[Use and acceptance of a basic geriatric assessment in primary care setting]

Outpatient geriatric health care in the German federal state of Mecklenburg-Western Pomerania: a population-based spatial analysis of claims data

BACKGROUND

Due to unidentified geriatric needs, elderly patients have a higher risk for developing chronic conditions and acute medical complications. Early geriatric screenings and assessments help to identify geriatric needs. Holistic and coordinated therapeutic approaches addressing those needs maintain the independence of elderly patients and avoid adverse effects. General practitioners are important for the timely identification of geriatric needs. The aims of this study are to examine the spatial distribution of the utilization of outpatient geriatric services in the very rural Federal State of Mecklenburg-Western Pomerania in the Northeast of Germany and to identify regional disparities.

METHODS

Geographical analysis and cartographic visualization of the spatial distribution of outpatient geriatric services of patients who are eligible to receive basic geriatric care (BGC) or specialized geriatric care (SGC) were carried out. Claims data of the Association of Statutory Health Insurance Physicians in Mecklenburg-Western Pomerania were analysed on the level of postcode areas for the quarter periods between 01/2014 and 04/2017. A Moran's I analysis was carried out to identify clusters of utilization rates.

RESULTS

Of all patients who were eligible for BGC in 2017, 58.3% (n = 129,283/221,654) received at least one BCG service. 77.2% (n = 73,442/95,171) of the patients who were eligible for SGC, received any geriatric service (BGC or SGC). 0.4% (n = 414/95,171) of the patients eligible for SGC, received SGC services. Among the postcode areas in the study region, the proportion of patients who received a basic geriatric assessment ranged from 3.4 to 86.7%. Several regions with statistically significant Clusters of utilization rates were identified.

CONCLUSIONS

The widely varying utilization rates and the local segregation of high and low rates indicate that the provision of outpatient geriatric care may depend to a large extent on local structures (e.g., multiprofessional, integrated networks or innovative projects or initiatives). The great overall variation in the provision of BGC services implicates that the identification of geriatric needs in GPs' practices should be more standardized. In order to reduce regional disparities in the provision of BGC and SGC services, innovative solutions and a promotion of specialized geriatric networks or healthcare providers are necessary.

Versorgung geriatrischer Krankheitsbilder unter ausgewählten ambulanten Facharztgruppen: Kombination von Befragungs- und GKV-Routinedaten zur Abbildung des Leistungsgeschehens

BACKGROUND

In light of an aging population, the German health system faces the challenge of adapting regional health care structures to the changing care needs of geriatric patients. Since geriatric care is interprofessional, a structural analysis of the service providers involved is required. Therefore, the aim of this study is to determine the primary and joint care responsibilities for geriatric patients with specific characteristics, to estimate the associated effort for selected outpatient medical service providers and to identify resulting care concentrations.

METHODS

The analysis includes six selected specialist disciplines in the outpatient sector and is based on two databases: 1) A representative survey among outpatient physicians related to geriatric care (n = 400) to examine both the primary geriatric care needs that professionals treat regularly and aggravating geriatric morbidity. 2) A claims data analysis determines services and efforts for approximately 300,000 geriatric patients for every year from 2014 to 2018. For the specialists included in the analysis, care concentration was determined by association analysis comparing the care efforts of outpatient physicians for patients with different geriatric characteristics.

RESULTS

General practitioners, in particular, serve as primary care providers for all geriatric characteristics; there is no concentration of care on specific patient groups. Concentrations associated with care efforts and joint care responsibilities for patients with certain geriatric characteristics are found among the more specialized physician groups. Across all professions, the physicians surveyed believe that geriatric-specific immobility, depression, anxiety disorders and cognitive deficits make the provision of care more difficult.

DISCUSSION

The results contribute to the understanding of primary and interdisciplinary care responsibilities of outpatient physicians related to the treatment of geriatric conditions and can thus represent an important basis for the structural planning of geriatric care. Nevertheless, it should be noted that within the scope of the analysis presented, only general practitioners and five specialist disciplines could be taken into account. Therefore, the considerations primarily allow initial conclusions about the care responsibility of outpatient physicians with regard to geriatric morbidity. To enable comprehensive structural planning, however, the analyses would have to be expanded to include all specialists involved in geriatric care.

CONCLUSION

The joint care responsibility of outpatient physicians for specific geriatric patients underlines the relevance for interdisciplinary care models and the need for expansion of geriatric expertise in the outpatient sector. In view of the ageing population and an increase in morbidity, the planning of care structures should be based on the needs of geriatric patients and the associated expenses incurred by the various health care providers.

[Four types of old patients in the emergency department : A geriatric medicine qualitative and economic viewpoint]

BACKGROUND

Lack of clinical management of old patients in the emergency department.

QUESTION

How can we manage old patients in the emergency department more effectively, medically and economically?

METHODS

Evaluation of current selection and screening methods and recommendations for old patients in the emergency department. Acute inpatient treatment needs, presence of dysfunction in at least two core areas and assessment of advance care needs are examined.

RESULT

The identification of old patients in the emergency department as geriatric patients alone shows no control potential. Combining the three test criteria of acute inpatient need for treatment, the presence of dysfunction in at least two core areas and the assessment of advance care needs generates four old patient types that have interesting control potential: the medical traumatology patient, the acute geriatric patient, the rehabilitative geriatric patient, and the ambulatory patient.

DISCUSSION

in addition to identifying geriatric patients, screening should map acute inpatient treatment needs, assessment of dysfunction, and analysis of advance care needs to define clinically steerable old patients.

[Educational film on the geriatric basic assessment in primary care-Methods of cinematic authenticity]

BACKGROUND

The relevance of care of older persons in general practice requires the conveyance of procedural and conditional knowledge of the geriatric basic assessment (GBA) even during medical studies. There is a need for action with respect to student knowledge on specific problems of older patients. This paper describes how the primary care situation can be made tangible for students based on a film project at the Hannover Medical School (MHH).

METHOD

During film production, strategies for creating authenticity were applied using cinematic means. The film is used in the teaching module of family medicine at MHH. Student evaluation investigated whether the educational film provided an emotional experience and whether the presentation mode of the GBA was perceived as authentic.

RESULTS

The majority of students were emotionally touched by the film. The educational film was successful in conveying the complexity of care of older people and in presenting the special role of family physicians in geriatric care.

DISCUSSION

The students recognized the necessity of the GBA and found the representation predominantly realistic; however, individual cinematic reception and previous experiences also influence the perception of the cinematic form with respect to the representation of reality. This method might improve the conveyance of authenticity in educational videos in medicine.

[Digital geriatric self-assessment-A narrative review]

BACKGROUND

Digital health apps have a large potential for autonomous screening and monitoring of older people with respect to maintaining their independence. Due to demographic change and the shortage of specialized personnel in medicine, these premedical self-assessment apps could be of great value in the future.

OBJECTIVE

This narrative review enables the assessment of whether a digital geriatric self-assessment for older people ≥ 70 years is feasible using currently available apps.

MATERIAL AND METHODS

A search was carried out for apps that enable a self-assessment in the following domains: physical capacity, cognition, emotion, nutrition, sensory perception and context factors. Based on predefined criteria apps were selected and presented.

RESULTS

Self-assessment apps could be identified in four of the six domains: physical capacity, cognition, emotion and sensory perception. In total five apps are presented as examples. No apps were identified regarding nutrition and context factors. Numerous self-assessment apps were identified for the field of physical activity.

CONCLUSION

The presented results indicate that digital self-assessment can currently be realized for certain domains of the comprehensive geriatric assessment. New promising apps are currently under development. More research is needed to verify test quality criteria and usability of available apps. Furthermore, there is a need for a platform that integrates individual assessment apps to provide users with an overview of the results and recommendations.

Rapid Geriatric Assessment Using Mobile App in Primary Care: Prevalence of Geriatric Syndromes and Review of Its Feasibility

With the aging population and consequent increase in associated prevalence of frailty, dementia, and multimorbidity, primary care physicians will be overwhelmed with the complexity of the psychosocial and clinical presentation. Geriatric syndromes including frailty, sarcopenia, cognitive impairment, and anorexia of aging (AA) either in isolation or in combination are associated with an increased risk of adverse outcomes and if recognized early, and appropriately managed, will lead to decreased disability. Primary care practices are often located in residential settings and are in an ideal position to incorporate preventive screening and geriatric assessment with personalized management. However, primary care physicians lack the time, multidisciplinary resources, or skills to conduct geriatric assessment, and the limited number of geriatricians worldwide further complicates the matter. There is no one effective strategy to implement geriatric assessment in primary care which is rapid, cost-effective, and do not require geriatricians. Rapid Geriatric Assessment (RGA) takes <5 min to complete. It screens for frailty, sarcopenia, AA, and cognition with assisted management pathway without the need of a geriatrician. We developed RGA iPad application for screening with assisted management in two primary care practices and explored the feasibility and overall prevalence of frailty, sarcopenia, and AA. The assessment was conducted by trained nurses and coordinators. Among 2,589 older patients ≥65 years old, the prevalence of frailty was 5.9%, pre-frail 31.2%, and robust 62.9%. Fatigue was present in 17.8%, and among them, the prevalence of undiagnosed depression as assessed by the Patient Health Questionnaire (PHQ)-9 was 76.4% and 13.5% of total. The prevalence of sarcopenia was 15.4%, and 13.9% experienced at least one fall in the past year. AA was prevalent in 10.9%. The time taken to do the assessment with defined algorithm was on average 5 min or less per patient, and 96% managed to complete the assessment prior to seeing their doctor in the same session. The RGA app is a rapid and feasible tool to be used by any healthcare professional in primary care for identification of geriatric syndrome with assisted management.

Evaluation of an ambulatory geriatric rehabilitation program - results of a matched cohort study based on claims data

Background

Ambulatory geriatric rehabilitation (AGR) is a multidisciplinary outpatient prevention program designed to decrease hospitalisation and dependence on nursing care in multimorbid patients ≥70 years of age. We evaluated the effectiveness of AGR compared to usual care on progression of nursing care levels, nursing home admissions, hospital admissions, incident fractures, mortality rate and total cost of care during a one-year follow-up period.

Methods

Analyses were based on claims data from the health insurance company AOK Nordost. Propensity Score matching was used to match 4 controls to each person receiving the AGR intervention.

Results

A total of 632 AGR participants and 2528 matched controls were included. The standardized mean difference of matching variables between cases and controls was small (mean: + 1.4%; range: − 4.4/3.9%). In AGR patients, the progression of nursing care levels (+ 2.2%, 95%CI: − 0.9 /5.3), nursing home admissions (+ 1.7%, 95%CI: − 0.1/3.5), hospital admissions (+ 1.1%, 95%CI: − 3.2/5.4), incident fractures (+ 11.1%, 95%CI: 7.3/15) and mortality rate (+ 1.2%, p = 0.20) showed a less favourable course compared to controls. The average total cost per AGR participant was lower than in the control group (− 353€, 95%CI: − 989€/282€), not including costs for AGR.

Conclusions

Analysis based on claims data showed no clinical benefit from AGR intervention regarding the investigated outcomes. The slightly worse outcomes may reflect limitations in matching based on claims data, which may have insufficiently reflected morbidity and psychosocial factors. It is possible that the intervention group had poorer health status at baseline compared to the control group.

Trial registration

German Clinical Trials Register DRKS00008926, registered 29.07.2015.

Evaluation of Ambulatory Geriatric Rehabilitation (EAGER): study protocol of a matched cohort study based on claims data

BACKGROUND

Ambulatory geriatric rehabilitation (AGR) is a community based outpatient intervention which aims to improve physical function, maintain independent living of geriatric patients, avoiding hospitalisation and institutionalisation. It should therefore reduce health care costs. The objective of our study is to evaluate the effectiveness of AGR for frail elderly patients insured by the statutory health insurance AOK Nordost compared to care as usual. Outcome variables are progression to higher nursing care levels, admission to nursing home, incident fractures, hospital admission, ambulatory care sensitive hospital admissions, days spent in hospital, and health care costs.

METHODS

This matched cohort study aims to estimate average treatment effects of AGR. For this purpose we will compare patients receiving AGR with matched patients receiving care as usual. Patients in the intervention group were treated between the years 2009 and 2013 from three centres in Mecklenburg-Vorpommern, Germany. Matching will be conducted using propensity score techniques. Claims data will be provided by the statutory health insurance AOK Nordost. The primary outcomes are the progression of nursing care levels, incident fractures, and admission to nursing home. Secondary outcomes are total and ambulatory care sensitive hospital admissions, and health care costs from the statutory health insurance perspective. Data will be analysed using appropriate regression models.

DISCUSSION

This study aims to quantify the effectiveness of AGR. Results will be important for providers of AGR, policy makers and stakeholders to make informed decisions on whether to continue, modify or extend AGR.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) S00008926 , registered 29.07.2015.

'We can do only what we have the means for' general practitioners' views of primary care for older people with complex health problems

Background

Due to demographic change, general practitioners (GPs) are increasingly required to care for older people with complex health problems. Little is known about the subjective appraisals of GPs concerning the demanded changes. Our objective is to explore how general practitioners view their professional mandates and capacities to provide comprehensive care for older people with complex health problems. Do geriatric training or experience influence viewpoints? Can barriers for the implementation of changes in primary care for older people with complex health problems be detected?

Methods

Preceding a controlled intervention study on case management for older patients in the primary care setting (OMAHA II), this qualitative study included 10 GPs with differing degrees of geriatric qualification. Semi structured interviews were conducted and audio-taped. Full interview transcripts were analyzed starting with open coding on a case basis and case descriptions. The emerging thematic structure was enriched with comparative dimensions through reiterated inter-case comparison and developed into a multidimensional typology of views.

Results

Based on the themes emerging from the data and their presentation by the interviewed general practitioners we could identify three different types of views on primary care for older people with complex health problems: ‘maneuvering along competence limits’, ‘Herculean task’, and ‘cooperation and networking’. The types of views differ in regard to role-perception, perception of their own professional domain, and action patterns in regard to cooperation. One type shows strong correspondence with a geriatrician. Across all groups, there is a shared concern with the availability of sufficient resources to meet the challenges of primary care for older people with complex health problems.

Conclusions

Limited financial resources, lack of cooperational networks, and attitudes appear to be barriers to assuring better primary care for older people with complex health problems. To overcome these barriers, geriatric training is likely to have a positive impact but needs to be supplemented by regulations regarding reimbursement. Most of all, general practitioners’ care for older people with complex health problems needs a conceptual framework that provides guidance regarding their specific role and contribution and assisting networks. For example, it is essential that general practice guidelines become more explicit with respect to managing older people with complex health problems.