LETTERS * CORRESPONDANCE
We will considerfor publication only letters submitted in duplicate, printed in letterquality type without proportional spacing and not exceeding 450 words. All the authors must sign a covering letter transferring copyright. Letters must not duplicate material being submitted elsewhere or already published. We routinely correspond only with authors of accepted letters. Rejected letters are destroyed. Accepted letters are subject to editing and abridgement.
Seules peuvent etre retenues pour publications les lettres recues en double dont la longueur n'excede pas 450 mots. Elles doivent etre mecanographie,es en qualite "correspondance" sans espacement proportionnel. Tous les auteurs doivent signer une lettre d'accompagnement portant cession du copyright. Les lettres ne doivent rien contenir qui ait dte presente ailleurs pour publication ou d&j? paru. En principe, la redaction correspond uniquement avec les auteurs des lettres retenues pour publication. Les lettres refusees sont detruites. Les lettres retenues peuvent etre abregees ou faire l'objet de modifications d'ordre redactionnel.
Effectiveness of a geriatric day hospital T| ahe negative conclusion in this paper by D. Joan Eagle and associates (Can Med Assoc J 1991; 144: 699-704) strikes a chill in those of us who work in a day hospital. I admire the intellectual honesty of the authors and their rigorous methods, but several points should be
raised. The study group was selected from a geriatrician-based clinic and was, therefore, prescreened by the family physician for the common problems that occur in the elderly. Most day hospitals receive referrals from primary care physicians or from outside agencies with the agreement of the primary care physician. Therefore, this ,
study group may not be comparable to those found in other day hospital settings. The inclusion criteria for the study mention rehabilitation potential. In our day hospital approximately one-third of the patients are referred for a functional assessment to help with either rehabilitation or long-term planning. Were all the patients referred to the day hospital accepted for an interdisciplinary rehabilitation program? Less than half of the patients were able to comprehend the Geriatric Quality of Life Questionnaire (GQLQ). For those of us who work with an ethnic population English-language testing can be very difficult to interpret. From my experience in the Chedoke-McMaster Day Hospital I know that it was undergoing massive changes in its program, personnel and philosophy. The home care services had been in place and were stable throughout the study period. This difference would tend to maximize the functional changes in the home care (control) group and the problems in the day hospital (treatment) group. The study is a valuable addition to the literature on day hospitals, but it should be viewed in light of the changes in the day hospital itself. A randomized controlled trial in which the backgrounds of both the home care services and the day hospital were stable would probably be a better test of the program's effectiveness. A. Elizabeth Watson, MB, BCh, FRCPC Head Department of Geriatric Medicine Seven Oaks General Hospital Winnipeg, Man.
51 9 1SEPTEMBER
9
1
We are deeply concerned that the paper by D. Joan Eagle and associates will be used to justify closure of day hospitals. The paper appears to be mistitled: we do not believe that it has measured the effectiveness of the day hospital, given the questions we have about the method of evaluation. These questions need to be addressed before meaningful conclusions about the data can be drawn; even then, the ability to&generalize is likely to be limited. What was done to the patients? The day hospital was evaluated from the day it opened, even though there were problems during this time in recruiting patients and assembling the team. The growing pains in developing a functioning team may therefore have impaired the effectiveness of the intervention. Indeed, this seems likely, since the patients' progressive decline in function was not in keeping with the experience of patients reported in other studies.1-6 Were these the patients most likely to benefit from the intervention? An early lesson in the development of specialized geriatric services has been that they are demonstrably effective when targeted on frail elderly patients, a group characterized by a high level of functional dependence.3'7 Although the mean Barthel Index score was recorded we do not know the distribution; this is particularly important given that the initial scores were comparatively high. What proportion was not *impaired? How many were frail? It appears that targeting was not carried out, since it was not described and there were initial difficulties with recruitment.
CNCAN MED ASSOCSOCJ 1991; 145(6)
613
We will considerfor publication only letters submitted in duplicate, printed in letterquality type without proportional spacing and not exceeding 450 words. All the authors must sign a covering letter transferring copyright. Letters must not duplicate material being submitted elsewhere or already published. We routinely correspond only with authors of accepted letters. Rejected letters are destroyed. Accepted letters are subject to editing and abridgement.
Seules peuvent etre retenues pour publications les lettres recues en double dont la longueur n'excede pas 450 mots. Elles doivent etre mecanographie,es en qualite "correspondance" sans espacement proportionnel. Tous les auteurs doivent signer une lettre d'accompagnement portant cession du copyright. Les lettres ne doivent rien contenir qui ait dte presente ailleurs pour publication ou d&j? paru. En principe, la redaction correspond uniquement avec les auteurs des lettres retenues pour publication. Les lettres refusees sont detruites. Les lettres retenues peuvent etre abregees ou faire l'objet de modifications d'ordre redactionnel.
Effectiveness of a geriatric day hospital T| ahe negative conclusion in this paper by D. Joan Eagle and associates (Can Med Assoc J 1991; 144: 699-704) strikes a chill in those of us who work in a day hospital. I admire the intellectual honesty of the authors and their rigorous methods, but several points should be
raised. The study group was selected from a geriatrician-based clinic and was, therefore, prescreened by the family physician for the common problems that occur in the elderly. Most day hospitals receive referrals from primary care physicians or from outside agencies with the agreement of the primary care physician. Therefore, this ,
study group may not be comparable to those found in other day hospital settings. The inclusion criteria for the study mention rehabilitation potential. In our day hospital approximately one-third of the patients are referred for a functional assessment to help with either rehabilitation or long-term planning. Were all the patients referred to the day hospital accepted for an interdisciplinary rehabilitation program? Less than half of the patients were able to comprehend the Geriatric Quality of Life Questionnaire (GQLQ). For those of us who work with an ethnic population English-language testing can be very difficult to interpret. From my experience in the Chedoke-McMaster Day Hospital I know that it was undergoing massive changes in its program, personnel and philosophy. The home care services had been in place and were stable throughout the study period. This difference would tend to maximize the functional changes in the home care (control) group and the problems in the day hospital (treatment) group. The study is a valuable addition to the literature on day hospitals, but it should be viewed in light of the changes in the day hospital itself. A randomized controlled trial in which the backgrounds of both the home care services and the day hospital were stable would probably be a better test of the program's effectiveness. A. Elizabeth Watson, MB, BCh, FRCPC Head Department of Geriatric Medicine Seven Oaks General Hospital Winnipeg, Man.
51 9 1SEPTEMBER
9
1
We are deeply concerned that the paper by D. Joan Eagle and associates will be used to justify closure of day hospitals. The paper appears to be mistitled: we do not believe that it has measured the effectiveness of the day hospital, given the questions we have about the method of evaluation. These questions need to be addressed before meaningful conclusions about the data can be drawn; even then, the ability to&generalize is likely to be limited. What was done to the patients? The day hospital was evaluated from the day it opened, even though there were problems during this time in recruiting patients and assembling the team. The growing pains in developing a functioning team may therefore have impaired the effectiveness of the intervention. Indeed, this seems likely, since the patients' progressive decline in function was not in keeping with the experience of patients reported in other studies.1-6 Were these the patients most likely to benefit from the intervention? An early lesson in the development of specialized geriatric services has been that they are demonstrably effective when targeted on frail elderly patients, a group characterized by a high level of functional dependence.3'7 Although the mean Barthel Index score was recorded we do not know the distribution; this is particularly important given that the initial scores were comparatively high. What proportion was not *impaired? How many were frail? It appears that targeting was not carried out, since it was not described and there were initial difficulties with recruitment.
CNCAN MED ASSOCSOCJ 1991; 145(6)
613
