Trial of a geriatric consultation team in an acute care hospital

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.

Bloodstream infections in the elderly: what is the real goal?

Bloodstream infections (BSI) represent a serious bacterial infection with substantial morbidity and mortality. Population-based studies demonstrate an increased incidence, especially among elderly patients. Controversy exists regarding whether presentation of BSI are different in older patients compared to younger patients; our narrative review of the literature suggests that BSI in elderly patients would probably include one or more of the traditional symptoms/signs of fever, severe sepsis or septic shock, acute kidney injury, and/or leukocytosis. Sources of BSI in older adults are most commonly the urinary tract (more so than in younger adults) and the respiratory tract. Gram-negative bacteria are the most common isolates in the old (~ 40-60% of BSI); isolates from the elderly patient population show higher antibiotic resistance rates, with long-term care facilities serving as reservoirs for multidrug-resistant bacteria. BSI entail significantly higher rates of mortality in older age, both short and long term. Some of the risk factors for mortality are modifiable, such as the appropriateness of empirical antibiotic therapy and nosocomial acquisition of infection. Health-related quality of life issues regarding the elderly patient with BSI are not well addressed in the literature. Utilization of comprehensive geriatric assessment and comprehensive geriatric discharge planning need to be investigated further in this setting and might serve as key for improved results in this population. In this review, we address all these aspects of BSI in old patients with emphasis on future goals for management and research.

Lessons and Outcomes of Mobile Acute Care for Elders Consultation in a Veterans Affairs Medical Center

OBJECTIVE

Describe the implementation and effects of Mobile Acute Care for Elders (MACE) consultation at a Veterans Affairs Medical Center (VAMC).

DESIGN

Retrospective cohort analysis.

INTERVENTION

Veterans aged 65 or older who were admitted to the medicine service between October 1, 2012, and September 30, 2014, were screened for geriatric syndromes via review of medical records within 48 hours of admission. If the screen was positive, the MACE team offered the admitting team a same-day consultation involving comprehensive geriatric assessment and ongoing collaboration with the admitting team and supportive services to implement patient-centric recommendations for geriatric syndromes.

RESULTS

Veterans seen by MACE (n = 421) were compared with those with positive screens but without consultation (n = 372). The two groups did not significantly differ in age, comorbidity, sex, or race. All outcomes (30-day readmission, 30-day mortality, readmission costs) were in the expected direction for patients receiving MACE but did not reach statistical significance. Patients receiving MACE had lower odds of 30-day readmission (11.9% vs 14.8%; odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.54-1.25; p = .360) and 30-day mortality (5.5% vs 8.6%; OR = 0.64; CI = 0.36-1.12; p = .115), and they had lower 30-day readmission costs (MACE $15,502; CI = $12,242-$19,631; comparison = $18,335; CI = $14,641-$22,962; p = .316) than those who did not receive MACE after adjusting for age and Charlson Comorbidity Index.

CONCLUSION

Our MACE consultation model for older veterans with geriatric syndromes leverages the limited supply of clinicians with expertise in geriatrics. Although not statistically significant in this study of 793 subjects, MACE patients had lower odds of 30-day readmission and mortality, and lower readmission costs. J Am Geriatr Soc 67:818-824, 2019.

Comprehensive geriatric assessment for older adults admitted to hospital

BACKGROUND

Comprehensive geriatric assessment (CGA) is a multi-dimensional, multi-disciplinary diagnostic and therapeutic process conducted to determine the medical, mental, and functional problems of older people with frailty so that a co-ordinated and integrated plan for treatment and follow-up can be developed. This is an update of a previously published Cochrane review.

OBJECTIVES

We sought to critically appraise and summarise current evidence on the effectiveness and resource use of CGA for older adults admitted to hospital, and to use these data to estimate its cost-effectiveness.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers on 5 October 2016; we also checked reference lists and contacted study authors.

SELECTION CRITERIA

We included randomised trials that compared inpatient CGA (delivered on geriatric wards or by mobile teams) versus usual care on a general medical ward or on a ward for older people, usually admitted to hospital for acute care or for inpatient rehabilitation after an acute admission.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures expected by Cochrane and Effective Practice and Organisation of Care (EPOC). We used the GRADE approach to assess the certainty of evidence for the most important outcomes. For this update, we requested individual patient data (IPD) from trialists, and we conducted a survey of trialists to obtain details of delivery of CGA. We calculated risk ratios (RRs), mean differences (MDs), or standardised mean differences (SMDs), and combined data using fixed-effect meta-analysis. We estimated cost-effectiveness by comparing inpatient CGA versus hospital admission without CGA in terms of cost per quality-adjusted life year (QALY) gained, cost per life year (LY) gained, and cost per life year living at home (LYLAH) gained.

MAIN RESULTS

We included 29 trials recruiting 13,766 participants across nine, mostly high-income countries. CGA increases the likelihood that patients will be alive and in their own homes at 3 to 12 months' follow-up (risk ratio (RR) 1.06, 95% confidence interval (CI) 1.01 to 1.10; 16 trials, 6799 participants; high-certainty evidence), results in little or no difference in mortality at 3 to 12 months' follow-up (RR 1.00, 95% CI 0.93 to 1.07; 21 trials, 10,023 participants; high-certainty evidence), decreases the likelihood that patients will be admitted to a nursing home at 3 to 12 months follow-up (RR 0.80, 95% CI 0.72 to 0.89; 14 trials, 6285 participants; high-certainty evidence) and results in little or no difference in dependence (RR 0.97, 95% CI 0.89 to 1.04; 14 trials, 6551 participants; high-certainty evidence). CGA may make little or no difference to cognitive function (SMD ranged from -0.22 to 0.35 (5 trials, 3534 participants; low-certainty evidence)). Mean length of stay ranged from 1.63 days to 40.7 days in the intervention group, and ranged from 1.8 days to 42.8 days in the comparison group. Healthcare costs per participant in the CGA group were on average GBP 234 (95% CI GBP -144 to GBP 605) higher than in the usual care group (17 trials, 5303 participants; low-certainty evidence). CGA may lead to a slight increase in QALYs of 0.012 (95% CI -0.024 to 0.048) at GBP 19,802 per QALY gained (3 trials; low-certainty evidence), a slight increase in LYs of 0.037 (95% CI 0.001 to 0.073), at GBP 6305 per LY gained (4 trials; low-certainty evidence), and a slight increase in LYLAH of 0.019 (95% CI -0.019 to 0.155) at GBP 12,568 per LYLAH gained (2 trials; low-certainty evidence). The probability that CGA would be cost-effective at a GBP 20,000 ceiling ratio for QALY, LY, and LYLAH was 0.50, 0.89, and 0.47, respectively (17 trials, 5303 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Older patients are more likely to be alive and in their own homes at follow-up if they received CGA on admission to hospital. We are uncertain whether data show a difference in effect between wards and teams, as this analysis was underpowered. CGA may lead to a small increase in costs, and evidence for cost-effectiveness is of low-certainty due to imprecision and inconsistency among studies. Further research that reports cost estimates that are setting-specific across different sectors of care are required.

Discharge planning from hospital

BACKGROUND

Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and to improve the co-ordination of services following discharge from hospital.This is the third update of the original review.

OBJECTIVES

To assess the effectiveness of planning the discharge of individual patients moving from hospital.

SEARCH METHODS

We updated the review using the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 9), MEDLINE, EMBASE, CINAHL, the Social Science Citation Index (last searched in October 2015), and the US National Institutes of Health trial register (ClinicalTrials.gov).

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to individual participants. Participants were hospital inpatients.

DATA COLLECTION AND ANALYSIS

Two authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies according to patient groups (elderly medical patients, patients recovering from surgery, and those with a mix of conditions) and by outcome. We performed our statistical analysis according to the intention-to-treat principle, calculating risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible because of differences in the reporting of outcomes, we summarised the reported data in the text.

MAIN RESULTS

We included 30 trials (11,964 participants), including six identified in this update. Twenty-one trials recruited older participants with a medical condition, five recruited participants with a mix of medical and surgical conditions, one recruited participants from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials recruited participants admitted to hospital following a fall. Hospital length of stay and readmissions to hospital were reduced for participants admitted to hospital with a medical diagnosis and who were allocated to discharge planning (length of stay MD - 0.73, 95% CI - 1.33 to - 0.12, 12 trials, moderate certainty evidence; readmission rates RR 0.87, 95% CI 0.79 to 0.97, 15 trials, moderate certainty evidence). It is uncertain whether discharge planning reduces readmission rates for patients admitted to hospital following a fall (RR 1.36, 95% CI 0.46 to 4.01, 2 trials, very low certainty evidence). For elderly patients with a medical condition, there was little or no difference between groups for mortality (RR 0.99, 95% CI 0.79 to 1.24, moderate certainty). There was also little evidence regarding mortality for participants recovering from surgery or who had a mix of medical and surgical conditions. Discharge planning may lead to increased satisfaction for patients and healthcare professionals (low certainty evidence, six trials). It is uncertain whether there is any difference in the cost of care when discharge planning is implemented with patients who have a medical condition (very low certainty evidence, five trials).

AUTHORS' CONCLUSIONS

A discharge plan tailored to the individual patient probably brings about a small reduction in hospital length of stay and reduces the risk of readmission to hospital at three months follow-up for older people with a medical condition. Discharge planning may lead to increased satisfaction with healthcare for patients and professionals. There is little evidence that discharge planning reduces costs to the health service.

Impact of geriatric consultation teams on clinical outcome in acute hospitals: a systematic review and meta-analysis

BACKGROUND

Comprehensive geriatric assessment for older patients admitted to dedicated wards has proven to be beneficial, but the impact of comprehensive geriatric assessment delivered by mobile inpatient geriatric consultation teams remains unclear. This review and meta-analysis aims to determine the impact of inpatient geriatric consultation teams on clinical outcomes of interest in older adults.

METHODS

An electronic search of Medline, CINAHL, EMBASE, Web of Science and Invert for English, French and Dutch articles was performed from inception to June 2012. Three independent reviewers selected prospective cohort studies assessing functional status, readmission rate, mortality or length of stay in adults aged 60 years or older. Twelve studies evaluating 4,546 participants in six countries were identified. Methodological quality of the included studies was assessed with the Methodological Index for Non-Randomized Studies.

RESULTS

The individual studies show that an inpatient geriatric consultation team intervention has favorable effects on functional status, readmission and mortality rate. None of the studies found an effect on the length of the hospital stay. The meta-analysis found a beneficial effect of the intervention with regard to mortality rate at 6 months (relative risk 0.66; 95% confidence interval 0.52 to 0.85) and 8 months (relative risk 0.51; confidence interval 0.31 to 0.85) after hospital discharge.

CONCLUSIONS

Inpatient geriatric consultation team interventions have a significant impact on mortality rate at 6 and 8 months postdischarge, but have no significant impact on functional status, readmission or length of stay. The reason for the lack of effect on these latter outcomes may be due to insufficient statistical power or the insensitivity of the measuring method for, for example, functional status. The questions of to whom IGCT intervention should be targeted and what can be achieved remain unanswered and require further research.

TRIAL REGISTRATION

CRD42011001420 (http://www.crd.york.ac.uk/PROSPERO).

Discharge planning from hospital to home

BACKGROUND

Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and improve the co-ordination of services following discharge from hospital.

OBJECTIVES

To determine the effectiveness of planning the discharge of individual patients moving from hospital.

SEARCH METHODS

We updated the review using the Cochrane EPOC Group Trials Register, MEDLINE, EMBASE and the Social Science Citation Index (last searched in March 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to the individual patient. Participants were hospital inpatients.

DATA COLLECTION AND ANALYSIS

Two authors independently undertook data analysis and quality assessment using a pre designed data extraction sheet. Studies are grouped according to patient group (elderly medical patients, patients recovering from surgery and those with a mix of conditions) and by outcome. Our statistical analysis was done on an intention to treat basis, we calculated risk ratios for dichotomous outcomes and mean differences for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible, because of differences in the reporting of outcomes, we have presented the data in narrative summary tables.

MAIN RESULTS

We included twenty-four RCTs (8098 patients); three RCTS were identified in this update. Sixteen studies recruited older patients with a medical condition, four recruited patients with a mix of medical and surgical conditions, one recruited patients from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials patients admitted to hospital following a fall (110 patients). Hospital length of stay and readmissions to hospital were statistically significantly reduced for patients admitted to hospital with a medical diagnosis and who were allocated to discharge planning (mean difference length of stay -0.91, 95% CI -1.55 to -0.27, 10 trials; readmission rates RR 0.82, 95% CI 0.73 to 0.92, 12 trials). For elderly patients with a medical condition there was no statistically significant difference between groups for mortality (RR 0.99, 95% CI 0.78 to 1.25, five trials) or being discharged from hospital to home (RR 1.03, 95% CI 0.93 to 1.14, two trials). This was also the case for trials recruiting patients recovering from surgery and a mix of medical and surgical conditions. In three trials, patients allocated to discharge planning reported increased satisfaction. There was little evidence on overall healthcare costs.

AUTHORS' CONCLUSIONS

The evidence suggests that a discharge plan tailored to the individual patient probably brings about reductions in hospital length of stay and readmission rates for older people admitted to hospital with a medical condition. The impact of discharge planning on mortality, health outcomes and cost remains uncertain.

Collaboration between local health and local government agencies for health improvement

BACKGROUND

In many countries, national, regional and local inter- and intra-agency collaborations have been introduced to improve health outcomes. Evidence is needed on the effectiveness of locally developed partnerships which target changes in health outcomes and behaviours.

OBJECTIVES

To evaluate the effects of interagency collaboration between local health and local government agencies on health outcomes in any population or age group.

SEARCH METHODS

We searched the Cochrane Public Health Group Specialised Register, AMED, ASSIA, CENTRAL, CINAHL, DoPHER, EMBASE, ERIC, HMIC, IBSS, MEDLINE, MEDLINE In-Process, OpenGrey, PsycINFO, Rehabdata, Social Care Online, Social Services Abstracts, Sociological Abstracts, TRoPHI and Web of Science from 1966 through to January 2012. 'Snowballing' methods were used, including expert contact, citation tracking, website searching and reference list follow-up.

SELECTION CRITERIA

Randomized controlled trials (RCTs), controlled clinical trials (CCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) where the study reported individual health outcomes arising from interagency collaboration between health and local government agencies compared to standard care. Studies were selected independently in duplicate, with no restriction on population subgroup or disease.

DATA COLLECTION AND ANALYSIS

Two authors independently conducted data extraction and assessed risk of bias for each study.

MAIN RESULTS

Sixteen studies were identified (28,212 participants). Only two were considered to be at low risk of bias. Eleven studies contributed data to the meta-analyses but a narrative synthesis was undertaken for all 16 studies. Six studies examined mental health initiatives, of which one showed health benefit, four showed modest improvement in one or more of the outcomes measured but no clear overall health gain, and one showed no evidence of health gain. Four studies considered lifestyle improvements, of which one showed some limited short-term improvements, two failed to show health gains for the intervention population, and one showed more unhealthy lifestyle behaviours persisting in the intervention population. Three studies considered chronic disease management and all failed to demonstrate health gains. Three studies considered environmental improvements and adjustments, of which two showed some health improvements and one did not.Meta-analysis of three studies exploring the effect of collaboration on mortality showed no effect (pooled relative risk of 1.04 in favour of control, 95% CI 0.92 to 1.17). Analysis of five studies (with high heterogeneity) looking at the effect of collaboration on mental health resulted in a standardised mean difference of -0.28, a small effect favouring the intervention (95% CI -0.51 to -0.06). From two studies, there was a statistically significant but clinically modest improvement in the global assessment of function symptoms score scale, with a pooled mean difference (on a scale of 1 to 100) of -2.63 favouring the intervention (95% CI -5.16 to -0.10).For physical health (6 studies) and quality of life (4 studies) the results were not statistically significant, the standardised mean differences were -0.01 (95% CI -0.10 to 0.07) and -0.08 (95% CI -0.44 to 0.27), respectively.

AUTHORS' CONCLUSIONS

Collaboration between local health and local government is commonly considered best practice. However, the review did not identify any reliable evidence that interagency collaboration, compared to standard services, necessarily leads to health improvement. A few studies identified component benefits but these were not reflected in overall outcome scores and could have resulted from the use of significant additional resources. Although agencies appear enthusiastic about collaboration, difficulties in the primary studies and incomplete implementation of initiatives have prevented the development of a strong evidence base. If these weaknesses are addressed in future studies (for example by providing greater detail on the implementation of programmes; using more robust designs, integrated process evaluations to show how well the partners of the collaboration worked together, and measurement of health outcomes) it could provide a better understanding of what might work and why. It is possible that local collaborative partnerships delivering environmental Interventions may result in health gain but the evidence base for this is very limited.Evaluations of interagency collaborative arrangements face many challenges. The results demonstrate that collaborative community partnerships can be established to deliver interventions but it is important to agree goals, methods of working, monitoring and evaluation before implementation to protect programme fidelity and increase the potential for effectiveness.

Enhancing care for hospitalized older adults with cognitive impairment: a randomized controlled trial

BACKGROUND

Approximately 40% of hospitalized older adults have cognitive impairment (CI) and are more prone to hospital-acquired complications. The Institute of Medicine suggests using health information technology to improve the overall safety and quality of the health care system.

OBJECTIVE

Evaluate the efficacy of a clinical decision support system (CDSS) to improve the quality of care for hospitalized older adults with CI.

DESIGN

A randomized controlled clinical trial.

SETTING

A public hospital in Indianapolis.

POPULATION

A total of 998 hospitalized older adults were screened for CI, and 424 patients (225 intervention, 199 control) with CI were enrolled in the trial with a mean age of 74.8, 59% African Americans, and 68% female.

INTERVENTION

A CDSS alerts the physicians of the presence of CI, recommends early referral into a geriatric consult, and suggests discontinuation of the use of Foley catheterization, physical restraints, and anticholinergic drugs.

MEASUREMENTS

Orders of a geriatric consult and discontinuation orders of Foley catheterization, physical restraints, or anticholinergic drugs.

RESULTS

Using intent-to-treat analyses, there were no differences between the intervention and the control groups in geriatric consult orders (56% vs 49%, P = 0.21); discontinuation orders for Foley catheterization (61.7% vs 64.6%, P = 0.86); physical restraints (4.8% vs 0%, P = 0.86), or anticholinergic drugs (48.9% vs 31.2%, P = 0.11).

CONCLUSION

A simple screening program for CI followed by a CDSS did not change physician prescribing behaviors or improve the process of care for hospitalized older adults with CI.

Impact of geriatric consultation on the number of medications in hospitalized older patients

OBJECTIVE

This study aims to determine the impact of the geriatric consultation on the number of medications in hospitalized older adults and the corresponding financial impact.

DESIGN

Retrospective chart review of patients seen by geriatric consultants.

SETTING

Tertiary-care teaching hospital.

MAIN OUTCOME MEASURES

The number of medications prescribed before hospitalization, at time of consult, and at discharge, and the number and category of medications adjusted by the geriatrician. The monthly cost of the pharmaceutical interventions was computed based on the drugstore.com cost of acquisition of drugs.

RESULTS

A cohort of 62 patients was reviewed with a mean age of 84.6 (± 7.3) years; 79% were women. The patients presented with an average of 5.6 (± 2.1) comorbidities of which hypertension, dementia, and musculoskeletal disorders were the most common. The most common reasons for geriatric consultations were neuropsychiatric, nutritional, and gait-related issues. The geriatric consultant identified 2.96 (± 1.5) additional diagnoses, of which debility, delirium, and pain were the most prevalent. The average number of medications on admission was 7.7 (± 3.7) and at discharge was 9.5 (± 2.12). The average number of medications adjusted by the geriatric consultant was 2.96 (± 2.12). The most common classes of adjusted medications were pain medications (22%), nutrition (13%), bowel regimens (8.5%), antipsychotics (8%), and osteoporosis (8%). The cost impact of the pharmaceutical intervention ranged between -$343 and $2,607, with an average increase of $102 (± 368).

CONCLUSION

Geriatric consultations increased the total number of medications and the cost of medications used by elderly patients.

Comprehensive geriatric assessment for older adults admitted to hospital

BACKGROUND

Comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological and functional capabilities of a frail elderly person in order to develop a co-ordinated and integrated plan for treatment and long-term follow up.

OBJECTIVES

We sought to evaluate the effectiveness of CGA in hospital for older adults admitted as an emergency.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), the Database of Abstracts of Reviews of Effects (DARE), MEDLINE, EMBASE, CINAHL and AARP Ageline, and handsearched high-yield journals.

SELECTION CRITERIA

We searched for randomised controlled trials comparing CGA (whether by mobile teams or in designated wards) to usual care.

DATA COLLECTION AND ANALYSIS

Two review authors initially assessed eligibility and trial quality and extracted published data.

MAIN RESULTS

Twenty-two trials evaluating 10,315 participants in six countries were identified. Patients in receipt of CGA were more likely to be alive and in their own homes at up to six months (OR 1.25, 95% CI 1.11 to 1.42, P = 0.0002) and at the end of scheduled follow up (median 12 months) (OR 1.16, 95% CI 1.05 to 1.28, P = 0.003) when compared to general medical care. In addition, patients were less likely to be institutionalised (OR 0.79, 95% CI 0.69 to 0.88, P < 0.0001). They were less likely to suffer death or deterioration (OR 0.76, 95% CI 0.64 to 0.90, P = 0.001), and were more likely to experience improved cognition in the CGA group (OR 1.11, 95% CI 0.20 to 2.01, P = 0.02). Subgroup interaction in the primary outcomes suggests that the effects of CGA are primarily the result of CGA wards.

AUTHORS' CONCLUSIONS

Comprehensive geriatric assessment increases a patient's likelihood of being alive and in their own home at up to 12 months.

Collaboration between local health and local government agencies for health improvement

BACKGROUND

In many countries, national, regional and local inter- and intra-agency collaborations have been introduced in order to improve health outcomes. Evidence is needed on the effectiveness of locally-developed partnerships which target changes in individual health outcomes and behaviours.

OBJECTIVES

To evaluate the effects of interagency collaboration between local health and local government agencies on health outcomes.

SEARCH STRATEGY

Twenty-five databases were searched using a highly sensitive search strategy. 'Snowballing' methods were also used, including expert contact, website searching and reference list follow up.

SELECTION CRITERIA

Randomized controlled trials (RCTs), controlled clinical trials (CCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) where the study reported on interagency collaboration between health and local government agencies. Studies were selected independently in duplicate by two of five authors.

DATA COLLECTION AND ANALYSIS

From the team of five review authors, two authors independently conducted data extraction and assessed risk of bias for each study.

MAIN RESULTS

Eleven studies were identified, presenting information on a total of 26,686 participants. Owing to the heterogeneity between studies a narrative synthesis was undertaken. The included studies covered a range of topics. Six studies examined mental health initiatives, of which one study showed health benefit; four showed modest improvement in one or more of the outcomes measured, but no clear overall health gain; and one study showed no evidence of health gain. Two studies were related to lifestyle improvements of which one failed to show health gains for the intervention population, while the other showed more unhealthy lifestyle behaviours persisting in the intervention population. Three studies were related to chronic disease management and all three failed to demonstrate health gains.

AUTHORS' CONCLUSIONS

Collaboration between local health and local government is commonly considered best practice. However, the review did not identify any reliable evidence that inter‑agency collaboration, compared to standard services, leads to health improvement. A few studies identified component benefits but these were not reflected in overall outcome scores and could have resulted from the use of significant additional resources. Although agencies appear enthusiastic about collaboration, methodological flaws in the primary studies and incomplete implementation of initiatives have prevented the development of a strong evidence base. If these flaws are addressed in future studies (for example by providing greater detail on the implementation of programs, using more robust designs, with integrated process evaluations and measurement of health outcomes) it could provide a better understanding of what might work and why.When updating this review, we will analyse any partnership or process evaluations of our included studies to try to identify markers of success in local collaborative partnerships that could inform policy developments in the future.

Integration of Research Methods and Outcome Measures: Comprehensive Care for the Frail Elderly

Les instruments de recherche peuvent être intégrées dans les soins de routine si ceux-ci sont utiles aux pourvoyeurs de soins. Ainsi, ils sont utiles s'ils facilitent la prestation de soins et si ce qu'ils mesurent reflètent des résultats qui importent aux patients. Bon nombre de mesures actuelles sont moins utiles parce qu'elles ne peuvent servir dans le quotidien ou mesurent de façon inadéquate les résultats pertinents. Au plan des soins auprès des personnes âgées frêles, qui ont des besoins complexes, ces défis sont particulièrement difficiles à relever. Les techniques d'évalutation gériatrique complète et l'établissement d'une échelle de l'atteinte des objectifs (Goal Attainment Scaling — GAS) sont proposées comme des moyens d'englober la complexité des besoins des personnes âgées frêles et de mesurer l'efficacité des interventions spécialisées. L'échelle GAS est conforme à la définition de la qualité de la vie de l'instrument Health-Related Quality of Life. Ce qui suggère que son utilisation dans le quotidien offre des avantages tant au niveau de la gestion que de la mesure des résultats.

Impact of Geriatric Consultation Services for Elderly Patients Admitted to Acute Care Hospitals

Certains centres hospitaliers de soins à courte durée ont mis sur pied des programmes de consultation gériatrique destinés à l'intention des patients âgés. Des études évaluatives explorant l'utilité de ces programmes ont produit des résultats variés. Ces résultats inconsistants pourraient être causés par la différence au niveau de la conception des études de recherche, les différentes stratégies utilisées, les différentes façons d'analyser les résultats, et finalement certains facteurs propres à l'institution même. De toute évidence, la variable critique serait celle qui porte sur les méthodes utilisées pour recruter les patients. Des études plus poussées devraient être mises au point dans le but de (1) développer des stratégies cibles optimales, (2) déterminer la composition appropriée de service et fonction (3) étudier l'interaction entre ces programmes et les autres éléments d'un programme gériatrique d'envergure, (4) documenter l'effet à long terme (une année) sur les patients évalués et (5) évaluer l'impact institutionnel de ces programmes.

Discharge planning from hospital to home

BACKGROUND

Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and improve the co-ordination of services following discharge from hospital.

OBJECTIVES

To determine the effectiveness of planning the discharge of patients moving from hospital.

SEARCH STRATEGY

We updated the review using the Cochrane EPOC Group Trials Register, MEDLINE, EMBASE and the Social Science Citation Index (last searched in March 2009).

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to the individual patient. Participants were hospital inpatients.

DATA COLLECTION AND ANALYSIS

Two authors independently undertook data analysis and quality assessment using a predesigned data extraction sheet. Studies are grouped according to patient group (elderly medical patients, surgical patients and those with a mix of conditions) and by outcome.

MAIN RESULTS

Twenty-one RCTs (7234 patients) are included; ten of these were identified in this update. Fourteen trials recruited patients with a medical condition (4509 patients), four recruited patients with a mix of medical and surgical conditions (2225 patients), one recruited patients from a psychiatric hospital (343 patients), one from both a psychiatric hospital and from a general hospital (97 patients), and the final trial recruited patients admitted to hospital following a fall (60 patients). Hospital length of stay and readmissions to hospital were significantly reduced for patients allocated to discharge planning (mean difference length of stay -0.91, 95% CI -1.55 to -0.27, 10 trials; readmission rates RR 0.85, 95% CI 0.74 to 0.97, 11 trials). For elderly patients with a medical condition (usually heart failure) there was insufficient evidence for a difference in mortality (RR 1.04, 95% CI 0.74 to 1.46, four trials) or being discharged from hospital to home (RR 1.03, 95% CI 0.93 to 1.14, two trials). This was also the case for trials recruiting patients recovering from surgery and a mix of medical and surgical conditions. In three trials patients allocated to discharge planning reported increased satisfaction. There was little evidence on overall healthcare costs.

AUTHORS' CONCLUSIONS

The evidence suggests that a structured discharge plan tailored to the individual patient probably brings about small reductions in hospital length of stay and readmission rates for older people admitted to hospital with a medical condition. The impact of discharge planning on mortality, health outcomes and cost remains uncertain.

Development and implementation of a proactive geriatrics consultation model in collaboration with hospitalists

Acutely ill hospitalized older adults often experience a decline in function that may be preventable using a proactive, interdisciplinary, patient-centered approach. Hospitalists are treating an increasing number of these patients. A collaborative geriatrics consultation model to prevent functional decline and improve care for older patients with geriatrics syndromes was developed and implemented in partnership with a large hospitalist group in a community teaching hospital. A team of a geriatrician and a geriatrics nurse practitioner led the new consultation service. The team assisted with identifying cases, provided consultation early in the hospital stay, focused its evaluation on functional and psychosocial issues, and assisted in clinical management to optimize implementation of recommendations. In the first 4 years, the consultation service conducted 1,538 consultations in patients with a mean age of 81 (range 56-103). The most frequent geriatrics diagnoses were gait instability, delirium, and depression; recommendations usually included consulting physical therapy, increasing activity, and changing medications. The number of referrals and referring physicians grew steadily each year. Twenty-eight of 34 (82%) of the referring hospitalists completed a Web-based satisfaction questionnaire. All responding hospitalists agreed that proactive geriatrics consultation helped them provide better care; 96% rated the service as excellent. Analysis of hospital administrative data revealed a lower length of stay index and lower hospital costs in patients receiving a geriatrics consultation. The Proactive Geriatrics Consultation Service represents a promising model of collaboration between hospitalists and geriatricians for improving care of hospitalized older adults.

Geriatrics on the run: rationale, implementation, and preliminary findings of a Belgian internal liaison team

This article describes the rationale, implementation, interventions and preliminary findings of a Belgian interdisciplinary internal liaison team in a 1470-bed teaching hospital. The motive to start the team was threefold: the ageing of the inhospital population, the conclusion that health care professionals working on non-geriatric wards often lack the necessary skills to deal with older patients' needs and Belgian law, obliging each general hospital to set up an internal liaison team. Our team aims at detecting geriatric patients at risk, assisting health care professionals in caring for older patients and sensitizing them regarding optimal geriatric care. The article explains the underlying philosophy and strategy for implementation, focusing on the concepts of reciprocity, flexibility and cooperation. The preliminary results are based on a process evaluation of 719 consultations carried out from November 2004 to November 2006, a time registration, and a Strengths, Weaknesses, Opportunities, and Threats analysis (SWOT). Although our data are preliminary and the implementation of the team was pragmatic rather than research driven, they provide insight into the development, implementation, functioning and interventions of a Belgian interdisciplinary internal liaison team.

Best practice interventions to improve the management of older people in acute care settings: a literature review

AIM

This paper is a report of a literature review of experimental evidence describing interventions to manage the older adult in the acute care hospital setting.

BACKGROUND

Older people are increasingly being cared for in a system largely geared towards acute care. This approach is often inadequate to meet the needs of older patients with chronic and complex conditions. In response to these challenges, evidence-based interventions are required to improve health outcomes.

METHOD

The MEDLINE and CINAHL databases and the Internet were searched using the keywords elderly, older, geriatric and aged care. Studies published between 1985 and 2006 were included if they reported, in English, a controlled trial of an intervention designed to improve the management of older adults in the acute care setting. The findings were synthesized using the method of a modified integrative literature review.

FINDINGS

Only 26 controlled trials met the inclusion criteria. The following elements of interventions appear critical in providing optimal health outcomes for older people admitted to acute care: (1) a team approach to care delivery either directly in a designated unit for older patients or indirectly using gerontological expertise in a consultancy model; (2) targeted assessment techniques to prevent complications; (3) an increased emphasis on discharge planning and (4) enhanced communication between care providers across the care continuum.

CONCLUSION

A multidisciplinary team approach, using gerontological expertise, in acute care settings is recommended to improve the care of older patients. Care delivery should occur in a specially designed unit, with communication strategies that emphasize discharge planning.

Exercise for acutely hospitalised older medical patients

BACKGROUND

A high incidence of functional decline (deterioration in physical or cognitive function) during hospitalisation of older adults is reported. The role of exercise in preventing these deconditioning effects is unclear.

OBJECTIVES

To determine the effect of exercise interventions for acutely hospitalised older medical patients on functional status, adverse events and hospital outcomes.

SEARCH STRATEGY

We searched MEDLINE (1966-Feb 2006), CINAHL (1982-Feb 2006), EMBASE (1988 to Feb 2006), Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2006), PEDro (1929- Feb 2006), Current Contents (1993- Feb 2006) and Sports Discus (1830-Feb 2006). The Journal of the American Geriatrics Society was hand searched. Additional studies were identified through reference and citation tracking, personal communications with a content expert and contacting authors of eligible trials. There was no language restriction.

SELECTION CRITERIA

Eligible studies were prospective randomised controlled trials (RCT) or prospective controlled clinical trials (CCT) comparing exercise for acutely hospitalised older medical patients to usual care or no treatment controls.

DATA COLLECTION AND ANALYSIS

Two independent reviewers extracted data relating to patient and hospital outcomes and assessed the method quality of included studies. Data were pooled in meta-analysis using the relative risk (RR) and absolute risk reduction (ARR) for dichotomous outcomes and the standardised mean difference (SMD) or the weighted mean difference (WMD) for continuous outcomes.

MAIN RESULTS

Of 3138 potentially relevant articles screened, 7 randomised controlled trials and 2 controlled clinical trials were included. The effect of exercise on functional outcome measures is unclear. No intervention effect was found on adverse events. Pooled analysis of multidisciplinary interventions that included exercise indicated a small significant increase in the proportion of patients discharged to home at hospital discharge (Relative Risk 1.08, 95% CI 1.03 to 1.14 and Numbers Needed to Treat 16, 95% CI 11 to 43) and a small but important reduction in acute hospital length of stay (weighted mean difference, -1.08 days, 95% CI -1.93 to -0.22) and total hospital costs (weighted mean difference, -US$278.65, 95% CI -491.85 to -65.44) compared to usual care. Pooled analysis of exercise intervention trials found no effect on the proportion of patients discharged to home or acute hospital length of stay.

AUTHORS' CONCLUSIONS

There is 'silver' level evidence (www.cochranemsk.org) that multidisciplinary intervention that includes exercise may increase the proportion of patients discharged to home and reduce length and cost of hospital stay for acutely hospitalised older medical patients.

Do geriatric interventions reduce emergency department visits? A systematic review

BACKGROUND

Hospital emergency departments (EDs) serve an aging population with an increased burden on health resources. Few studies have examined the effects of comprehensive geriatric assessment interventions on ED use. This study aimed to systematically review the literature and compare the effects of these interventions on ED visits.

METHODS

Relevant articles were identified through electronic databases and a search of reference lists and personal files. Inclusion criteria included: original research (written in English or French) on interventions conducted in noninstitutionalized populations 60 years old or older, not restricted to a particular medical condition, in which ED visits were a study outcome. Data were abstracted and checked by the first author and a research assistant using a standard protocol.

RESULTS

Twenty-six relevant studies were identified, reported in 28 articles, with study samples obtained from EDs (9), hospitals (4), outpatient or primary care settings (10), home care (4), and community (1). The study designs included 17 randomized controlled trials, 3 trials with nonrandom allocation, 4 before-after studies, 1 quasi-experimental time-series study, and 1 cross-sectional study. Hospital-based interventions (mostly short-term assessment and/or liaison) had little overall effect on ED utilization, whereas many interventions in outpatient and/or primary care or home care settings (including geriatric assessment and management and case management) reduced ED utilization. Heterogeneity in study methods, measures of comorbidity, functional status, and ED utilization precluded meta-analysis of the results.

CONCLUSION

Further research, using improved methodologies and standardized measures, is needed to address the effects of innovative geriatric interventions on ED visits.

Discharge planning from hospital to home

BACKGROUND

Discharge planning is a routine feature of health systems in many countries. The aim is to reduce hospital length of stay and unplanned readmission to hospital, and improve the co ordination of services following discharge from hospital thereby bridging the gap between hospital and place of discharge. Sometimes discharge planning is offered as part of an integrated package of care, which may cover both the hospital and community. The focus of this review is discharge planning that occurs while a patient is in hospital; we exclude studies that evaluate discharge planning with follow up care.

OBJECTIVES

To determine the effectiveness of planning the discharge of patients moving from hospital.

SEARCH STRATEGY

Relevant studies were identified using Medline, Embase, SIGLE database for grey literature, Bioethics database, Health Plan, Psych. Lit, Sociofile, CINAHL, Cochrane Library, Econ Lit, Social Science Citation Index, EPOC register. The review was updated using the EPOC trials register in August 2002.

STUDY DESIGN

randomised controlled trials (RCTs) that compare discharge planning (the development of an individualised discharge plan) with routine discharge care.

PARTICIPANTS

all patients in hospital.

INTERVENTION

the development of an individualised discharge plan.

DATA COLLECTION AND ANALYSIS

Data analysis and quality assessment was undertaken independently by two reviewers using a data checklist. Studies are grouped according to patient group (elderly medical patients, surgical patients, and those with a mix of conditions), and by outcome.

MAIN RESULTS

Three new studies were included in this update. In total we included eleven RCTS: 6 trials recruited patients with a medical condition (2,368 patients), and four recruited patients with a mix of medical and surgical conditions (2,983 patients), one of these four recruited medical and surgical patients as separate groups, and the final trial recruited 97 patients in a psychiatric hospital and from a general hospital. We failed to detect a difference between groups in mortality for elderly patients with a medical condition (OR 1.44 95% CI 0.82 to 2.51), hospital length of stay (weighted mean difference -0.86, 95% CI -1.9 to 0.18), readmission rates (OR 0.91 95% CI 0.67 to 1.23) and being discharged from hospital to home (OR 1.15 95% CI 0.72 to 1.82). This was also the case for trials recruiting patients recovering from surgery and those recruiting patients with a mix of medical and surgical conditions. One trial comparing a structured care pathway for patients recovering from a stroke with multidisciplinary care reported a significant rate of improvement in functional ability and quality of life for the control group (median change in Barthel score between 4 to 12 weeks of 2 points for the treatment group, versus 6 for the control group, p<0.01); (Euroqol scores at 6 months 63 for the treatment group, vs. 72 for the control group, p<0.005). Two trials reported that patients with medical conditions allocated to discharge planning reported increased satisfaction compared with those who received routine discharge. No statistically significant differences were reported for overall health care costs.

REVIEWER'S CONCLUSIONS

The impact of discharge planning on readmission rates, hospital length of stay, health outcomes and cost is uncertain. This reflects a lack of power as the degree to which we could pool data was restricted by the different reported measures of outcome. It is possible that even a small reduction in length of stay, or readmission rate, could have an impact on the timeliness of subsequent admissions in a system where there is an shortage of acute hospital beds.

Comprehensive geriatric assessment for older hospital patients

In-patient comprehensive geriatric assessment (CGA) may reduce short-term mortality, increase the chances of living at home at 1 year and improve physical and cognitive function. We systematically reviewed the literature and found 20 randomized controlled trials (10 427 participants) of in-patient CGA for a mixed elderly population. This includes seven more recent randomized controlled trials that update a previous review. Newer data confirm the benefit of in-patient CGA, increasing the chance of patients living at home in the long term. Overall, for every 100 patients undergoing CGA, three more will be alive and in their own homes compared with usual care [95% confidence interval (CI) 1-6]. Most of the benefit was seen for ward-based management units (four patients per 100 treated, 95% CI 1-7) with little contribution from team-based care (no patients per 100, 95% CI -4 to +5). However, CGA does not reduce long-term mortality. This evidence should inform future service developments.

A comparison of observational studies and randomized, controlled trials

BACKGROUND

For many years it has been claimed that observational studies find stronger treatment effects than randomized, controlled trials. We compared the results of observational studies with those of randomized, controlled trials.

METHODS

We searched the Abridged Index Medicus and Cochrane data bases to identify observational studies reported between 1985 and 1998 that compared two or more treatments or interventions for the same condition. We then searched the Medline and Cochrane data bases to identify all the randomized, controlled trials and observational studies comparing the same treatments for these conditions. For each treatment, the magnitudes of the effects in the various observational studies were combined by the Mantel-Haenszel or weighted analysis-of-variance procedure and then compared with the combined magnitude of the effects in the randomized, controlled trials that evaluated the same treatment.

RESULTS

There were 136 reports about 19 diverse treatments, such as calcium-channel-blocker therapy for coronary artery disease, appendectomy, and interventions for subfertility. In most cases, the estimates of the treatment effects from observational studies and randomized, controlled trials were similar. In only 2 of the 19 analyses of treatment effects did the combined magnitude of the effect in observational studies lie outside the 95 percent confidence interval for the combined magnitude in the randomized, controlled trials.

CONCLUSIONS

We found little evidence that estimates of treatment effects in observational studies reported after 1984 are either consistently larger than or qualitatively different from those obtained in randomized, controlled trials.

Discharge planning from hospital to home

BACKGROUND

Discharge planning is the development of an individualised discharge plan for the patient prior to leaving hospital for home, with the aim of containing costs and improving patient outcomes. It has been suggested that discharge planning can reduce unplanned readmission to hospital.

OBJECTIVES

To assess the effects of discharge planning for patients moving from hospital to home.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, the Cochrane Controlled Trials Register, MEDLINE (1966 to 1996), EMBASE (1980 to 1996), Sigle (1980 to 1996), Bioethics (1985 to 1996), Health Plan (all available years), PsycLit (1974 to 1996), Cinahl (1982 to 1996), EconLit (1969 to 1996), Social Science Citation Index (1992 to 1996), and reference lists of articles.

SELECTION CRITERIA

Randomised trials and controlled trials comparing discharge planning with routine discharge for hospital patients. The outcomes were mortality, clinical complications, hospital length of stay, readmissions, discharge destination, general and disease specific health status, functional status, psychological well-being, patient satisfaction, carer satisfaction, carer burden, cost to the health service, patient and family, general practice, and community services.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Eight studies were included involving 4837 patients. Four studies recruited patients with a medical condition; four recruited patients with a mix of medical and surgical conditions, and one of these recruited medical and surgical patients as separate groups. There was a small reduction in hospital length of stay for elderly medical patients allocated to discharge planning (weighted mean difference -1.01, 95% CI -2.06 to 0.05). The effects of discharge planning on readmission rates were mixed. No statistically significant differences were detected for patient health outcomes. Patients with medical conditions allocated to discharge planning reported increased satisfaction compared with those receiving routine discharge. No statistically significant differences were reported for overall health care costs, although one study reported a significant reduction in readmission costs for medical patients allocated to discharge planning.

REVIEWER'S CONCLUSIONS

The studies showed mixed results, which may reflect the different study populations and the different ways the intervention was implemented. There is some evidence that discharge planning may lead to reduced hospital length of stay, and in some cases reduced readmission to hospital. There is also some evidence that discharge planning increased patient satisfaction. There was no evidence that discharge planning reduced health care costs; however few studies conducted a formal economic analysis.

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.

Aging-related clinical and health services research in Canada

Research by Canadian geriatricians has grown significantly since the Canadian Society of Geriatric Medicine was founded in 1981. Most research has been clinical or related to health service use. More recently, the Canadian Study of Health and Aging (CSHA) has proved an important focus for population-based research, and research on dementia. An increasing number of Canadian geriatricians have undertaken formal research training, and the CSHA study team and other groups are providing opportunities for multicentre, multidisciplinary, collaborative studies. These developments point to continued growth in research by Canadian geriatricians, most likely research with a clinical and population focus and employing multicenter designs.

A randomized trial of geriatric liaison intervention in elderly medical inpatients

OBJECTIVE

The aim of this study was to examine the effect of psychogeriatric intervention in a group of elderly medical inpatients over 75 years of age. In addition to usual care, intervention consisted of multidisciplinary joint treatment by a psychogeriatric team. The main purpose of intervention was to obtain the optimal level of physical functioning.

METHOD

In a prospective randomized trial the effect of the intervention (N = 140) compared with usual care (N = 97) was estimated for physical functioning, length of stay, and nursing home placement within 12 months of discharge.

RESULTS

Substantially more patients assigned to the intervention group improved in their physical functioning, and fewer became worse. The mean length of stay was 5 days shorter for the intervention group. There were more readmissions to hospital in the usual care group (29.9%) compared with the intervention group (17.4%). Of the patients assigned to the intervention treatment, 18% were admitted to a nursing home. In the usual care group this was 27%. The effects of intervention remained statistically significant for all the outcome variables after controlling for possible confounding baseline characteristics.

CONCLUSIONS

The intervention we studied had clinically relevant effects on important outcome variables. Psychiatric co-morbidity was an important risk factor for the outcome of the patients in our study. By combining elements from a psychiatric and geriatric consultation service with elements from a unit-driven service, we were able to improve health care for the elderly in our hospital in a feasible and cost-effective way.

A geriatric consultation team in the emergency department

BACKGROUND

The proportion and absolute number of older patients presenting to emergency departments (EDs) are increasing. Older ED patients tend to have multiple medical and psychosocial problems that make their care in the ED problematic. Despite this, there have been no previous descriptions of geriatric ED consultative services.

SETTING

The Sir Mortimer B. Davis Jewish General Hospital is a 628-bed tertiary care McGill University teaching hospital. It serves a population of about 160,000, of which 23% are aged 65 and older. In response to the special needs of this group, the Division of Geriatric Medicine at the Jewish General Hospital has developed, among its clinical and teaching services, an ED consultation team.

PROGRAM DESCRIPTION

The consultation team is composed of a geriatrician, a full-time nurse clinician, and part-time physical and occupational therapists. Consultations are received from referring, primarily Ed physicians and encompass all aspects of medical and psychosocial issues. Geriatric assessment is geared toward decision making for rapid disposition: discharge home or admission to acute geriatrics ward or other services. Thus, the service functions as a gatekeeper for admission to the acute geriatrics ward, as well as coordinating geriatric follow-up both in-hospital (for patients admitted to other services) and in the community (for patients discharged home), via the outpatient geriatric clinic, home visits, or linkage to other community resources.

What do we know about patient targeting in geriatric evaluation and management (GEM) programs?

Evidence indicates that institution-based programs for interdisciplinary geriatric evaluation and management (GEMs) improve outcomes of care, but results vary considerably between studies. Targeting (i.e., selective admission of frail elderly patient subgroups who are thought particularly to benefit) has been advocated as a means to improve the cost-effectiveness of GEM programs, and results from meta-analysis give this concept some support. Our review has several objectives: 1) describing approaches to GEM targeting and development of selection criteria; 2) assessing evidence from randomized trials concerning effects of targeting on outcome; and 3) suggesting an agenda for further research and development on GEM targeting.

Meta-analytic methods for health services research--an example from geriatrics

The authors recently published a meta-analysis of controlled trials of comprehensive geriatric assessment (CGA). The results supported the view that efficacy of CGA is strongly related to the patients, objectives, and basic design of CGA programs, and that particular program models and design features are associated with important health outcome improvements (e.g., survival, living at home, and functional improvement at follow-up). Present objectives include the outline of methods and how they were developed given the condition of the trial database and scientific context. Aspects of the approach, such as (a) survey of primary trialists to recover unpublished information and standardize data, (b) development of a program typology to guide the principal analysis, and (c) incorporation of program design features as covariates where statistical heterogeneity was detected, proved extremely useful, and have implications for other systematic reviews of similarly complex primary trials of new health care technologies, health services, and organizational interventions.

Evaluation of outpatient geriatric assessment: a randomized multi-site trial

OBJECTIVE

To evaluate the process and outcome of outpatient consultative geriatric assessment compared with traditional community care.

DESIGN

Randomized, controlled clinical trial, with 12-month follow-up.

SETTING

Four hospital-based ambulatory geriatric assessment clinics and community physicians' offices.

PARTICIPANTS

442 recruited older adults with a health problem or recent change in health status.

INTERVENTION

Outpatient consultative geriatric assessment or usual physician assessment.

MAIN OUTCOME MEASURES

Identification of health problems, mortality, nursing home admissions, health status, health services utilization, satisfaction with care, and caregiver well-being.

RESULTS

Geriatric assessment, in comparison with usual community care, resulted in the identification of a significantly greater number of patients with cognitive impairment (P < .0001), depression (P = .0004) and incontinence (P < .0001). The group receiving a geriatric assessment had greater improvement in anxiety levels at 1 year (P = .036). Caregivers of participants in the geriatric assessment group had less caregiver stress at 1 year (P = .002). No outcome differences in mortality, nursing home admissions, cognitive health, functional health, or health services utilization were observed. Some evidence of greater patient satisfaction with respect to qualities of the physician was found for the geriatric assessment group.

CONCLUSIONS

Consultative outpatient geriatric assessment led to significantly improved diagnosis of the common health problems of cognitive impairment, depression, and incontinence, to psychological and emotional benefits for patients, and to reduced levels of caregiver stress. Even with limited follow-up care and control of treatment, outpatient geriatric assessment has potential for significant positive effects.

A model of regular geriatric follow-up by home visits to selected patients discharged from a geriatric ward: a randomized controlled trial

The aim of this randomized controlled trial was to describe and evaluate a model of regular follow-up by home visits to selected elderly patients discharged from a geriatric ward. Ninety-seven patients were randomized to receive regular follow-up visits by a geriatric team at 1, 3, 8 and 16 weeks after discharge, and 96 patients to receive standard care. Based on the geriatric evaluation, medical and social adjustment was carried out, if indicated. Six months after discharge, significantly more patients in the intervention group were allocated to home help (p < 0.05), but only 42 (44%) were readmitted to a hospital, vs 62 (64%) in the control group (p < 0.005). Differences between the groups in mortality and nursing-home placement were not statistically significant. Regular follow-up home visits by a geriatric team after in-patient geriatric evaluation and management reduce the risk of hospital readmissions among highly selected frail geriatric patients.

A randomized trial of comprehensive geriatric assessment in the care of hospitalized patients

BACKGROUND

Although many studies describe benefits from the comprehensive assessment of elderly patients by an interdisciplinary team (comprehensive geriatric assessment), the most supportive evidence for the process has come from programs that rely on specialized inpatient units and long hospital stays. We examined whether an inpatient geriatric consultation service might also be beneficial in a trial involving four medical centers of a group-practice health maintenance organization (HMO).

METHODS

We conducted a randomized clinical trial with 2353 hospitalized patients 65 years of age or older in whom at least 1 of 13 screening criteria were present: stroke, immobility, impairment in any basic activity of daily living, malnutrition, incontinence, confusion or dementia, prolonged bed rest, recent falls, depression, social or family problems, an unplanned readmission to the hospital within three months of a previous hospital stay, a new fracture, and age of 80 years or older. Of the 1337 patients assigned to the experimental group, 1261 (94 percent) received a comprehensive geriatric assessment in the form of a consultation, with limited follow-up; the 1016 patients assigned to the control group received usual care. The functional and health status of the patients was measured at base line and 3 and 12 months later; survival was assessed at 12 months. Subgroups of patients who might be presumed to benefit from comprehensive assessment were also studied.

RESULTS

The survival rate at 12 months was 74 percent in the experimental group and 75 percent in the control group. At base line, 3 months, and 12 months the scores of the two groups on measures of functional and health status were similar. The analysis of 16 subgroups did not identify any with either clearly improved functional status or improved survival.

CONCLUSIONS

In this HMO, comprehensive geriatric assessment by a consultation team, with limited follow-up, did not improve the health or survival of hospitalized patients selected on the basis of screening criteria.

A geriatric assessment and intervention team for hospital inpatients awaiting transfer to a geriatric unit: a randomized trial

The objective of this study, designed as a randomized controlled trial, was to decrease the length-of-stay (LOS) of hospitalized patients on a waiting list for admission to an inpatient geriatric assessment unit (GAU), and to optimize use of the GAU and other hospital services. The participants included 108 elderly, functionally impaired inpatients referred for geriatric consultation, and appropriate for GAU admission, stratified into high and low ADL functioning groups. They were admitted to a 354-bed acute hospital, with a 31-bed long-stay ward and a 15-bed GAU; a 25-30 day delay occurred between screening and admission of inpatients to the GAU. Experimental subjects (N = 25) received the consultative services of a geriatric assessment and intervention team (GAIT) immediately after being qualified for GAU admission, in place of waiting for GAU services. Controls (N = 52) received usual hospital care until admitted to the GAU. While high-function patients randomized to the GAIT had significantly shorter hospital LOS than comparable controls (41.4 vs 56.5 days; p = 0.03), LOS reduction was even greater in the low-function stratum (44.5 vs 74.5 days; p = 0.001). Further, significantly more GAIT than control patients were discharged home (28% vs 11%; p = 0.044). A trend toward reduced mortality in the GAIT group was non-significant. We conclude that for Canadian hospitals in which extensive stays of frail elderly patients, "bed blockage", and thus access to unit-based geriatric services are common problems, the GAIT can efficiently decrease hospital LOS, increase home placement, and may improve outcomes.

Geriatric psychiatry consultation in the community

While increasing emphasis is being placed on geriatric psychiatry consultation and outreach services, there is considerable variation in terms of the composition and direction of these programs. Programs vary in terms of their objectives, location, target population, use of health professions and other resources and their method of consultation. The purposes of this paper are to review the characteristics of existing programs, to review the needs of the targets of consultation and to consider theoretical and methodological approaches which have been found to be useful in mental health/psychiatric consultation, in continuing medical education, and in program evaluation. On the basis of this review, future directions for effective approaches to consultative outreach in geriatric psychiatry will then be proposed.

Rationale and design of a multi-center randomized trial of comprehensive geriatric assessment consultation for hospitalized patients in an HMO

OBJECTIVE

To describe the evaluation of an interdisciplinary comprehensive geriatric assessment (CGA) consultation program for targeted hospitalized patients.

DESIGN

Multi-center randomized clinical trial (RCT) at four hospitals where patients were randomly assigned to CGA consultation or usual care by the attending physician, and a non-equivalent control group (NCG) at two hospitals.

SETTING

Six hospitals in a multi-specialty group practice model health maintenance organization (HMO).

PARTICIPANTS

3593 patients age 65 years or older meeting at least one of 13 inclusionary criteria at admission.

INTERVENTION

Screening by hospital staff and standardized CGA consultation conducted by a nurse practitioner, social worker, and geriatrician at the four RCT hospitals.

MAIN OUTCOME MEASURES

Functional and health status, mortality, rehospitalization, and cost-effectiveness of the CGA program at 1 year post-randomization; validation of targeting (inclusionary) criteria that identify subgroups of patients deriving benefit from CGA; and physician contamination (learning from CGA and changing treatment provided to control patients).

CONCLUSIONS

A number of methodological issues need to be considered when conducting effectiveness trials of CGA. The concurrent design of a multi-center RCT, coupled with the NCG to determine physician contamination, is an innovative approach intended to determine more precisely the cost-effectiveness of CGA for frail hospitalized elderly persons. The large and heterogeneous patient population and the broad array of inclusionary criteria will permit the evaluation of the benefit of CGA for subgroups. All these features are intended to enhance the generalizability of study results.

High-Risk Elderly Patients in Acute Care Institutions: A Canadian Perspective

Hospitalised elderly patients institutionalised for prolonged periods present a significant challenge to health professionals, but relatively few acute care hospitals provide specialised programmes designed to address their unique and individual needs. This article presents a review of relevant from 1978 to the present related to the needs of high-risk elderly patients in acute care institutions and comments on hypothesis versus reality. The literature indicates that when an active team approach is used with the elderly patient, focusing on rehabilitation and activities of daily living, a decreased length of stay can result. However, no studies were found that tested the results of a dynamic ‘enriched programme of care’.

After a review of inpatient data on two acute orthopaedic wards at two Ontario medical centres, the authors set out to establish if it was feasible to conduct a pilot study. The proposed study included a detailed outline of an enriched programme of care utilising the resources of occupational therapists, ward nursing staff and volunteers. Over a period of 6 months there were several multidisciplinary of health professionals and volunteers, who reviewed the demographics of this population which indicated that acute elderly orthopaedic patients over 65 are being discharged fairty quickly from hospital. This reality appears to contradict the literature which suggests that this group of patients are hospitalised for long periods and therefore require more functionally focused physical rehabilitation orientated programmes. It also begs the important question regarding adequate preparation of this population for return home and continuity of care between hospital and community.

A controlled trial of a nursing-centered intervention in hospitalized elderly medical patients: the Yale Geriatric Care Program

OBJECTIVE

To test the effectiveness of a nursing-centered intervention to prevent functional decline among hospitalized elderly medical patients.

DESIGN

Prospective cohort study with stratified and matched cohort analyses.

SETTING

General medicine wards of a university teaching hospital.

PATIENTS

Two hundred sixteen patients aged > or = 70 years (85 intervention and 131 control patients).

INTERVENTION

The intervention included identification and surveillance of frail older patients, twice-weekly rounds of the Geriatric Care Team, and a nursing-centered educational program.

MAIN OUTCOME MEASURE

Functional decline, defined as a net decline in five activities of daily living (ADLs).

RESULTS

In stratified analyses, the intervention resulted in a beneficial effect with a relative risk of 0.82 (95% confidence interval [CI] 0.54 to 1.24) in patients (n = 106) with one of four geriatric target conditions at baseline (eg, delirium, functional impairment, incontinence, and pressure sores). The intervention had no effect in patients without target conditions at baseline (n = 110); thus, this subgroup was excluded from further analyses. When patients were matched on number of target conditions and risk for functional decline at baseline (n = 66), the intervention resulted in a significant beneficial effect, with a reduction in functional decline from 64% in controls to 41% in the intervention group, for a relative risk of 0.64 (95% CI, 0.43 to 0.96). The intervention group had significantly less decline in ADL score and in individual ADLs than control subjects. Specific interventions aimed at maximizing function, such as physical therapy, were received more often by intervention patients; however, the beneficial effects of the intervention were achieved without increasing per-day hospital costs.

CONCLUSIONS

The intervention appears effective to decrease functional decline in targeted elderly hospitalized medical patients.

A predictive index for functional decline in hospitalized elderly medical patients

OBJECTIVE

To prospectively develop and validate a predictive index to identify on admission elderly hospitalized medical patients at risk for functional decline.

DESIGN

Two prospective cohort studies, in tandem. The predictive model developed in the initial cohort was subsequently validated in a separate cohort.

SETTING

General medical wards of a university teaching hospital.

PATIENTS

For the development cohort, 188 hospitalized general medical patients aged > or = 70 years. For the validation cohort, 142 comparable patients.

MEASUREMENT AND MAIN RESULTS

The subjects and their nurses were interviewed twice weekly using standardized, validated instruments. Functional decline occurred among 51/188 (27%) patients in the development cohort. Four independent baseline risk factors (RFs) for functional decline were identified: decubitus ulcer (adjusted relative risk [RR] 2.7; 95% confidence interval [CI] 1.4, 5.2); cognitive impairment (RR 1.7; CI 0.9, 3.1); functional impairment (RR 1.8; CI 1.0, 3.3); and low social activity level (RR 2.4; CI 1.2, 5.1). A risk-stratification system was developed by adding the numbers of RFs. Rates of functional decline for the low- (0 RF), intermediate- (1-2 RFs), and high- (3-4 RFs) risk groups were 8%, 28%, and 63%, respectively (p < 0.0001). The corresponding rates in the validation cohort, of whom 34/142 (24%) developed functional decline, were 6%, 29%, and 83% (p < 0.0001). The rates of death or nursing home placement, clinical outcomes associated with functional decline in the hospital, were 6%, 19%, and 41% (p < 0.002) in the development cohort and 10%, 32%, and 67% (p < 0.001) in the validation cohort, respectively, for the three risk groups.

CONCLUSIONS

Functional decline among hospitalized elderly patients is common, and a simple predictive model based on four risk factors can be used on admission to identify elderly persons at greatest risk.

The Yale Geriatric Care Program: a model of care to prevent functional decline in hospitalized elderly patients

OBJECTIVE

To describe the structure and implementation of the Yale Geriatric Care Program, an innovative, nursing-centered model for developing geriatric nursing expertise throughout an acute-care hospital.

DESIGN

Descriptive study of an intervention in a prospective cohort of patients.

SETTING

University teaching hospital.

PATIENTS

Two hundred forty four patients aged 70 years and older on four non-intensive care intervention units during the study period (July 9, 1990 to July 31, 1991).

INTERVENTION

The Geriatric Care Program involved an integrated model of primary nurses, specially trained unit-based geriatric resource nurses, gerontological nurse specialists, and geriatric physicians. The intervention included surveillance and identification of frail older patients, unit-based geriatric educational programs for all nurses, special education and support for the geriatric resource nurses, and twice-weekly rounds of the Geriatric Care Team.

RESULTS

The Geriatric Care Program has been successfully implemented on four units. The interventions ranged from general clarification of goals in 226 (92%) to specific recommendations for management of immobility in 100 (41%), bladder/bowel problems in 99 (41%), pressure ulcer treatment or prevention in 61 (25%), confusion evaluation or management in 62 (25%), and adjustment of medications in 43 (18%). Overall, 68% of the specific recommendations were documented to have been implemented. Barriers to implementation of the program have included initial difficulties with recruitment and retainment of geriatric resource nurses (due to high nursing turnover and the increased time commitment required), breakdown in communication and carryover of recommendations between nursing shifts, and obstacles to communication between the nursing and medical staff.

CONCLUSIONS

An innovative model of care, in which geriatric nursing was integrated as part of standard nursing care on selected medical and surgical units, has been designed and implemented. Evaluation of the effectiveness and costs of this intervention are currently underway.

Comprehensive geriatric assessment: a meta-analysis of controlled trials

There is disagreement on the usefulness of comprehensive geriatric assessment (CGA) due to conflicting results from individual trials. We did a meta-analysis on 28 controlled trials comprising 4959 subjects allocated to one of five CGA types and 4912 controls. Published data were supplemented with reanalysed data provided by the original investigators. We calculated combined odds ratios of important outcomes by pooling data from individual trials with multivariate logistic regression. Combined odds ratio (95% confidence interval) of living at home at follow-up was 1.68 (1.17-2.41) for geriatric evaluation and management units, 1.49 (1.12-1.98) for hospital-home assessment services, and 1.20 (1.05-1.37) for home assessment services. Covariate analysis showed that programmes with control over medical recommendations and extended ambulatory follow-up were more likely to be effective. Our analysis suggests that CGA programmes linking geriatric evaluation with strong long-term management are effective for improving survival and function in older persons.

Continuous geriatric care in orthopedic wards: a valuable alternative to orthogeriatric units

The aim of this study was to assess whether assigning a geriatrician to provide daily medical care to geriatric patients in the orthopedic ward can improve the prognosis and reduce the length of stay. Time series analysis was performed in two parts: 1) prospective analysis of two years' workload, and 2) retrospective analysis of data collected over the 4 years prior to the intervention. Intervention and control populations were pooled, and the effects of geriatric care and patient-related factors on outcome measures were assessed by logistic regression analysis. All subjects were patients aged > or = 70 years who attended the orthopedic ward in a university hospital in years 1989-90 (studied group: 287 cases) and in years 1985-88 (control group: 474 cases). In the study period, mortality was 8.4% compared to 18% in 1985-86 (p < 0.0006) and 14% in 1987-88 (p < 0.01). The operation rate in the study period was 89.9% vs 83.8% in 1985-86 (p < 0.02) and 81.8% in 1987-88 (p < 0.005). Length of stay was 26.2 +/- 14.4 days vs 32.9 +/- 30.9 days in 1985-86 (p < 0.05) and 26.9 +/- 16.5 days in 1987-88 (NS). Length of stay was more strikingly shortened in the subset of patients with femoral fracture undergoing surgical management (28.5 +/- 12.7 vs 37.6 +/- 32.6 days in 1985-86, p < 0.003, and 30.8 +/- 15 days in 1987-88, p < 0.02). Given the positive relationship between geriatric care and operation rate (o.r. = 1.5, CI = 1.1-1.9), the protective effect of surgical treatment on mortality (o.r. = 0.6, CI = 0.4-0.8) to some extent may mask the collinear effect of geriatric care. We conclude that assigning a geriatrician to assist with the medical care of elderly orthopedic patients in orthopedic wards is associated with increased operation rate, decreased mortality and shortened length of stay.

Hospital Outcomes Project for the Elderly (HOPE): rationale and design for a prospective pooled analysis

OBJECTIVE

To describe a collaborative investigation that is based on a series of six clinical studies aimed at reducing functional decline in the acutely-ill hospitalized elderly.

DESIGN

A prospective, multicenter pooled analysis project involving collection of a common set of data from a group of related but distinct intervention trials with similar objectives.

SETTING

Five university-affiliated hospitals and one community hospital.

PARTICIPANTS

Elderly patients (age minimums from 65 to 75 years) admitted for a range of acute illnesses.

INTERVENTIONS

Site-specific interventions include exercise and physical therapy; developing and implementing methods to improve detection and evaluation of delirious patients; a multidisciplinary geriatric care unit; a multidisciplinary intervention implemented in-hospital that includes some post-discharge care; and a nursing-centered geriatric care program.

MAIN OUTCOME MEASURE

Functional status.

CONCLUSION

The prospective, multicenter design of the Hospital Outcomes Project for the Elderly (HOPE) provides an innovative approach for analysis of hospital outcomes in the elderly. Although differences in study populations and interventions exist, qualitative comparisons across sites will enhance generalizability and will provide a great opportunity to examine consistency among the sites. The HOPE pooled analysis project will impart greater statistical power to detect the primary and secondary outcomes compared with previous single-center trials that have assessed interventions related to functional decline in the hospitalized elderly.

Inpatient community-based geriatric assessment reduces subsequent mortality

OBJECTIVE

To evaluate the effect of an Inpatient Geriatric Consultation Team on patient outcome.

DESIGN

Randomized controlled clinical trial.

SETTING

A non-academic-affiliated 503-bed community hospital.

PATIENTS

All inpatients over the age of 70 years. Sixty-two patients received multidimensional geriatric assessment, and 58 patients received no intervention.

INTERVENTION

Team assessment, leading to formal recommendations to the attending physician.

MEASUREMENTS

Data were collected on hospital length of stay, referrals to community service, discharge destination, hospital readmissions in 6 months, number of post-discharge physician visits, and change in functional status. Mortality at 6 months and at 1 year was determined for each patient.

MAIN RESULTS

At 6 months, 12/58 patients (21%) had died in the control group versus 3/62 (6%) patients in the experimental group (P = 0.01). During hospitalization, the length-of-stay was 10.1 days for the control group versus 9.0 days for the experimental group (P = 0.20). The control group had significantly more readmissions (0.6 per patient vs 0.3 per patient, P = 0.02). A higher number of experimental patients, 22% (13/59), showed improvement in ADL scores compared with 7% (4/46) of control patients, P = 0.07. At one year for all randomized patients, 7/68 (10%) of experimental patients and 13/64 (20%) of control patients had died.

CONCLUSIONS

Short-term mortality can be reduced in community inpatient acute hospital settings by comprehensive geriatric consultation teams. Important differences in mortality remain at 1 year of followup. Trends towards improved functional status and fewer hospital readmissions favor the intervention group.