A systematic review and meta-analysis by Legg et al. [1
] of nine trials (1258 participants) found that in stroke survivors, occupational therapy (OT) increased personal activities of daily living scores (i.e., standardised mean difference 0.18; 95% confidence interval 0.04 to 0.32; p
0.01). Furthermore, for every 100 people who received OT after a stroke, 11 (95% confidence interval 7 to 30) would be spared a poor outcome (i.e., death, deterioration in personal activities of daily living or dependency on others; Odds ratio 0.67; 95% confidence interval 0.51 to 0.87; p
0.003). A care setting where OT might be particularly beneficial is in care homes, where 20% to 40% of all people newly admitted have stroke-related disabilities as their admittance diagnosis [2
]. Generalisation of results from community studies should be treated with caution, as the characteristics of stroke survivors resident in a care home are likely to be different to those living in their own homes. For instance, 78% of residents in a care home have cognitive impairment, 76% need some form of assistance with ambulation and 71% are incontinent [2
]. These factors might affect the capacity of care home residents to engage in OT.
OT in care homes has been embraced in countries such as The Netherlands, where 93% of residents regularly receive this form of therapy [4
], in contrast to the United Kingdom (UK), where as few as 3% of residents in care homes receive OT [5
]. Over the last decade, the government in the UK has established a framework to assess eligibility and prioritise care needs of residents [6
]. However, a recent audit of 112 care homes in the Midlands area of the UK found that only 6% of homes used the services of an OT at least once a week [8
]. The under-utilisation of OT in this setting might be the result of staff being unaware of the role of an occupational therapist and/or how to access the services. Conversely, from a service commissioner’s perspective there is little evidence that the provision of OT services for care homes residents following a stroke is effective and/or cost-effective [8
In the literature there is conflicting evidence on the efficacy of OT for on activities of daily life in care homes residents with stroke-related disabilities [9
]. For instance, a study by Sackley et al. [9
], which involved 249 care homes residents with mobility limitations, found that after a three month OT and physiotherapy programme there was no measureable improvements in functional independence and mobility. Although the findings suggest the therapy intervention to be ineffective, it could be argued that therapists in this study delivered interventions to maintain physical abilities of the residents rather than actively rehabilitate them. Furthermore, the therapy was applied relatively unselectively to all care home residents, rather than specifically targeted towards care homes residents with stroke-related disabilities. A cluster randomised trial, which evaluated the effect of OT compared to usual care over 3
months in 118 residents with a stroke-related disability at 12 care homes, found that residents who received OT were less likely to deteriorate in their ability to perform activities of daily living [10
]. From baseline to 3
months the mean Barthel Activities of Daily Living Index (Barthel index) score had increased by 0.6 (SD
3.9) in the intervention group, but decreased by 0.9 (SD
2.2) in the control group. This equated to a difference between the groups of 1.5 and 95% confidence interval of -0.5 to 3.5 (allowing for a cluster design). The difference between the groups in Barthel index was maintained at 6
months (i.e., difference of 1.9 and 95% confidence interval of -0.7 to 4.4). The sample size was very small especially when taking into account the high intra class correction (ICC) of 0.37 (Barthel index at baseline), which is consistent with the ICC of 0.39 found in a subsequent pilot study of incontinence care in the same setting [11
The findings from these studies demonstrate that even modest levels of OT may have detectable and lasting effects on morbidity and possibly mortality. It would, therefore, be appropriate to replicate the study with a larger sample to investigate the clinical impact of OT on activities of daily life in care homes residents with stroke-related disabilities.
In addition to the investigation of clinical impact of OT, a larger sample size will enable a full assessment of the economic impact that OT has on providing health care. Previous work in Canada [12
] and in the UK [13
] investigated the cost of OT in care homes, based on cost-consequence analyses. The Canadian study studied two types of OT and physiotherapy intensities, which compared 1 therapist to 50 bed ratio to 1 therapist to 200 bed ratio. Improvements in functional outcome measures favoured OT and physiotherapy delivered at the 1:50 ratio, which resulted in reduced direct nurse time and equated to an annual saving of 283 Canadian dollars per resident [12
]. The study conducted in the UK, examined the effect of OT on levels of depression and quality of life in care homes residents [13
]. It was found that, at 2005 levels, the net cost of providing the OT service was 16 British pounds per resident per week. However, it was suggested by the authors that OT might have resulted in a reduction in overall health costs [13
]. Both studies suggest that providing OT to residents in a care homes incurs an initial cost to health care providers, but generates savings in the long-term through the improvement of functional outcomes of residents without stroke-related disabilities [12
]. There is, therefore, a need to analyse the economic impact of OT on residents with stroke-related disabilities in care homes.
The purpose of this study is to conduct a large scale cluster randomised control trial to evaluate the effects of the provision of OT, which include task related training, the provision of adaptive equipment, minor environmental adaptations and staff education, compared to usual care, on activities of daily living, mobility, depression and quality of life for residents with stroke-related disabilities in care homes. Allocation of therapy cannot be concealed from the carers and/or residents so, to minimise contamination of intervention, the unit of randomisation will be the care home. Furthermore, we aim to conduct a health economic evaluation of the effect of the provision of OT services has on the health care system compared to usual care. Given the findings of previous studies on clinical [1
] and health economic [12
] impact of OT compared to usual care in the UK [5
], it is hypothesised that the provision of OT services will have a favourable impact on activities of daily living, and reduce long-term costs to health care providers.