Effects of locality based community hospital care on independence in o
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《英国医生杂志》
1 Department of Health Care for the Elderly, St Luke's Hospital, Bradford BD5 0NA, 2 Aysgarth Statistics, Beaconsfield HP9 2AS, 3 York Health Economics Consortium, University of York, York YO10 5NH, 4 School of Health Studies, University of Bradford, Bradford BD5 0BB
Correspondence to: J Green becarrd.1@bradfordhospitals.nhs.uk
Objective To determine the effects on independence in older people needing rehabilitation in a locality based community hospital compared with care on a ward for elderly people in a district general hospital.
Design Randomised controlled trial.
Setting Care in a community hospital and district general hospital in Bradford, England.
Participants 220 patients needing rehabilitation after an acute illness that required hospital admission.
Interventions Patients were randomly allocated to a locality based community hospital or to remain within a department for the care of elderly people in a district general hospital.
Main outcome measures Primary outcomes were Nottingham extended activities of daily living scale and general health questionnaire 28 (carer). Secondary outcomes were activities of daily living (Barthel index), Nottingham health profile, hospital anxiety and depression scale, mortality, destination after discharge, satisfaction with services, carer strain index, and carer's satisfaction with services.
Results The median length of stay was 15 days for both the community hospital and the district general hospital groups (interquartile range: community hospital 9-25 days; district general hospital 9-24 days). Independence at six months was greater in the community hospital group (adjusted mean difference 5.30, 95% confidence interval 0.64 to 9.96). Results for the secondary outcome measures, including care satisfaction and measures of carer burden, were similar for both groups.
Conclusions Care in a locality based community hospital is associated with greater independence for older people than care in wards for elderly people in a district general hospital.
Community hospitals, loosely defined as small hospitals with few onsite diagnostic facilities or specialised services,1 are a long established but contentious2 component of healthcare provision. Interest in community hospitals in England has been renewed, stimulated by the contraction of the district general hospital and the shift towards locality based health services under the umbrella term intermediate care.3 This revival, however, is more an opportunistic development than an evidence based one.1 4 Few reports describe evaluations of community hospitals and these are unconvincing, being dominated by considerations of resources rather than clinical outcomes.1 A community hospital can result in lower bed usage in a district general hospital, but overall bed utilisation (district general hospital and community hospital combined) may be higher.5-7 This increased hospital stay may be acceptable if the overall quality of care is improved such that patient satisfaction and clinical outcomes are superior. To date, no studies have tackled these issues. We assessed the effectiveness of a locality based community hospital on independence in older people needing rehabilitation.
Participants and methods
Our study was based in a department dealing with the care of elderly people in a metropolitan city with a population of about 400 000 people. The department has five wards in a district general hospital and receives emergency admissions from casualty and general practitioners for patients aged over 76 years with acute medical conditions. The wards provide multidisciplinary care, with nurses, therapists, dieticians, and pharmacists led by 10 geriatricians in accordance with described good practice.8
The community hospital we studied opened in 1996 and provides locality based care for predominantly older patients who reside in one of the three primary care trusts in Bradford city (population 92 272; 17% over 65). The hospital has strong links to local general practitioners and local community health and social services (see table A on bmj.com).
Protocol
Patients were eligible for the trial if they were registered with a general practitioner in the primary care trust served by the community hospital and were considered by the responsible geriatrician to be medically stable and in need of post-acute rehabilitation care. We excluded patients if they had features of medical instability (pyrexia, breathlessness at rest, history of chest pain within the previous 48 hours, or need for intravenous drugs)10; were drowsy or unconscious; required specialist rehabilitation in the stroke unit, or treatment in other departments such as surgery or coronary care; or needed new placement in a care home. Patients and their carers gave written informed consent or assent was sought from a carer or relative when patients had impaired capacity.
Baseline assessment by a research nurse included reason for admission, current input from social care services, cognitive function (abbreviated mental test score),11 activity restriction before admission (Nottingham extended activities of daily living and Barthel index),12-14 and other outcome measures (see bmj.com).
Assignment
We stratified patients by cognitive impairment using the abbreviated mental test (categories 0-7; 8-10) and by activity restriction using the baseline Barthel index score (categories 0-13; 14-20). Randomisation to community hospital (intervention) or usual care (control) was by numbered, sealed, opaque envelopes prepared from random numbers tables, which initially used four length permuted blocks in a ratio of one intervention group to each control group. Owing to pressures on beds in the district general hospital, we changed the randomisation schedule after two months (26 patients had been recruited) to three length permuted blocks in a ratio of two intervention groups to each control group. We used short length blocks to minimise the potential for disruption to clinical services. Randomisation was carried out away from the clinical setting and, as patients were recruited from several wards, the ward staff were blinded to randomisation. The research nurse responsible for recruitment was unaware of the stratification boundaries and block length. We aimed to transfer patients randomised to the community hospital group within two days in accord with existing local practice.
Intervention group
Patients allocated to community hospital care were assessed by the multidisciplinary team and received an individual care plan designed to maximise recovery and promote independence. Home assessments before discharge are commonly arranged, and discharge is coordinated with the local social service team. The consultant visited the hospital at least twice a week and the hospital practitioner visited the hospital each weekday. Local general practitioners provided out of hours cover (see bmj.com for input from nursing and therapy teams).
Control group
Usual care consisted primarily of an extended stay in the care of the elderly ward in the local district general hospital but could include transfer to a non-locality based community hospital or to social service facilities, both of which offered slow track rehabilitation.
Outcome measures, follow up, and blinding
For the primary outcome measures we used the Nottingham extended activities of daily living scale for patients, a valid and reliable measure,12 15 and the general health questionnaire 28 for carers.16 Other outcome measures are listed in table B on bmj.com. Information on death, length of stay in hospital, and destination after discharge was collected.
Follow-up assessments were at one week after hospital discharge, and at three and six months after recruitment.
A researcher who had not been involved with recruitment visited the patients at home and completed the outcome measures. Unblinding of patient allocation was recorded and the researcher stated the perceived trial group for each patient at the final assessment. We measured agreement between perceived and actual allocation using the statistic.
Statistical analysis
We defined a clinically meaningful difference as a two point improvement of the Nottingham extended activities of daily living scale (0-22 scoring). We used the revised 0-66 scoring in accord with recent practice. For our sample size calculation we used a standard deviation of 5.3 recently obtained from an intermediate care study of over 300 frail older people.22 This method indicated a sample size of 400 for 1% significance and 85% power, and 240 for 5% significance and 85% power. We planned to recruit 500 patients to allow for dropouts.
Our primary analysis was an intention to treat comparison of change in scores on the Nottingham extended activities of daily living scale from baseline to six months between the intervention and control groups. We used unpaired t test and the Mann-Whitney U test for unadjusted values. We also carried out an adjusted intention to treat comparison using analysis of covariance to adjust for the baseline variables of age, sex, institutional care, mental status, and baseline Barthel index score. To allow for potential bias due to the exclusion of patients who had died, we used the Mann-Whitney U test to compare the groups for the change in Nottingham extended activities of daily living scale scores from preadmission to the six month assessment after recoding the six month scores for these patients as zero (worst outcome). The primary outcome for carers was the difference between the groups for change in general health questionnaire 28 scores between baseline and six months using the Mann-Whitney U test.
For our secondary analyses we used the Mann-Whitney U test to compare the groups for changes in the total Nottingham extended activities of daily living scale scores and general health questionnaire 28 scores between baseline and the follow-up assessments at one week and three months. We carried out similar analyses for each assessment point for the subsections of the Nottingham health profile, the total Barthel index score, and the anxiety and depression subsections of the hospital anxiety and depression scale. We used the Mann-Whitney U test to examine the differences between the groups for the carer strain index scores at the follow-up assessments at one week and three and six months. The 2 test was used to examine differences in mortality and destination after discharge between the groups. We created a dichotomous response (satisfied or not satisfied) for patient and carer satisfaction scores, and we compared the groups using the 2 test.
Results
Of the 2232 potential participants identified between November 2000 and September 2002, 266 remained medically unstable and died, 137 were transferred to other departments, and 1829 became medically stable. Overall, we excluded 1497 of the 1829 patients. Of the remaining 332 patients we randomised 141 to locality based community hospital care (intervention group) and 79 to usual care (control group) (figure). Twenty six patients did not achieve group allocation: 16 in the community hospital group remained in the district general hospital and 10 in the usual care group were transferred to the community hospital. The main reasons for deviation from allocation were bed closures in the community hospital through infective gastroenteritis (8/16) and extreme pressures on beds in the district general hospital (8/10). In the community hospital group, 73 patients were transferred or died within two days of randomisation (72 transferred, one died), and 52 patients were transferred after more than two days or died in hospital after more than two days without transfer (49 transferred, three died). Eleven control patients were subsequently transferred to a non-locality based community hospital.
Flow of participants through trial
Participant flow and follow up
Both groups were well matched for baseline characteristics and length of hospital stay (table 1). Thirty two patients were not assessed one week after hospital discharge (29 died), 21 patients were not assessed at three months, and a further 13 patients were not assessed at six months (figure). Tables 2 and 3 provide the results of outcome measures. The outcome assessor was unblinded to treatment allocation at the six month assessment by 18 patients and carers in the treatment group and six patients and carers in the control group. The assessor correctly guessed the allocation of 67 of the remaining 128 patients (52%) at the six month assessment (eight patients had missing data). Agreement was poor ( < 0.20).
Table 1 Baseline characteristics of patients and lengths of stay. Values are numbers (percentages) unless stated otherwise
Table 2 Summary scores for Nottingham extended activities of daily living scale at each assessment point
Table 3 Summary scores of outcome measures for patients and carers at each assessment point
Primary outcome analyses
The unadjusted intention to treat comparison of changes in scores on the Nottingham extended activities of daily living scale at six months showed a non-significant difference between the groups (mean difference 4.88, 95% confidence interval 0.18 to 9.59). A significant difference was suggested by the t tests, but this was largely due to the effect of an outlier. The adjusted intention to treat comparison showed a significant difference between the two groups (mean difference 5.30, 0.64 to 9.96). Although the data were reasonably normal, we did find an outlier, which once removed had no material effect on the result (mean difference 4.68, 0.27 to 9.09). The difference remained after patients who had died were assigned the worst score on the Nottingham extended activities of daily living scale.
We found no differences between the groups for emotional distress in carers, measured using the general health questionnaire.
Secondary analyses
The secondary analyses showed few differences. We found improvements in favour of the community hospital in the sleep subsection of the Nottingham health profile at one week and three months (median difference -10.5, -16.8 to 0.0 and -12.6, -22.4 to 0.0, respectively). The intervention group showed a greater increase in the depression subsection of the hospital anxiety and depression scale at one week (median difference 1.0, 0.0 to 2.0). Similar numbers of patients in the intervention and control groups died before the six month assessment (34 (23%) v 21 (27%), respectively) or were discharged to a new care home place (30/134 (22%) v 21/74 (28.4%), respectively).
Both groups had similar reported patient and carer satisfactions. At three months the intervention group showed greater satisfaction with the question "I get all the support I need from services such as meals on wheels, home helps, district nursing, etc" (odds ratio 3.43, 95% confidence interval 1.05 to 11.24).
Discussion
Young J, Donaldson K. Community hospitals and older people. Age Ageing 2001;30-S3: 7-10.
Bevan A. National Health Services Bill. House of Commons official report (Hansard). 30 Apr 1946:cols 43-149.
Department of Health. The NHS plan: a plan for investment, a plan for reform. Cm 4818-I. London: Stationery Office, 2000.
McCormack B. The developing role of community hospitals: an essential part of a quality service. Qual Saf Health Care 1993;2: 253-8.
Baker JE, Goldacre M, Gray JAM. Community hospitals in Oxfordshire: their effect on the use of specialist inpatient services. J Epidemiol Community Health 1986;40: 117-20.
Hine C, Wood VA, Taylor S, Charny M. Do community hospitals reduce the use of district general hospital inpatient beds? J R Soc Med 1996;89: 681-7.
Cook PJ, Porter L. Community hospitals and district general hospital medical bed use by elderly people: a study of 342 general practitioner beds in Oxfordshire. Age Ageing 1998;27: 357-61.
Department of Health. National service framework for older people. London: DoH, 2001.
Department of Health. Intermediate care. London: DoH, 2001. (HSC 2001/01: LAC (2001) 01.)
Brook RH, Kahn KL, Kosecoff J. Assessing clinical stability at discharge. JAMA 1992;268: 1321-2.
Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;1: 233-8.
Nouri FM, Lincoln NB. An extended activities of daily living scale for stroke patients. Clin Rehabil 1987;1: 301-5.
Mahoney FI, Barthel DW. Functional evaluation: the Barthel index. Md State Med J 1965;14: 61-5.
Collin C, Wade DT, Davies S, Horne V. The Barthel ADL index: a reliability study. Int Disabil Stud 1988;10: 61-3.
Harwood RH, Ebrahim S. The validity, reliability and responsiveness of the Nottingham extended activities of daily living scale in patients undergoing total hip replacement. Disabil Rehabil 2002;24: 371-7.
Goldberg DP, Hillier VF. A scaled version of the general health questionnaire. Psychol Med 1979;9: 139-45.
Hunt SM, McEwen J, McKenna SP. Measuring health status. London: Croom Helm, 1986.
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67: 361-70.
Pound P, Gompertz P, Ebrahim S. Patients' satisfaction with stroke services. Clin Rehabil 1994;8: 7-17.
Robinson BC. Validation of a caregiver strain index. J Gerontol 1983;38: 344-8.
Pound P, Gompertz P, Ebrahim S. Development and results of a questionnaire to measure carer satisfaction after stroke. J Epidemiol Community Health 1993;47: 500-5.
Young J, Robinson M, Chell S, Sanderson D, Chaplin S, Burns E, et al. A prospective baseline study of frail older people before the introduction of an intermediate care service. Health Soc Care Community 2005;13: 307-12.
Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993;342: 1032-6.
Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care. Cochrane Database Syst Rev 2001;(2): CD000356.(John Green, research fellow1, John Young)
Correspondence to: J Green becarrd.1@bradfordhospitals.nhs.uk
Objective To determine the effects on independence in older people needing rehabilitation in a locality based community hospital compared with care on a ward for elderly people in a district general hospital.
Design Randomised controlled trial.
Setting Care in a community hospital and district general hospital in Bradford, England.
Participants 220 patients needing rehabilitation after an acute illness that required hospital admission.
Interventions Patients were randomly allocated to a locality based community hospital or to remain within a department for the care of elderly people in a district general hospital.
Main outcome measures Primary outcomes were Nottingham extended activities of daily living scale and general health questionnaire 28 (carer). Secondary outcomes were activities of daily living (Barthel index), Nottingham health profile, hospital anxiety and depression scale, mortality, destination after discharge, satisfaction with services, carer strain index, and carer's satisfaction with services.
Results The median length of stay was 15 days for both the community hospital and the district general hospital groups (interquartile range: community hospital 9-25 days; district general hospital 9-24 days). Independence at six months was greater in the community hospital group (adjusted mean difference 5.30, 95% confidence interval 0.64 to 9.96). Results for the secondary outcome measures, including care satisfaction and measures of carer burden, were similar for both groups.
Conclusions Care in a locality based community hospital is associated with greater independence for older people than care in wards for elderly people in a district general hospital.
Community hospitals, loosely defined as small hospitals with few onsite diagnostic facilities or specialised services,1 are a long established but contentious2 component of healthcare provision. Interest in community hospitals in England has been renewed, stimulated by the contraction of the district general hospital and the shift towards locality based health services under the umbrella term intermediate care.3 This revival, however, is more an opportunistic development than an evidence based one.1 4 Few reports describe evaluations of community hospitals and these are unconvincing, being dominated by considerations of resources rather than clinical outcomes.1 A community hospital can result in lower bed usage in a district general hospital, but overall bed utilisation (district general hospital and community hospital combined) may be higher.5-7 This increased hospital stay may be acceptable if the overall quality of care is improved such that patient satisfaction and clinical outcomes are superior. To date, no studies have tackled these issues. We assessed the effectiveness of a locality based community hospital on independence in older people needing rehabilitation.
Participants and methods
Our study was based in a department dealing with the care of elderly people in a metropolitan city with a population of about 400 000 people. The department has five wards in a district general hospital and receives emergency admissions from casualty and general practitioners for patients aged over 76 years with acute medical conditions. The wards provide multidisciplinary care, with nurses, therapists, dieticians, and pharmacists led by 10 geriatricians in accordance with described good practice.8
The community hospital we studied opened in 1996 and provides locality based care for predominantly older patients who reside in one of the three primary care trusts in Bradford city (population 92 272; 17% over 65). The hospital has strong links to local general practitioners and local community health and social services (see table A on bmj.com).
Protocol
Patients were eligible for the trial if they were registered with a general practitioner in the primary care trust served by the community hospital and were considered by the responsible geriatrician to be medically stable and in need of post-acute rehabilitation care. We excluded patients if they had features of medical instability (pyrexia, breathlessness at rest, history of chest pain within the previous 48 hours, or need for intravenous drugs)10; were drowsy or unconscious; required specialist rehabilitation in the stroke unit, or treatment in other departments such as surgery or coronary care; or needed new placement in a care home. Patients and their carers gave written informed consent or assent was sought from a carer or relative when patients had impaired capacity.
Baseline assessment by a research nurse included reason for admission, current input from social care services, cognitive function (abbreviated mental test score),11 activity restriction before admission (Nottingham extended activities of daily living and Barthel index),12-14 and other outcome measures (see bmj.com).
Assignment
We stratified patients by cognitive impairment using the abbreviated mental test (categories 0-7; 8-10) and by activity restriction using the baseline Barthel index score (categories 0-13; 14-20). Randomisation to community hospital (intervention) or usual care (control) was by numbered, sealed, opaque envelopes prepared from random numbers tables, which initially used four length permuted blocks in a ratio of one intervention group to each control group. Owing to pressures on beds in the district general hospital, we changed the randomisation schedule after two months (26 patients had been recruited) to three length permuted blocks in a ratio of two intervention groups to each control group. We used short length blocks to minimise the potential for disruption to clinical services. Randomisation was carried out away from the clinical setting and, as patients were recruited from several wards, the ward staff were blinded to randomisation. The research nurse responsible for recruitment was unaware of the stratification boundaries and block length. We aimed to transfer patients randomised to the community hospital group within two days in accord with existing local practice.
Intervention group
Patients allocated to community hospital care were assessed by the multidisciplinary team and received an individual care plan designed to maximise recovery and promote independence. Home assessments before discharge are commonly arranged, and discharge is coordinated with the local social service team. The consultant visited the hospital at least twice a week and the hospital practitioner visited the hospital each weekday. Local general practitioners provided out of hours cover (see bmj.com for input from nursing and therapy teams).
Control group
Usual care consisted primarily of an extended stay in the care of the elderly ward in the local district general hospital but could include transfer to a non-locality based community hospital or to social service facilities, both of which offered slow track rehabilitation.
Outcome measures, follow up, and blinding
For the primary outcome measures we used the Nottingham extended activities of daily living scale for patients, a valid and reliable measure,12 15 and the general health questionnaire 28 for carers.16 Other outcome measures are listed in table B on bmj.com. Information on death, length of stay in hospital, and destination after discharge was collected.
Follow-up assessments were at one week after hospital discharge, and at three and six months after recruitment.
A researcher who had not been involved with recruitment visited the patients at home and completed the outcome measures. Unblinding of patient allocation was recorded and the researcher stated the perceived trial group for each patient at the final assessment. We measured agreement between perceived and actual allocation using the statistic.
Statistical analysis
We defined a clinically meaningful difference as a two point improvement of the Nottingham extended activities of daily living scale (0-22 scoring). We used the revised 0-66 scoring in accord with recent practice. For our sample size calculation we used a standard deviation of 5.3 recently obtained from an intermediate care study of over 300 frail older people.22 This method indicated a sample size of 400 for 1% significance and 85% power, and 240 for 5% significance and 85% power. We planned to recruit 500 patients to allow for dropouts.
Our primary analysis was an intention to treat comparison of change in scores on the Nottingham extended activities of daily living scale from baseline to six months between the intervention and control groups. We used unpaired t test and the Mann-Whitney U test for unadjusted values. We also carried out an adjusted intention to treat comparison using analysis of covariance to adjust for the baseline variables of age, sex, institutional care, mental status, and baseline Barthel index score. To allow for potential bias due to the exclusion of patients who had died, we used the Mann-Whitney U test to compare the groups for the change in Nottingham extended activities of daily living scale scores from preadmission to the six month assessment after recoding the six month scores for these patients as zero (worst outcome). The primary outcome for carers was the difference between the groups for change in general health questionnaire 28 scores between baseline and six months using the Mann-Whitney U test.
For our secondary analyses we used the Mann-Whitney U test to compare the groups for changes in the total Nottingham extended activities of daily living scale scores and general health questionnaire 28 scores between baseline and the follow-up assessments at one week and three months. We carried out similar analyses for each assessment point for the subsections of the Nottingham health profile, the total Barthel index score, and the anxiety and depression subsections of the hospital anxiety and depression scale. We used the Mann-Whitney U test to examine the differences between the groups for the carer strain index scores at the follow-up assessments at one week and three and six months. The 2 test was used to examine differences in mortality and destination after discharge between the groups. We created a dichotomous response (satisfied or not satisfied) for patient and carer satisfaction scores, and we compared the groups using the 2 test.
Results
Of the 2232 potential participants identified between November 2000 and September 2002, 266 remained medically unstable and died, 137 were transferred to other departments, and 1829 became medically stable. Overall, we excluded 1497 of the 1829 patients. Of the remaining 332 patients we randomised 141 to locality based community hospital care (intervention group) and 79 to usual care (control group) (figure). Twenty six patients did not achieve group allocation: 16 in the community hospital group remained in the district general hospital and 10 in the usual care group were transferred to the community hospital. The main reasons for deviation from allocation were bed closures in the community hospital through infective gastroenteritis (8/16) and extreme pressures on beds in the district general hospital (8/10). In the community hospital group, 73 patients were transferred or died within two days of randomisation (72 transferred, one died), and 52 patients were transferred after more than two days or died in hospital after more than two days without transfer (49 transferred, three died). Eleven control patients were subsequently transferred to a non-locality based community hospital.
Flow of participants through trial
Participant flow and follow up
Both groups were well matched for baseline characteristics and length of hospital stay (table 1). Thirty two patients were not assessed one week after hospital discharge (29 died), 21 patients were not assessed at three months, and a further 13 patients were not assessed at six months (figure). Tables 2 and 3 provide the results of outcome measures. The outcome assessor was unblinded to treatment allocation at the six month assessment by 18 patients and carers in the treatment group and six patients and carers in the control group. The assessor correctly guessed the allocation of 67 of the remaining 128 patients (52%) at the six month assessment (eight patients had missing data). Agreement was poor ( < 0.20).
Table 1 Baseline characteristics of patients and lengths of stay. Values are numbers (percentages) unless stated otherwise
Table 2 Summary scores for Nottingham extended activities of daily living scale at each assessment point
Table 3 Summary scores of outcome measures for patients and carers at each assessment point
Primary outcome analyses
The unadjusted intention to treat comparison of changes in scores on the Nottingham extended activities of daily living scale at six months showed a non-significant difference between the groups (mean difference 4.88, 95% confidence interval 0.18 to 9.59). A significant difference was suggested by the t tests, but this was largely due to the effect of an outlier. The adjusted intention to treat comparison showed a significant difference between the two groups (mean difference 5.30, 0.64 to 9.96). Although the data were reasonably normal, we did find an outlier, which once removed had no material effect on the result (mean difference 4.68, 0.27 to 9.09). The difference remained after patients who had died were assigned the worst score on the Nottingham extended activities of daily living scale.
We found no differences between the groups for emotional distress in carers, measured using the general health questionnaire.
Secondary analyses
The secondary analyses showed few differences. We found improvements in favour of the community hospital in the sleep subsection of the Nottingham health profile at one week and three months (median difference -10.5, -16.8 to 0.0 and -12.6, -22.4 to 0.0, respectively). The intervention group showed a greater increase in the depression subsection of the hospital anxiety and depression scale at one week (median difference 1.0, 0.0 to 2.0). Similar numbers of patients in the intervention and control groups died before the six month assessment (34 (23%) v 21 (27%), respectively) or were discharged to a new care home place (30/134 (22%) v 21/74 (28.4%), respectively).
Both groups had similar reported patient and carer satisfactions. At three months the intervention group showed greater satisfaction with the question "I get all the support I need from services such as meals on wheels, home helps, district nursing, etc" (odds ratio 3.43, 95% confidence interval 1.05 to 11.24).
Discussion
Young J, Donaldson K. Community hospitals and older people. Age Ageing 2001;30-S3: 7-10.
Bevan A. National Health Services Bill. House of Commons official report (Hansard). 30 Apr 1946:cols 43-149.
Department of Health. The NHS plan: a plan for investment, a plan for reform. Cm 4818-I. London: Stationery Office, 2000.
McCormack B. The developing role of community hospitals: an essential part of a quality service. Qual Saf Health Care 1993;2: 253-8.
Baker JE, Goldacre M, Gray JAM. Community hospitals in Oxfordshire: their effect on the use of specialist inpatient services. J Epidemiol Community Health 1986;40: 117-20.
Hine C, Wood VA, Taylor S, Charny M. Do community hospitals reduce the use of district general hospital inpatient beds? J R Soc Med 1996;89: 681-7.
Cook PJ, Porter L. Community hospitals and district general hospital medical bed use by elderly people: a study of 342 general practitioner beds in Oxfordshire. Age Ageing 1998;27: 357-61.
Department of Health. National service framework for older people. London: DoH, 2001.
Department of Health. Intermediate care. London: DoH, 2001. (HSC 2001/01: LAC (2001) 01.)
Brook RH, Kahn KL, Kosecoff J. Assessing clinical stability at discharge. JAMA 1992;268: 1321-2.
Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;1: 233-8.
Nouri FM, Lincoln NB. An extended activities of daily living scale for stroke patients. Clin Rehabil 1987;1: 301-5.
Mahoney FI, Barthel DW. Functional evaluation: the Barthel index. Md State Med J 1965;14: 61-5.
Collin C, Wade DT, Davies S, Horne V. The Barthel ADL index: a reliability study. Int Disabil Stud 1988;10: 61-3.
Harwood RH, Ebrahim S. The validity, reliability and responsiveness of the Nottingham extended activities of daily living scale in patients undergoing total hip replacement. Disabil Rehabil 2002;24: 371-7.
Goldberg DP, Hillier VF. A scaled version of the general health questionnaire. Psychol Med 1979;9: 139-45.
Hunt SM, McEwen J, McKenna SP. Measuring health status. London: Croom Helm, 1986.
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67: 361-70.
Pound P, Gompertz P, Ebrahim S. Patients' satisfaction with stroke services. Clin Rehabil 1994;8: 7-17.
Robinson BC. Validation of a caregiver strain index. J Gerontol 1983;38: 344-8.
Pound P, Gompertz P, Ebrahim S. Development and results of a questionnaire to measure carer satisfaction after stroke. J Epidemiol Community Health 1993;47: 500-5.
Young J, Robinson M, Chell S, Sanderson D, Chaplin S, Burns E, et al. A prospective baseline study of frail older people before the introduction of an intermediate care service. Health Soc Care Community 2005;13: 307-12.
Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993;342: 1032-6.
Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care. Cochrane Database Syst Rev 2001;(2): CD000356.(John Green, research fellow1, John Young)