study on the satisfaction of services

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2/13

MEDICAL

CARE

Volume

31,

Number

9,

pp

SS38-SS49,

Supplement

?

1993,

J.

B.

LippincottCompany

Effects of

VA

Adult

Day

Health Care on

Health

Outcomes and

SatisfactionWithCare

MARGARET

.

ROTHMAN,

PHD,*

SUSAN

C.

HEDRICK,

HD,t

KRIS

A.

BULCROFT,

PHD,t

WILLIAM

W.

ERDLY,PHD,?

AND

DAVIDG.

NICKINOVICH,

A?

It was

hypothesized

that

ADHC

would have a

positive

effect on the health

of

patients

and their

care

givers

and result in

greater

satisfaction with

care than

customary care. Measurement of health outcomes for patients included assess-

ment of

overall,

psychological,

and social

health,

and survival. Care

giver

as-

sessment

concentrated

on

psychosocial

health.

Findings

indicated no difference

in

health outcomes between

patients

assigned

to ADHC

or their care

givers

and

their

counterparts

assigned

to

customary

care. Further

analysis

of

subgroups

found

that

there were 3

subgroups

of

patients

for whom

those

assigned

to

ADHC had better outcomes

(as

indicated

by

lower Sickness

Impact

Profile

scores)

than those

assigned

to

customary

care.

These

subgroups

included those

who were

1)

not

married,

2)

most satisfied with

their

social

support

network,

and

3)

not

hospitalized

at

the time

of enrollment in the

study.

Patients and their

care

givers

assigned

to ADHC

were

more satisfied

with

their

care than those

in

nursing

homes,

but not more

satisfied than those

in

hospital-based

home care.

Care givers reported significantly greater satisfaction with patient care in

ADHC than did care

givers

of

patients

receiving

care

in

nursing

homes

or

ambulatory

care

clinics.

Adult

day

health care was

expected

to

benefit

patients

and

their care

givers.

Pa-

tients were

expected

to

benefit from

receipt

*

From the

Battelle

Medical

Technology

Assessment

&

Policy

Research

Center,

Washington,

DC.

t

From the HSR&D

Field

Program,

VA Medical

Center,

Department

of Health

Services,

University

of

Washington,

Seattle,

Washington.

t

From the

Department

of

Sociology,

Western

Wash-

ington

University,

Bellingham,

Washington.

?

From

the

Department

of Liberal

Studies,

University

of

Washington,

Seattle,

Washington.

?

From the

Department

of

Sociology, University

of

Washington,

Seattle,

Washington.

Address

correspondence

to:

Margaret

L.

Rothman,

PHD, Battelle,

Medical

Technology

Assessment and

Pol-

icy

Research

Center,

370 L'Enfant Promenade

S.W.,

#900,

Washington,

DC

20024-2115.

SS38

of more

intensive

medical

and

auxiliary

ser-

vices

such as closer

supervision

of

drug

ther-

apy

and more

frequent

physical

therapy.

Consequently,

they

were

expected

to

have

higher

levels of

physical

and

psychosocial

functioning

and

greater

satisfaction

with

care

compared

with

those

who did

not re-

ceive such

services.

Care

givers

were ex-

pected

to

benefit

directly through

respite

care and

indirectly through improved

func-

tioning

of the

patients

for

whom

they

pro-

Supported by Department

of

Veterans

Affairs Health

Services Research

and

Development

Service,

Project

#SDR 85-07 and

071.

The

opinions

expressed

are those of the authors

and

do not

necessarily

reflect the

views of the

Department.

http://www.jstor.org/page/info/about/policies/terms.jsp


3/13

Vol.

31,

No.

9,

Supplement

EFFECTSOF

ADULT

DAY HEALTH

CARE

ON

HEALTHAND

SATISFACTION

vided

care.

They

also

were

expected

to

re-

port

higher

levels of satisfaction

with the

pa-

tient's care.

Methods

Assessment of Bias

Comparison

of

the

groups

on all

primary

variables available at baseline showed

no

sig-

nificant

differences,

thereby

indicating

the

randomization

was

successful. Differences

in

attrition,

using

the Cox

proportional

haz-

ards

model,1

were not

significant.2

Procedures for Missing Data

Item

mean

substitution was

used

when no

more than

20%

of the items

were

missing

from the Sickness

Impact

Profile

(SIP),

Psy-

chological

Distress

Scale,

Satisfaction

with

Care

Scales,

or

Caregiver

Burden

Scale.2

Zero substitution

(maximum

impairment)

was used for

Mini-Mental

State Exam items

when no more than

1

item

was

missing.

Proxy SIPs were collected from caregivers

and

from

long-term

care

staff

if a

patient

was in a

nursing

home at

the time of

data

collection

in

addition to

patient-generated

data. When

no

patient-generated

responses

were available or

when more

than

20%

of

the

patient-generated

items

were

missing,

proxy responses

were

substituted for

the

en-

tire scale.

Care

giver

data were

substituted

unless no care

giver

was

available,

in

which

case long-term care staff data were substi-

tuted.

Although

the

data

provided by

pa-

tients

and

proxies

may

differ,

especially

in

the

psychosocial

domain,3

substitution of

proxy

data

was

considered a

better

alterna-

tive than

deletion

of the case.

Proxy

re-

sponses

were not

considered

valid

substi-

tutes for

affective or

cognitive

data,

there-

fore no

proxy

data

were

collected

for the

Mini-Mental

State

Exam,

Psychological

Dis-

tress Scale, or Satisfaction With Care Scales.

Satisfaction With

Care.

The

patient

sat-

isfaction

with

care

scales

were

potentially

collected at

3 times:

6 and 12

months,

if

the

patient

had been in a

specific

care

environ-

ment for 30

days

or more

(i.e.,

ADHC,

nurs-

ing

home,

or home

care);

and at

discharge

from ADHC. A substitution scheme

was im-

plemented to ensure that only the most re-

cent value entered

into the

analysis

and

that

only

1 value was entered for each

respon-

dent. For the

patients

in

VA-ADHC,

the

fol-

lowing

scheme

was used:

1)

discharge

inter-

views were selected

first;

2)

if

there

was

no

discharge

interview,

the 12-month

satisfac-

tion

scores

were

entered,

3)

if there was

no

12-month

score,

the

6-month score was

en-

tered.

For the customary care group, the same

substitution scheme

was

used,

first for

nurs-

ing

home,

then for

hospital-based

home

care.

Selection

on care environment

was

nec-

essary

because

the

customary

care

group

may

have

responded

to

multiple

question-

naires based on their situation

at the

time

of

the

interview.

A

similar

substitution

scheme

that

included

postbereavement

was

imple-

mented

for the care

giver

data.

Group

Comparisons

Mean

health outcomes

for

the

VA-ADHC

and

customary

care

groups

were

compared

at 6

and

12

months

using

analysis

of

covari-

ance with

the baseline value of the

indepen-

dent

variable as the

covariate.

Satisfaction

scores

were

compared using

a t-test

of inde-

pendent

means.

The

conventional

level

of

0.05 (two-tailed test) was used to denote sta-

tistical

significance.

The

actual

probability

values are

shown

in

the tables

for all

values

of

0.10 or less.

Survival curves

were con-

structed

using

the

Kaplan-Meier

method

and

tested for

significance

using

the

Cox

proportional

hazard

model.

An

analysis

of

6-month

outcomes for

only

those

respondents

who

completed

the

study

(i.e.,

for whom

12-month

scores

were avail-

able) was also conducted for the health out-

come

data,

allowing

a

comparison

of

6- and

12-month

scores

that was

unbiased

by drop-

outs

during

the

last 6

months

of

participa-

SS39



4/13

ROTHMAN

ET AL.

tion.

The

results of these

analyses

are

pre-

sented

when

they

differ

from

the

analysis

of

all

people

who

completed

the

6-month

in-

terview.

Six

primary

outcome variables as well

as

a

number of

subscales were

analyzed

in this

portion

of the

study,

thus

increasing

the

probability

of

making

a

type

1

error.

To

de-

crease the likelihood

of

making

such an

error,

we examined

the

pattern

of

findings

for other similar outcomes and whether the

finding

occurred at both 6 and 12

months,

as

well

as the

P

value

for

each individual

out-

come.

Subgroup

Analyses

The

study

research

questions

include

a

de-

termination

of

whether

ADHC

outcomes

differ

across sites and

among patients

with

different

characteristics.

A

limited number

of

subgroup

variables

(n

=

24

variables)

based

on

the results of other

studies

of

com-

munity-based long-term

care

alternatives4

were selected before data analysis. Sub-

groups

were defined

in

an

identical

manner

for

the

ADHC and

customary

care

groups

and

formed

using

baseline

variables that

could not

have been affected

by

the treat-

ment.

Data

were

analyzed

by analysis

of co-

variance

in

which

condition

(VA-ADHC

versus

customary

care)

and

the

subgrouping

variables

were considered

independent

vari-

ables.

Those

subgroupings

that

yielded

a

sig-

nificant treatment-by-subgroup interaction

were

further examined

using

t-tests within

each

level of

the

subgroup

(levels

for each

subgroup

are defined

below).

Seven

types

of

subgroups

were consid-

ered:

1)

patients

with

specified

characteris-

tics at

study

intake,

2)

patients

at

the 4

VA-

ADHC

sites,

3)

patients

who

entered

the

study during

the first

or second

half of the

enrollment

period,

4)

patients

who were

likely to be high utilizers of VA-ADHC, 5)

patients

who were

at

higher

risk of

going

to

a

nursing

home,

6)

patients

who were

at

risk

of

using

greater

amounts of

ambulatory

SS40

care,

and

7)

patients

who were

at

greater

risk

of

hospital

admission.

The

methods for

forming

each of

these

types

of

subgroups

are

discussed below.

Subgroups Based on Intake Character-

istics.

Whenever

possible,

established

categories

were

used in

the

analysis.

Those

continuous

variables that

did not have es-

tablished

categories,

e.g.,

SIP

scores,

were

divided into 2 or 3

categories

to

achieve

equivalent

numbers

of

patients

in

each cate-

gory.

Patients

by

Site.

Although

efforts were

made

by

VA

Central

Office

to standardize

the clinical care provided across site by man-

dated

staffing

levels

and

training

sessions,

there

were differences

in

such

factors as the

philosophy

and

goals

of the

ADHC staff and

Medical

Center

case mix. These variations

offered some

opportunity

to assess

the ex-

tent to

which

they

were associated with

pro-

gram

effectiveness;

with

only

4

programs,

however,

the

relationship

of site characteris-

tics to outcome can

be

at most

suggestive.

Patients Entering Study in First or Sec-

ond Half

of Enrollment

Period. Out-

comes were

compared

for

subgroups

enter-

ing

the

study

in

either the first or last 9

months

of

enrollment

for 2

reasons:

1)

to

determine whether

there was

a differential

effect

based

on the

experience

of the

pro-

gram

in

providing

care,

i.e.,

did

programs

become more effective over

time?;

and

2)

to

assess whether there was

a

differential effect

caused by any changes in program case mix

over

time. For

example,

programs might

have

initially

admitted the

patients thought

to be most

appropriate

for

ADHC,

and later

switched to

less

appropriate patients

as the

available

pool

decreased.

Patients

Who Were

High

ADHC

Uti-

lizers.

Patients differed

considerably

in

the number

of

days

they

attended

ADHC.

Some

patients

did

not attend at

all or at-

tended so few days that one could not rea-

sonably expect

to see an effect

on

patient

outcomes.

For this

reason,

we examined cost

and

efficacy

for

patients

who

were

likely

to

MEDICALCARE



5/13

Vol.

31,

No.

9,

Supplement

EFFECTSOF

ADULT DAY HEALTH

CAREON

HEALTHAND

SATISFACTION

be

high

utilizers

of

ADHC

using

a

regression

equation

to

predict

use based on

baseline val-

ues. In the

analyses

of

high

utilizers

of

ADHC or

VA

clinics,

and the

analyses

of

those most likely to go to a nursing home or

hospital,

described

below,

the

subgroups

were

composed

of

patients

with a

high

ver-

sus

low

probability

of

use, i.e.,

propensity

to

use these

services rather than

patients

who

actually

used

high

or

low levels of

these

ser-

vices.

Estimates of

service use were based on

the

propensity

to use

services,

i.e.,

regres-

sion

equations

predicting

the

probability

of

high

or

low service

use based

on baseline

characteristics. This procedure was followed

because

if

the

patient's

actual use of services

was used

to select

patients

for

analysis,

the

findings

could be

biased because

the 2

groups being compared

would not

represent

individuals with an

equal

a

priori

likelihood

of

being

in

either

group.

Because

patients

with

high probabilities

to

use

services were

selected in the

same

way

in

the

2

groups,

as

a

function of baseline

characteristics

only,

there should be no bias in comparing these

subgroups.

Predictors

of

the likelihood

of

being

in the

top

one-third

(55

or

more

visits)

and the

top

two-thirds

(12

or more

visits)

of

attenders

were

identified.

Being

among

the

top

third

of

ADHC utilizers

was

predicted by

pre-

vious admission

to

ADHC,

not

being

hospi-

talized at

entry

into

the

study,

not

being

in

a

nursing

home

during

the 6 months

before

entry into the study, lower SIP Physical Di-

mension

Scores

(i.e.,

being

less

physically

impaired),

being

married,

and better

care

giver

psychosocial

health.

Being

among

the

top

two-thirds

of ADHC

utilizers

was

pre-

dicted

by

2

variables:

previous

admission to

ADHC

and lower

SIP

Physical

Dimension

scores.

Patients at

Higher

Risk of

Nursing

Home

Placement.

Patients at

the

highest

risk of going to a nursing home were identi-

fied in the

customary

care

group by

compar-

ing

those

patients

who

were

admitted

to a

nursing

home with

those

patients

who

did

not enter a

nursing

home

during

the

year

of

follow-up.

Five

characteristics

assessed at

intake

into

the

study predicted nursing

home

entry: residency

in a

nursing

home

any time during the 6 previous months, be-

ing

in a

nursing

home

at

entry

into the

study,

higher

SIP

Physical

Dimension

Scores

(i.e.,

being

more

physically impaired),

being

white,

and

exhibiting

more

behavioral

prob-

lems as

reported by

the care

giver

at

base-

line.

Patients with the

highest

one-third

of

the

utilization scores

were selected

because

that is

approximately

the

proportion

who

ac-

tually

entered

a

nursing

home

during

the

study period.

Patients at Risk of

High

Use of

Ambula-

tory

Care.

Patients

likely

to be

high

uti-

lizers of

VA clinics

were identified

in the

cus-

tomary

care

group by

a

regression

predicting

whether

a

patient

would be

in the

top

one-

third

of VA clinic utilizers.

Having

a

greater

than

50%

service

connected

disability

(i.e.,

severely

disabled

patients

whose

condition

is

recognized

by

VA as

related to their

mili-

tary service, and who have high priority for

VA

services)

was the

only

variable

signifi-

cantly

related to

clinic utilization.

Patients

at

High

Risk of

Hospital

Admission.

Only

the

patient's

SIP

physi-

cal

score

at

study entry

predicted

entry

into

a

hospital

during

the

year

of

follow-up

for the

customary

care

group.

Patients

having

a

SIP

physical

score of 23 or

greater

were

desig-

nated

as

being

at

highest

risk

of

hospital

ad-

mission.

Results

Patient

Health Outcomes

Overall

Health.

The

primary

health

outcome

measure

used in

the

ADHC

study

was

the

SIP.5

Scores on

the SIP

may

range

from 0

to

100,

with a

high

score

indicating

greater

dysfunction.

Outcomes

for the 2

di-

mensions (physical and psychosocial) and

the

total

score of

the SIP

for the

ADHC

and

customary

care

groups

at

baseline, 6,

and

12

months

are

shown

in

Table 1.

Although

cus-

SS41



6/13

ROTHMAN ET AL.

TABLE

.

Comparisona

of Meanb

Sickness

Impact

Profile Scoresc at

Baseline,

6

and 12

Months Between

VA-ADHCand

Customary

Care

Baseline Six

Months

Twelve Months

Sickness

Customary

Customary

Customary

ImpactProfile VA-ADHC Care VA-ADHC Care VA-ADHC Care

n 367

362 310 296

259

251

Physical

Mean 31.7 33.8

30.2 32.6 29.0

32.1

SD

18.8 18.4 21.6 21.8 18.6 18.8

Psychosocial

Mean 34.7

35.7 34.3 35.3 34.1

34.5

SD 21.3 21.7 21.6 21.8 22.2 20.6

Total

Mean

33.3 35.0 32.3

34.1 31.8

33.2

SD

16.9 16.5

17.2 17.0

17.3

16.4

Confidence

nterval

-5.1

to 3.3

-4.8

to

5.8

a

Multipleregression

used to

compare

means after

controlling

or the

baselinevalue of the

dependent

variable.

b95%

onfidence

ntervalsare for

differences

between

adjusted

means.

c

Higher

SIP scores ndicate

worse function.

Scores

range

from

0

to 100.

tomary

care

patients

had

slightly

higher

scores,

the mean level

of

impairment

was

not

significantly

different

between the

groups

and

appears

to

be

very

similar

across

time.

The survival curves shown in Figure 1 in-

dicate

that

77%

of

patients

who

completed

the

first

interview

in the

ADHC

group

and

81%

in the

customary

care

group

survived.

This difference

is not

significant.

Health

perceptions

were assessed

by

self-

report

of overall

health

and

health com-

pared

with

one's

age-peers.

There

were no

significant

differences

between

the

VA-

ADHC

and

customary

care

groups

at 6 or

12

months, as shown in Table 2.

Psychological

Health.

Psychological

health

was

assessed

by

the

Psychological

Distress

Scale6

and

the Mini-mental

State

Exam.7Pa-

tient scores

on the

3 subscales

of the

Psycho-

logical

Distress

Scale

(anxiety,

depression,

and

behavioral/emotional

control)

as well

as

the

total

score

are shown

in Table 2.

The

mean

responses

show

almost

no difference

between

baseline

and

12 months and

no

sig-

nificant differences between the groups at

any point.

The

mean Mini-mental

State

Exam score

for

the combined

sample

at baseline

was

SS42

23.5,

with

36%

of the

sample

scoring

below

23,

the

score

generally

considered indicative

of need for further

evaluation

for

cognitive

impairment.8'9

The

percentage

of the

sample

scoring

below 23

dropped

to

33%

by

the

12-

month assessment, but there were no signifi-

cant

differences

in

group

means

at

6 or

12

months

(Table

2).

Social Health.

Six dimensions

of

the so-

cial

support

network were measured:

impor-

tance

of individual

members,

satisfaction

with the

help/support

received

from

net-

work

members,

size

of

the

support

network,

degree

of

upset

and

degree

of

helpfulness

experienced

by

patient

when network

members were providing assistance, and

number

of confidants.

The mean

size

of the

social

support

network

at baseline

was 5

members.

Twenty-eight percent

of

the

re-

spondents

reported

having

2

or less

network

members,

and

29%

reported

no

confidants.

The

overall

level

of satisfaction

with the

help

and

support

received

from

network

members

was

positive,

with

only

13%

of the

sample

expressing

dissatisfaction.

There

were no significant differences between the

groups

at

6

or

12 months

(not

shown).

Results

for

Subgroups

of

Patients.

Significant

differences

were

observed

on

the

MEDICAL

CARE



7/13

Vol.

31,

No.

9,

Supplement

EFFECTS

OF

ADULT DAY

HEALTH

CARE ON

HEALTH AND

SATISFACTION

PROP

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

,QRTION

0

0

1

2 3

4

5

6

MONTH

7

8

9 10 11

-

VA-ADHC

*

CUSTOMARY CARE

-

CONTRACT ADHC

FIG.

1.

Comparison

of

survival of

VA-ADHC,

Customary

Care,

and Contract

ADHC

groups.

SIP

for

only

3

groups

of

patients.

Table 3

shows that

among

unmarried

patients,

those

assigned

to ADHC had lower mean

total SIP

scores

(less

dysfunction)

at 6

months than

those

in the

customary

care

group,

and

lower mean

physical,

psychosocial,

and

total

SIP

scores at 12

months.

Among

those

patients

most

satisfied with

the help and support they received from

their

social

support

network

at

the

initial in-

terview,

the

ADHC

group

showed

signifi-

cantly

lower

SIP

psychosocial

and total

scores than the

customary

care

group

at

6

months,

as shown

in

Table

4.

Differences

between the

groups

were

significant

for

physical

and

total

SIP

scores,

but

not for

psychosocial

function at

12

months. No

such differences were

observed for

patients

who were less satisfied with their social net-

works.

Table

5

shows that

among

patients

not in

the

hospital

at

enrollment,

those

assigned

to

ADHC

had

significantly

lower

physical,

psychosocial,

and total

SIP scores at 6

months,

but

only

the

physical

dimension

difference

remained

significant

at

12

months.

In

contrast,

the

adjusted

mean dif-

ferences for

those

in

hospital

at

enrollment

were

quite

small

and

nonsignificant.

The level of

significance

for

the

6-month

comparisons for only those persons who

completed

the

study

varied

slightly

from

those

that

included

persons

who

dropped

out or

died

during

the second 6 months for 2

subgroups.

For

patients

who were

very

satis-

fied with

their social

support,

and

for those

not

hospitalized

at

enrollment,

the differ-

ence between

groups

in

psychosocial

func-

tion became

nonsignificant

when

dropouts

were

deleted,

indicating

that

the

change

in

level of significance from 6 to 12 months

may

have

been due to differences in

sample

composition

rather than to

change

in

mean

level

for the

entire

group.

SS43

12

2-

I I I

I

I

I

I I

T

I I

lfDi

2

0



8/13

ROTHMAN ET AL.

TABLE2.

Comparisona

of Meanb

Patient

Psychological

Distressc

Cognitive

Functiond

and Health

Perceptionsc

at

Baseline,

6

and 12

Months Between

VA-ADHC

and

Customary

Care

Baseline

6

Months

12

Months

Customary

Customary

Customary

Scale VA-ADHC Care VA-ADHC Care VA-ADHC Care

Overall

Health

Perception

n 380 371 315 311 275 273

Mean 3.9 3.9 3.7

3.7

3.6

3.6

SD

1.2

1.2 1.2

1.1

1.2

1.2

Confidence nterval -.3 to .1 -.3

to

.1

Psychological

Distress

n

294

271

223 210 157 125

Anxiety

Mean

29.5

28.1

27.7

28.5 27.9 28.7

SD 10.7 10.5 10.4 10.4 10.8 10.9

Depression

Mean

14.4

14.0 13.1

13.7 13.7 13.7

SD

5.9

6.0 6.0 6.0 6.1

6.3

Control

Mean

22.2

21.3

21.0

20.6 21.1

20.7

SD

8.0

8.4 8.2 7.9

8.7

8.9

Total

Mean 66.2

63.4 62.0 62.9 62.8 63.3

SD 22.6

23.0 22.2 22.2 23.2

24.1

Confidence nterval -5.1 to 1.0 -4.8 to 5.8

Mini-mentalState Exam

n

329

305 250

229

193 175

Mean 23.8

23.3

23.8

23.7

23.7

24.3

SD 4.7

5.2 4.9 5.1

5.3

5.0

Confidence nterval -.8 to 1.0 -4.8 to 5.8

a

Multiple

regression

used

to

compare

means

after

controlling

or the baseline value

of

the

dependent

variable.

b95%

onfidence

ntervalsare for

differencesbetween

adjusted

means.

c

A

high

score ndicates

greaterpsychological

distress.Totalscores

range

from 24 to 144.

d

A

high

score

ndicatesbetter

cognitive unctioning.

Scores

range

from0 to 30.

'A

high

score ndicates

greater mpairment.

cores

range

from

1 to

5.

In

an effort

to further

understand

the out-

comes

described

above,

we examined the

characteristics of the patients who com-

posed

those

subgroups

at

entry

into the

study.

For each

group

we

compared

the

mean

values

of the

subgroup

that

showed

significant

differences

with those

who

did

not,

e.g.,

characteristics

of

married versus

unmarried

patients.

Results

of

the

univariate

comparisons

(analysis

of variance was used

to

compare

group

means)

showed that

pa-

tients

who were

not married

had

signifi-

cantly lower SIP scores (on both dimensions

and

total

scores),

smaller

network

sizes,

re-

ported

less

upset

with

the

help

they

received

from

network

members,

and were

younger

SS44

(mean

age,

71.3

years)

than those

who were

married

(mean

age,

73.7)

at

study

entry.

Those most satisfied with their social sup-

port

networks

had lower

Psychological

Dis-

tress

Scale

scores

(all

subscales)

and

psycho-

social SIP

scores. Other

aspects

of their

net-

work

also

appeared

more

positive

in that the

most

satisfied

group

of

patients

reported

having

significantly

more

confidants

and

perceived

their

support

network

as

more

helpful

and less

upsetting

when

providing

support.

The

only

difference

in

health

out-

comes among those hospitalized at enroll-

ment

and those who

were

not was

that the

former

group

were more

satisfied

with their

support

network.

Multivariate

analysis

(dis-

MEDICAL

CARE



9/13

Vol.

31,

No.

9,

Supplement

EFFECTS OF

ADULT DAY HEALTH

CARE

ON HEALTH AND

SATISFACTION

TABLE

.

Comparison

of Meana SIP Scores at

6 and 12 Months Between VA-ADHC

and

Customary

Care

By

Initial

Marital

Status

Customary Adjusted

VA-ADHC

Care

Mean Difference

pb

Not Married

6

Months

Physical'

24.7 28.9

-2.5

NS

Psychosocial

26.7

31.6

-3.9

0.06

Total

26.0 30.7 -3.2

0.04

n

127 116

12

Months

Physical

22.9 27.9

-4.0

0.05

Psychosocial

25.5

32.7 -6.0

0.01

Total

25.3 30.8 -4.7

0.01

n

108

108

Married

6 Months

Physical

34.0

34.9

.2

NS

Psychosocial

39.7

37.7

.8 NS

Total

36.8

36.2 .8

NS

n

175

181

12

Months

Physical

33.4

34.5

-.2

NS

Psychosocial

40.3

36.3

2.6

NS

Total

36.7

35.2

1.3 NS

n

154

172

a

Multile

regression

used to

compare

means

after

controlling

or

the

baseline

value

of the

dependent

variable.

b

P valuesare based on adjustedmeandifferences.

A

high

score

represents

reater

dysfunction.

Scores

range

from

0 to

100.

criminant

analysis)

failed

to

significantly

dis-

criminate between

the

ADHC

and

custom-

ary

care

groups.

Satisfaction

With

Care.

Satisfaction

with

care

was

measured

by

an

instrument

developed

for

the

ADHC

study.2

It

was de-

signed to elicit the respondent's opinion re-

garding

the

presence

of

specific

aspects

of

a

care

environment that

are

generally

consid-

ered indicators

of

high-quality

care.

The

respondents

in

customary

care re-

ceived

their care in

either a

nursing

home,

ambulatory

care

clinic,

or

home care

(al-

though

in

some

cases

they reported

receiv-

ing

no care

from

any

source).

The

satisfac-

tion

questionnaire

was

not

applicable

to

re-

spondents in the ambulatory care clinic;

thus,

patients

receiving

this

type

of

care are

not

included in

the

analysis.2

The

findings

for

patient

satisfaction

with

care

shown

in Table 6

indicate that

the

VA-

ADHC

group

was

significantly

more

satis-

fied

than

customary

care

patients

in

nursing

homes,

but

not

more

satisfied

than

patients

in

home

care.

Overall,

patients

assigned

to

ADHC

were more

satisfied with their

care

than those assigned to customary care.

These

differences remained

even

after con-

trolling

for

level

of

illness

(total

SIP score at

baseline).

Care Giver Health

Outcomes.

Almost

three-fourths

(71%)

of the

patients

in

the

VA-ADHC

study

reported

having

care

givers.

Of

this

number,

76%

were

spouses,

11%

were

adult

children,

and

3%

were

sib-

lings.

The

remaining

care

givers

consisted of

parents, long-term care staff, and others.

Care

giver ages

ranged

from

20 to

100,

with

a

mean

age

of

62.5

years

(standard

deviation

[SD],

12.9).

Spouse

care

givers

were

slightly

SS45



10/13

ROTHMAN

ET

AL.

TABLE

.

Comparison

of

Meana

SIP Scores

at

6

and

12

Months Between

VA-ADHC

and

Customary

Care

by

Initial Patient

Satisfaction with

Social

Support

Customary Adjusted

VA-ADHC

Care

Mean Difference

pb

Very

satisfied

6

Months

Physical'

26.7

32.3

-2.9

0.08

Psychosocial

28.5

31.6 -4.2

0.03d

Total

28.2

32.4 -3.5

0.02

n

151 143

12 Months

Physical

23.4 31.6

-5.2

0.005

Psychosocial

27.9 21.1

-3.1

NS

Total 26.0 31.7

-4.2

0.01

n

131

127

Very

dissatisfied o

moderately

atisfied

6 Months

Physical

31.0

27.5

1.4

NS

Psychosocial

36.3 37.4

-0.8

NS

Total 33.7 32.9 0.4

NS

n

35

69

12 Months

Physical

33.7

27.8 3.3

0.06

Psychosocial

37.1 38.4 -1.0

NS

Total

35.7

33.3 1.9

NS

n 70

68

a

Multile regression used to compare means after controlling for the baseline value of the dependent variable.

P

values

are

based

on

adjusted

mean differences.

cA

high

score

represents

greater

dysfunction.

Scores

range

from

0

to 100.

d

The

difference etween

groups

s not

significant

when those

patients

who

dropped

out

between6 and

12

months

are deleted.

older

(mean,

65.8; SD,

9.4).

The

length

of

time care

givers

reported providing

the same

level of care

to

the

patient

ranged

from 0

to

41

years

(mean,

3.0; SD,

4.7).

Care givers in both groups reported very

little

impairment

at baseline

in

activities

of

daily

living

(98%

reported

no

activity

limita-

tions),

but

40%

rated their

overall

health

as

fair to

poor,

and

35%

reported

their health

as

worse than others

their

own

age

(not

shown).

Psychological

distress was assessed

by

the

Psychological

Distress Scale de-

scribed

in a

previous

section.

The results

shown

in

Table

7

indicate

a

high

level

of

psychological distress (comparable to that of

the

study patients),

but no

significant

differ-

ences

between

VA-ADHC

and

customary

care at

6

or

12

months.

SS46

The

Caregiver

Burden

Questionnaire10

was used to assess

subjective

and

objective

burden related

to

caring

for

the

patient.

The

subscale

and

total

scores

shown in

Table

7

indicate very little change in perception of

burden related

to

caregiving

between

the

baseline

and

12

month interview

and

no

sig-

nificant differences between

the

VA-ADHC

and

customary

care

groups

at

any

time.

A

subgroup

consisting

of

only

those care

givers

who were

spouses

of

patients

was

ex-

amined

separately. Although

spouse

care

givers

were

consistently

more

impaired

on

all

health

outcomes,

we found no

significant

differences between the VA-ADHC and cus-

tomary

care

groups.

Satisfaction

With Care. Care

givers

re-

sponded

to

the same satisfaction

with

care

MEDICALCARE



11/13

Vol.

31,

No.

9,

Supplement

EFFECTS OF ADULT

DAY HEALTH

CARE ON

HEALTH

AND

SATISFACTION

TABLE

.

Comparison

of Meana SIP Scores

at 6 and 12 Months Between VA-ADHC and

Customary

Care

by

Patient's

Hospital

Status at Enrollment

Customary

Adjusted

VA-ADHC

Care

Mean Difference

Pb

Not in

hospital

6 Months

Physical'

30.4

37.7 -2.5

0.00

Psychosocial

34.9

37.3

-3.0

0.04d

Total

29.8

34.8

-3.7

0.01

n

117

96

12 Months

Physical

29.8

39.8

-5.7

0.01

Psychosocial

35.5

38.0

-1.4 NS

Total

32.4

38.0

-3.2

0.10

n

96

74

In the

hospital6 Months

Physical

29.9

30.3

0.5

NS

Psychosocial

33.8

34.7

-0.6

NS

Total 32.0

32.7

0.0

NS

n

185

203

12 Months

Physical

28.9

28.8

-0.2 NS

Psychosocial

33.4

33.7

-1.1 NS

Total 31.8

31.6

-0.3

NS

n 164

181

a

Multile

regression

used to

compare

means after

controlling

or the baseline

value of the

dependent

variable.

bP valuesare based on adjustedmean differences.c

A

high

score

represents

reaterdysfunction.

Scores

range

from 0 to 100.

d

The difference etween

groups

s not

significant

when those

patients

who

dropped

out between6 and

12 months

are deleted.

questionnaire

as the

patients,

with

only

slight

modifications

(the

subject

was the

pa-

tient rather than the

respondent).

The find-

TABLE

6.

Comparisona

of Satisfactionb with

Care for

Patient

Assigned

to VA-ADHC

and

Customary

Care

VA-ADHC

Customary

Care

Care

Environment Mean

SD

n

Mean SD

n P

VA-ADHCvs.

Nursing

Home

32.9 6.0

199

25.3 8.0

27

0.01

VA-ADHC

vs.

Home Care 32.9 6.0 199 32.8 5.3 25 NS

a

T-testsused to

compare

means.

bA

high

score

represents reater

atisfaction.

Scores

range

from 8 to

40.

ings,

shown

in Table

8,

indicate

that,

similar

to

patients,

care

givers

of ADHC

patients

were more satisfied

than care

givers

of

pa-

tients in

nursing

homes but not more

satis-

fied

than

care

givers

of

patients

in

home

care. Controlling for patient health status

(total

SIP

score)

at baseline did not

change

these results.

Discussion

There were

no

significant

differences be-

tween the VA-ADHC and

customary

care

groups

on

any

of the

patient

or care

giver

health outcome variables. This

indicates

that, overall, the ADHC programdid not sig-

nificantly improve

or even slow the

mean

rate of decline

in

any

measured domain of

patient

health relative

to the

customary

care

SS47



12/13

ROTHMAN

ET AL.

TABLE

.

Comparisona

of

Meanb

Caregiver Psychological

Distressc and Burdendat Six

and Twelve

Months Between

VA-ADHC and

Customary

Care

Baseline Six Months

Twelve Months

Customary

Customary

Customary

Scale VA-ADHC Care VA-ADHC Care VA-ADHC Care

Psychological

Distress

n 264 255

216 203 180

169

Physical

Mean

29.5 29.8

29.1 28.9 28.9

28.8

SD

9.9 9.9 9.2

9.7

9.7 10.1

Depression

Mean

14.8 14.8

14.5 14.6

14.3 14.9

SD

5.2 5.7 5.1

5.7 5.6

5.6

Control

Mean

19.8 19.7 19.9

20.0 19.2

19.7

SD

7.1

7.4

6.9

7.9 7.4

8.7

Total

Mean

64.1

64.3

63.5

63.6 62.4

63.4

SD

20.8 20.9

19.8 22.5

22.7 23.9

Confidence

interval

-2.3 to

1.3 -2.4 to

1.8

Caregiver

Burden

n 262 255

214 202

180

169

Subjective

Mean

12.4 12.4

12.5 12.8

12.9

13.1

SD

4.3 4.4

4.3

4.4 4.4

4.7

Objective

Mean

18.8

18.9

21.1 21.2

20.8

21.0

SD

6.2 6.2

6.4 6.5

6.7

6.9

Total

Mean 33.9

34.0

33.6

34.1 33.7

34.0

SD 9.3 9.5 9.3

9.3

9.8

9.8

Confidence

interval

-4.5

to .9 -4.5

to 1.5

a

Multile

regression

used to

compare

means after

controlling

for the baseline

value of the

dependent

variable.

b

Confidence

intervals

are for differences

between

adjusted

means.

c

A

high

score

indicates

greater

distress.

Total scores

range

from

44

to

144.

d

A

high

score indicates

greater

burden.

Total scores

range

from

12 to 60.

group.

Significant

differences

were ob-

served,

however,

for

3

subgroups

of

pa-

tients. Patients who, at study enrollment,

were

not

married,

were

most satisfied

with

their

social

support

network,

or were

in

hos-

pital

had

significantly

more

positive

out-

comes

(lower

SIP

scores)

when

assigned

to

ADHC

than

those

assigned

to

customary

care,

after

controlling

for baseline

health

status.

Examination

of the

characteristics

of

these

patient

groups,

however,

did

not show

any

consistent

patterns

that

might

explain

these findings.

The

results

of the

subgroup

analyses

must

be

taken

as

tentative

for

2

reasons.

First,

be-

cause

of the

large

number

of

subgroup

analy-

SS48

ses

involved,

there

is

a

high probability

of

finding

some

comparisons

significant

by

chance; and second, there is little opportu-

nity

of corroboration

of these

findings

in the

current literature

because

few

previous

stud-

ies of

ADHC

analyzed subgroups.

For

these

reasons,

it is

suggested

that

these

findings

be

considered

as

suggestions

for

future

re-

search.

Patients

and

their care

givers

did

report

greater

satisfaction

with care

in the

ADHC

programs

than

their

counterparts

in

nursing

homes. These differences were large and re-

mained

significant

even

after

controlling

for

overall

level

of

health

(total

SIP

score).

It

should

be

noted

that

these

comparisons

vio-

MEDICAL

CARE



13/13

Vol.

31,

No.

9,

Supplement

EFFECTS

OF ADULT

DAY

HEALTH CARE ON HEALTH

AND

SATISFACTION

TABLE

.

Comparisona

of Mean

Caregiver

Satisfaction

with Care VA-ADHC

and

Customary

Care

VA-ADHC

Customary

Care

Comparison

Mean SD n Mean SD n P

VA-ADHC

vs.

Nursing

Homeb 35.6 4.0

178 28.5 7.9

33 0.00

VA-ADHC vs.

Home Careb

35.6

4.0

178

34.3

6.5

36 NS

a

T-tests used

to

compare

means.

b

Scores

range

from

8 to

40.

A

high

score

indicates

greater

satisfaction.

late

the

assumptions

of the

randomized trial

because a

large

portion

of the

customary

care

group

patients

did not

receive

care in

the

2

environments

that

were

evaluated

(i.e.,

satisfaction

with care in

ambulatory

care

clinic was

not

evaluated

with

this

measure).

It

is

possible

that

the

observed

differences

could

be attributed

to uncontrolled

differ-

ences in the type of patients admitted to

nursing

homes

rather than

to an

effect

of

ADHC.

Care

givers

reported

psychological

dis-

tress

levels as

high

as

those

reported

by

pa-

tients,

although

they

indicated

almost no

impairment

in

activities of

daily

living.

The

perceived

burden

of care

giving

was

also

high,

exceeding

that

of care

givers

of

pa-

tients with

Alzheimer's

disease and

other

types of cognitive impairment.11 There were

no

differences in

these

measures

at

any

time

for

those care

givers

of

patients

assigned

to

ADHC versus

customary

care;

thus,

the VA-

ADHC

programs

were

not

effective

in

re-

ducing

the

care

giver's

psychological

distress

or burden.

References

1. Breslow

NE. The

proportional

hazard model:

Ap-

plications

in

epidemiology.

Comm

Statist A

Theory

Methods

1978;A7:315.

2.

Chapko

MK,

Rothman

ML,

Ehreth

JL,

et al.

Data

collection in the

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day

health

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study.

Med

Care

1993;31(Suppl.):SS15.

3.

Rothman

ML,

Hedrick

SC,

Bulcroft

KA,

et al.

The

validity

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health status.

Med

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1991;29:115.

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Weissert

WG,

Cready

M,

Pawelak

JE.

Home and

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An

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M,

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SS49

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Documents