Assessing the effectiveness of audit in long-stay hospital care for elderly people

We wished to assess the impact of an audit package (the Royal College of Physicians CARE scheme) on outcomes in institutional care for elderly people. We compared patients in audited and unaudited units in four hospital continuing-care wards and a National Health Service nursing home. Ninety-three hospital long-stay patients and 26 nursing home patients were observed. Changes in disability (measured using the Barthel Index, Clifton Assessment Procedure for the Elderly and Crichton Royal Behaviour Rating Scale), deaths, satisfaction with life, and relative's satisfaction with care were recorded. Odds ratios for unfavourable outcomes were calculated after adjusting for potential confounders. Initial disability was similar on two audited wards and two control wards, but significantly less in the (audited) nursing home; 11% of patients died on the control wards, compared with 35% on the audited wards (p = 0.02). There were no consistent differences between changes in disability or satisfaction scores on the intervention and control units, although confidence intervals were wide. Staff attitudes towards the scheme were positive. We conclude that audit in long-term care was not associated with measurable improvements in outcomes. Intermediate process indicators of the impact of audit are needed. Positive staff attitudes to audit were encouraging, and suggest that further modifications of the CARE scheme should be evaluated.