***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The purpose of this study was to examine the impact of  geriatric day care and homemaker services on patient outcomes . Patients were r and omly assigned to receive the experimental services in three study sample s. In comparing outcomes between the experimental and control groups , it was found that there were significant differences in physical functioning and activity level for the day care sample s , in physical functioning and contentment level for the homemaker study sample , and in all of these outcome measures for the combined services group . Among users of the experimental services , increased use of the services was associated with improved outcomes of care . Multivariate analysis of data showed that factors other than the use of the experimental services were more effective in explaining variation in outcomes . Significant factors that affected all four outcome measures in both the day care and homemaker study were primary diagnosis , impairment prognosis , and number of inpatient hospital days The effectiveness and cost of day hospital care in rehabilitation were studied in a r and omised controlled trial in 120 elderly patients who were assessed at referral and six weeks and five months later in activities of daily living skills and mood .  Day hospital patients were compared with a control group , who were managed as they would have been before the availability of day hospital care . Day hospital patients showed a significant improvement in performance of activities of daily living at six weeks but not at five months ; however , they had a sustained improvement in mood . The cost of day hospital rehabilitation  was one third greater than that of rehabilitation by alternative means . In its current form the geriatric day hospital is not a cheap alternative to other means of rehabilitation . Expensive components of the day hospital should be critically re-examined and renewed emphasis placed on sufficient inpatient beds , domiciliary services , and day care centres OBJECTIVE To determine whether a new model of primary care , Chronic Care Clinics , can improve outcomes of common geriatric syndromes ( urinary incontinence , falls , depressive symptoms ,  high risk medications  ,  functional impairment ) in frail older adults . DESIGN R and omized controlled trial with 24 months of follow-up . Physician practice s were r and omized either to the Chronic Care Clinics intervention or to usual care . SETTING Nine primary care physician practice s that comprise an ambulatory clinic in a large staff-model HMO in western Washington State . PARTICIPANTS Those patients aged 65 and older in each practice with the highest risk for being hospitalized or experiencing functional decline . INTERVENTION Intervention practice s ( 5 physicians , 96 patients ) held half-day Chronic Care Clinics every 3 to 4 months . These clinics included an extended visit with the physician and nurse dedicated to planning chronic disease management ; a pharmacist visit that emphasized reduction of polypharmacy and high-risk medications ; and a patient self-management/support group . Control practice s ( 4 physicians , 73 patients ) received usual care . MEASUREMENTS Changes in self-reported urinary incontinence , frequency of falls , depressive symptoms , physical function , and satisfaction were analyzed using an intention-to-treat analysis adjusted for baseline differences , covariates , and practice -level variation . Prescriptions for high-risk medications and cost/utilization data obtained from administrative data were similarly analyzed . RESULTS After 24 months , no significant improvements in frequency of incontinence , proportion with falls , depression scores , physical function scores , or prescriptions for high risk medications were demonstrated . Costs of medical care including frequency of hospitalization , hospital days , emergency and ambulatory visits , and total costs of care were not significantly different between intervention and control groups . A higher proportion of intervention patients rated the overall quality of their medical care as excellent compared with control patients ( 40.0 % vs 25.3 % , P = .10 ) . CONCLUSIONS Although intervention patients expressed high levels of satisfaction with Chronic Care Clinics , improved outcomes for selected geriatric syndromes were not demonstrated . These findings suggest the need for developing greater system-wide support for managing geriatric syndromes in primary care and illustrate the challenges of conducting practice improvement research in a rapidly changing delivery system Falls in older people are a major public health concern in terms of morbidity , mortality and cost . Previous studies suggest that multifactorial interventions can reduce falls , and many geriatric day hospitals are now offering falls intervention programmes . However , no studies have investigated whether these programmes , based in the day hospital are effective , nor whether they can be successfully applied to high-risk older people screened in primary care . The hypothesis is that a multidisciplinary falls assessment and intervention at Day hospitals can reduce the incidence of falls in older people identified within primary care as being at high risk of falling . This will be tested by a pragmatic parallel-group r and omised controlled trial in which the participants , identified as at high risk of falling , will be r and omised into either the intervention Day hospital arm or to a control ( current practice ) arm . Those participants preferring not to enter the full r and omised study will be offered the opportunity to complete brief diaries only at monthly intervals . This data will be used to vali date the screening question naire . Three day hospitals ( 2 Nottingham , 1 Derby ) will provide the interventions , and the University of Nottingham 's Departments of Primary Care , the Division of Rehabilitation and Ageing Unit , and the Trent Institute for Health Service Research will provide the method ological and statistical expertise . Four hundred subjects will be r and omised into the two arms . The primary outcome measure will be the rate of falls over one year . Secondary outcome measures will include the proportion of people experiencing at least one fall , the proportion of people experiencing recurrent falls ( > 1 ) , injuries , fear of falling , quality of life , institutionalisation rates , and use of health services . Cost-effectiveness analyses will be performed to inform health commissioners about re source allocation issues . The importance of this trial is that the results may be applicable to any UK day hospital setting .SitesGeneral practice s across Nottinghamshire and Derbyshire . Day hospitals : Derbyshire Royal Infirmary ( Southern Derbyshire Acute Hospitals NHS Trust)Sherwood Day Service ( Nottingham City Hospital Trust)Leengate Day Hospital ( Queen 's Medical Centre Nottingham University Hospital NHS Trust OBJECTIVE To assess the effectiveness of  comprehensive geriatric assessment conducted in day hospitals . DESIGN Retrospective cohort comparison study with restricted inclusion ary criteria and adjustment for baseline characteristics . SETTING A hospital-based geriatric day hospital and geriatric clinic sites ( both in the university and in the community ) . PATIENTS Four hundred sixty-eight patients referred for comprehensive geriatric assessment during a 12-month period . INTERVENTION Comprehensive geriatric assessment in a geriatric day hospital compared with assessment received in clinic sites without a day hospital . MAIN OUTCOME MEASURES Services received in the first 2 weeks ; hospitalization , emergency room visits , placement , death , and change in selected health status measures . Follow-up data was obtained from medical records , a telephone survey , and death certificates . RESULTS Except in the case of rehabilitative services , day hospital patients were more likely to receive interdisciplinary services . The population seen in the day hospital was more functionally impaired and had significantly more dementia and depression . After adjusting for subjects ' baseline characteristics and limiting the analyses to subjects meeting specific inclusion ary criteria , the day hospital had no significant effect on mortality , use of emergency or hospital services , placement , or change on selected measures of health status . For example , compared with the clinic patients , receiving care in the day hospital was associated with an adjusted odds ratio of 1.01 ( 95 % confidence interval : 0.53 , 1.91 ) of being at a higher level of care at 6 months . The results were not sensitive to the choice of inclusion ary criteria . CONCLUSION Given their cost and uncertain effectiveness , day hospitals need additional evaluation before their further diffusion occurs OBJECTIVES To compare the effectiveness of Cooperative Health Care Clinic ( ( CHCC ) group outpatient model for chronically ill , older health maintenance organization ( HMO ) patients ) with usual care .  DESIGN Two-year , r and omized , controlled trial conducted with recruitment from February 1995 through July of 1996 . SETTING Nonprofit group model HMO . PARTICIPANTS Two hundred ninety-four adults ( 145 intervention and 149 usual care ) , aged 60 and older ( mean age 74.1 ) with 11 or more outpatient visits in the prior 18 months , one or more self-reported chronic conditions , and expressed interest in participating in a group clinic . INTERVENTION Monthly group meetings held by patients ' primary care physicians . MEASUREMENT Differences in clinic visits , inpatient admissions , emergency room visits , hospital outpatient services , professional services , home health , and skilled nursing facility admissions ; measures of patient satisfaction , quality of life , self-efficacy , and activities of daily living ( ADLs ) . RESULTS Outpatient , pharmacy services , home health , and skilled nursing facility use did not differ between groups , but CHCC patients had fewer hospital admissions ( P=.012 ) , emergency visits ( P=.008 ) , and professional services ( P=.005 ) . CHCC patients ' costs were $ 41.80 per member per month less than those of control patients . CHCC patients reported higher satisfaction with their primary care physician ( P=.022 ) , better quality of life ( P=.002 ) , and greater self-efficacy ( P=.03 ) . Health status and ADLs did not differ between groups . CONCLUSION The CHCC model result ed in fewer hospitalizations and emergency visits , increased patient satisfaction , and self-efficacy , but no effect on outpatient use , health , or functional status OBJECTIVES To compare the effectiveness and costs of a new domiciliary rehabilitation service for elderly stroke patients with geriatric day-hospital care . DESIGN R and omized controlled trial . PARTICIPANTS Stroke patients aged 55 + who required further rehabilitation after hospital discharge or after referral to geriatricians from the community .  SETTING Poole area , East Dorset , a mixed urban/rural area on the south coast of Engl and . MAIN OUTCOMES Primary -changes between hospital discharge and 6-month follow-up in physical function as measured by Barthel index . Secondary -changes over 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 social service cost per patient were compared for the two groups . RESULTS 180 patients were eligible and 140 ( 78 % ) were r and omized . The groups were well balanced for age , sex , social class and initial Barthel index . We achieved follow-up in 88 % of subjects who were alive at 6 months . We detected no significant differences in patient outcomes , although there was a non-significant improvement in measures of physical function and social activity in the domiciliary group . Domiciliary patients had more physiotherapy time per session and more district nurse time , and made greater use of social service day 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 of 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 community stroke rehabilitation , but this requires further evaluation This study compared the functional ability and perceived health status of stroke patients treated by a domiciliary rehabilitation team or by routine hospital-based services after discharge from hospital . Patients discharged from two acute and three rehabilitation hospitals in Nottingham were r and omly allocated in three strata ( Health Care of the Elderly , General Medical and Stroke Unit ) to receive domiciliary or hospital-based care after discharge . Functional recovery was assessed by the Extended Activities of Daily Living ( ADL ) scale three and six months after discharge and perceived health at six months was measured by the Nottingham Health Profile .  A total of 327 eligible patients of 1119 on a register of acute stroke admissions were recruited over 16 months . Overall there were no differences between the groups in their Extended ADL scores at three or six months , or their Nottingham Health Profile scores at six months . In the Stroke Unit stratum , patients treated by the domiciliary team had higher household ( p = 0.02 ) and leisure activity ( p = 0.04 ) scores at six months than those receiving routine care . In the Health Care of the Elderly stratum , death or a move into long-term institutional care at six months occurred less frequently in patients allocated to the routine service , about half of whom attended a geriatric day hospital . Overall there was no difference in the effectiveness of the domiciliary and hospital-based services , although younger stroke unit patients appeared to do better with home therapy while some frail elderly patients might have benefited from day hospital attendance The DOMINO study ( DOMiciliary rehabilitation In NOttingham ) was a r and omized 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 5 
    Output:
    
These compared day hospital with a ) comprehensive elderly care ( five trials ) , b ) domiciliary care ( five trials ) , or c ) no comprehensive elderly care ( three trials).There were no significant differences between day hospital attendance and the sub-categories of comparison treatments for the outcomes of death , death or requiring institutional care , death or deterioration in ADL .
Using the outcome of deterioration in ADL among survivors , day hospital patients showed a reduced odds of deterioration when compared with those receiving no comprehensive elderly care ( OR 0.60 ; 95 % CI 0.38 to 0.97 ; P < 0.05).When re source use was examined the day hospital group showed trends towards reductions in hospital bed use and placement of survivors in institutional care .
Medical day hospital care for the elderly appears to be more effective than no intervention but may have no clear advantage over other forms of comprehensive elderly medical services