Costs and Effects of an Ambulatory Geriatric Unit (the AGe-FIT Study): A Randomized Controlled Trial

The impact of a mobile geriatric acute team on healthcare consumption

PURPOSE

This study describes the effects of a mobile geriatric acute team (GAT) treating acutely ill geriatric patients in their homes. GAT offered more advanced diagnostic and treatment options than are normally available to primary-care led mobile teams. The aim of this study was to evaluate if interventions by GAT had effect on the number of emergency department (ED) visits, hospitalisations, and length of stay in hospital.

METHODS

This is a before-after study, with outcomes recorded for each participant during the 3 months prior to the first visit by GAT and compared to the same outcomes for each participant during the 3 months after the first visit.

RESULTS

The participant's mean age was 84.6 years, 56% were women. There was no observed difference in ED visits, hospitalisations, and length of stay in hospital for all participants (n = 102). However, for the 27 participants living in nursing homes; ED-visits reduced on average by 0.5/participant (p = 0.002), the number of hospitalisations reduced by 0.3/participant (p = 0.018) and length of stay in hospital reduced by 4.3 days/participant (p = 0.045). For the 13 participants referred by ambulance, the number of hospitalisations reduced by 0.7/participant (p = 0.044) and length of stay in hospital reduced by 4.1 days/participant (p = 0.028). The participants who got intravenous antibiotics also had less hospital care.

CONCLUSION

This geriatric acute mobile team did not cause reduced hospital care among the participants overall. However, it might have reduced hospitalization in some subgroups, such as patients living in nursing homes or those who got intravenous antibiotics.

Effectiveness of integrated person-centered interventions for older people's care: Review of Swedish experiences and experts' perspective

Older adults have multiple medical and social care needs, requiring a shift toward an integrated person-centered model of care. Our objective was to describe and summarize Swedish experiences of integrated person-centered care by reviewing studies published between 2000 and 2023, and to identify the main challenges and scientific gaps through expert discussions. Seventy-three publications were identified by searching MEDLINE and contacting experts. Interventions were categorized using two World Health Organization frameworks: (1) Integrated Care for Older People (ICOPE), and (2) Integrated People-Centered Health Services (IPCHS). The included 73 publications were derived from 31 unique and heterogeneous interventions pertaining mainly to the micro- and meso-levels. Among publications measuring mortality, 15% were effective. Subjective health outcomes showed improvement in 24% of publications, morbidity outcomes in 42%, disability outcomes in 48%, and service utilization outcomes in 58%. Workshop discussions in Stockholm (Sweden), March 2023, were recorded, transcribed, and summarized. Experts emphasized: (1) lack of rigorous evaluation methods, (2) need for participatory designs, (3) scarcity of macro-level interventions, and (4) importance of transitioning from person- to people-centered integrated care. These challenges could explain the unexpected weak beneficial effects of the interventions on health outcomes, whereas service utilization outcomes were more positively impacted. Finally, we derived a list of recommendations, including the need to engage care organizations in interventions from their inception and to leverage researchers' scientific expertise. Although this review provides a comprehensive snapshot of interventions in the context of Sweden, the findings offer transferable perspectives on the real-world challenges encountered in this field.

Sense of Security Mediates the Relationship Between Self-care Behavior and Health Status of Patients With Heart Failure: A Cross-sectional Study

BACKGROUND

Promoting patients' sense of security is among the goals of nursing care within heart failure management.

OBJECTIVE

The aim of this study was to examine the role of sense of security in the relationship between self-care behavior and health status of patients with heart failure.

METHODS

Patients recruited from a heart failure clinic in Iceland answered a questionnaire about their self-care (European Heart Failure Self-care Behavior Scale; possible scores, 0-100), their sense of security (Sense of Security in Care-Patients' Evaluation; possible scores, 1-100), and their health status (Kansas City Cardiomyopathy Questionnaire, including symptoms, physical limitations, quality of life, social limitations, and self-efficacy domains; possible scores, 0-100). Clinical data were extracted from electronic patient records. Regression analysis was used to examine the mediation effect of sense of security on the relationship between self-care and health status.

RESULTS

The patients (N = 220; mean [SD] age, 73.6 [13.8] years; 70% male, 49% in New York Heart Association functional class III) reported a high sense of security (mean [SD], 83.2 [15.2]) and inadequate self-care (mean [SD], 57.2 [22.0]); their health status, as assessed by all domains of the Kansas City Cardiomyopathy Questionnaire, was fair to good except for self-efficacy, which was good to excellent. Self-care was associated with health status ( P < .01) and sense of security ( P < .001). Regression analysis confirmed the mediating effect of sense of security on the relationship between self-care and health status.

CONCLUSIONS

Sense of security in patients with heart failure is an important part of daily life and contributes to better health status. Heart failure management should not only support self-care but also aim to strengthen sense of security through positive care interaction (provider-patient communication) and the promotion of patients' self-efficacy, and by facilitating access to care.

Predictive Strategies to Reduce the Risk of Rehospitalization with a Focus on Frail Older Adults: A Narrative Review

Frailty is a geriatric syndrome that has physical, cognitive, psychological, social, and environmental components and is characterized by a decrease in physiological reserves. Frailty is associated with several adverse health outcomes such as an increase in rehospitalization rates, falls, delirium, incontinence, dependency on daily living activities, morbidity, and mortality. Older adults may become frailer with each hospitalization; thus, it is beneficial to develop and implement preventive strategies. The present review aims to highlight the epidemiological importance of frailty in rehospitalization and to compile predictive strategies and related interventions to prevent hospitalizations. Firstly, it is important to identify pre-frail and frail older adults using an instrument with high validity and reliability, which can be a practically applicable screening tool. Comprehensive geriatric assessment-based care is an important strategy known to reduce morbidity, mortality, and rehospitalization in older adults and aims to meet the needs of frail patients with a multidisciplinary approach and intervention that includes physiological, psychological, and social domains. Moreover, effective multimorbidity management, physical activity, nutritional support, preventing cognitive frailty, avoiding polypharmacy and anticholinergic drug burden, immunization, social support, and reducing the caregiver burden are other recommended predictive strategies to prevent post-discharge rehospitalization in frail older adults.

Effectiveness of outpatient geriatric evaluation and management intervention on survival and nursing home admission: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The benefit of inpatient comprehensive geriatric assessment on patient survival and function has been demonstrated among frail older patients. However, the influence of outpatient geriatric evaluation and management (GEM) on clinical outcomes remains debated. This study aimed to update the research evidence detailing the effect of outpatient GEM on survival and nursing-home admission through a comparison with conventional care.

METHODS

Cochrane Library, EMBASE, and MEDLINE databases were searched up to January 29th, 2022, to identify randomized controlled trials (RCTs) including older people over age 55 that compared outpatient GEM with conventional care on mortality (primary outcome) and nursing-home admission (secondary outcome) during a follow-up period of 12 to 36 months.

RESULTS

Nineteen reports from 11 studies that recruited 7,993 participants (mean age 70-83) were included. Overall, outpatient GEM significantly reduced mortality (risk ratio (RR) = 0.87, 95% confidence interval (CI) = 0.77-0.99, I2 = 12%). For the subgroup analysis categorized by different follow-up periods, its prognostic benefit was only disclosed for 24-month mortality (RR = 0.68, 95% CI = 0.51-0.91, I2 = 0%), but not for 12- or 15 to 18-month mortality. Furthermore, outpatient GEM had significantly trivial effects on nursing-home admission during the follow-up period of 12 or 24 months (RR = 0.91, 95% CI = 0.74-1.12, I2 = 0%).

CONCLUSIONS

Outpatient GEM led by a geriatrician with a multidisciplinary team improved overall survival, specifically during the 24-month follow-up period. This trivial effect was demonstrated in rates of nursing-home admission. Future research on outpatient GEM involving a larger cohort is warranted to corroborate our findings.

Health outcomes and implementation barriers and facilitators of comprehensive geriatric assessment in community settings: a systematic integrative review [PROSPERO registration no.: CRD42021229953]

BACKGROUND

Comprehensive geriatric assessment (CGA) addresses the bio-psycho-social needs of older adults through multidimensional assessments and management. Synthesising evidence on quantitative health outcomes and implementation barriers and facilitators would inform practice and policy on CGA for community-dwelling older adults.

METHODS

We systematically searched four medical and social sciences electronic databases for quantitative, qualitative, and mixed methods studies published from 1 January 2000 to 31 October 2020. Due to heterogeneity of articles, we narratively reviewed the synthesis of evidence on health outcomes and implementation barriers and facilitators.

RESULTS

We screened 14,151 titles and abstracts and 203 full text articles, and included 43 selected articles. Study designs included controlled intervention studies (n = 31), pre-post studies without controls (n = 4), case-control (n = 1), qualitative methods (n = 3), and mixed methods (n = 4). A majority of articles studied populations aged ≥75 years (n = 18, 42%). CGAs were most frequently conducted in the home (n = 25, 58%) and primary care settings (n = 8, 19%). CGAs were conducted by nurses in most studies (n = 22, 51%). There was evidence of improved functional status (5 of 19 RCTs, 2 of 3 pre-post), frailty and fall outcomes (3 of 6 RCTs, 1 of 1 pre-post), mental health outcomes (3 of 6 RCTs, 2 of 2 pre-post), self-rated health (1 of 6 RCTs, 1 of 1 pre-post), and quality of life (4 of 17 RCTs, 3 of 3 pre-post). Barriers to implementation of CGAs involved a lack of partnership alignment and feedback, poor acceptance of preventive work, and challenges faced by providers in operationalising and optimising CGAs. The perceived benefits of CGA that served to facilitate its implementation included the use of highly skilled staff to provide holistic assessments and patient education, and the resultant improvements in care coordination and convenience to the patients, particularly where home-based assessments and management were performed.

CONCLUSION

There is mixed evidence on the quantitative health outcomes of CGA on community-dwelling older adults. While there is perceived positive value from CGA when carried out by highly skilled staff, barriers such as bringing providers into a partnership, greater acceptance of preventive care, and operational issues could impede its implementation.

"To be seen" - older adults and their relatives' care experiences given by a geriatric mobile team (GerMoT)

Background

The proportion of older people in the population has increased globally and has thus become a challenge in health and social care. There is good evidence that care based on comprehensive geriatric assessment (CGA) is superior to the usual care found in acute hospital settings; however, the evidence is scarcer in community-dwelling older people.

This study is a secondary outcome of a randomized controlled trial of community-dwelling older people in which the intervention group (IG) received CGA-based care by a geriatric mobile geriatric team (GerMoT). The aim of this study is to obtain a better understanding, from the patients’ perspective, the experience of being a part of the IG for both the participants and their relatives.

Methods

Qualitative semistructured interviews of twenty-two community dwelling participants and eleven of their relatives were conducted using content analysis for interpretation.

Results

The main finding expressed by the participants and their relatives was in the form of feelings related to safety and security and being recognized. The participants found the care easily accessible, and that contacts could be taken according to needs by health care professionals who knew them. This is in accordance with person-centred care as recommended by the World Health Organisation (WHO) for older people in need of integrated care. Other positive aspects were recurrent health examinations and being given the time needed when seeking health care. Not all participants were positive as some found the information about the intervention to be unclear especially regarding whom to contact when in different situations.

Conclusions

CGA-based care of community-dwelling older people shows promising results as the participants in GerMoT found the care was giving a feeling of security and safety. They found the care easily accessible and that it was provided by health care professionals who knew them as a person and knew their health care problems. They found this to be in contrast to the usual care provided, but GerMoT care did not fulfill some people’s expectations.

Barriers and facilitators to interprofessional collaborative practice for community-dwelling older adults: An integrative review

AIMS AND OBJECTIVES

The aim of this integrative review was to synthesise empirical reports of interprofessional collaborative practice (IPCP) for community-dwelling older adults and uncover barriers and facilitators related to its success as a model of care for this population.

BACKGROUND

IPCP is a model of care that has demonstrated positive outcomes for community-dwelling older adults. However, a summary of barriers and facilitators to IPCP models has not been presented.

METHODS

An integrative review using the method posited by Whittemore and Knafl was completed to identify barriers and facilitators to IPCP for community-dwelling older adults. The literature search was reported following PRISMA guidelines.

RESULTS

Four themes emerged as barriers to IPCP: (1) A (Potential) Logistical Nightmare, (2) All About the Money, (3) If We Can't Test It, Can We Recommend It? and (4) Challenging for the Team, Challenging for the Client. Three themes emerged as facilitators to IPCP: (1) Reducing Resource Waste, (2) The "C" in IPCP and (3) What Matters Most.

CONCLUSIONS

IPCP models for community-dwelling older adults must adapt to the setting of care and client needs. Interprofessional education opportunities for team members facilitate effective IPCP. Healthcare policies and funding structures need to address IPCP for community-dwelling older adults for this model to be successful and sustainable.

RELEVANCE TO CLINICAL PRACTICE

Nurses participate on and lead IPCP teams caring for community-dwelling older adults and, therefore, need to be aware of barriers and facilitators to this model of care.

Comparative Effectiveness of a Complex Care Program for High-Cost/High-Need Patients: a Retrospective Cohort Study

BACKGROUND

High-cost/high-need (HCHN) adults and the healthcare systems that provide their care may benefit from a new patient-centered model of care involving a dedicated physician and nurse team who coordinate both clinical and social services for a small patient panel.

OBJECTIVE

Evaluate the impact of a Complex Care Program (CCP) on likelihood of patient survival and hospital admission in 180 days following empanelment to the CCP.

DESIGN

Retrospective cohort study using a quasi-experimental design with CCP patients propensity score matched to a concurrent control group of eligible but unempaneled patients.

SETTING

Kaiser Permanente Mid-Atlantic States (KPMAS) during 2017-2018.

PARTICIPANTS

Nine hundred twenty-nine CCP patients empaneled January 2017-June 2018, 929 matched control patients for the same period.

INTERVENTIONS

The KPMAS CCP is a new program consisting of 8 teams each staffed by a physician and nurse who coordinate care across a continuum of specialty care, tertiary care, and community services for a panel of 200 patients with advanced clinical disease and recent hospitalizations.

MAIN OUTCOMES

Time to death and time to first hospital admission in the 180 days following empanelment or eligibility.

RESULTS

Compared to matched control patients, CCP patients had prolonged time to death (hazard ratio [HR]: 0.577, 95% CI: 0.474, 0.704), and CCP decedents had longer survival (median days 69.5 vs. 53.0, p=0.03). CCP patients had similar time to hospital admission (HR: 1.081, 95% CI: 0.930, 1.258), with similar results when adjusting for competing risk of death (HR: 1.062, 95% CI: 0.914, 1.084).

LIMITATIONS

Non-randomized intervention; single healthcare system; patient eligibility limited to specific conditions.

CONCLUSION

The KPMAS CCP was associated with significantly reduced short-term mortality risk for eligible patients who volunteered to participate in this intervention.

Intervention effectiveness by pharmacists integrated within an interdisciplinary health team on chronic complex patients

BACKGROUND

Nowadays, it is difficult to establish a specific method of intervention by the pharmacist and its clinical repercussions. Our aim was to identify interventions by pharmacists integrated within an interdisciplinary team for chronic complex patients (CCPs) and determine which of them produce the best results.

METHODS

A systematic review (SR) was performed based on PICO(d) question (2008-18): (Population): CCPs; (Intervention): carried out by health system pharmacists in collaboration with an interdisciplinary team; (Comparator): any; (Outcome): clinical and health resources usage outcomes; (Design): meta-analysis, SR and randomized clinical trials.

RESULTS

Nine articles were included: one SR and eight randomized clinical trials. The interventions consisted mainly in putting in order the pharmacotherapy and the review of the medication adequacy, medication reconciliation in transition of care and educational intervention for health professionals. Only one showed significant improvements in mortality (27.9% vs. 38.5%; HR = 1.49; P = 0.026), two in health-related quality of life [according to EQ-5D (European Quality of Life-5 Dimensions) and EQ-VAS (European Quality of Life-Visual Analog Scale) tests] and four in other health-related results (subjective self-assessment scales, falls or episodes of delirium and negative health outcomes associated with medication). Significant differences between groups were found in hospital stay and frequency of visits to the emergency department. No better results were observed in hospitalization rate. Otherwise, one study measured cost utility and found a cost of €45 987 per quality-adjusted life year gained due to the intervention.

CONCLUSIONS

It was not possible to determine with certainty which interventions produce the best results in CCPs. The clinical heterogeneity of the studies and the short follow-up of most studies probably contributed to this uncertainty.

Effectiveness of comprehensive geriatric assessment intervention on quality of life, caregiver burden and length of hospital stay: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Comprehensive geriatric assessment (CGA) interventions can improve functional ability and reduce mortality in older adults, but the effectiveness of CGA intervention on the quality of life, caregiver burden, and length of hospital stay remains unclear. The study aimed to determine the effectiveness of CGA intervention on the quality of life, length of hospital stay, and caregiver burden in older adults by conducting meta-analyses of randomised controlled trials (RCTs).

METHODS

A literature search in PubMed, Embase, and Cochrane Library was conducted for papers published before February 29, 2020, based on inclusion criteria. Standardised mean difference (SMD) or mean difference (MD) with 95% confidence intervals (CIs) was calculated using the random-effects model. Subgroup analyses, sensitivity analyses, and publication bias analyses were also conducted.

RESULTS

A total of 28 RCTs were included. Overall, the intervention components common in different CGA intervention models were interdisciplinary assessments and team meetings. Meta-analyses showed that CGA interventions improved the quality of life of older people (SMD = 0.12; 95% CI = 0.03 to 0.21; P = 0.009) compared to usual care, and subgroup analyses showed that CGA interventions improved the quality of life only in participants' age > 80 years and at follow-up ≤3 months. The change value of quality of life in the CGA intervention group was better than that in the usual care group on six dimensions of the 36-Item Short-Form Health Survey questionnaire (SF-36). Also, compared to usual care, the CGA intervention reduced the caregiver burden (SMD = - 0.56; 95% CI = - 0.97 to - 0.15, P = 0.007), but had no significant effect on the length of hospital stay.

CONCLUSIONS

CGA intervention was effective in improving the quality of life and reducing caregiver burden, but did not affect the length of hospital stay. It is recommended that future studies apply the SF-36 to evaluate the impact of CGA interventions on the quality of life and provide supportive strategies for caregivers as an essential part of the CGA intervention, to find additional benefits of CGA interventions.

Costs and effects of comprehensive geriatric assessment in primary care for older adults with high risk for hospitalisation

Background

The healthcare system needs effective strategies to identify the most vulnerable group of older patients, assess their needs and plan their care proactively. To evaluate the effectiveness of comprehensive geriatric assessment (CGA) of older adults with a high risk of hospitalisation we conducted a prospective, pragmatic, matched-control multicentre trial at 19 primary care practices in Sweden.

Methods

We identified 1604 individuals aged 75 years and older using a new, validated algorithm that calculates a risk score for hospitalisation from electronic medical records. After a nine-month run-in period for CGA in the intervention group, 74% of the available 646 participants had accepted and received CGA, and 662 participants remained in the control group. Participants at intervention practices were invited to CGA performed by a nurse together with a physician. The CGA was adapted to the primary care context. The participants thereafter received actions according to individual needs during a two-year follow-up period. Participants at control practices received care as usual. The primary outcome was hospital care days. Secondary outcomes were number of hospital care episodes, number of outpatient visits, health care costs and mortality. Outcomes were analysed according to intention to treat and adjusted for age, gender and risk score. We used generalised linear mixed models to compare the intervention group and control group regarding all outcomes.

Results

Mean age was 83.2 years, 51% of the 1308 participants were female. Relative risk reduction for hospital care days was − 22% (− 35% to − 4%, p = 0.02) during the two-year follow-up. Relative risk reduction for hospital care episodes was − 17% (− 30% to − 2%, p = 0.03). There were no significant differences in outpatient visits or mortality.

Health care costs were significantly lower in the intervention group, adjusted mean difference was € − 4324 (€ − 7962 to − 686, p = 0.02).

Conclusions and relevance

Our findings indicate that CGA in primary care can reduce the need for hospital care days in a high-risk population of older adults. This could be of great importance in order to manage increasing prevalence of frailty and multimorbidity.

Trial registration

clinicaltrials.gov Identifier: NCT03180606, first posted 08/06/2017.

The Seniors' Community Hub: An Integrated Model of Care for the Identification and Management of Frailty in Primary Care

(1) Background: Integrated models of primary care deliver the comprehensive and preventative approach needed to identify and manage frailty in older people. Seniors' Community Hub (SCH) was developed to deliver person-centered, evidence-informed, coordinated, and integrated care services to older community dwelling adults living with frailty. This paper aims to describe the SCH model, and to present patient-oriented results of the pilot. (2) Methods: SCH was piloted in an academic clinic with six family physicians. Eligible patients were community dwelling, 65 years of age and older, and considered to be at risk of frailty (eFI > 0.12). Health professionals within the clinic received training in geriatrics and interprofessional teamwork to form the SCH team working with family physicians, patients and caregivers. The SCH intervention consisted of a team-based multi-domain assessment with person-centered care planning and follow-up. Patient-oriented outcomes (EQ-5D-5L and EQ-VAS) and 4-metre gait speed were measured at initial visit and 12 months later. (3) Results: 88 patients were enrolled in the pilot from April 2016-December 2018. No statistically significant differences in EQ-5D-5L/VAS or the 4-metre gait speed were detected in 38 patients completing the 12-month assessment. (4) Conclusions: Future larger scale studies of longer duration are needed to demonstrate impacts of integrated models of primary care on patient-oriented outcomes for older adults living with frailty.

Symptom management strategies used by older community-dwelling people with multimorbidity and a high symptom burden - a qualitative study

BACKGROUND

Older community-dwelling people with multimorbidity are often not only vulnerable, but also suffer from several conditions that could produce a multiplicity of symptoms. This results in a high symptom burden and a reduced health-related quality of life. Even though these individuals often have frequent contact with healthcare providers they are expected to manage both appropriate disease control and symptoms by themselves or with the support of caregivers. The aim of this study was therefore to describe the symptom management strategies used by older community-dwelling people with multimorbidity and a high symptom burden.

METHOD

A qualitative descriptive design using face-to-face interviews with 20 community-dwelling older people with multimorbidity, a high healthcare consumption and a high symptom burden. People ≥75 years, who had been hospitalized ≥3 times during the previous year, ≥ 3 diagnoses in their medical records and lived at home were included. The participants were between 79 and 89 years old. Data were analysed using content analyses.

RESULT

Two main strategy categories were found: active symptom management and passive symptom management. The active strategies include the subcategories; to plan, to distract, to get assistance and to use facilitating techniques. An active strategy meant that participants took matters in their own hands, they could often describe the source of the symptoms and they felt that they had the power to do something to ease their symptoms. A passive symptom management strategy includes the subcategories to give in and to endure. These subcategories often reflected an inability to describe the source of the symptoms as well as the experience of having no alternative other than passively waiting it out.

CONCLUSIONS

These findings show that older people with multimorbidity and a high symptom burden employ various symptom management strategies on daily basis. They had adopted appropriate strategies based on their own experience and knowledge. Healthcare professionals might facilitate daily life for older people with multimorbidity by providing guidance on active management strategies with focus on patient's own experience and preferences.

Clinically useful prediction of hospital admissions in an older population

Background

The healthcare for older adults is insufficient in many countries, not designed to meet their needs and is often described as disorganized and reactive. Prediction of older persons at risk of admission to hospital may be one important way for the future healthcare system to act proactively when meeting increasing needs for care. Therefore, we wanted to develop and test a clinically useful model for predicting hospital admissions of older persons based on routine healthcare data.

Methods

We used the healthcare data on 40,728 persons, 75–109 years of age to predict hospital in-ward care in a prospective cohort. Multivariable logistic regression was used to identify significant factors predictive of unplanned hospital admission. Model fitting was accomplished using forward selection. The accuracy of the prediction model was expressed as area under the receiver operating characteristic (ROC) curve, AUC.

Results

The prediction model consisting of 38 variables exhibited a good discriminative accuracy for unplanned hospital admissions over the following 12 months (AUC 0.69 [95% confidence interval, CI 0.68–0.70]) and was validated on external datasets. Clinically relevant proportions of predicted cases of 40 or 45% resulted in sensitivities of 62 and 66%, respectively. The corresponding positive predicted values (PPV) was 31 and 29%, respectively.

Conclusion

A prediction model based on routine administrative healthcare data from older persons can be used to find patients at risk of admission to hospital. Identifying the risk population can enable proactive intervention for older patients with as-yet unknown needs for healthcare.

Mobile Geriatric Teams - A Cost-Effective Way Of Improving Patient Safety And Reducing Traditional Healthcare Utilization Among The Frail Elderly? A Randomized Controlled Trial

Background

Demographic changes combined with costly technological progress put a financial strain on the healthcare sector in the industrialized world. Hence, there is a constant need to develop new cost-effective treatment procedures in order to optimize the use of available resources. As a response, the concept of a Mobile Geriatric Team (MGT) has emerged not only nationally but also internationally during the last decade; however, scientific evaluation of this initiative has been very scarce. Thus, the objective of this study was to perform a mixed methods analysis, including a prospective, controlled and randomized quantitative evaluation, in combination with an interview-based qualitative assessment, to measure the effectiveness and user satisfaction of MGT.

Materials and methods

Community-dwelling, frail elderly people were randomized to an intervention group (n=31, mean age 84) and a control group (n=31, mean age 86). A two-year retrospective quantitative data collection and a prospective one-year follow-up on healthcare utilization were combined with qualitative interviews. Non-parametric statistics and difference-in-difference (DiD) analyses were applied to the quantitative data. Qualitative data were analyzed using content analysis.

Results

No significant group differences in healthcare utilization were found before inclusion. Post intervention, primary care contact (including MGTs) increased for the MGT group. Inpatient care decreased dramatically for both groups. Hence, the increase in primary care contact for MGT patients was not accompanied by a reduction in inpatient care compared to the control group. Utilization of non-primary care was lower (p< 0.01) post-intervention in both groups.

Conclusion

There appears to be a "natural" variation in healthcare needs over time among frail elderly people. Hence, it is vital to perform open, controlled clinical studies in tandem with the implementation of new caregiving strategies. The MGT initiative was clearly appreciated but did not fully achieve the desired reduction in healthcare utilization in this study.

Trial registration

Retrospectively registered 09/10/2018, ClinicalTrials.gov ID NCT03662945.

Effects Of Increasing The Involvement Of Community-Dwelling Frail Older Adults In A Proactive Assessment Service: A Pragmatic Trial

BACKGROUND

Older adults and care professionals advocate a more integrated and proactive care approach. This can be achieved by proactive outpatient assessment services that offer comprehensive geriatric assessments to better understand the needs of older adults and deliver person-centered and preventive care. However, the effects of these services are inconsistent. Increased involvement of the older adult during the assessment service could increase the effects on older adult's well-being.

METHODS

We studied the effect of an assessment service (Sage-atAge) for community-dwelling frail adults aged ≥65 years. After studying the local experiences, this service was adapted with the aim to increase participant involvement through individual goal setting and using motivational interviewing techniques by health-care professionals (Sage-atAge+). Within Sage-atAge+, when finishing the assessment, a "goal card" was written together with the older adult: a summary of the assessment, including goals and recommendations. We measured well-being with a composite endpoint consisting of health, psychological, quality of life, and social components. With regression analysis, we compared the effects of the Sage-atAge and Sage-atAge+ services on the well-being of participants.

RESULTS

In total, 453 older adults were eligible for analysis with a mean age of 77 (± 7.0) years of whom 62% were women. We found no significant difference in the change in well-being scores between the Sage-atAge+ service and the original Sage-atAge service (B, 0.037; 95% CI, -0.188 to 0.263). Also, no change in well-being scores was found even when selecting only those participants for the Sage-atAge+ group who received a goal card.

CONCLUSION

Efforts to increase the involvement of older adults through motivational interviewing and goal setting showed no additional effect on well-being. Further research is needed to explore the relationship between increased participant involvement and well-being to further develop person-centered care for older adults.

Factors related to health-related quality of life in older people with multimorbidity and high health care consumption over a two-year period

BACKGROUND

The prevalence of multimorbidity is increasing worldwide, and older people with multimorbidity are frequent users of health care services. Since multimorbidity has a significant negative impact on Health-related Quality of Life (HrQoL) and is more common in older age it would be expected that factors related to HrQoL in this group might have been thoroughly researched, but this is not the case. Furthermore, it is important to look at old people living at home, considering the shift from residential to home-based care. Therefore, we aim to investigate factors that are related to HrQoL in older people with multimorbidity and high health care consumption, living at home.

METHODS

This is a secondary analysis of a RCT study conducted in a municipality in south-eastern Sweden. The study had a longitudinal design with a two-year follow-up period assessing HrQoL, symptom burden, activities of daily living, physical activity and depression.

RESULTS

In total, 238 older people with multimorbidity and high health care consumption, living at home were included (mean age 82, 52% female). A multiple linear regression model including symptom burden, activities of daily living and depression as independent variables explained 64% of the HrQoL. Higher symptom burden, lower ability in activities of daily living and a higher degree of depression were negatively related to HrQoL. Depression at baseline and a change in symptom burden over a two-year period explained 28% of the change in HrQoL over a two-year period variability. A higher degree of depression at baseline and negative change in higher symptom burden were related to a decrease in HrQoL over a two-year period.

CONCLUSION

In order to facilitate better delivery of appropriate health care to older people with high health care consumption living at home it is important to assess HrQoL, and HrQoL over time. Symptom burden, activities of daily living, depression and change in symptom burden over time are important indicators for HrQoL.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT01446757 , the trial was registered prospectively with the date of trial registration October 5^th, 2011.

Does comprehensive geriatric assessment (CGA) in an outpatient care setting affect the causes of death and the quality of palliative care? A subanalysis of the age-FIT study

PURPOSE

The purposes of this study were to retrospectively study whether comprehensive geriatric assessment (CGA) given to community-dwelling old patients with high health care usage has effects regarding: (1) the cause of death and (2) the quality of the provided palliative care when compared to patients without CGA-based care.

METHOD

This study includes secondary data from a randomised controlled trial (RCT) with 382 participants that took place in the periods 2011-2013. The present study examines all electronical medical records (EMR) from the deceased patients in the original study regarding cause of death [intervention group (IG) N = 51/control group (CG) N = 66] and quality of palliative care (IG N = 33/CG N = 41). Descriptive and comparative statistics were produced and the significance level was set at p < 0.05.

RESULTS

The causes of death in both groups were dominated by cardiovascular and cerebrovascular diseases with no statistical difference between the groups. Patients in the intervention group had a higher degree of support from specialised palliative care teams than had the control group (p = 0.01).

CONCLUSION

The present study in an outpatient context cannot prove any effects of CGA on causes of death. The study shows that CGA in outpatient care means a higher rate of specialised palliative care, but the study cannot show any effects on the palliative quality parameters measured. Further studies with statistical power are needed.

Outpatient comprehensive geriatric assessment: effects on frailty and mortality in old people with multimorbidity and high health care utilization

BACKGROUND

Multimorbidity and frailty are often associated and Comprehensive Geriatric Assessment (CGA) is considered the gold standard of care for these patients.

AIMS

This study aimed to evaluate the effect of outpatient Comprehensive Geriatric Assessment (CGA) on frailty in community-dwelling older people with multimorbidity and high health care utilization.

METHODS

The Ambulatory Geriatric Assessment-Frailty Intervention Trial (AGe-FIT) was a randomized controlled trial (intervention group, n = 208, control group n = 174) with a follow-up period of 24 months. Frailty was a secondary outcome. Inclusion criteria were: age ≥ 75 years, ≥ 3 current diagnoses per ICD-10, and ≥ 3 inpatient admissions during 12 months prior to study inclusion. The intervention group received CGA-based care and tailored interventions by a multidisciplinary team in an Ambulatory Geriatric Unit, in addition to usual care. The control group received usual care. Frailty was measured with the Cardiovascular Health Study (CHS) criteria. At 24 months, frail and deceased participants were combined in the analysis.

RESULTS

Ninety percent of the population were frail or pre-frail at baseline. After 24 months, there was a significant smaller proportion of frail and deceased (p = 0.002) and a significant higher proportion of pre-frail patients in the intervention group (p = 0.004). Mortality was high, 18% in the intervention group and 26% in the control group.

CONCLUSION

Outpatient CGA may delay the progression of frailty and may contribute to the improvement of frail patients in older persons with multimorbidity.

A patient-centred intervention to improve the management of multimorbidity in general practice: the 3D RCT

Background

People with multimorbidity experience impaired quality of life, poor health and a burden from treatment. Their care is often disease-focused rather than patient-centred and tailored to their individual needs.

Objective

To implement and evaluate a patient-centred intervention to improve the management of patients with multimorbidity in general practice.

Design

Pragmatic, cluster randomised controlled trial with parallel process and economic evaluations. Practices were centrally randomised by a statistician blind to practice identifiers, using a computer-generated algorithm.

Setting

Thirty-three general practices in three areas of England and Scotland.

Participants

Practices had at least 4500 patients and two general practitioners (GPs) and used the EMIS (Egton Medical Information Systems) computer system. Patients were aged ≥ 18 years with three or more long-term conditions.

Interventions

The 3D (Dimensions of health, Depression and Drugs) intervention was designed to offer patients continuity of care with a named GP, replacing separate reviews of each long-term condition with comprehensive reviews every 6 months. These focused on individualising care to address patients’ main problems, attention to quality of life, depression and polypharmacy and on disease control and agreeing treatment plans. Control practices provided usual care.

Outcome measures

Primary outcome – health-related quality of life (assessed using the EuroQol-5 Dimensions, five-level version) after 15 months. Secondary outcomes – measures of illness burden, treatment burden and patient-centred care. We assessed cost-effectiveness from a NHS and a social care perspective.

Results

Thirty-three practices (1546 patients) were randomised from May to December 2015 [16 practices (797 patients) to the 3D intervention, 17 practices (749 patients) to usual care]. All participants were included in the primary outcome analysis by imputing missing data. There was no evidence of difference between trial arms in health-related quality of life {adjusted difference in means 0.00 [95% confidence interval (CI) –0.02 to 0.02]; p = 0.93}, illness burden or treatment burden. However, patients reported significant benefits from the 3D intervention in all measures of patient-centred care. Qualitative data suggested that both patients and staff welcomed having more time, continuity of care and the patient-centred approach. The economic analysis found no meaningful differences between the intervention and usual care in either quality-adjusted life-years [(QALYs) adjusted mean QALY difference 0.007, 95% CI –0.009 to 0.023] or costs (adjusted mean difference £126, 95% CI –£739 to £991), with wide uncertainty around point estimates. The cost-effectiveness acceptability curve suggested that the intervention was unlikely to be either more or less cost-effective than usual care. Seventy-eight patients died (46 in the intervention arm and 32 in the usual-care arm), with no evidence of difference between trial arms; no deaths appeared to be associated with the intervention.

Limitations

In this pragmatic trial, the implementation of the intervention was incomplete: 49% of patients received two 3D reviews over 15 months, whereas 75% received at least one review.

Conclusions

The 3D approach reflected international consensus about how to improve care for multimorbidity. Although it achieved the aim of providing more patient-centred care, this was not associated with benefits in quality of life, illness burden or treatment burden. The intervention was no more or less cost-effective than usual care. Modifications to the 3D approach might improve its effectiveness. Evaluation is needed based on whole-system change over a longer period of time.

Trial registration

Current Controlled Trials ISRCTN06180958.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 7, No. 5. See the NIHR Journals Library website for further project information.

Self-reported health and quality of life outcomes of heart failure patients in the aftermath of a national economic crisis: a cross-sectional study

AIMS

There are indications that economic crises can affect public health. The aim of this study was to describe characteristics, health status, and socio-economic status of outpatient heart failure (HF) patients several years after a national economic crisis and to assess whether socio-economic factors were associated with patient-reported outcome measures (PROMs).

METHODS AND RESULTS

In this cross-sectional survey, PROMs were measured with seven validated instruments, as follows: self-care (the 12-item European Heart Failure Self-Care Behaviour scale), HF-related knowledge (Dutch Heart Failure Knowledge Scale), symptoms (Edmonton Symptom Assessment System), sense of security (Sense of Security in Care-'Patients' evaluation'), health status (EQ-5D visual analogue scale), health-related quality of life (HRQoL) (Kansas City Cardiomyopathy Questionnaire), and anxiety and depression (Hospital Anxiety and Depression Scale). Additional data were collected on access and use of health care, household income, demographics, and clinical status. The patients' (n = 124, mean age 73 ± 14.9, 69% male) self-care was low for exercising (53%) and weight monitoring (50%) but optimal for taking medication (100%). HF-specific knowledge was high (correct answers 12 out of 15), but only 38% knew what to do when symptoms worsened suddenly. Patients' sense of security was high (>70% had a mean score of 5 or 6, scale 1-6). The most common symptom was tiredness (82%); 12% reported symptoms of anxiety, and 18% had symptoms of depression. Patients rated their overall health (EQ-5D) on average at 65.5 (scale 0-100), and 33% had poor or very bad HRQoL. The monthly income per household was <€3900 for 84% of the patients. A total of 22% had difficulties making appointments with a general practitioner (GP), and 5% had no GP. On average, patients paid for six health care-related items, and >90% paid for medications, primary care, and visits to hospital and private clinics out of their own pocket. The cost of health care had changed for 71% of the patients since the 2008 economic crisis, and increased out-of-pocket costs were most often explained by a greater need for health care services and medication expenses. There was no significant difference in PROMs related to changes in out-of-pocket expenses after the crisis, income, or whether patients lived alone or with others.

CONCLUSIONS

This Icelandic patient population reported similar health-related outcomes as have been previously reported in international studies. This study indicates that even after a financial crisis, most of the patients have managed to prioritize and protect their health even though a large proportion of patients have a low income, use many health care resources, and have insufficient access to care. It is imperative that access and affordable health care services are secured for this vulnerable patient population.

Is care based on comprehensive geriatric assessment with mobile teams better than usual care? A study protocol of a randomised controlled trial (The GerMoT study)

INTRODUCTION

Comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process used to determine the medical, psychological and functional capabilities of frail older people. The primary aim of our current study is to confirm whether CGA-based outpatient care is superior than usual care in terms of health-related outcomes, resource use and costs.

METHODS AND ANALYSIS

The Geriatric Mobile Team trial is designed as a single-centre randomised, controlled, assessor-blinded (at baseline) trial. All participants will be identified via local healthcare registries with the following inclusion criteria: age ≥75 years, ≥3 different diagnoses and ≥3 visits to the emergency care unit (with or without admittance to hospital) during the past 18 months. Nursing home residency will be an exclusion criterion. Baseline assessments will be done before the 1:1 randomisation. Participants in the intervention group will, after an initial CGA, have access to care given by a geriatric team in addition to usual care. The control group receives usual care only. The primary outcome is the total number of inpatient days during the follow-up period. Assessments of the outcomes: mortality, quality of life, health care use, physical functional level, frailty, dependence and cognition will be performed 12 and 24 months after inclusion. Both descriptive and analytical statistics will be used, in order to compare groups and for analyses of outcomes over time including changes therein. The primary outcome will be analysed using analysis of variance, including in-transformed values if needed to achieve normal distribution of the residuals.

ETHICS AND DISSEMINATION

Ethical approval has been obtained and the results will be disseminated in national and international journals and to health care leaders and stakeholders. Protocol amendments will be published in ClinicalTrials.gov as amendments to the initial registration NCT02923843. In case of success, the study will promote the implementation of CGA in outpatient care settings and thereby contribute to an improved care of older people with multimorbidity through dissemination of the results through scientific articles, information to politicians and to the public.

TRIAL REGISTRATION NUMBER

NCT02923843; Pre-results.

The potential impact of multidimesional geriatric assessment in the social security system

AIM

To evaluate the efficacy of multidimensional geriatric assessment (MGA/CGA) in patients over 65 years old in predicting the release of the accompaniment allowance (AA) indemnity by a Local Medico-Legal Committee (MLC-NHS) and by the National Institute of Social Security Committee (MLC-INPS).

METHODS

In a longitudinal observational study, 200 Italian elder citizens requesting AA were first evaluated by MLC-NHS and later by MLC-INPS. Only MLC-INPS performed a MGA/CGA (including SPMSQ, Barthel Index, GDS-SF, and CIRS). This report was written according to the STROBE guidelines.

RESULTS

The data analysis was performed on January 2016. The evaluation by the MLC-NHS and by the MLC-INPS was in agreement in 66% of cases. In the 28%, the AA benefit was recognized by the MLC-NHS, but not by the MLC-INPS. By the multivariate analysis, the best predictors of the AA release, by the MLC-NHS, were represented by gender and the Barthel Index score. The presence of carcinoma, the Barthel Index score, and the SPMQ score were the best predictors for the AA release by MLC-INPS.

CONCLUSIONS

MGA/CGA could be useful in saving financial resources reducing the risk of incorrect indemnity release. It can improve the accuracy of the impairment assessment in social security system.

Short-term Resource Utilization and Cost-Effectiveness of Comprehensive Geriatric Assessment in Acute Hospital Care for Severely Frail Elderly Patients

OBJECTIVE

The objective of this study was to estimate the 3-month within-trial cost-effectiveness of comprehensive geriatric assessment (CGA) in acute medical care for frail elderly patients compared to usual medical care, by estimating health-related quality of life and costs from a societal perspective.

DESIGN

Clinical, prospective, controlled, 1-center intervention trial with 2 parallel groups.

INTERVENTION

Structured, systematic interdisciplinary CGA-based care in an acute elderly care unit. If the patient fulfilled the inclusion criteria, and there was a bed available at the CGA unit, the patient was included in the intervention group. If no bed was available at the CGA unit, the patient was included in the control group and admitted to a conventional acute medical care unit.

SETTING AND PARTICIPANTS

A large county hospital in western Sweden. The trial included 408 frail elderly patients, 75 years or older, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n = 206) or control group (n = 202). Mean age of the patients was 85.7 years, and 56% were female.

MEASURES

The primary outcome was the adjusted incremental cost-effectiveness ratio associated with the intervention compared to the control at the 3-month follow-up.

RESULTS

We undertook cost-effectiveness analysis, adjusted by regression analyses, including hospital, primary, and municipal care costs and effects. The difference in the mean adjusted quality-adjusted life years gained between groups at 3 months was 0.0252 [95% confidence interval (CI): 0.0082-0.0422]. The incremental cost, that is, the difference between the groups, was -3226 US dollars (95% CI: -6167 to -285).

CONCLUSION

The results indicate that the care in a CGA unit for acutely ill frail elderly patients is likely to be cost-effective compared to conventional care after 3 months.

Geriatrician-performed comprehensive geriatric care in older adults referred to an outpatient community rehabilitation unit: A randomized controlled trial

BACKGROUND

Older adults make increasing demands on all sectors of the healthcare system. We investigated the effect of geriatrician-performed comprehensive geriatric care (CGC) in older adults referred to an outpatient community rehabilitation unit.

DESIGN

Randomized controlled trial.

SETTING

Two Danish non-hospital based rehabilitation units.

PARTICIPANTS

Persons aged 65 or older admitted from home or hospital.

INTERVENTION

CGC performed by a geriatrician at the rehabilitation unit.

OUTCOMES

Primary outcome was number of hospital admissions and emergency department (ED) visits. Secondary outcomes were number of ambulatory contacts, general practitioner (GP) contacts, activities of daily living (ADL) and overall quality of life (OQoL). Outcomes were measured within 90 days of admission to the rehabilitation units.

RESULTS

368 persons were randomized: 185 to the intervention group (IG) vs 183 to the control group (CG). Groups were comparable at baseline. The number of hospital admissions and ED visits, ambulatory contacts and out of hour GP visits or phone calls did not differ between the groups. The number of daytime GP consultations and visits or phone and email consultations was lower in the IG (P < 0.001). There were no differences in the mean between the groups for ADL and OQoL, but more participants in the IG improved their OQoL (OR 1.63, 95% CI: 1.07-2.48, P = 0.023).

CONCLUSION

Geriatrician-performed CGC in older adults in an outpatient community rehabilitation unit had no effect on the secondary healthcare utilization, but may reduce primary healthcare utilization and improve OQoL during the 90-day follow-up period.

TRIAL REGISTRATION

ClinicalTrials.govNCT01506219.

The effect of complex interventions on supporting self-care among community-dwelling older adults: a systematic review and meta-analysis

Background

self-care is critical to enable community-dwelling older adults to live independently. Complex interventions have emerged as a strategy to support self-care, but their effectiveness is unknown. Our objective was to review systematically their effectiveness on both positive (increased scores in self-rated health, Activities of Daily Living, Instrumental Activities of Daily Living, quality of life) and negative aspects (increased incidence of falls, fear of falling, hospital and nursing home admission, increased depression score), and to determine which intervention components explain the observed effects.

Methods

CINAHL, MEDLINE, British Nursing Index, PsycInfo and Cochrane CENTRAL were searched from January 2006 to October 2016. Randomised controlled trials providing at least two of these components: individual assessment, care planning or provision of information were reviewed. Outcomes were pooled by random-effects meta-analysis.

Results

twenty-two trials with 14,364 participants were included with a low risk of bias. Pooled effects showed significant benefits on positive aspects including self-rated health [standardised mean difference (SMD) 0.09, 95% confidence interval (CI) 0.01-0.17] and the mental subscale of quality of life (SMD 0.44, 95% CI 0.09-0.80) as well as on the negative aspect of incidence of falls [odds ratio (OR) 0.60, 95% CI 0.46-0.79]. There was no significant improvement in ADL, IADL, overall quality of life, fear of falling, reduction in health service utilisation or depression levels. Meta-regression and subgroup analysis did not identify any specific component or characteristic in complex interventions which explained these effects.

Conclusion

based on current evidence, supporting self-care in community-dwelling older adults using complex interventions effectively increases self-rated health, reduces the occurrence of falls and improves the mental subscale of quality of life.

Frailty and healthcare costs-longitudinal results of a prospective cohort study

Objective

to investigate how frailty and frailty symptoms affect healthcare costs in older age longitudinally.

Methods

data were gathered from a prospective cohort study in Saarland, Germany (two waves with 3-year interval, n = 1,636 aged 57-84 years at baseline). Frailty was assessed by the five Fried frailty criteria. Frailty was defined as having at least three criteria, the presence of 1-2 criteria as 'pre-frail'. Healthcare costs were quantified based on self-reported healthcare use in the sectors of inpatient treatment, outpatient treatment, professional nursing care and informal care as well as the provision of pharmaceuticals, medical supplies and dental prostheses.

Results

while the onset of pre-frailty did not increase (log) total healthcare costs after adjusting for potential confounders including comorbidity, progression from non-frailty to frailty was associated with an increase in total healthcare costs (for example, costs increased by ~54 and 101% if 3 and 4 or 5 symptoms were present, respectively). This association of frailty onset with increased healthcare costs was in particular observed in the inpatient sector and for informal nursing care. Among the frailty symptoms, the onset of exhaustion was associated with an increase in total healthcare costs, whereas changes in slowness, weakness, weight loss and low-physical activity were not significantly associated with an increase in total healthcare costs.

Conclusions

our data stress the economic relevance of frailty in late life. Postponing or reducing frailty might be fruitful in order to reduce healthcare costs.

Cost-effectiveness of comprehensive geriatric assessment at an ambulatory geriatric unit based on the AGe-FIT trial

Background

Older people with multi-morbidity are increasingly challenging for today’s healthcare, and novel, cost-effective healthcare solutions are needed. The aim of this study was to assess the cost-effectiveness of comprehensive geriatric assessment (CGA) at an ambulatory geriatric unit for people ≥75 years with multi-morbidity.

Method

The primary outcome was the incremental cost-effectiveness ratio (ICER) comparing costs and quality-adjusted life years (QALYs) of a CGA strategy with usual care in a Swedish setting. Outcomes were estimated over a lifelong time horizon using decision-analytic modelling based on data from the randomized AGe-FIT trial. The analysis employed a public health care sector perspective. Costs and QALYs were discounted by 3% per annum and are reported in 2016 euros.

Results

Compared with usual care CGA was associated with a per patient mean incremental cost of approximately 25,000 EUR and a gain of 0.54 QALYs resulting in an ICER of 46,000 EUR. The incremental costs were primarily caused by intervention costs and costs associated with increased survival, whereas the gain in QALYs was primarily a consequence of the fact that patients in the CGA group lived longer.

Conclusion

CGA in an ambulatory setting for older people with multi-morbidity results in a cost per QALY of 46,000 EUR compared with usual care, a figure generally considered reasonable in a Swedish healthcare context. A rather simple reorganisation of care for older people with multi-morbidity may therefore cost effectively contribute to meet the needs of this complex patient population.

Trial registration

The trial was retrospectively registered in clinicaltrial.gov, NCT01446757. September, 2011.

Electronic supplementary material

The online version of this article (10.1186/s12877-017-0703-1) contains supplementary material, which is available to authorized users.

Are frail elderly patients treated in a CGA unit more satisfied with their hospital care than those treated in conventional acute medical care?

OBJECTIVES

Our aim was to study whether the acute care of frail elderly patients directly admitted to a comprehensive geriatric assessment (CGA) unit is superior to the care in a conventional acute medical care unit in terms of patient satisfaction.

DESIGN

TREEE (Is the TReatment of frail Elderly patients Effective in an Elderly care unit?) is a clinical, prospective, controlled, one-center intervention trial comparing acute treatment in CGA units and in conventional wards.

SETTING

This study was conducted in the NÄL-Uddevalla county hospital in western Sweden.

PARTICIPANTS

In this follow-up to the TREEE study, 229 frail patients, aged ≥75 years, in need of acute in-hospital treatment, were eligible. Of these patients, 139 patients were included in the analysis, 72 allocated to the CGA unit group and 67 to the conventional care group. Mean age was 85 years and 65% were female.

INTERVENTION

Direct admittance to an acute elderly care unit with structured, systematic interdisciplinary CGA-based care, compared to conventional acute medical care via the emergency room.

MEASUREMENTS

The primary outcome was the satisfaction reported by the patients shortly after discharge from hospital. A four-item confidential questionnaire was used. Responses were given on a 4-graded scale.

RESULTS

The response rate was 61%. In unadjusted analyses, significantly more patients in the intervention group responded positively to the following three questions about the hospitalization: "Did you get the nursing from the ward staff that you needed?" (p=0.003), "Are you satisfied with the information you received on your diseases and medication?" (p=0.016), and "Are you satisfied with the planning before discharge from the hospital?" (p=0.032). After adjusted analyses by multiple regression, a significant difference in favor of the intervention remained for the first question (p=0.027).

CONCLUSION

Acute care in a CGA unit with direct admission was associated with higher levels of patient satisfaction compared with conventional acute care via the emergency room.

Effectiveness of Intensive Primary Care Interventions: A Systematic Review

BACKGROUND

Multicomponent, interdisciplinary intensive primary care programs target complex patients with the goal of preventing hospitalizations, but programs vary, and their effectiveness is not clear. In this study, we systematically reviewed the impact of intensive primary care programs on all-cause mortality, hospitalization, and emergency department use.

METHODS

We searched PubMed, CINAHL, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Reviews of Effects from inception to March 2017. Additional studies were identified from reference lists, hand searching, and consultation with content experts. We included systematic reviews, randomized controlled trials (RCTs), and observational studies of multicomponent, interdisciplinary intensive primary care programs targeting complex patients at high risk of hospitalization or death, with a comparison to usual primary care. Two investigators identified studies and abstracted data using a predefined protocol. Study quality was assessed using the Cochrane risk of bias tool.

RESULTS

A total of 18 studies (379,745 participants) were included. Three major intensive primary care program types were identified: primary care replacement (home-based; three RCTs, one observational study, N = 367,681), primary care replacement (clinic-based; three RCTs, two observational studies, N = 9561), and primary care augmentation, in which an interdisciplinary team was added to existing primary care (five RCTs, three observational studies, N = 2503). Most studies showed no impact of intensive primary care on mortality or emergency department use, and the effectiveness in reducing hospitalizations varied. There were no adverse effects reported.

DISCUSSION

Intensive primary care interventions demonstrated varying effectiveness in reducing hospitalizations, and there was limited evidence that these interventions were associated with changes in mortality. While interventions could be grouped into categories, there was still substantial overlap between intervention approaches. Further work is needed to identify program features that may be associated with improved outcomes.

Acute care of severely frail elderly patients in a CGA-unit is associated with less functional decline than conventional acute care

Background

A high percentage of individuals treated in specialized acute care wards are frail and elderly. Our aim was to study whether the acute care of such patients in a comprehensive geriatric assessment (CGA) unit is superior to care in a conventional acute medical care unit when it comes to activities of daily living (ADLs), frailty, and use of municipal help services.

Patients and methods

A clinical, prospective, controlled trial with two parallel groups was conducted in a large county hospital in West Sweden and included 408 frail elderly patients, age 75 or older (mean age 85.7 years; 56% female). Patients were assigned to the intervention group (n=206) or control group (n=202). Primary outcome was decline in functional activity ADLs assessed by the ADL Staircase 3 months after discharge from hospital. Secondary outcomes were degree of frailty and use of municipal help services.

Results

After adjustment by regression analyses, treatment in a CGA unit was independently associated with lower risk of decline in ADLs [odds ratio (OR) 0.093; 95% confidence interval (CI) 0.052–0.164; P<0.0001], and with a less prevalent increase in the degree of frailty (OR 0.229; 95% CI 0.131–0.400; P<0.0001). When ADLs were classified into three strata (independence, instrumental ADL-dependence, and personal ADL-dependence), changes to a more dependence-associated stratum were less prevalent in the intervention group (OR 0.194; 95% CI 0.085–0.444; P=0.0001). There was no significant difference between the groups in increased use of municipal help services (OR 0.682; 95% CI 0.395–1.178; P=0.170).

Conclusion

Acute care of frail elderly patients in a CGA unit was independently associated with lesser loss of functional ability and lesser increase in frailty after 3 months.

Is the acute care of frail elderly patients in a comprehensive geriatric assessment unit superior to conventional acute medical care?

OBJECTIVE

The aim of this study was to investigate whether the acute care of frail elderly patients in a comprehensive geriatric assessment (CGA) unit is superior to the care in a conventional acute medical care unit.

DESIGN

This is a clinical, prospective, randomized, controlled, one-center intervention study.

SETTING

This study was conducted in a large county hospital in western Sweden.

PARTICIPANTS

The study included 408 frail elderly patients, aged ≥75 years, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n=206) or control group (n=202). Mean age of the patients was 85.7 years, and 56% were female.

INTERVENTION

This organizational form of care is characterized by a structured, systematic interdisciplinary CGA-based care at an acute elderly care unit.

MEASUREMENTS

The primary outcome was the change in health-related quality of life (HRQoL) 3 months after discharge from hospital, measured by the Health Utilities Index-3 (HUI-3). Secondary outcomes were all-cause mortality, rehospitalizations, and hospital care costs.

RESULTS

After adjustment by regression analysis, patients in the intervention group were less likely to present with decline in HRQoL after 3 months for the following dimensions: vision (odds ratio [OR] =0.33, 95% confidence interval [CI] =0.14-0.79), ambulation (OR =0.19, 95% CI =0.1-0.37), dexterity (OR =0.38, 95% CI =0.19-0.75), emotion (OR =0.43, 95% CI =0.22-0.84), cognition (OR = 0.076, 95% CI =0.033-0.18) and pain (OR =0.28, 95% CI =0.15-0.50). Treatment in a CGA unit was independently associated with lower 3-month mortality adjusted by Cox regression analysis (hazard ratio [HR] =0.55, 95% CI =0.32-0.96), and the two groups did not differ significantly in terms of hospital care costs (P>0.05).

CONCLUSION

Patients in an acute CGA unit were less likely to present with decline in HRQoL after 3 months, and the care in a CGA unit was also independently associated with lower mortality, at no higher cost.

Symptom trajectory and symptom burden in older people with multimorbidity, secondary outcome from the RCT AGe-FIT study

AIM

The aim of this study was to follow the symptom trajectory of community-dwelling older people with multimorbidity and to explore the effect on symptom burden from an ambulatory geriatric care unit, based on comprehensive geriatric assessment.

BACKGROUND

Older community-dwelling people with multimorbidity suffer from a high symptom burden with a wide range of co-occurring symptoms often resulting to decreased health-related quality of life. There is a need to move from a single-disease model and address the complexity of older people living with multimorbidity.

DESIGN

Secondary outcome data from the randomized controlled Ambulatory Geriatric Assessment Frailty Intervention Trial (AGe-FIT).

METHODS

Symptom trajectory of 31 symptoms was assessed with the Memorial Symptom Assessment Scale. Data from 247 participants were assessments at baseline, 12 and 24 months, 2011-2013. Participants in the intervention group received care from an ambulatory geriatric care unit based on comprehensive geriatric assessment in addition to usual care.

RESULTS

Symptom prevalence and symptom burden were high and stayed high over time. Pain was the symptom with the highest prevalence and burden. Over the 2-year period 68-81% of the participants reported pain. Other highly prevalent and persistent symptoms were dry mouth, lack of energy and numbness/tingling in the hands/feet, affecting 38-59% of participants. No differences were found between the intervention and control group regarding prevalence, burden or trajectory of symptoms.

CONCLUSIONS

Older community-dwelling people with multimorbidity had a persistent high burden of symptoms. Receiving advanced interdisciplinary care at an ambulatory geriatric unit did not significantly reduce the prevalence or the burden of symptoms.

Long-Term Evaluation of the Ambulatory Geriatric Assessment: A Frailty Intervention Trial (AGe-FIT): Clinical Outcomes and Total Costs After 36 Months

OBJECTIVE

To compare the effects of care based on comprehensive geriatric assessment (CGA) as a complement to usual care in an outpatient setting with those of usual care alone. The assessment was performed 36 months after study inclusion.

DESIGN

Randomized, controlled, assessor-blinded, single-center trial.

SETTING

A geriatric ambulatory unit in a municipality in the southeast of Sweden.

PARTICIPANTS

Community-dwelling individuals aged ≥ 75 years who had received inpatient hospital care 3 or more times in the past 12 months and had 3 or more concomitant medical diagnoses were eligible for study inclusion. Participants were randomized to the intervention group (IG) or control group (CG).

INTERVENTION

Participants in the IG received CGA-based care for 24 to 31 months at the geriatric ambulatory unit in addition to usual care.

OUTCOME MEASURES

Mortality, transfer to nursing home, days in hospital, and total costs of health and social care after 36 months.

RESULTS

Mean age (SD) of participants was 82.5 (4.9) years. Participants in the IG (n = 208) lived 69 days longer than did those in the CG (n = 174); 27.9% (n = 58) of participants in the IG and 38.5% (n = 67) in the CG died (hazard ratio 1.49, 95% confidence interval 1.05-2.12, P = .026). The mean number of inpatient days was lower in the IG (15.1 [SD 18.4]) than in the CG (21.0 [SD 25.0], P = .01). Mean overall costs during the 36-month period did not differ between the IG and CG (USD 71,905 [SD 85,560] and USD 65,626 [SD 66,338], P = .43).

CONCLUSIONS

CGA-based care resulted in longer survival and fewer days in hospital, without significantly higher cost, at 3 years after baseline. These findings add to the evidence of CGA's superiority over usual care in outpatient settings. As CGA-based care leads to important positive outcomes, this method should be used more extensively in the treatment of older people to meet their needs.