,457. A total of 1,247 abstracts were independently scrutinised by two reviewers (DW/MS) to assess their eligibility. Full text papers for 99 studies were obtained to assess if they fulfilled the review's comparison inclusion criteria. This process resulted in 12 papers being assessed further for methodological validity. However, none of these studies met the inclusion criteria.

REVIEWER'S CONCLUSIONS: There is insufficient evidence to compare the effects of care home environments, hospital environments and own home environments on older persons rehabilitation outcomes. Although the authors acknowledge that absence of effect is not no effect. There are three main reasons; the first is that the description and specification of the environment is often not clear; secondly, the components of the rehabilitation system within the given environments are not adequately specified and; thirdly, when the components are clearly specified they demonstrate that the control and intervention sites are not comparable with respect to the methodological criteria specified by Cochrane EPOC group (Cochrane 1998). The combined effect of these factors resulted in the comparability between intervention and control groups being very weak. For example, there were differences in the services provided in the intervention and control arms, due possibly to differences in dominant remuneration systems, nature of the rehabilitation transformation, patient characteristics, skill mix and academic status of the care environment.