How does the team approach to outpatient geriatric evaluation compare with traditional care: a report of a randomized controlled trial

Effect of nurse-physician collaboration on the incidence of complications, negative emotions and quality of life in cervical cancer patients: a randomized controlled study

The aim of this study was to evaluate the effect of nurse-physician collaboration on the incidence of complications, anxiety and depression, quality of life, and satisfaction with nursing care among cervical cancer patients undergoing three-dimensional intracavitary brachytherapy. In this randomized, single-blinded, placebo-controlled trial, 92 eligible cervical cancer patients were equally divided into two groups upon admission. The control group was given routine nursing, and the intervention group received a nurse-physician collaboration in addition to routine care. Anxiety, depression, and health-related quality of life in both groups were assessed and compared at baseline and discharge. The intervention group had significantly fewer complications and showed marked improvements in mental health and quality of life compared to the control group. Satisfaction with nursing care was substantially greater in the intervention group. These results support the clinical adoption of a nurse-physician collaborative care model in the management of cervical cancer with three-dimensional intracavitary brachytherapy.

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.

Community case managers' challenges collaborating with primary care when managing complex patients in the community: A qualitative study in Singapore

Community case managers (CCMs) play a crucial role in the continuity of care for complex patients in the community. However, they are often considered as non-members of the healthcare team and not actively engaged by the primary care team because of the unique landscape of social services in Singapore. Given that these two distinct professional groups had minimal collaboration previously, integrating CCMs as partners of patient care within the primary care team may pose many challenges. The objective of this qualitative study was to understand the challenges encountered by CCMs when collaborating with primary care services. This exploratory qualitative descriptive study used individual in-depth interviews. CCMs were selected using convenience and snowball sampling. The interviews were semi-structured, guided by a topic guide. Fourteen CCMs were interviewed within a period of 12 weeks (October-December 2018). Thematic analysis was used to analyse the transcripts. Two researchers coded each transcript independently, and a coding framework was agreed upon. Potential themes were then independently developed based on the coding framework. Fourteen individual in-depth interviews were conducted. Six themes emerged from the data, i.e., self-identity, patient factor, inter-professional factor, collaborative culture, confidentiality and organisational structure. Challenges that resonated with previous studies were self-identity, inter-professional factors and confidentiality, whereas other challenges such as patient factors, collaborative culture and organisational structure were unique to Singapore's healthcare landscape. Significant challenges were encountered by CCMs when collaborating with primary care services. Understanding these challenges is key to refining intervention in current models of comprehensive community care between medical and non-medical professionals.

Clinical Impact of Nurses-Physicians Collaboration Intervention on the Treatment of Immune Recurrent Spontaneous Abortion with Low-Molecular-Weight Heparin

Anticoagulation is currently the preferred and effective treatment for patients with recurrent spontaneous abortion (RSA), but, due to the prevalence of mood disorders in RSA patients and the high number of adverse effects associated with long-term medication, effective care measures are often required. In this study, 94 patients with immune-type RSA who were admitted to our hospital from January 2018 to June 2019 were selected and randomly divided into a control group and a study group of 47 patients each; both groups received low-molecular-weight heparin treatment after admission, and the control group received conventional nursing interventions during treatment, while the patients in the study group received integrated medical and nursing care interventions. Pregnancy outcomes, pre- and postintervention scores on the Self-Assessment Scale (SAS), Self-Depression Scale (SDS), and Pittsburgh Sleep Quality Index (PSQI), levels of serum gamma-interferon (IFN-γ) and interleukin-4 (IL-4) and their ratios, complications, and patient satisfaction with the intervention were observed in both groups. The results showed that the success rate of fetal preservation in the study group (89.36%) was significantly higher than that in the control group (68.09%) (P < 0.05). After treatment, SAS, SDS, and PSQI scores decreased in both groups, with the study group being lower (P < 0.05). IFN-γ and IFN-γ/IL-4 levels decreased and IL-4 levels increased in both groups after treatment, with IFN-γ and IFN-γ/IL-4 being significantly lower and IL-4 levels being significantly higher in the study group than in the control group (P < 0.05). The incidence of adverse drug reactions in the study group was significantly lower than that in the control group (P < 0.05). Patients in the study group were more satisfied with all aspects of the intervention than the control group (P < 0.05). These results suggest that nurses-physicians collaboration intervention may improve the effectiveness of low-molecular-weight heparin therapy in patients with immune-type RSA. It helps to improve patient pregnancy outcomes, mood, sleep quality, and immune function and increases patient satisfaction.

Interventions for frail community-dwelling older adults have no significant effect on adverse outcomes: a systematic review and meta-analysis

BACKGROUND

According to some studies, interventions can prevent or delay frailty, but their effect in preventing adverse outcomes in frail community-dwelling older people is unclear. The aim is to investigate the effect of an intervention on adverse outcomes in frail older adults.

METHODS

A systematic review and meta-analysis of Medline, Embase, the Cochrane Library, and Social Sciences Citation Index. Randomized controlled studies that aimed to treat frail community-dwelling older adults, were included. The outcomes were mortality, hospitalization, formal health costs, accidental falls, and institutionalization. Several sub-analyses were performed (duration of intervention, average age, dimension, recruitment).

RESULTS

Twenty-five articles (16 original studies) were included. Six types of interventions were found. The pooled odds ratios (OR) for mortality when allocated in the experimental group were 0.99 [95% CI: 0.79, 1.25] for case management and 0.78 [95% CI: 0.41, 1.45] for provision information intervention. For institutionalization, the pooled OR with case management was 0.92 [95% CI: 0.63, 1.32], and the pooled OR for information provision intervention was 1.53 [95% CI: 0.64, 3.65]. The pooled OR for hospitalization when allocated in the experimental group was 1.13 [95% CI: 0.95, 1.35] for case management. Further sub-analyses did not yield any significant findings.

CONCLUSION

This systematic review and meta-analysis does not provide sufficient scientific evidence that interventions by frail older adults can be protective against the included adverse outcomes. A sub-analysis for some variables yielded no significant effects, although some findings suggested a decrease in adverse outcomes.

TRIAL REGISTRATION

Prospero registration CRD42016035429 .

Community screening for visual impairment in older people

BACKGROUND

Visual problems in older people are common and frequently under-reported. The effects of poor vision in older people are wide reaching and include falls, confusion and reduced quality of life. Much of the visual impairment in older ages can be treated (e.g. cataract surgery, correction of refractive error). Vision screening may therefore reduce the number of older people living with sight loss.

OBJECTIVES

The objective of this review was to assess the effects on vision of community vision screening of older people for visual impairment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 10); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov and the ICTRP. The date of the search was 23 November 2017.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared vision screening alone or as part of a multi-component screening package as compared to no vision screening or standard care, on the vision of people aged 65 years or over in a community setting. We included trials that used self-reported visual problems or visual acuity testing as the screening tool.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. We graded the certainty of the evidence using GRADE.

MAIN RESULTS

Visual outcome data were available for 10,608 people in 10 trials. Four trials took place in the UK, two in Australia, two in the United States and two in the Netherlands. Length of follow-up ranged from one to five years. Three of these studies were cluster-randomised trials whereby general practitioners or family physicians were randomly allocated to undertake vision screening or no vision screening. All studies were funded by government agencies. Overall we judged the studies to be at low risk of bias and only downgraded the certainty of the evidence (GRADE) for imprecision.Seven trials compared vision screening as part of a multi-component screening versus no screening. Six of these studies used self-reported vision as both screening tool and outcome measure, but did not directly measure vision. One study used a combination of self-reported vision and visual acuity measurement: participants reporting vision problems at screening were treated by the attending doctor, referred to an eye care specialist or given information about resources that were available to assist with poor vision. There was a similar risk of "not seeing well" at follow-up in people screened compared with people not screened in meta-analysis of six studies (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.97 to 1.14, 4522 participants high-certainty evidence). One trial reported "improvement in vision" and this occurred slightly less frequently in the screened group (RR 0.85, 95% CI 0.52 to 1.40, 230 participants, moderate-certainty evidence).Two trials compared vision screening (visual acuity testing) alone with no vision screening. In one study, distance visual acuity was similar in the two groups at follow-up (mean difference (MD) 0.02 logMAR, 95% CI -0.02 to 0.05, 532 participants, high-certainty evidence). There was also little difference in near acuity (MD 0.02 logMAR, 95% CI -0.03 to 0.07, 532 participants, high-certainty evidence). There was no evidence of any important difference in quality of life (MD -0.06 National Eye Institute 25-item visual function questionnaire (VFQ-25) score adjusted for baseline VFQ-25 score, 95% CI -2.3 to 1.1, 532 participants, high-certainty evidence). The other study could not be included in the data analysis as the number of participants in each of the arms at follow-up could not be determined. However the authors stated that there was no significant difference in mean visual acuity in participants who had visual acuity assessed at baseline (39 letters) as compared to those who did not have their visual acuity assessed (35 letters, P = 0.25, 121 participants).One trial compared a detailed health assessment including measurement of visual acuity (intervention) with a brief health assessment including one question about vision (standard care). People given the detailed health assessment had a similar risk of visual impairment (visual acuity worse than 6/18 in either eye) at follow-up compared with people given the brief assessment (RR 1.07, 95% CI 0.84 to 1.36, 1807 participants, moderate-certainty evidence). The mean composite score of the VFQ-25 was 86.0 in the group that underwent visual acuity screening compared with 85.6 in the standard care group, a difference of 0.40 (95% CI -1.70 to 2.50, 1807 participants, high-certainty evidence).

AUTHORS' CONCLUSIONS

The evidence from RCTs undertaken to date does not support vision screening for older people living independently in a community setting, whether in isolation or as part of a multi-component screening package. This is true for screening programmes involving questions about visual problems, or direct measurements of visual acuity.The most likely reason for this negative review is that the populations within the trials often did not take up the offered intervention as a result of the vision screening and large proportions of those who did not have vision screening appeared to seek their own intervention. Also, trials that use questions about vision have a lower sensitivity and specificity than formal visual acuity testing. Given the importance of visual impairment among older people, further research into strategies to improve vision of older people is needed. The effectiveness of an optimised primary care-based screening intervention that overcomes possible factors contributing to the observed lack of benefit in trials to date warrants assessment; trials should consider including more dependent participants, rather than those living independently in the community.

Which factors affect the implementation of geriatric recommendations by primary care physicians?

Background

The overall implementation rate for outpatient comprehensive geriatric assessment (OCGAU) recommendations ranges from 48.6 to 71%.

The purpose of the study was to identify factors that reduce the implementation rate of geriatric recommendations.

Methods

The medical records of patients who were assessed in the comprehensive geriatric assessment unit over an 8 year study period were surveyed. Data collected included patient's characteristics (socio-demographic, functional, cognitive, and affective condition, co-morbidity), number of recommendations, the identity of the geriatrician, and data related to the primary physician (age, sex, seniority, number of patients referred for geriatric assessment).

Results

Three thousand four hundred thirty-four recommendations were made for 488 patients (mean age 83.6 ± 0.6 years) of which 1,634 (47.6%) were implemented by their primary physician. In univariate analyses patients with an implementation rate < 25%, compared to patients with implementation rate ≥75%, had a higher Charlson Comorbidity Index Total Score (CCITS) (2.5 ± 1.9 vs. 1.8 ± 1.7, P < 0.05), a lower Barthel Index (82.8 ± 16.2 vs. 87.0 ± 15.3, P < 0.05), and a lower Instrumental Activity of Daily Living score (7.2 ± 3.5 vs. 8.2 ± 3.7, P < 0.05). There were no differences between these groups in other patient characteristics or the number of recommendations made during the assessment. Similarly, there were no differences in the identity of the geriatrician or the primary physician's characteristics. In the multivariate analysis only higher CCITS was associated with a lower rate of recommendation implementation by primary physicians.

Conclusions

There is a need to increase the implementation rate by primary physicians by increasing and strengthening the link with them and by further training in the field of geriatrics medicine.

Trial registration

The Helsinki committee of the Meir Medical Center approved the study (Approval #024/2015 [k]).

Geriatric Interdisciplinary Team Training Program

Geriatric interdisciplinary team training has long been a goal in health education with little progress. In 1997, the John A. Hartford Foundation funded eight programs nationally to create Geriatric Interdisciplinary Team Training (GITT) programs. Faculty trained 1,341 health professions students. The results of the evaluation, including presentation of new measures developed to assess interdisciplinary knowledge, are presented, and the implications of the program as a model of interdisciplinary education are discussed. Evaluation data from 537 student trainees are presented. At posttest, GITT trainees demonstrated improvement on all measures of attitudinal change, no change on the geriatric care planning measure, and a change in some of the questions on the test of team dynamics that varied by discipline. Changes were greatest for all the attitudinal measures with the self-reported Team Skills Scale indicating the most significant change—a change that is significant across medicine, nursing, and social work trainees.

Compliance With Recommendations From an Outpatient Geriatric Consultation Team

For outpatient geriatric consultation to be effective, it is necessary, although not sufficient, that recommendations made to patients are followed. This prospective cohort study describes the nature of, types of, and compliance with, recommendations made to patients by clinicians at a university-based outpatient geriatric clinic. All patients seen by an internal medicine physician or family practitioner were contacted 1 year following their initial visit to determine compliance with recommendations. Clinicians identified 4.6 problems per patient; more than one half had never been documented previously. The most common problems were medical (53.1%) and neuropsychiatric (26.7%). Pahents had substantial limitations in both instrumental (X = 2.3) and physical (X = 1.3) activities of daily living. Clinicians made 5.9 recommendations per patient, 67.1% of which were followed. Compliance was similar for medical and social recommendations. No predictors of compliance were identified. Practitioners need to be aware that one third of their recommendations are not followed, and characterizing patients at increased risk for noncompliance is difficult.

Can team-based care improve patient satisfaction? A systematic review of randomized controlled trials

Background

Team-based approaches to patient care are a relatively recent innovation in health care delivery. The effectiveness of these approaches on patient outcomes has not been well documented. This paper reports a systematic review of the relationship between team-based care and patient satisfaction.

Methods

We searched MEDLINE, EMBASE, Cochrane Library, CINAHL, and PSYCHOINFO for eligible studies dating from inception to October 8, 2012. Eligible studies reported (1) a randomized controlled trial, (2) interventions including both team-based care and non-team-based care (or usual care), and (3) outcomes including an assessment of patient satisfaction. Articles with different settings between intervention and control were excluded, as were trial protocols. The reference lists of retrieved papers were also evaluated for inclusion.

Results

The literature search yielded 319 citations, of which 77 were screened for further full-text evaluation. Of these, 27 articles were included in the systematic review. The 26 trials with a total of 15,526 participants were included in this systematic review. The pooling result of dichotomous data (number of studies: 10) showed that team-based care had a positive effect on patient satisfaction compared with usual care (odds ratio, 2.09; 95% confidence interval, 1.54 to 2.84); however, combined continuous data (number of studies: 7) demonstrated that there was no significant difference in patient satisfaction between team-based care and usual care (standardized mean difference, −0.02; 95% confidence interval, −0.40 to 0.36).

Conclusions

Some evidence showed that team-based care is better than usual care in improving patient satisfaction. However, considering the pooling result of continuous data, along with the suboptimal quality of included trials, further large-scale and high-quality randomized controlled trials comparing team-based care and usual care are needed.

Are multidisciplinary teams in secondary care cost-effective? A systematic review of the literature

Objective

To investigate the cost effectiveness of management of patients within the context of a multidisciplinary team (MDT) meeting in cancer and non-cancer teams in secondary care.

Design

Systematic review.

Data sources

EMBASE, MEDLINE, NHS EED, CINAHL, EconLit, Cochrane Library, and NHS HMIC.

Eligibility criteria for selecting studies

Randomised controlled trials (RCTs), cohort, case–control, before and after and cross-sectional study designs including an economic evaluation of management decisions made in any disease in secondary care within the context of an MDT meeting.

Data extraction

Two independent reviewers extracted data and assessed methodological quality using the Consensus on Health Economic Criteria (CHEC-list). MDTs were defined by evidence of two characteristics: decision making requiring a minimum of two disciplines; and regular meetings to discuss diagnosis, treatment and/or patient management, occurring at a physical location or by teleconferencing. Studies that reported on the costs of administering, preparing for, and attending MDT meetings and/or the subsequent direct medical costs of care, non-medical costs, or indirect costs, and any health outcomes that were relevant to the disease being investigated were included and classified as cancer or non-cancer MDTs.

Results

Fifteen studies (11 RCTs in non-cancer care, 2 cohort studies in cancer and non-cancer care, and 2 before and after studies in cancer and non cancer care) were identified, all with a high risk of bias. Twelve papers reported the frequency of meetings which varied from daily to three monthly and all reported the number of disciplines included (mean 5, range 2 to 9). The results from all studies showed mixed effects; a high degree of heterogeneity prevented a meta-analysis of findings; and none of the studies reported how the potential savings of MDT working may offset the costs of administering, preparing for, and attending MDT meetings.

Conclusions

Current evidence is insufficient to determine whether MDT working is cost-effective or not in secondary care. Further studies aimed at understanding the key aspects of MDT working that lead to cost-effective cancer and non-cancer care are required.

Interventions to prevent disability in frail community-dwelling older persons: an overview

This narrative review was conducted to provide an overview of the variety of interventions aimed at disability prevention in community-dwelling frail older persons and to summarize promising elements. The search strategy and selection process found 48 papers that met the inclusion criteria. The 49 interventions described in these 48 papers were categorized into 'comprehensive geriatric assessment', 'physical exercise', 'nutrition', 'technology', and 'other interventions'. There is a large diversity within and between the groups of interventions in terms of content, disciplines involved, duration, intensity, and setting. For 18 of the 49 interventions, significant positive effects for disability were reported for the experimental group. Promising features of interventions seem to be: multidisciplinary and multifactorial, individualized assessment and intervention, case management, long-term follow-up, physical exercise component (for moderate physically frail older persons), and the use of technology. Future intervention studies could combine these elements and consider the addition of new elements.

[Geriatric evaluation in oncology in the elderly subject]

The heterogeneity of the elderly population makes the simple application of standard therapeutic programs in oncological management complex, particularly if they have been validated on young populations. The NCCN and the SIOG recommend using a geriatric evaluation before setting up an individualized care program. Geriatric assessment has demonstrated its efficacy in a number of domains. This concept covers two broad activities: the Multidimensional Geriatric Evaluation (MGE), which is a standardized geriatric evaluation for detecting co-morbidities and broad geriatric syndromes, and the Detailed Geriatric Evaluation (DGE). The objective of the DGE is to inventory the patient's various problems, distinguish somatic and/or psychiatric pathologies from the physiological consequences of aging, assess the functional impact of diseases, understand how these diseases interfere with one another, assess their consequences on the patient's social environment, and prioritize the patient's different health issues. The DGE is a medical action organized into five phases designed to set up care so that the recommendations made can be followed.

Nurse-physician relationships in hospitals: 20,000 nurses tell their story

"Good" relationships between nurses and physicians are important to high-quality patient care. Five different types of nurse-physician relationships exist on clinical units. What are the differences in the nurse-physician climate between magnet and comparison hospitals? What are the organizational structures and best leadership practices that help nurses develop collegial and collaborative relationships with physicians?

Integrating social workers into primary care: physician and nurse perceptions of roles, benefits, and challenges

The primary aim of this article is to identify, from the perspective of primary care physicians and nurses, the challenges encountered in provision of health care to older adults and to identify potential roles, challenges, and benefits of integrating social workers into primary care teams. As more older adults live longer with multiple chronic conditions, primary care has been confronted with complex psychosocial problems that interact with medical problems pointing to a potential role for a social worker. From a policy perspective, the lack of strong evidence documenting the benefits that will accrue to patients and providers is a key barrier preventing the wider use of social workers in primary care. This article presents findings from three focus groups with primary care physicians and nurses to examine the perspectives of these key providers about the benefits and challenges of integrating social workers into the primary care team.

Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis

BACKGROUND

In old age, reduction in physical function leads to loss of independence, the need for hospital and long-term nursing-home care, and premature death. We did a systematic review to assess the effectiveness of community-based complex interventions in preservation of physical function and independence in elderly people.

METHODS

We searched systematically for randomised controlled trials assessing community-based multifactorial interventions in elderly people (mean age at least 65 years) living at home with at least 6 months of follow-up. Outcomes studied were living at home, death, nursing-home and hospital admissions, falls, and physical function. We did a meta-analysis of the extracted data.

FINDINGS

We identified 89 trials including 97 984 people. Interventions reduced the risk of not living at home (relative risk [RR] 0.95, 95% CI 0.93-0.97). Interventions reduced nursing-home admissions (0.87, 0.83-0.90), but not death (1.00, 0.97-1.02). Risk of hospital admissions (0.94, 0.91-0.97) and falls (0.90, 0.86-0.95) were reduced, and physical function (standardised mean difference -0.08, -0.11 to -0.06) was better in the intervention groups than in other groups. Benefit for any specific type or intensity of intervention was not noted. In populations with increased death rates, interventions were associated with reduced nursing-home admission. Benefit in trials was particularly evident in studies started before 1993.

INTERPRETATION

Complex interventions can help elderly people to live safely and independently, and could be tailored to meet individuals' needs and preferences.

Community screening for visual impairment in the elderly

BACKGROUND

While the aims of multicomponent screening of older people are broad, any benefit arising from the inclusion of a vision component in the assessment will necessarily be dependent on improving vision.

OBJECTIVES

To assess the effects on vision of mass screening of older people for visual impairment.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Group Trials Register, in The Cochrane Library (Issue 1, 2006), NRR (Issue 1, 2006), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006), PubMed (on 8th March; last 90 days), SciSearch and reference lists of relevant trial reports and review articles. We contacted investigators to identify additional published and unpublished trials.

SELECTION CRITERIA

We included randomised trials of visual or multicomponent screening for identifying vision impairment in people aged 65 years or over in a community setting.

DATA COLLECTION AND ANALYSIS

Both authors independently extracted data and assessed trial quality.

MAIN RESULTS

Visual outcome data were available for 3494 people in five trials of multicomponent assessment. Length of follow up ranged from two to four years. All the trials used self-reported measures for visual impairment, both as screening tools and as outcome measures. In four of the trials people reporting visual problems were referred to either eye services or a physician. In one trial people reporting visual problems received information about resources in the community designed to assist those with poor vision. The proportions of participants in the intervention and control groups who reported visual problems at the time of outcome assessment were 0.26 and 0.23 respectively (risk ratio for visual impairment 1.03, 95% confidence interval (CI) 0.92 to 1.15). Visual outcome data were also available for 1807 people aged 75 years and over in a cluster randomised trial in which physicians' general practices were randomised to two different screening strategies; universal or targeted. Three to five years after screening, the risk ratio for visual acuity less than 6/18 in either eye comparing universal with targeted screening was 1.07 (95% CI 0.84 to 1.36, P = 0.58). The mean composite score of the National Eye Institute 25 item visual function questionnaire was 85.6 in the targeted screening group and 86.0 in the universal group, a difference of 0.4 (95% CI -1.7 to 2.5, P = 0.69).

AUTHORS' CONCLUSIONS

There is no evidence that community-based screening of asymptomatic older people results in improvements in vision.

Moving Evidence-Based Interventions to Populations: A Case Study Using Social Workers in Primary Care

This article describes a study to expand a proven evidence- based practice for depression to a population-based intervention for frail older adults. Problem-Solving Therapy (PST) has been proven effective in reducing depression and other mental health conditions in cognitively intact adults in many studies. The current study employs a randomized controlled trial to test the effectiveness of a social work intervention for frail older adults that uses PST to address depression and other psychosocial issues. The intervention employs Master's trained social workers integrated into a large primary care practice. The study population is comprised of home-dwelling older adults with multiple chronic conditions, a recent history of unnecessary hospitalizations, and no more than mild cognitive impairment.

Excellence Through Evidence

Multiple nurse-physician (RNMD) relationships coexist on hospital units; collegial and collaborative (C/C) relationships positively impact, more than others, patient outcomes. The goal of this multisite evidence-based management practice initiative was to identify structures that enable C/C RNMD relationships. In part 1, the authors discuss the methodology and selection of the sample of 141 physicians, managers, and staff nurses from 44 clinical units in 5 hospitals that had previously demonstrated extensive C/C RNMD relationships. These 141 experts were interviewed to identify structures enabling C/C RNMD relationships. Part 1 presents the structures that enable C/C RNMD relationships as described and tested in the literature, as well as a description of the characteristics of the clinical units, experts, and C/C RNMD relationships found in this study. In part 2, the structures identified by the experts as needed for securing C/C RNMD relationships will be presented, along with suggestions for attainment.

The abbreviated comprehensive geriatric assessment (aCGA): a retrospective analysis

BACKGROUND

A comprehensive geriatric assessment (CGA) is a multidimensional assessment that is designed to detect health problems. A barrier to conducting the CGA is the length of time required to complete the entire assessment.

OBJECTIVE

To understand what items contained in the instruments that make up the CGA could be compiled to construct an abbreviated CGA (aCGA).

DESIGN/SETTING

A retrospective chart review of patients at the H. Lee Moffitt Cancer Center.

PARTICIPANTS

Over 500 charts between 1995 and 2001 were reviewed on patients 70 and over.

MEASUREMENTS

Item-to-total correlations and Cronbach's alpha coefficient were calculated. Construct validity was assessed using a Pearson's product moment correlation coefficient.

RESULTS

Fifteen items were compiled to form the aCGA. Cronbach's alpha was 0.65-0.92 on each instrument of the entire CGA compared to 0.70-0.94 on the aCGA. Correlations ranged from 0.84 to 0.96 for the entire CGA and the aCGA.

CONCLUSION

An aCGA can be helpful in screening for those seniors who would benefit from the entire CGA.

The influence of outpatient comprehensive geriatric assessment on survival: a meta-analysis

Although outpatient Comprehensive Geriatric Assessment (CGA) has shown certain benefits in functional status and quality of life by many randomized controlled trials, no survival benefit has been reported. We hypothesized that the lack of survival benefit may be due to insufficient power of individual trials. In order to assess the influence of outpatient CGA on survival of older persons, we performed a meta-analysis of all randomized controlled trials of outpatient CGA. Nine studies consisting of 3750 subjects fulfilled the predetermined eligible criteria and were included in the meta-analysis. Combined mortality risk ratio with outpatient CGA intervention compared to usual care group was 0.95 (95% confidence interval, CI 0.82-1.12, P = 0.62). Treatment effects were homogeneous across the trials. This meta-analysis did not demonstrate survival benefit for outpatient CGA. Inadequate statistical power is unlikely to explain the results. Future researches of outpatient CGA should focus on coordinated and standardized measurement of outcomes related to functional status, institutionalization rate, and quality of life.

State of the art in geriatric rehabilitation. Part I: review of frailty and comprehensive geriatric assessment

OBJECTIVES

To increase recognition of geriatric rehabilitation and to provide recommendations for practice and future research.

DATA SOURCES

A CINAHL and 2 MEDLINE searches were conducted for 1980 to 2001. A fourth search used the Cochrane database.

STUDY SELECTION

One author reviewed the reference for relevance and another for quality. A total of 336 articles were selected. Excluded articles were unrelated to geriatric rehabilitation or were anecdotal or descriptive reports.

DATA EXTRACTION

The following major geriatric rehabilitation subtopics were identified: frailty, comprehensive geriatric assessment, admission screening, assessment tools, interdisciplinary teams, hip fracture, stroke, nutrition, dementia, and depression. Part I describes the first 5 subtopics on concepts and processes in geriatric rehabilitation. Part II focuses on the latter 5 subtopics of common clinical problems in frail older persons. A level-of-evidence framework was used to review the literature. Level 1 evidence was a randomized controlled trial (RCT) or a meta-analysis or systematic review of RCTs. Level 2 evidence included controlled trials without randomization, cohort, or case-control studies. Level 3 evidence involved consensus statements from experts or descriptive studies.

DATA SYNTHESIS

Of the 336 articles evaluated, 108 were level 1, 39 were level 2, and 189 were level 3. Recommendations were made for each subtopic. In cases in which several articles were written on the same topic and drew similar conclusions, the authors chose those articles with the strongest level of evidence, reducing the total number of references.

CONCLUSIONS

Frail elderly patients should be screened for rehabilitation potential. Standardized tools are recommended to aid diagnosis, assessment, and outcome measurement. The team approach to geriatric rehabilitation should be interdisciplinary and use a comprehensive geriatric assessment. Medication reviews and self-medication programs may be beneficial. Future research should address cost effectiveness, consensus on outcome measures, which components of geriatric rehabilitation are most effective, screening, and what outcomes are sustainable.

Cost-effectiveness of a brief two-stage emergency department intervention for high-risk elders: results of a quasi-randomized controlled trial

STUDY OBJECTIVE

: We determine the cost-effectiveness of a 2-stage emergency department intervention in addition to usual ED care compared with that of usual care alone.

METHODS

The intervention comprises 2 steps: (1) identification of high-risk patients by using a screening tool and (2) a brief standardized nursing assessment to identify unresolved problems, followed by referral to an appropriate community provider. The patient population was composed of individuals aged 65 years and older to be released from the EDs of 4 Montreal hospitals. Patients were randomized by day of ED visit. The perspective of the study is societal, including patients, caregivers, and the formal health care (government-funded) system. Outcomes, measured from randomization to 4 months after randomization, included (1) functional decline, as measured by an activities of daily living instrument, or death, and (2) changes in depressive symptoms. Costs include post-ED care, including hospitalization, physician services, community care, outpatient drugs, and patient and caregiver costs. Cost items were measured with administrative databases and self-reported questionnaires. Unit costs for these items were either province-wide rates or else were estimated directly by using provider data. Cost-effectiveness is assessed in qualitative terms, such that outcomes and costs are compared separately.

RESULTS

The intervention was associated with a reduced rate of functional decline (including death) at 4 months. There was no effect of the intervention on change in the patient's depressive symptoms at 4 months relative to baseline. The estimated ratio of overall costs per patient in the intervention versus the control group, adjusted for covariates, was 0.94 (95% credible interval 0.75 to 1.17). Among patients who had visited the ED during the 30 days before the index visit, the ratio was 0.66 (95% credible interval 0.44 to 0.97).

CONCLUSION

In this study setting, the intervention is preferred over usual care because beneficial functional outcomes were observed, and overall societal costs were no higher than if usual care only was given.

Implementation of consultative geriatric recommendations: the role of patient-primary care physician concordance

OBJECTIVES

To examine the effect on primary care physicians' implementation and their patients' adherence behaviors of patient-physician concordance about recommended geriatric health care.

DESIGN

Case-series, independent interviews of patients and their physicians about their perceptions of the patients' health and the comprehensive geriatric assessment (CGA).

SETTING

Community.

PARTICIPANTS

Community-dwelling older patients (n = 111) who received consultative outpatient CGA and their primary care physicians.

MEASUREMENTS

Concordance variables were generated using physician and patient responses to 10 questions on health- and CGA-related perceptions. An overall concordance score was generated by summing the total number of items on which patients and physicians agreed. Measures of the two dependent variables (physician implementation of and patient adherence to CGA recommendations) were by self-report.

RESULTS

In multiple logistic regression analyses, overall concordance between patient and physician proved to be a significant and powerful predictor of physician implementation of (adjusted odds ratio (OR) = 2.7, 95% confidence interval (CI) = 1.6-4.6, P <.001) and patient adherence to (OR = 2.7, 95% CI = 1.7-4.2, P <.001) CGA recommendations, controlling for patient and physician gender and age, patients' functional status, duration of the patient-physician relationship, and frequency of visits in the previous year. Further analysis revealed that mutual patient-physician concordance on health-related perceptions was a significant predictor of these outcomes, whereas individual patient or physician perceptions were not.

CONCLUSION

Concordance between older patients and their primary care physicians is a powerful predictor of physician implementation of and patient adherence to outpatient consultative CGA recommendations. Future research should focus on ways physicians can assess and negotiate patient-physician agreement on geriatric healthcare recommendations.

Community-based case management: a model for outcome-based research for non-institutionalized elderly

Medical treatment and research has changed subsequent to a paradigm shift in fiscal management strategies for health care. The demand for greater fiscal and clinical accountability in health care has resulted in more bureaucratic control of physicians, health care providers and health care delivery. Institutional-based care has been deferred to community-based care, and outcomes-based measurement of treatment interventions are becoming the benchmark of effective care. The increase in our elderly population's numbers and longevity of life, combined with fiscal and clinical constraints, invite a potential health care delivery crisis for our noninstitutionalized elderly. Interdisciplinary programs, such as community-based case management, that promote the health and well-being of our noninstitutionalized elderly can be an effective response to this crisis. However, the need for empirical evidence of their effectiveness is essential.

Evaluation of a guided protocol for quality improvement in identifying common geriatric problems

OBJECTIVES

Many common geriatric problems are underrecognized and undertreated. A simple and reliable tool to facilitate a standard approach to evaluating geriatric patients might improve the quality of medical care delivered to geriatric patients. The objective of this study was to evaluate a standardized, semistructured quality-improvement protocol (the guided geriatric care protocol) for the assessment of common geriatric problems.

DESIGN

Sequential comparison cohorts, with chart review to evaluate study measures before and after introduction of the guided geriatric care protocol.

SETTING

The outpatient consultative geriatric assessment center of Yale-New Haven Hospital in New Haven, Connecticut.

PARTICIPANTS

One hundred consecutive new patients before and 100 consecutive new patients after introduction of the guided geriatric care protocol.

MEASUREMENTS

Number and type of problems identified and recommendations made during the clinical encounter, duration of the clinical encounter, clinician acceptance.

RESULTS

The two patient groups were similar in sociodemographics, cognitive and functional status, and reasons for evaluation. Significantly more problems were identified after (mean 5.51) than before (mean 3.49) introduction of the guided geriatric care protocol (P< .001); likewise, significantly more recommendations were made after (mean 10.45) than before (mean 8.48) introduction of the protocol (P< .001). The duration of the clinical encounter did not differ significantly between the two groups. The protocol was well accepted by participating clinicians.

CONCLUSIONS

Use of the guided geriatric care protocol assured a standard approach to evaluating common geriatric problems and may have led to the identification and treatment of more problems than usual care without increasing the duration of the clinical encounter. A quality-improvement tool that standardizes the evaluation of common geriatric problems, if validated in other clinical settings, holds the potential to improve the quality of care for vulnerable older patients.

Collaboration improves the quality of care: methodological challenges and evidence from US health care research

At the present time when interprofessional collaboration in practice is reaching new levels of interest related to health care system changes in both the UK and the US, a key question being raised is: What are the outcomes and costs of interprofessional collaborative models of care? The purposes of this paper are to: (a) summarize past research efforts, primarily in the US, to examine whether interprofessional collaboration improves the outcomes of care, (b) articulate the continuing conceptual and methodological challenges associated with efforts to examine this relationship, (c) present more recent research in the US in which investigators have overcome some of the conceptual and methodological barriers to this type of research, and (d) identify gaps in knowledge and areas for future research on the relationship between collaborative models of care and care outcomes.

Interdisciplinary education in a community-based geriatric evaluation clinic

BACKGROUND

Demographic predictions are challenging schools of medicine to emphasize geriatrics. This article describes a geriatric evaluation (GET) clinic and explores the opportunity for residents to attain core geriatric competencies.

DESCRIPTION

The GET clinic is located in a small Midwestern city associated with a community-based medical school. It is staffed by an interdisciplinary team consisting of a geriatrician, a gerontological nurse specialist, and a social worker. Residents, medical students, and nursing students are frequent participants.

EVALUATION

Descriptive data indicate that the clinic experience addresses the core competencies set forth by the American Geriatric Society. The clinical outcomes indicate that the clinic is effective in maintaining the functional status of patients and has a positive effect on family caregivers. Residents and students rate their experience as excellent.

CONCLUSIONS

The GET clinic provides a unique interdisciplinary educational opportunity. Further investigation is needed to determine if residents who participate do attain core competencies.

Fully integrated care for frail elderly: two American models

Purpose

Integrated care for the frail elderly and other populations with complex, chronic, disabling conditions has taken centre stage among policymakers, planners and providers in the United States and other countries. There is a growing belief that integrated care strategies offer the potential to improve service co-ordination, quality outcomes, and efficiency. Therefore, it is critical to have a conceptual understanding of the meaning of integrated care and its various organisational models, as well as practical examples of how such models work. This article examines so-called “fully integrated” models of care in detail, concentrating on two major, well-established American programs, the social health maintenance organisation and the program of all-inclusive care for the elderly.

Theory

A major challenge to understanding the performance and outcomes of fully integrated care and other organisational models is the lack of a meaningful, analytical paradigm. This article builds upon the work of Walter Leutz, to develop a framework by which new and existing programs can be analysed. This framework is then applied to the two American models that are the focus of this article.

Methods

Existing data about integrated care in general, and the two model programs in particular, were collected and analysed from reports published by governmental and non-governmental organisations, and journal articles retrieved from Medline, HealthStar and other sources.

Results and conclusions

This analysis strongly suggests that fully integrated models of care, such as the social health maintenance organisation and program of all-inclusive care for the elderly, are not only feasible, but offer significant potential to improve the delivery of health and social care for frail elderly patients. In addition, the authors identify the factors that are the most critical to the success of fully integrated care, and offer lessons for their development and implementation. Finally, issues are raised concerning the transferability of this complex model to other countries, as well as the vital importance of evidence-based evaluation research in furthering the evolution of integrated care.

A thorough going over: evidence for health assessments for older persons

OBJECTIVE

To review published randomised controlled trials of health assessments for older people; consider the effects of assessments in maintaining health and quality of life for older people; and identify those factors associated with more successful health assessment programs.

METHODS

A systematic literature search and methodological review of published studies of health assessments for people aged 65 years and over, living in the community.

RESULTS

Twenty-one trials were identified. They were widely heterogeneous in terms of methodological quality, assessment content and outcome variables. While the studies' results are inconsistent, the majority of the more methodologically sound studies report improvements in health. The studies reporting positive health outcomes were not specifically targeted to particular groups at high need, but were applied to all people in the source population who had reached a set age, usually 75 plus. In the majority of studies reviewed, the assessments were conducted by non-medical personnel (nurse, lay interviewer/volunteer or office staff).

CONCLUSIONS

Health assessments have been associated with improved health outcomes for older people. An evidence base for specific components to be included in the assessments is yet to be derived.

IMPLICATIONS

In November 1999, new Medicare items to provide for health assessments for persons in Australia aged 75 years and over were introduced. The acceptability, adoption and effectiveness of these items needs careful monitoring.

Goals in geriatric assessment: are we measuring the right outcomes?

Previous evaluative studies of outpatient geriatric assessment have focused on a limited set of outcomes related to functioning, health services utilization, and costs. The purpose of this study was to identify important goals for care as described by patients and family caregivers being cared for in this setting. Using a cross-section of 226 consecutive sets of patients and their primary family caregivers, physicians, and case managers, goals of care for individual patients were coded from open-ended interview responses. The most common categories of goals expressed by family caregivers were obtaining education and referrals (57.5%) and improving social and family relationships (53.0%). The process of establishing and meeting such goals should be explicitly included in the design of future evaluations of outpatient geriatric assessment.

What nursing home residents value in their doctors

Patient satisfaction is influenced by multiple factors, and different populations are expected to define satisfaction in terms of their novel perspectives. Despite growing interest in patient satisfaction, an extensive literature search reveals no studies of nursing home residents' satisfaction with respect to medical care. In an initial qualitative study using transcripts of interviews conducted as part of a state quality control mandate, categories are identified that make up this population's construct of satisfaction and dissatisfaction. These categories serve as building blocks for designing future studies investigating these issues and allowing for comparison of nursing home residents' ideas of satisfaction and dissatisfaction to other older patients, including those in an outpatient geriatric setting.

Interdisciplinary geriatric primary care evaluation and management: two-year outcomes

BACKGROUND

The long-term efficacy of interdisciplinary outpatient primary care Geriatric Evaluation and Management (GEM) has not been proven. This article focuses on results obtained during the 2 years of the study.

METHODS

In this 2-year randomized clinical trial, at the Veterans Affairs Medical Center, Memphis, TN, 128 veterans, age 65 years and older, were randomized to outpatient GEM or usual care (UC). Two-year follow-up analyses are based on the 98 surviving individuals. Study outcome measurements included health status, function, and quality of life including affect, cognition, and mortality.

RESULTS

At 2 years, there were positive intervention effects for eight of 1 outcome measures, five of which had attained significance at 1 year. GEM subjects, compared with UC subjects, had significantly greater improvement in health perception (P = .001), smaller increases in numbers of clinic visits (P = .019) and instrumental activities of daily living (IADL) impairments (P = .006), improved social activity (P<.001), greater improvement in Center for Epidemiologic Studies-Depression (CES-D) scores (P = .003), general well-being (P = .001), life satisfaction (P<.001), and Mini-Mental State Exam (MMSE) scores (P = .025). There were no significant treatment effects in activities of daily living (ADL) scores (P = .386), number of hospitalizations (P = .377), or mortality (P = .155).

CONCLUSIONS

These findings suggest that a primary care approach that combines an initial interdisciplinary comprehensive assessment with long-term, interdisciplinary outpatient management may improve outcomes for targeted older adults significantly. Findings suggest further that outcomes may continue to improve over time and that the GEM care model provides an effective way to manage health care of older adults.

Community screening for visual impairment in the elderly

BACKGROUND

While the aims of multicomponent screening of older people are broad, any benefit arising from the inclusion of a vision component in the assessment will necessarily be dependent on improved vision.

OBJECTIVES

The objective of this review is to assess the effects on vision of mass screening of older people for visual impairment.

SEARCH STRATEGY

We searched the Cochrane Eye and Vision Group specialised register, the Cochrane Controlled Trials Register - Central, MEDLINE, EMBASE, SciSearch and reference lists of relevant trial reports and review articles. We contacted investigators to identify additional published and unpublished trials. The most recent searches were conducted in April 1998.

SELECTION CRITERIA

We included randomised trials of visual or multicomponent screening for vision impairment in people aged 65 or over in a community setting.

DATA COLLECTION AND ANALYSIS

Both reviewers independently extracted data and assessed trial quality.

MAIN RESULTS

Visual outcome data were available for 3494 people in five trials of multicomponent assessment. Length of follow up ranged from two to four years. All the trials used self-reported measures for visual impairment, both as screening tools and as outcome measures. In four of the trials people reporting visual problems were referred to either the eye services or to a physician. In one trial people reporting visual problems received information about resources in the community designed to assist those with poor vision. The proportions of participants in the intervention and control groups who reported visual problems at the time of outcome assessment were 0.26 and 0.23 respectively (relative risk for visual impairment 1.03, 95% confidence interval 0.92 to 1.15).

REVIEWER'S CONCLUSIONS

There is no evidence that community-based screening of asymptomatic older people results in improvements in vision.

The comprehensive geriatric assessment: when, where, how

Cancer is increasingly a disease of the aged, a segment of the population that is the fastest growing. Often, cancer adds on to the progressive deterioration of normal aging and to the impairment associated with the presence of multiple concomitant medical problems. Thus, the likelihood that cancer leads to disability is much greater among older patients than younger ones. In consideration of the dimension of the problem, and of the peculiarities of the elderly patient, it has recently been proposed that a new approach termed 'comprehensive geriatric assessment' (CGA) might allow a better management and more efficient care of elderly patients with cancer. The systematic introduction of CGA in clinical research and in daily practice can contribute to: identify cancer patients for whom we could expect the greatest benefit from treatment; assess their physiologic, functional and health-related quality of life; formulate appropriate treatment and management strategies; monitor clinical and functional outcomes; provide a more accurate evaluation of prognostic indicators.

Cost-effectiveness of outpatient geriatric assessment with an intervention to increase adherence

BACKGROUND

Comprehensive geriatric assessment (CGA) can be effective in inpatient units, but such inpatient settings are prohibitively expensive. If similar benefits could be obtained in outpatient settings, CGA might be a more attractive option.

OBJECTIVES

To assess the cost-effectiveness (CE) of an outpatient geriatric assessment with an intervention to increase adherence.

SUBJECTS

Three hundred fifty-one community-dwelling, elderly subjects with at least one of four geriatric conditions.

MEASURES

In addition to the measures of functioning, we collected data on the costs of the intervention itself and on the use of medical services in the 64 weeks after the intervention.

RESULTS

The intervention, which prevented functional decline, cost $273 per participant. The intervention group averaged three more visits than the control group in the first 32 weeks after the intervention, but only 1.2 extra visits in the next 32 weeks. We estimate that the costs of these additional medical services would be $473 for the 5 years after the intervention, leading to a total cost per Quality Adjusted Life Year (QALY) of $10,600.

CONCLUSIONS

The CE of this program compares favorably with many common medical interventions. Whether investments should be made in health care resources on treatments that lead to modest improvements in the functioning of community-dwelling elderly people remains a societal decision.

Effect of a practice guideline on the process of emergency department care of falls in elder patients

OBJECTIVE

To determine the effect of a practice guideline on the process of ED care in a health maintenance organization.

METHODS

A prepost-intervention comparison with a one-year pre-intervention phase followed by a one-year post-educational intervention phase was used to study the effect of the guideline on ED care. Emergency physicians and nurses were provided the details of the guideline during a two-week interval between the two periods.

RESULTS

During the two years of the study, 1,140 pre-intervention and 759 post-intervention patients met study eligibility criteria. More patients were diagnosed as having had falls due to loss of consciousness, stroke, and seizures during the post-intervention period (pre-intervention 3.8% vs post-intervention 8.4%, p < 0.001). There was a significant improvement in documentation of six of ten history items: cause of fall (64.5% vs 72.9%), location of fall (54.7% vs 60.5%), ability to get up unassisted (5.4% vs 12.5%), long lie after fall (1.5% vs 10.1%), prescription medications (79.0% vs 92.2%), and Pneumovax immunization status (20.8% vs 43.0%); and two of the four physical examination items: visual acuity (1.5% vs 3.2%) and the "get up and go test" (1.3% vs 11.2%). Prescribing of calcium and vitamin D increased from 0% to 6.6%.

CONCLUSIONS

The educational intervention to the practice guideline for the ED management of falls in elders led to small but significant improvements in the documentation of selected history and physical examination items and the prescribing of calcium and vitamin D, and to a greater consideration of the causes of falls.

Effect of a practice guideline for emergency department care of falls in elder patients on subsequent falls and hospitalizations for injuries

OBJECTIVE

To determine the effect of a practice guideline for the ED management of falls in community-dwelling elders on selected health outcomes.

METHODS

The experimental design was a prepost-intervention comparison with one-year pre- and post-intervention phases. The guideline was presented to emergency physicians and nurses during a two-week interval between these two periods. The intervention also included health information provided to the subjects and a one-time educational intervention directed at primary care providers. The number of falls in the year following the ED visit was determined by telephone interview. The number of hospitalizations for falls was determined from the HMO database of all health care encounters.

RESULTS

1,899 patients were eligible for the study; 1,140 pre-intervention and 759 post-intervention patients. Of these, 1,504 (79%) were interviewed by telephone 12 to 15 months after their initial ED visits. Eighteen percent of the pre-intervention and 21% of the post-intervention subjects reported at least one fall in the 12 months following their ED visits (p = 0.162). The rate of falls per 100 patient years was 36.2 in both groups. Three percent of both groups were hospitalized at least once for a fall in the year following their ED visits. One percent in each group were hospitalized for a hip fracture.

CONCLUSIONS

The attempted implementation of a practice guideline for the ED management of falls in community-dwelling elders did not result in a reduction in total falls, or in hospitalizations for falls, injuries, or fractures.

The effect of visual and hearing impairments on functional status

OBJECTIVES

To describe the prevalence of visual and auditory impairment in frail older persons and to evaluate the association between sensory impairment and overall functional status.

DESIGN

Prospective patient evaluation and retrospective analysis of data.

SETTING

The outpatient geriatric assessment clinic of a university medical center.

PARTICIPANTS

Consecutive patients seen in the University of Nebraska Medical Center Outpatient Geriatric Assessment Clinic from 1986 to 1992 for whom both vision and hearing information were available (n = 576).

MEASUREMENTS

Visual acuity was measured by the Lighthouse Near Visual Acuity Test, and auditory acuity was evaluated with the whisper test. Functional status was determined by Lawton-Brody activities of daily living (ADL) and instrumental activities of daily living (IADL) scales. Comorbid illness was classified by the Cumulative Illness Rating Scale, and mental status was assessed by the Folstein Mini-Mental State Exam.

RESULTS

Eighteen percent of patients had visual impairment of 20/70 or worse. Hearing impairment was found in 64%. The mean ADL and IADL scores were 20/24 and 12/23, respectively, for patients with visual acuity better than 20/70, compared with 18/24 and 8/23 for visually impaired patients (P < .001 for both comparisons). ADL and IADL scores were also higher in hearing intact patients compared with those with hearing impairment: respectively, 21/24 vs 19/24 (P < .001) and 13/23 vs 11/23 (P < .001). The effects of visual acuity and hearing acuity on IADL score are independent of mental status and comorbid illness (P < .001). The effect of visual acuity on ADL score is independent of mental status and comorbid illness (P < .001), whereas the effect of hearing on ADL score is not. Subjects with both hearing and vision impairment had mean IADL (P < = .05) and ADL (P < = .05) scores significantly lower than those with no impairment

CONCLUSIONS

Impairments of vision and hearing are common in this frail older outpatient population. Functional status, as measured by IADL and ADL scores, is diminished for sensory impaired subjects. Combined vision and hearing impairments have a greater effect on function than single sensory impairments and influence functional status independent of mental status and comorbid illness. Overall, these results suggest that interventions to improve sensory function may improve functional independence.

Geriatric assessment

A comprehensive geriatric assessment involves the evaluation of the physical, psychosocial, and environmental factors affecting the health of an elderly person. In the office setting a geriatric assessment is best accomplished by the use of screening questions, which are incorporated into the patient's medical questionnaire; the use of validated, brief screening tests that measure the patient's performance of daily living activities, cognition, nutritional status, and risk of falls; and a review of the patient's personal values and social support network. The screening assessment can be completed in an average of ten minutes by using self-administered questionnaires and brief performance-based measures of physical functioning. The comprehensive assessment performed on the initial visit with an elderly patient will help to (1) improve diagnostic accuracy, (2) guide the selection of interventions to restore or preserve health, (3) recommend an optimal environment for care, (4) predict health outcomes, and (5) monitor clinical change over time. The effectiveness of geriatric assessment has been demonstrated in clinical trials and is likely to be most effective when conducted by the patient's primary care physician.

Using admission characteristics to predict return to the community from a post-acute geriatric evaluation and management unit

OBJECTIVE

To compare the Cumulative Illness Rating Scale (CIRS) and the Nursing Severity Index (NSI) as independent predictors of discharge outcome from a post-acute GEM unit and to define a multivariate model for predicting the same outcome.

DESIGN

Retrospective chart review for the entire sample. The sample was split into two cohorts, a derivation cohort (n = 298) and a validation cohort (n = 154).

SETTING

A 20-bed, post-acute GEM unit in a nonproprietary skilled nursing facility.

PARTICIPANTS

All 452 patients admitted to the GEM from the unit's inception in December 1994 until January 1998.

MEASUREMENT

Demographics, CIRS, NSI, functional status, and social support variables were measured using data available on admission to the GEM unit. The discharge outcome was dichotomized as return to the community or not.

RESULTS

A total of 99.7% of the individuals in the derivation cohort were living in the community before the index hospitalization; 75.8% of patients in the derivation cohort returned to the community. The NSI, individual "severe" items from the CIRS, age, and social support were in the final logistic regression model fitted to the derivation cohort. A total of 87.7% of the observed discharge outcomes were predicted when the model was applied to the validation cohort and the calculated probability of return to the community.

CONCLUSIONS

Variables for severity of illness, function, social support, and age combined into a logistic regression equation that predicted more than 80% of the dichotomized discharge outcome in the derivation cohort. The proportion of discharge outcomes that were predicted with the validation cohort remained high at 87.7%. The NSI and CIRS were each important to a model that is anticipated to refine the selection of geriatric patients for post-acute services.