hong kong was a british colony up until 1997 , when it became a special administrative region of the people s republic of china . with this historical background ,
the health care system in hong kong is therefore largely modeled after the british system .
the british health care system , ie , the national health service , is the world s largest publicly funded health care system , and residents can utilize almost all services , particularly general practitioners , free of charge .
however , unlike britain , hong kong has a low tax rate that never rises above 15% , so maintaining a universal health care system is not feasible .
consequently , hong kong has assigned more of its public resources to tertiary care as opposed to primary care .
the hospital authority , a statutory body that manages hong kong s public hospitals , provides over 90% of inpatient services , while private physicians in fee - for - service practices provide about 30% of outpatient services.1 the government s fundamental philosophy is that  no one is denied adequate medical care due to lack of means.2 the hospital authority provides services at no or very low fees , and has a fee - waiving mechanism.3 however , this usually results in long queues for public hospital services.4 the life expectancy of hong kong s population is increasing ; however , this poses a potentially higher risk of morbidity and frailty in later life , leading to greater utilization of health care services .
currently , over half of the beds in public hospitals in hong kong are occupied by the elderly.5 the proportion of hong kong s population aged 65 years and above doubled from 6.7% in 1982 to 13.7% in 2012.6 this will no doubt lead to further overloading of the public health care system . in light of the rapidly aging population , the hong kong government is actively investigating health care reform.4 one proposal aims to provide more options , with the rationale that when some people opt to use non - publicly funded health care , the pressure on the public system will be relieved .
one way to achieve this is to promote user - pay or copayment services in partnership with the private sector and nongovernmental organizations .
medical care for elderly stroke patients in hong kong well illustrates the challenges of the current system .
hong kong has a higher overall stroke incidence than other developed countries ( taking into account the differences in the age composition of the population by age - standardization ) , and the incidence has been decreasing for ischemic stroke , but not hemorrhagic stroke.7 meanwhile , the mortality rate from stroke has been declining.8 with the aging population , the health care burden that stroke patients present will likely increase .
currently , stroke patients admitted to hong kong public hospitals usually remain at acute hospitals for a week before transferring to nonacute hospitals for convalescence for an average of 3 weeks.9,10 after discharge , patients visit a geriatric day hospital for rehabilitation for approximately 3 months . because patients must travel to the day hospital
fees for inpatient service in a local public hospital are hk$100 ( us$13 ) per day for acute beds and hk$68 ( us$9 ) per day for nonacute beds , and fees include daily attendance of doctors , general nursing , core pathology investigations , rehabilitation , and catering.3 here , fees only refers to the charges to the users , but not the total costs of running the services . while fees that service users need to pay are extremely low , the government has to bear the rest ( about 97% ) of the costs of running the services . on the other hand ,
the fees for inpatient service at private hospitals vary from hk$400 ( us$51 ) per day for a general bed to over hk$980 ( us$126 ) per day for a first class bed , and the fees for medicines , dressings , and daily attendance fees for doctors have to be billed separately.11 meanwhile , the administrative process makes switching to the public system difficult , and subsequent charges are much higher .
when inpatients discharged from private hospitals wish to be followed up by public hospitals after discharge , they have to go through the hospital authority clinical system and queue up for outpatient services . in practice
, patients referred from private hospitals may be liable for hospital authority private fees which are much higher than ordinary fees .
further , rehabilitation care in private hospitals is very limited and unreasonably expensive . in both cases ,
discharged stroke patients , particularly elderly ones , who are not ready to return home , may end up in old - age homes .
indeed , over one third of home - dwelling stroke patients are reportedly institutionalized upon hospital discharge , and 43% of stroke patients receive post - discharge rehabilitation at a geriatric day hospital.10 in other countries , home - based rehabilitation is used as an alternative to geriatric day hospitals , focusing more on maintaining activities of daily living.12,13 however , home - based therapy is limited by a lack of sufficient treatment intensity and a small physical environment.14 in hong kong , home - based rehabilitation is provided by domiciliary physiotherapists and occupational therapists .
its advantages include saving traveling and undertaking rehabilitation according to the real home environment . at the same time
, it faces challenges from the small physical environment and lack of outreach service providers . on the other hand , rehabilitation in conventional long - term care facilities is insufficient15,16 and seldom encourages users to return to independent living.17 thus , a service that can provide onsite rehabilitation and residential care , and encourage users to return to independent living , may address the service gap . in response to the service gap , one nongovernmental organization , aiming to provide more options for stroke patients able to afford user - pay / copayment services , created a short - term residential care service with onsite rehabilitation for elderly stroke patients . because of sustainability concerns , this option runs on a user - pay model and its fees start from hk$10,800 ( us$1,385 ) per month , varying according to the room standard and level of care required .
the fees are more than ordinary nursing home services , but less than private hospital services .
after the subsidies expire , the service will solely rely on fees paid by users . to maintain sustainability
, the fees paid by users are adjusted according to market demand and the costs incurred .
the service team conducted an inhouse evaluation of their new service by pre - post study design during the trial run , and improvements in outcome measures ( including functional status , cognitive status , and caregiver burden ) were observed . however , their evaluation study did not include a comparison group .
thus , to provide results that are more valid and to avoid a possible conflict of interest , we , as a third - party , conducted this evaluation study using a quasi - experimental design to examine if the new service was comparable with the usual care option in terms of rehabilitation outcomes .
the objective of this study was to evaluate the effectiveness of this new stroke rehabilitation service in terms of rehabilitation outcomes compared with the usual care option .
the new service option was a nongovernmental organization - operated user - pay program providing post - discharge rehabilitation for stroke patients ( aged 50 years and older ) in a residential care setting for approximately 4 months . at the time of study
, this service was operated at a single center . as with other regular services ,
in addition , the new service highlighted the aim of facilitating clients to return to their home afterwards .
this service allows patients more time for recovery after hospital discharge and family caregivers more time to prepare for home care .
the services included : regular case conferences where a multidisciplinary team formulated plans and reviewed progress , physiotherapy , acupuncture , and occupational therapy ( 2 hours per day , 6 days per week ) , doctor consultations , round - the - clock nursing care , meals designed by a dietitian , counseling for patients and family members , and caregiver training , predischarge home visits and assessments , and social programs and personal care typical of residential care . a usual care option , ie , a low - charged program providing post - discharge rehabilitation for stroke patients ( mainly elderly ) in a publicly funded geriatric day hospital , served as the control group .
geriatric day hospitals in hong kong are effective for achieving functional recovery in elderly stroke patients when compared with conventional inpatient services.18 owing to the limited capacity of subsidized facilities , patients could only visit the geriatric day hospital twice a week for approximately 3 months ( patients could also opt for less ) . also , because travelling was involved , visiting a geriatric day hospital more frequently might be exhausting for patients .
the services included : regular case conferences where a multidisciplinary team formulated plans and reviewed progress , physiotherapy and occupational therapy ( 46 hours per day , 2 days per week ) , doctors assessments and consultations , lunch designed by a dietitian , predischarge home visits and assessments for selected patients , and optional transportation to the geriatric day hospital at an extra charge .
the differences between the two services included the round - the - clock nursing care and residential care provided by the new service but not the usual care option ; the saving of tiring travelling by the new service as compared with usual care ; and the home - like environment in the new service but hospital setting in the usual care . in terms of rehabilitation ,
the new service was similar to the usual care option in that there were approximately 12 hours of physiotherapy and occupational therapy a week .
the two services differed in that the new service provided such therapy 6 days a week , but the usual care option squeezed all therapy hours into 2 days .
the new service also used more advanced rehabilitation equipment , eg , computer games , than the usual care option .
a randomized controlled trial was not feasible given that the new service was already available and stroke patients were free to choose their service .
the intervention group and control group consisted of stroke patients using the new service and the usual service provided by one geriatric day hospital , respectively .
the primary outcome measures were functional and cognitive status as measured by the chinese version of the modified barthel index ( mbi)19,20 and mini - mental status examination ( mmse),21 respectively .
the mbi score , ranging from 0 to 100 , has good psychometric properties for application with older stroke patients.19,20 higher scores indicate more independent activities of daily living .
mmse scores could range from 0 to 30 ; this scale has good psychometric properties for application with the elderly,21 with higher scores indicating better cognitive status .
secondary outcome measures included psychosocial status measured by the chinese version of the geriatric depression scale ( gds)22 and the state self - esteem scale ( sses).23,24 we also assessed caregiver burden using the chinese version of the zarit burden interview ( zbi).25,26 depression was measured by the gds , with higher scores indicating more depressive symptoms ; a cutoff point of 8 indicates depression.22 patients current feelings of self - worth were measured by the sses,23,24 with higher scores indicating greater feelings of self - worth .
psychosocial outcomes were not collected from participants with cognitive impairment ( mmse scores below 19 ) .
for caregiver burden ( zbi ) , higher scores indicated greater caregiver burden.25,26 for both the intervention and control groups , participants were screened for eligibility and recruited at admission .
the patients caregivers , if any , were also recruited for assessment of caregiver burden as measured by the zbi .
included were chinese stroke patients at hospital discharge who had no known communicable disease , were emotionally calm , could understand rehabilitation instructions , were within the 6-month post - stroke period , and were living in the community before stroke onset . to enhance similarity between the intervention and control groups ,
controls were matched to the intervention group for age , gender , and functional status as measured by mbi.19,20 stroke patients with mbi scores greater than 70 were excluded from the control group unless an intervention participant with a similarly high score was included .
we excluded participants with serious medical conditions that would affect outcome measures , such as stroke recurrence within the study period and readmission to hospital around follow - up and failure to be discharged within 1 month .
informed consent was sought from all participants and ethical approval was granted by the chinese university of hong kong . trained research assistants collected participant demographic information and medical history at the beginning of the rehabilitation program ( baseline ) and assessed their outcome measures . although the rehabilitation program usually lasted for 34 months , the outcome measures were not measured at the end of the rehabilitation program because there is a natural course of recovery for stroke . instead ,
a fixed time , ie , 4 months after stroke , was used as the follow - up point to minimize differences arising from the natural progression of health status , regardless of whether participants had completed the program . to collect qualitative feedback about the new service ,
some caregivers in the intervention group were asked an open - ended question about general comments toward the new service .
since the subsample was not representative , we treated the feedback as informal and supplementary to the main results .
we expected that the full capacity of the service during recruitment would be approximately 165 stroke patients , about 65% of whom ( ie , 107 patients ) would meet our eligibility criteria .
since the new service might not be operating at full capacity , fewer than 107 participants from the intervention group might be recruited .
in contrast with the limited availability of intervention group participants , we expected the usual capacity for stroke patients at the geriatric day hospital ( approximately 500 ) during the recruitment period .
we set a target ratio of 2:1 for control to intervention participants , to achieve sufficient statistical power .
since the sample size was constrained for the intervention group , a post hoc power analysis was conducted to assess the statistical power resulted from the achieved sample size .
changes in outcome measures at 4-month follow - up compared with baseline were calculated for each participant .
multiple linear regressions were used to compare mean changes in each outcome variable between the two groups .
an insignificant treatment group effect indicated an insignificant between - group difference . to control for possible differences in age , gender , and baseline outcome measures , these variables were included as independent variables in the multiple linear regression models , in addition to the treatment group .
interactions between treatment group and age , gender , and baseline outcomes were also included .
all independent variables entered into the model and insignificant interaction terms would be removed from the model .
the proportion of variance explained by treatment group out of the variance unexplained by the remainder of the model ( partial  ) was used to report the effect of between - group differences . statistical package for the social sciences version 20 software ( spss inc , chicago , il , usa ) was used for the analysis and a significance level of 5% was adopted .
the new service option was a nongovernmental organization - operated user - pay program providing post - discharge rehabilitation for stroke patients ( aged 50 years and older ) in a residential care setting for approximately 4 months . at the time of study
, this service was operated at a single center . as with other regular services ,
in addition , the new service highlighted the aim of facilitating clients to return to their home afterwards .
this service allows patients more time for recovery after hospital discharge and family caregivers more time to prepare for home care .
the services included : regular case conferences where a multidisciplinary team formulated plans and reviewed progress , physiotherapy , acupuncture , and occupational therapy ( 2 hours per day , 6 days per week ) , doctor consultations , round - the - clock nursing care , meals designed by a dietitian , counseling for patients and family members , and caregiver training , predischarge home visits and assessments , and social programs and personal care typical of residential care . a usual care option , ie , a low - charged program providing post - discharge rehabilitation for stroke patients ( mainly elderly ) in a publicly funded geriatric day hospital , served as the control group .
geriatric day hospitals in hong kong are effective for achieving functional recovery in elderly stroke patients when compared with conventional inpatient services.18 owing to the limited capacity of subsidized facilities , patients could only visit the geriatric day hospital twice a week for approximately 3 months ( patients could also opt for less ) . also , because travelling was involved , visiting a geriatric day hospital more frequently might be exhausting for patients .
the services included : regular case conferences where a multidisciplinary team formulated plans and reviewed progress , physiotherapy and occupational therapy ( 46 hours per day , 2 days per week ) , doctors assessments and consultations , lunch designed by a dietitian , predischarge home visits and assessments for selected patients , and optional transportation to the geriatric day hospital at an extra charge .
the differences between the two services included the round - the - clock nursing care and residential care provided by the new service but not the usual care option ; the saving of tiring travelling by the new service as compared with usual care ; and the home - like environment in the new service but hospital setting in the usual care . in terms of rehabilitation ,
the new service was similar to the usual care option in that there were approximately 12 hours of physiotherapy and occupational therapy a week .
the two services differed in that the new service provided such therapy 6 days a week , but the usual care option squeezed all therapy hours into 2 days .
the new service also used more advanced rehabilitation equipment , eg , computer games , than the usual care option .
a randomized controlled trial was not feasible given that the new service was already available and stroke patients were free to choose their service .
the intervention group and control group consisted of stroke patients using the new service and the usual service provided by one geriatric day hospital , respectively .
the primary outcome measures were functional and cognitive status as measured by the chinese version of the modified barthel index ( mbi)19,20 and mini - mental status examination ( mmse),21 respectively .
the mbi score , ranging from 0 to 100 , has good psychometric properties for application with older stroke patients.19,20 higher scores indicate more independent activities of daily living .
mmse scores could range from 0 to 30 ; this scale has good psychometric properties for application with the elderly,21 with higher scores indicating better cognitive status .
secondary outcome measures included psychosocial status measured by the chinese version of the geriatric depression scale ( gds)22 and the state self - esteem scale ( sses).23,24 we also assessed caregiver burden using the chinese version of the zarit burden interview ( zbi).25,26 depression was measured by the gds , with higher scores indicating more depressive symptoms ; a cutoff point of 8 indicates depression.22 patients current feelings of self - worth were measured by the sses,23,24 with higher scores indicating greater feelings of self - worth .
psychosocial outcomes were not collected from participants with cognitive impairment ( mmse scores below 19 ) .
for caregiver burden ( zbi ) , higher scores indicated greater caregiver burden.25,26 for both the intervention and control groups , participants were screened for eligibility and recruited at admission .
the patients caregivers , if any , were also recruited for assessment of caregiver burden as measured by the zbi .
included were chinese stroke patients at hospital discharge who had no known communicable disease , were emotionally calm , could understand rehabilitation instructions , were within the 6-month post - stroke period , and were living in the community before stroke onset . to enhance similarity between the intervention and control groups ,
controls were matched to the intervention group for age , gender , and functional status as measured by mbi.19,20 stroke patients with mbi scores greater than 70 were excluded from the control group unless an intervention participant with a similarly high score was included .
we excluded participants with serious medical conditions that would affect outcome measures , such as stroke recurrence within the study period and readmission to hospital around follow - up and failure to be discharged within 1 month .
informed consent was sought from all participants and ethical approval was granted by the chinese university of hong kong . trained research assistants collected participant demographic information and medical history at the beginning of the rehabilitation program ( baseline ) and assessed their outcome measures . although the rehabilitation program usually lasted for 34 months , the outcome measures were not measured at the end of the rehabilitation program because there is a natural course of recovery for stroke . instead ,
a fixed time , ie , 4 months after stroke , was used as the follow - up point to minimize differences arising from the natural progression of health status , regardless of whether participants had completed the program . to collect qualitative feedback about the new service ,
some caregivers in the intervention group were asked an open - ended question about general comments toward the new service .
since the subsample was not representative , we treated the feedback as informal and supplementary to the main results .
we expected that the full capacity of the service during recruitment would be approximately 165 stroke patients , about 65% of whom ( ie , 107 patients ) would meet our eligibility criteria .
since the new service might not be operating at full capacity , fewer than 107 participants from the intervention group might be recruited .
in contrast with the limited availability of intervention group participants , we expected the usual capacity for stroke patients at the geriatric day hospital ( approximately 500 ) during the recruitment period .
we set a target ratio of 2:1 for control to intervention participants , to achieve sufficient statistical power .
since the sample size was constrained for the intervention group , a post hoc power analysis was conducted to assess the statistical power resulted from the achieved sample size .
changes in outcome measures at 4-month follow - up compared with baseline were calculated for each participant .
multiple linear regressions were used to compare mean changes in each outcome variable between the two groups .
an insignificant treatment group effect indicated an insignificant between - group difference . to control for possible differences in age , gender , and baseline outcome measures , these variables were included as independent variables in the multiple linear regression models , in addition to the treatment group .
interactions between treatment group and age , gender , and baseline outcomes were also included .
all independent variables entered into the model and insignificant interaction terms would be removed from the model .
the proportion of variance explained by treatment group out of the variance unexplained by the remainder of the model ( partial  ) was used to report the effect of between - group differences . statistical package for the social sciences version 20 software ( spss inc , chicago , il , usa ) was used for the analysis and a significance level of 5% was adopted .
sixty and 128 participants were recruited for the intervention and control groups , respectively ( response rate , 90.8% ) .
fifty intervention participants and 105 control participants completed the 4-month follow - up ( attrition rate , 17.6% ) .
we observed no significant differences in baseline outcome measures between dropout participants and those who completed the follow - up , after controlling for age and gender .
post hoc power analysis showed that , with 50 intervention and 105 control participants , our analysis had a power of 82% to detect a medium effect size ( cohen s d = 0.5 ) at a 5% level of significance .
in other words , a nonsignificant result for the between - group assessment implied that the differences between control and intervention groups were likely to be small . at baseline , the mean age (  standard deviation ) of intervention participants was 70.0  11.3 years and that of controls was 72.7  10.4 years .
the two groups did not differ significantly in most demographic characteristics , although the intervention group had more female patients ( p = 0.040 ) and more patients with higher household income ( p = 0.001 ) than the control group . for baseline outcome measures
, the two groups did not significantly differ in mmse ( p = 0.951 ) , sses ( p = 0.337 ) , or zbi ( p = 0.179 ) scores . however , intervention participants had lower mbi scores by 10.1 points ( 95% confidence interval [ ci ] 3.416.7 , p = 0.003 ) and higher gds scores by 1.8 points ( 95% ci 0.53.1 , p = 0.007 ) compared with controls .
differences in baseline outcome measures may have an influence on changes in measures at 4 months .
hence , we controlled for baseline differences by including the baseline outcome measures as independent variables in the multiple linear regression models . on average
, intervention participants utilized the service for a mean of 4.1  2.9 months and control participants for 3.2  1.6 months .
intervention participants had a significantly longer duration of service by 0.9 months ( 95% ci 0.11.7 ) compared with controls .
there were insignificant interactions between treatment group and age , gender , and baseline outcomes .
hence , these interaction terms were removed from the multiple linear regression models . at 4-month follow - up ,
the intervention group had an increased mbi score of 15.3 ( 95% ci 10.819.8 ) and an mmse score of 1.3 ( 95% ci 0.42.1 ) . by comparison , the control group had an increased mbi score of 13.3 ( 95% ci 9.716.8 ) and an mmse score of 1.1 ( 95% ci 0.41.9 ) .
while there was significant improvement in both functional and cognitive status for both groups , there was no significant between - group difference , as shown by the insignificant treatment group effect ( mbi , p = 0.648 ; mmse , p = 0.936 ) after controlling for age , gender , and baseline measurements .
the mean changes in sses , gds , and zbi scores between assessment times are shown in table 2 , and there were no significant improvements within each group between baseline and follow - up , except that the control group had a decreased zbi score of 3.9 ( 95% ci 1.26.7 ) .
the two groups did not show significant differences for any secondary outcome measure improvements , caregiver burden included , ( p > 0.05 , see table 2 ) after controlling for age , gender , and baseline measurements .
partial  of the treatment group ranged from 0.005% to 1.5% in the five multiple linear regression models , implying that differences in changes in the outcome measures between the two treatment groups were very small . a possible confounder , ie , household income , was not included in the multiple linear regression model .
this was because about 10% of intervention participants and 2% of control participants did not provide this information , and including it would have decreased overall statistical power .
nevertheless , multiple linear regression models were performed including this variable , and the same conclusion that there was no significant between - group differences in changes in outcome measures , was reached .
partial  of the treatment group ranged from 0.005% to 1.1% in the five multiple linear regression models , implying differences in changes in the outcome measures between the two treatment groups were very small .
eleven caregivers in the intervention group were invited to give informal feedback regarding the new service .
eight of them accepted the invitation ( 16% of those completed the 4-month follow - up ) . among them , three had positive comments , two had negative comments , and three had no comment . those with positive comments were particularly satisfied with the physiotherapy and occupational therapy as well as the home - like environment provided by the new service .
those with negative comments mentioned the quality of services , particularly services provided by the personal caretakers and the high cost .
the changes in caregiver burden ( measured by zbi ) did not seem to relate to the informal feedback .
those reporting negative comments , having no comment , or refusing to comment had a decreased zbi score of 2.5 , 2.0 , and 6.7 , respectively .
to ensure a sustainable health care system , particularly for a rapidly aging population , providing alternative user - pay service options should be encouraged . further , to encourage users to utilize nongovernmental organization or private sector health care services , it is important to show that the alternatives are as good as , if not better than , existing services .
this quasi - experimental study showed that a new service option providing rehabilitation in a transitional residential care setting promoted improvements in functional and cognitive status in elderly stroke patients comparable with those of a usual service option ( geriatric day hospital rehabilitation ) .
thus , stroke patients who can afford user - pay / copayment services might consider alternative service options , freeing up public resources for patients with financial constraints .
nevertheless , this new service was targeted for those who could afford user - pay / copayment services as an alternative rather than as a replacement for existing services .
people may expect a new option that charges users more to provide better outcomes than the cheaper option .
however , the rationale for providing the user - pay option should not be judged solely in terms of cost - effectiveness . indeed , apart from the monetary costs , patients have other costs in life , including time and personal experiences .
for example , geriatric day hospital - based care involves travelling , which is exceedingly tiring for elderly stroke patients , who must often wait for public transport , and would have difficulty entering and exiting the vehicle .
hence , the self - financing care option , which we have shown to be comparable with the existing public option in terms of rehabilitation outcomes , is worth considering despite its higher fees .
in fact , the intervention group s point estimates of the improvements in mbi , mmse , gds , and sses scores were larger than those of the control group , despite the between - group differences not reaching statistical significance .
larger samples might show that the new option brings greater improvements in outcomes than the usual option .
ideally , service effectiveness should be studied before a service is launched ; however , in practice , new services are introduced due to market demands , making randomized controlled trials difficult to apply . instead , a quasi - experimental design was used . however
, our nonrandom assignment of groups may have resulted in selection bias , with overrepresentation of certain participant characteristics in one group ( eg , higher income and frailer participants in the intervention group ) .
nevertheless , when conducting between - groups comparison , the outcome measures at baseline were controlled by including them as independent variables in the multiple linear regression models . moreover , the assessors were not blinded because the first assessment was on the date of admission at the service venue .
hong kong has a high proportion ( about 7% ) of older people staying in old - age homes , more so than in mainland china.27 about one third of residents in old - age homes have a history of stroke.28 stroke is a major contributor to disability , and post - stroke dementia is not uncommon .
a local longitudinal study showed that deterioration in functional status was a risk factor for institutionalization among people with function and cognitive impairments.29 further , about one third of home - dwelling stroke patients in hong kong were reportedly institutionalized at hospital discharge.10 a study of chinese stroke patients showed that more sessions of physiotherapy and occupational therapy were related to greater functional improvement within the first 6 months after a stroke ( ie , the golden rehabilitation period).30 however , in usual care settings , rehabilitation programs are not tailored to stroke patients ; indeed , the intensity of these programs might not be able to maximize rehabilitation potential during the golden rehabilitation period .
when patients are unable to recover their functional status , their independent living capability is affected , increasing their likelihood of residing in old - age homes for the rest of their lives .
however , the new service option , ie , providing transitional residential care together with an onsite rehabilitation program , fills this service gap .
while patients can receive usual personal and nursing care at a residential care setting , they aim to be discharged to their own homes .
indeed , this new option provides onsite rehabilitation and traveling is not necessary . however , as the new service uses a user - pay model , which is an unavoidable trend in health care , only patients who can afford it can make use of this service . since the launch of elderly health care vouchers targeted at primary care , the hong kong government has been actively exploring options to facilitate older people s use of user - pay / copayment community services . in september 2013 ,
the government will launch a pilot scheme to provide direct subsidy using a community care service voucher for eligible elderly people , allowing them to pay for community services offered by nongovernmental or nonprofit organizations .
more elderly people will then be able to afford user - pay / copayment services .
while the users feelings about the new service could not be reflected by the rehabilitation outcomes , the informal feedback we obtained revealed that service users clearly had expectations toward the quality of services , including staff attitude , environment , meals , and personal care , in addition to the rehabilitation provided by the program .
thus , clients of user - pay services in general may have higher expectations of quality . the intervention group also showed higher study refusal and attrition rates . because they paid for the service ,
they may have believed that they did not need to take part in a research study .
hence , service providers should take note of the demands and needs of patients , in addition to rehabilitation outcomes . to conclude , our study examined the effectiveness of providing onsite rehabilitation care for elderly stroke survivors in a residential setting .
findings at the 4-month follow - up showed that the new service option promoted improvement in rehabilitation outcomes comparable with that of usual care .
partnership with the private sector and nongovernmental organizations is a way to relieve the burden placed on the public health care system . providing alternative
care options using a user - pay model should be encouraged to ensure a sustainable health care system , particularly for the current rapidly aging population . because some patients who could afford user - pay / copayment services would opt for these alternative options , public resources
we noted suggestions for improving the alternative service options , highlighting that the quality of the supplementary services is as important as rehabilitation outcomes .
 we conducted a quasi - experimental study to compare the effectiveness of a new short - term residential care option for stroke rehabilitation with that of usual day hospital care . 
 primary data were collected from stroke patients and their caregivers from june 2009 to may 2012 . 
 new service option users and their caregivers were recruited for the intervention group , while users of usual public geriatric day hospital care and their caregivers were recruited for the control group . 
 the primary outcome measures were modified barthel index ( mbi ) and mini - mental status examination ( mmse ) scores . trained research assistants assessed the outcome measures at the beginning of the rehabilitation program ( baseline ) and at a 4-month follow - up . 
 sixty and 128 stroke patients were recruited for the intervention and control groups , respectively ; 50 and 105 participants , respectively , completed the 4-month follow - up . at 4-month follow - up , 
 the intervention group had an increased mbi score of 15.3 ( 95% confidence interval [ ci ] 10.819.8 ) and an mmse score of 1.3 ( 95% ci 0.42.1 ) . in comparison , the control group had an increased mbi score of 13.3 ( 95% ci 9.716.8 ) and an mmse score of 1.1 ( 95% ci 0.41.9 ) . 
 both groups showed a significant improvement in mbi and mmse scores after 4 months , and there was no significant between - group difference . 
 to conclude , the new service option and the usual care option showed similar improvement in rehabilitation outcomes at 4 months after baseline . 
 initiatives to provide alternative care options on a user - pay model should be encouraged to ensure a sustainable health care system . 
Introduction
Materials and methods
Study design
Sample size
Statistical analysis
Results
Discussion