Cost comparison of domiciliary and hospital-based stroke rehabilitation

Age and Ageing,  May, 1994  by John Gladman,  David Whynes,  Nadina Lincoln

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The DOMINO study (DOMiciliary rehabilitation In Nottingham) was a randomized controlled trial comparing domiciliary and hospital-based rehabilitation for stroke patients after discharge from hospital, stratified according to the ward at hospital discharge. The outcomes of these patients have been reported previously. In this paper, we present estimates of health service costs of care.

No difference in outcome had been found between the overall services, but we have found the hospital-based costs to be 27% cheaper. However, different cost-effectiveness patterns are observable when the strata are analysed. Patients from geriatric wards had been shown to be 2.4 times less likely to die or become institutionalized by 6 months if allocated to a day hospital service, although the cost of this service was 25% more than that of the domiciliary service. Patients from the Stroke Unit who had received domiciliary rehabilitation had been shown to have greater household and leisure abilities at 6 months than those treated in outpatient departments, but the domiciliary service was found to cost 2.6 times more. Patients from general medical wards had similar outcomes whether treated at home or in outpatient departments, but the cost of the latter service was 56% of the former.

Some patients may be best cared for in day hospitals and others may do better if treated at home, but for these groups the clinical advantages are achieved at an expense greater than that incurred by the alternative services. Other patients may do as well if treated in outpatient departments as at home, but the former approach is cheaper. A range of services is required for stroke patients leaving hospital.

Introduction

The provision of rehabilitation--physiotherapy and occupational therapy--for stroke patients following discharge from hospital can be organized in any of three ways: via outpatient rehabilitation departments, day hospitals or domiciliary rehabilitation services. Healthcare planners are therefore faced with a choice between these methods of organization, a choice dependent upon relative efficacy and cost (1).

The DOMINO study was a randomized controlled trial which compared a domiciliary rehabilitation service to hospital-based rehabilitation for stroke patients discharged from hospital in Nottingham. The methodology and clinical findings at 6 months have been reported elsewhere (2). All patients who had been admitted to hospital with acute stroke and who were being discharged to their own homes in Nottingham were eligible for the trial unless they had not been physically disabled by their stroke, required respite care or refused to give consent. Overall, the trial reported no difference at 6 months between the domiciliary and hospital-based services in terms of the functional ability and perceived health of the patients or the social engagement or life satisfaction of their carers.

In view of the variation amongst stroke patients and the services they receive, randomization in the DOMINO study was stratified according to ward at discharge from hospital. The largest stratum included patients discharged from the Health Care of the Elderly wards. This was a group of elderly and frail patients for whom routine hospital care was in a geriatric day hospital. There may have been a benefit of day hospital attendance over domiciliary therapy in this stratum, since the rate of death and institutionalization by 6 months was 2.4 times lower. The smallest stratum included patients discharged from the Stroke Unit. Patients on the Stroke Unit had been selected, according to the usual practice at the time, if they were likely to require (and able to participate in) prolonged and intensive rehabilitation. Thus, they were younger patients who had survived extensive strokes. Routine hospital-based care for patients leaving the Stroke Unit was in outpatient departments. Patients discharged from the Stroke Unit who subsequently had therapy at home had better household and leisure abilities at 6 months (assessed using the Nottingham Extended ADL scale) (3)(4) than those who attended outpatient departments. The third stratum included stroke patients who were discharged from General Medical wards. Patients in this stratum were of intermediate age compared with those of the other strata and were characterized by a short hospital stay. Routine hospital-based care for this stratum was also in outpatient departments, but no differences in outcome were found between patients treated at home or in outpatient departments.

In this pragmatic study, the domiciliary and hospital-based rehabilitation services differed in several ways, as they would in ordinary clinical practice. Apart from the obvious difference in the place where treatment was given, the intensity of the treatment and the proportion of eligible patients who actually received further therapy differed. Most of the patients allocated to the domiciliary service were assessed at home for their need for further therapy, whereas the decision to give further hospital-based treatment was made in the conventional manner during hospital stay. Thus, when comparing the relative costs of hospital and domiciliary rehabilitation services, not only should the cost per visit or attendance be compared but also the cost per course of treatment and the cost per patient eligible for rehabilitation. The present paper examines the health service costs of these therapy options.