Inpatient community-based geriatric assessment reduces subsequent mortality

Factors associated with one-year mortality after hospital discharge: A multicenter prospective cohort study

OBJECTIVES

1) To identify predictors of one-year mortality in hospitalized medical patients using factors available during their hospital stay. 2) To evaluate whether healthcare system use within 30 days of hospital discharge is associated with one-year mortality.

STUDY DESIGN AND SETTING

This prospective, observational study included adult patients from four mid-sized hospital general internal medicine units. During index hospitalization, we retrieved patient characteristics, including demographic and socioeconomic indicators, diagnoses, and early simplified HOSPITAL scores from electronic health records and patient interviews. Data on healthcare system use was collected using telephone interviews 30 days after discharge. Survival status at one year was collected by telephone and from health records. We used a univariable analysis including variables available from the hospitalization and 30-day post-discharge periods. We then performed multivariable analyses with one model using index hospitalization data and one using 30-day post-discharge data.

RESULTS

Of 934 patients, 123 (13.2%; 95% CI 11.0-15.4%) were readmitted or died within 30 days. Of 814 patients whose primary outcome was available, 108 died (13.3%) within one year. Using factors obtained during hospitalization, the early simplified HOSPITAL score (OR 1.50; 95% CI 1.31-1.71; P < 0.001) and not living at home (OR 4.0; 95% CI 1.8-8.3; P < 0.001) were predictors of one-year mortality. Using 30-day post-discharge predictors, hospital readmission was significantly associated with one-year mortality (OR 4.81; 95% CI 2.77-8.33; P < 0.001).

SIGNIFICANCE

Factors predicting one-year mortality were a high early simplified HOSPITAL score, not living at home, and a 30-day unplanned readmission.

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.

Comprehensive Geriatric Assessment in hospital and hospital-at-home settings: a mixed-methods study

Background

The Comprehensive Geriatric Assessment (CGA) is a multidisciplinary process that determines a frail older person’s medical, functional, psychological and social capability to ensure that they have a co-ordinated plan for treatment and follow-up.

Objectives

To improve our understanding of the effectiveness, cost-effectiveness and implementation of the CGA across hospital and hospital-at-home settings.

Methods

We used a variety of methods. We updated a Cochrane review of randomised trials of the CGA in hospital for older people aged ≥ 65 years, conducted a national survey of community CGA, analysed data from three health boards using propensity score matching (PSM) and regression analysis, conducted a qualitative study and used a modified Delphi method.

Results

We included 29 trials recruiting 13,766 participants in the Cochrane review of the CGA. Older people admitted to hospital who receive the CGA are more likely to be living at home at 3–12 months’ follow-up [relative risk (RR) 1.06, 95% confidence interval (CI) 1.01 to 1.10] (high certainty). The probability that the CGA would be cost-effective at a £20,000 ceiling ratio for quality-adjusted life-years (QALYs), life-years (LYs) and LYs living at home was 0.50, 0.89, and 0.47, respectively (low-certainty evidence). After PSM and regression analysis comparing CGA hospital with CGA hospital at home, we found that the health-care cost (from admission to 6 months after discharge) in site 1 was lower in hospital at home (ratio of means 0.82, 95% CI 0.76 to 0.89), in site 2 there was little difference (ratio of means 1.00, 95% CI 0.92 to 1.09) and in site 3 it was higher (ratio of means 1.15, 95% CI 0.99 to 1.33). Six months after discharge (excluding the index admission), the ratio of means cost in site 1 was 1.27 (95% CI 1.14 to 1.41), in site 2 was 1.09 (95% CI 0.95 to 1.24) and in site 3 was 1.70 (95% CI 1.40 to 2.07). At 6 months’ follow-up (excluding the index admission), there may be an increased risk of mortality (adjusted) in the three hospital-at-home cohorts (site 1: RR 1.09, 95% CI 1.00 to 1.19; site 2: RR 1.29, 95% CI 1.15 to 1.44; site 3: RR 1.27, 95% CI 1.06 to 1.54). The qualitative research indicates the importance of relational aspects of health care, incorporating caregivers’ knowledge in care planning, and a lack of clarity about the end of an episode of health care. Core components that should be included in CGA focus on functional, physical and mental well-being, medication review and a caregiver’s ability to care.

Limitations

The risk of residual confounding limits the certainty of the findings from the PSM analysis; a second major limitation is that the research plan did not include an investigation of social care or primary care.

Conclusions

The CGA is an effective way to organise health care for older people in hospital and may lead to a small increase in costs. There may be an increase in cost and the risk of mortality in the population who received the CGA hospital at home compared with those who received the CGA in hospital; randomised evidence is required to confirm or refute this. Caregiver involvement in the CGA process could be strengthened.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

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.

Interventions to reduce readmissions: can complex adaptive system theory explain the heterogeneity in effectiveness? A systematic review

Background

Successfully transitioning patients from hospital to home is a complex, often uncertain task. Despite significant efforts to improve the effectiveness of care transitions, they remain a challenge across health care systems. The lens of complex adaptive systems (CAS) provides a theoretical approach for studying care transition interventions, with potential implications for intervention effectiveness. The aim of this study is to examine whether care transition interventions that are congruent with the complexity of the processes and conditions they are trying to improve will have better outcomes.

Methods

We identified a convenience sample of high-quality care transition intervention studies included in a care transition synthesis report by Kansagara and colleagues. After excluding studies that did not meet our criteria, we scored each study based on (1) the presence or absence of 5 CAS characteristics (learning, interconnections, self-organization, co-evolution, and emergence), as well as system-level interdependencies (resources and processes) in the intervention design, and (2) scored study readmission-related outcomes for effectiveness.

Results

Forty-four of the 154 reviewed articles met our inclusion criteria; these studies reported on 46 interventions. Nearly all the interventions involved a change in interconnections between people compared with care as usual (96% of interventions), and added resources (98%) and processes (98%). Most contained elements impacting learning (67%) and self-organization (69%). No intervention reflected either co-evolution or emergence. Almost 40% of interventions were rated as effective in terms of impact on hospital readmissions. Chi square testing for an association between outcomes and CAS characteristics was not significant for learning or self-organization, however interventions rated as effective were significantly more likely to have both of these characteristics (78%) than interventions rated as having no effect (32%, p = 0.005).

Conclusions

Interventions with components that influenced learning and self-organization were associated with a significant improvement in hospital readmissions-related outcomes. Learning alone might be necessary but not be sufficient for improving transitions. However, building self-organization into the intervention might help people effectively respond to problems and adapt in uncertain situations to reduce the likelihood of readmission.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3712-7) contains supplementary material, which is available to authorized users.

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.

[Establishment of a short-form screening test for cognitive decline as part of a newly developed comprehensive geriatric assessment initiative named 'Dr. Superman']

AIM

The assessment of cognitive function is important in comprehensive geriatric assessment (CGA), and several standardized screening tests for dementia such as the Mini-Mental State Examination (MMSE) are available. However, it takes 5 to 20 minutes to perform the MMSE. We have developed a CGA initiative named 'Dr. Superman' which is designed to accomplish CGA within 10 minutes. In this study, we evaluated a short-form screening test for cognitive decline preceding the MMSE.

METHODS

The MMSE and a question on episodic memory, ("What kind of food did you have last night?") were administered to 90 elderly outpatients with various diseases. They were divided into 2 groups according to their MMSE scores: a normal group (MMSE score≥24) and an abnormal group (MMSE score≤23). Within these groups, each domain (D) (D1: time orientation, D2: place orientation, D3: immediate memory, D4: calculation, D5: recall, D6: language, and D7: spatial cognition) and episodic memory was separately scored and the sensitivity, specificity, and positive predicative value of each were calculated. Based on these data, the best combination of the domains was evaluated for practical use as an assessment tool.

RESULTS

The MMSE scores ranged from 10 to 30, and 42 cases were classified into the normal group. High sensitivity, specificity, or positive predicative value was observed in D1, D2, D4, D5 and episodic memory categories. On the basis of the characteristics of each item in these domains in order to make a short-form assessment, a combination of "What is this year" in D1, "Serial 7's twice" in D4, and a question on episodic memory was found to be superior to other combinations (sensitivity: 93.8%; specificity: 71.4%; positive predicative value: 78.9%). Using this combination for 50 outpatients with 2 raters, it took 32 to 55 seconds to accomplish the assessment with good inter-rater reliability (κ=0.861).

CONCLUSIONS

The combination of "What is this year?", "Serial 7's twice", and "What kind of food did you have last night?" was the best and most valuable short-form screening test for cognitive decline.

Interventions to reduce hospital readmissions in the elderly: in-hospital or home care. A systematic review

RATIONALE, AIMS AND OBJECTIVES

Unplanned hospital readmissions of elderly people represent an increasing burden on health care systems. This burden could theoretically be reduced by adequate preventive interventions, although there is uncertainty about the effectiveness of different types of interventions. The objective of this systematic review was to identify interventions that effectively reduce the risk of hospital readmissions in patients of 75 years and older, and to assess the role of home follow-up.

METHODS

We searched studies in MEDLINE, CINAHL, CENTRAL and seven other electronic databases up to October 2007, and we updated the MEDLINE search in October 2009. Clinical trials (randomized or controlled) evaluating the effectiveness of an intervention aimed at reducing readmissions in elderly patients were selected. Quality was assessed using the SIGN tool and the information extracted is presented in text and tables.

RESULTS

Thirty-two clinical trials were included and they were divided into two groups: in-hospital interventions (17 studies) and interventions with home follow-up (15 studies). A positive effect of the intervention evaluated on the readmission outcome was found in three studies from the first group and in seven from the second group.

CONCLUSIONS

Most of the interventions evaluated did not have any effect on the readmission of elderly patients. However, those interventions that included home care components seem to be more likely to reduce readmissions in the elderly.

Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials

OBJECTIVE

To evaluate the effectiveness of comprehensive geriatric assessment in hospital for older adults admitted as an emergency.

SEARCH STRATEGY

We searched the EPOC Register, Cochrane's Controlled Trials Register, the Database of Abstracts of Reviews of Effects (DARE), Medline, Embase, CINAHL, AARP Ageline, and handsearched high yield journals.

SELECTION CRITERIA

Randomised controlled trials of comprehensive geriatric assessment (whether by mobile teams or in designated wards) compared with usual care. Comprehensive geriatric assessment is a multidimensional interdisciplinary diagnostic process used to determine the medical, psychological, and functional capabilities of a frail elderly person to develop a coordinated and integrated plan for treatment and long term follow-up.

DATA COLLECTION AND ANALYSIS

Three independent reviewers assessed eligibility and trial quality and extracted published data. Two additional reviewers moderated.

RESULTS

Twenty two trials evaluating 10,315 participants in six countries were identified. For the primary outcome "living at home," patients who underwent comprehensive geriatric assessment were more likely to be alive and in their own homes at the end of scheduled follow-up (odds ratio 1.16 (95% confidence interval 1.05 to 1.28; P = 0.003; number needed to treat 33) at a median follow-up of 12 months versus 1.25 (1.11 to 1.42; P < 0.001; number needed to treat 17) at a median follow-up of six months) compared with patients who received general medical care. In addition, patients were less likely to be living in residential care (0.78, 0.69 to 0.88; P < 0.001). Subgroup interaction suggested differences between the subgroups "wards" and "teams" in favour of wards. Patients were also less likely to die or experience deterioration (0.76, 0.64 to 0.90; P = 0.001) and were more likely to experience improved cognition (standardised mean difference 0.08, 0.01 to 0.15; P = 0.02) in the comprehensive geriatric assessment group.

CONCLUSIONS

Comprehensive geriatric assessment increases patients' likelihood of being alive and in their own homes after an emergency admission to hospital. This seems to be especially true for trials of wards designated for comprehensive geriatric assessment and is associated with a potential cost reduction compared with general medical care.

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.

Effect of an inpatient geriatric consultation team on functional outcome, mortality, institutionalization, and readmission rate in older adults with hip fracture: a controlled trial

OBJECTIVES

To evaluate the effect of an inpatient geriatric consultation team (IGCT) on end points of interest in people with hip fracture: length of stay, functional status, mortality, new nursing home admission, and hospital readmission.

DESIGN

Controlled trial based on assignment by convenience.

SETTING

Trauma ward in a university hospital.

PARTICIPANTS

One hundred seventy-one people with hip fracture aged 65 and older.

INTERVENTION

Participants were assigned to a multidisciplinary geriatric intervention (n=94) or usual care (n=77) during hospitalization after hip fracture.

MEASUREMENTS

End points were functional status, length of stay, mortality, new nursing home admission, and hospital readmission 6 weeks, 4 months, and 12 months after surgery.

RESULTS

Mean length of stay was 11.1 ± 5.1 days in the intervention group and 12.4 ± 8.5 days in the control groups (P=.24). Complete adherence to IGCT recommendations was 56.8%. A significant benefit of intervention on functional status in univariate analyses (P=.02) 8 days after surgery disappeared in a linear mixed model. Participants with dementia had better functional status in a linear mixed model than those without (P=.03), but this effect was no longer significant after Bonferroni correction for multiple testing. After 6 weeks, 4 months, and 12 months, no between-group differences could be documented for mortality, new nursing home admission, or readmission rate.

CONCLUSION

This trial could not document functional benefits of an IGCT intervention in people with hip fracture. More research is needed to investigate whether a more-intensive approach with more-direct control over patient management, more-specific recommendations, and more-intense education would be effective.

[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.

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.

Early readmissions to the department of medicine as a screening tool for monitoring quality of care problems

With growing awareness of medical fallibility, researchers need to develop tools to identify and study medical mistakes. We examined the utility of hospital readmissions for this purpose in a prospective case-control study in a large academic medical center in Israel. All patients with nonelective readmissions to 2 departments of medicine within 30 days of discharge were interviewed, and their medical records were carefully examined with emphasis on the index admission. Patient data were compared to data for age- and sex-matched controls (n = 140) who were not readmitted. Medical records of readmitted and control patients were blindly evaluated by 2 senior clinicians who independently identified potential quality of care (QOC) problems during the index admission. Inhospital and late mortality was determined 6 months after discharge.Over a period of 3 months there were 1988 urgent admissions; 1913 discharges and subsequently 271 unplanned readmissions occurred (14.1% of discharges). Readmissions occurred an average of 10 days after discharge, and readmitted patients were sicker than controls (mean, 4.3 vs. 3.3 diagnoses per patient), although their length of stay was similarly short (3.4 +/- 2.8 d). Analysis of all readmissions revealed QOC problems in 90/271 (33%) of readmissions, 4.5% of hospitalizations. All were deemed preventable. Interobserver agreement was good (83%, kappa = 0.67). Among matched controls, only 8/140 admissions revealed QOC problems (6%, p < 0.001) (k = 0.77). The preventable readmissions mostly involved a vascular event or congestive heart failure; they occurred within a mean of 10 +/- 8 days of the index admission, and their inpatient mortality was 6.7% vs. 1.7% among readmissions that had no QOC problems (odds ratio, 4.1; 95% confidence interval, 1.0-16.7). The main pitfalls identified during the index admission included incomplete workup (33%), too short hospital stay (31%), inappropriate medication (44%), diagnostic error (16%), and disregarding a significant laboratory result (12%). In many patients more than 1 pitfall was identified (mean, 1.5 per patient). Risk factors for preventable readmission include older age and living in an institution (p < 0.05). Almost two-thirds of the readmitted patients with QOC problems were discharged after spending 2 days or fewer at the hospital. In conclusion, unplanned readmissions within 30 days of discharge are frequent, more prevalent in sicker patients, and possibly associated with increased mortality. In a third of readmitted patients a QOC problem can be identified, and these problems are preventable. Thus, readmission may be used as a screening tool for potential QOC problems in the department of medicine. Routine monitoring of all readmissions may provide a simple cost-effective means of identifying and addressing medical mistakes.

Less money, less care: how nurses in long-term care allocate hours of needed care in a context of chronic shortage

The average funding of long-term care in Quebec, Canada, currently covers < 70% of the care hours required, which means that 30% of needs are unmet. The aims of this study were to understand how nurses, when they are in a position to do so, assign care hours, which needs are unmet by care dimensions and whether dimensions with unmet needs vary with client profiles. One-hundred-and-four nurses working in long-term care facilities participated in the study. They filled out individual questionnaires containing three case studies in the form of vignettes. When obliged to cut 30% of the care hours, the nurses ensured that treatment and diagnostic methods were done as prescribed and that vital feeding and elimination functions were preserved. However, they made the choice to cut some mobility and personal-care activities and, especially, communication with patients, families and other professionals. In this, they partly follow the theoretical care prioritization approach of Lefebvre and Dupuis, who take into account the degree of discomfort caused by the situation, the problem's place in Maslow's hierarchy of needs and the availability of a solution. Thus, although the choices made by the nurses follow a logical pattern, they could result in medium-term deterioration in the functional autonomy of their older patients. The overall consequences of these decisions are discussed.

Demographic and clinical characteristics of patients admitted to medical departments

INTRODUCTION

The significant changes, which have affected departments of medicine over the last two decades, have been much editorialized. Surprisingly few data have been published that document these changes. We describe the demographic and clinical characteristics of patients admitted to one hospital's departments of internal medicine.

METHODS

During a 3 months prospective study, 1039 patients (46% of all 2277 new admissions to the departments of medicine, consisting of +/- 175 beds) were randomized for inclusion. Information was extracted from the medical records regarding demography; functional capacity; clinical data and outcome.

RESULTS

The mean age of the patients was 72 +/- 16 years (mean +/- SD); 51% were male, 56% were married, and 83% lived at home. Although 293 patients (28%) were defined as dependent, the majority lived at home (170, 58%). Cognition was normal in only 74%. The four most common disease categories leading to admission were infections (383 patients, 37%), cardiovascular disorders (372, 36%), respiratory conditions (284, 27%) and genito-urinary problems (90, 9%). Overall, 98 persons died (9%). Independent risk factors for death were: mechanical ventilation; a 'do not resuscitate' order; a high APACHE-II score; a low serum albumin level; higher age; and not being married (P < 0.01).

CONCLUSIONS

Geriatric patients occupy a central position in our medical wards. These data are relevant for allocation of special resources for departments with high proportions of geriatric patients; for the design of employment conditions that ascertains continuing job satisfaction; as well as for the planning of teaching opportunities for residents and students.

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.

Post-hospitalization mortality in the elderly

The level of disability and polypathology in hospitalized elderly is usually high. Multidimensional and functional assessment allows to identify risk factors for clinical and functional failure of patients. Many studies point out that identifying predictors of high-risk patients is a necessary step in accurate targeting. We evaluated 395 subjects (175 women, 202 men, mean age 77.9 year) during their hospitalization in our Geriatric ward. Baseline data included: demographics variables, medical diagnosis, functional evaluation, and laboratory values. After a 6-month follow up 80 (20.2%) subjects died. In our study, male gender, dependence at the Dependence Medical Index (DMI), low serum albumin (< 2.8 g/dl), impaired score at the Instrumental Activities of Daily Living scale (IADL), score lower than 13.7 at the acute physiology and chronic health evaluation (APACHE II) and neoplasm were independent predictors of 6-month post-hospitalization mortality. The high mortality rate of our sample could be a marker of considerable frailty among elderly patients. Our study shows that a poor functional status is a more reliable prognostic factor than type and number of admitting diagnosis. Clinical evaluation, improved with information about functional status, is a feasible and practical way of detecting risk of short term post-hospitalization mortality of elderly subjects.

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.

Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of Acute Care for Elders (ACE) in a community hospital

BACKGROUND

Older persons frequently experience a decline in function following an acute medical illness and hospitalization.

OBJECTIVE

To test the hypothesis that a multicomponent intervention, called Acute Care for Elders (ACE), will improve functional outcomes and the process of care in hospitalized older patients.

DESIGN

Randomized controlled trial.

SETTING

Community teaching hospital.

PATIENTS

A total of 1,531 community-dwelling patients, aged 70 or older, admitted for an acute medical illness between November 1994 and May 1997.

INTERVENTION

ACE includes a specially designed environment (with, for example, carpeting and uncluttered hallways); patient-centered care, including nursing care plans for prevention of disability and rehabilitation; planning for patient discharge to home; and review of medical care to prevent iatrogenic illness.

MEASUREMENTS

The main outcome was change in the number of independent activities of daily living (ADL) from 2 weeks before admission (baseline) to discharge. Secondary outcomes included resource use, implementation of orders to promote function, and patient and provider satisfaction.

RESULTS

Self-reported measures of function did not differ at discharge between the intervention and usual care groups by intention-to-treat analysis. The composite outcome of ADL decline from baseline or nursing home placement was less frequent in the intervention group at discharge (34% vs 40%; P = .027) and during the year following hospitalization (P = .022). There were no significant group differences in hospital length of stay and costs, home healthcare visits, or readmissions. Nursing care plans to promote independent function were more often implemented in the intervention group (79% vs 50%; P = .001), physical therapy consults were obtained more frequently (42% vs 36%; P = .027), and restraints were applied to fewer patients (2% vs 6%; P = .001). Satisfaction with care was higher for the intervention group than the usual care group among patients, caregivers, physicians, and nurses (P < .05).

CONCLUSIONS

ACE in a community hospital improved the process of care and patient and provider satisfaction without increasing hospital length of stay or costs. A lower frequency of the composite outcome ADL decline or nursing home placement may indicate potentially beneficial effects on patient outcomes.

Geriatric-based versus general wards for older acute medical patients: a randomized comparison of outcomes and use of resources

BACKGROUND

The effects of residence in an acute geriatrics-based ward (AGW) with emphasis on early rehabilitation and discharge planning for older patients with acute medical illnesses were assessed. Outcome and use of resources were compared with those of patients treated in general medical wards (MWs). A per-protocol rather than intention-to-treat analysis was performed.

METHODS

A randomized trial with 3-months follow-up. A total of 190 patients aged 70 years and older were randomized to an acute geriatrics-based ward, and 223 patients were randomized to general medical wards.

RESULTS

The two groups were comparable at inclusion. However, after care in the AGW, 71% of patients could be discharged directly home compared with 64% of those treated in MWs (relative risk 1.17; 95% CI, 0.93-1.49). The length of stay was shorter in the AGW (mean 5.9 vs 7.3 days; P = .002). The proportion of patients in geriatric or other hospital wards or in nursing homes did not differ, but the proportion of AGW patients in sheltered living tended to be lower (P = .085). At the follow-up, case fatality, ADL function, psychological well-being, need for daily personal assistance, drug consumption, need for readmission to hospital, and total health care costs after discharge did not differ between the two groups. Poor global outcome was observed in 37% of AGW and 34% of MW patients.

CONCLUSIONS

A geriatric approach with greater emphasis on early rehabilitation and discharge planning in the AGW shortened the length of hospital stay and may have reduced the need for long-term institutional living. This occurred despite patients in an acute geriatric ward not having better medical or functional outcome than older acute patients treated in general medical wards.

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.

Functional status and health service planning

Functional status indicators have been proposed as instruments to aid health service planning for patients. This study examines functional status at three points surrounding an acute health episode: admission, discharge and 3 months post discharge from a community hospital. The aim of the study is to determine the most appropriate time to measure functional status to assist health service planning. A longitudinal cohort study was conducted at Manly Hospital, Australia. Four hundred patients aged 65 years and over representing a 10% random sample of all hospital admissions in a 10-month period were interviewed on admission, discharge and 3 months post discharge. Repeated measure multiple analysis of variance identified a decline in functional status between admission and discharge. At 3 months post discharge functional status had improved to levels higher than admission. Functional status assessment at discharge can assist consumers, clinicians, health planners and health insurers to make effective decisions to maximize health outcomes.

Compliance of frail elderly with health services prescribed at discharge from an acute-care geriatric ward

OBJECTIVES

A model of compliance by frail elderly with prescribed healthcare services was developed and tested. The discrepancy between primary care, geriatric and community health center (CLSC) services prescribed at discharge after comprehensive geriatric evaluation and treatment was measured, as were those services actually used during a 6-week interval (compliance). In this model, compliance was directly related to elders' intention to adhere to prescribed services, but this relationship was modified by organizational factors, reinforcing factors, and changes in health status during the observation period. Intention to adhere resulted from individual and reinforcing factors existing before discharge.

METHODS

This model was tested on 211 patients discharged to community settings from an acute-care hospital geriatrics ward. Information was obtained through interviews with the patients or care givers and from hospital, outpatient, and local community health center charts.

RESULTS

On average, patients used 56.9% of services prescribed; 13% of patients did not use any of the services prescribed for them, whereas 22% used all the services prescribed. Intention to adhere was influenced by patients' perception of the benefits of prescribed services and by their perception of the ease of access to transportation. Intention itself was not found to be an important determinant of overall compliance. Among organizational factors, having the ward staff make a follow-up appointment with the patients' family doctor and with the geriatric clinic before discharge and communication with the local community health center increased overall compliance. Moreover, patients who perceived they had access to transportation and to an accompanying person were more likely to comply.

CONCLUSIONS

The results suggest that when discharging patients to the community, steps taken for them by the discharging healthcare providers will improve compliance.

Effects of home-based intervention on unplanned readmissions and out-of-hospital deaths

OBJECTIVE

To determine the effect of a home-based intervention (HBI) on the frequency of unplanned readmission and out-of-hospital death among patients discharged home from acute hospital care.

DESIGN

A randomized controlled trial comparing HBI with usual care (UC).

SETTING

A tertiary referral hospital servicing the northwestern region of Adelaide, South Australia.

PARTICIPANTS

Medical and surgical patients (n = 762) discharged home after hospitalization.

INTERVENTION

Home-based intervention (n = 381) consisted of counseling of all patients before discharge followed by a single home visit (by a nurse and pharmacist) to those patients considered to be at high risk of readmission (n = 314) in order to optimize compliance with and knowledge of the treatment regimen, identify early clinical deterioration, and intensify follow-up of such patients where appropriate.

MEASUREMENTS

The primary endpoint was the number of unplanned readmissions plus out-of-hospital deaths over a 6-month follow-up period.

RESULTS

During the study follow-up, the major endpoint occurred most commonly in the UC group (217 vs 155 episodes: P < .001). Overall, the HBI group demonstrated fewer unplanned readmissions (154 vs 197: P = .022), out-of-hospital deaths (1 vs. 20: P < .001), total deaths (12 vs. 29: P = .006), emergency department attendances (236 vs 314: P < .001), and total days of hospitalization (1452 vs 1766: P < .001). There was a disproportionate reduction in multiple events among HBI patients (P = .035). Hospital-based costs of health care during study follow-up tended to be lower in the HBI group ($A2190 vs $A2680 per patient: P = .102). Mean cost of HBI was $A190 per patient visited, whereas other community-based health care costs were similar for both groups.

CONCLUSIONS

Among high-risk patients discharged from acute hospital care, HBI is beneficial in limiting unplanned readmissions and reducing risk of out-of-hospital death. It may be particularly cost-effective if applied selectively to patients with a history of frequent unplanned hospital admission.

Association of the Resident Assessment Instrument (RAI) with changes in function, cognition, and psychosocial status

OBJECTIVE

To evaluate the impact of the Resident Assessment Instrument (RAI) on changes in nursing home residents' functional status, cognitive status, and psychosocial well-being.

DESIGN

A quasi-experiment involving the collection of longitudinal data on two cohorts of nursing home residents. One cohort was assessed before the implementation of the RAI, and the other was assessed after the implementation of the new assessment process.

SETTING AND PARTICIPANTS

Over 2000 nursing home residents in 267 nursing homes located in 10 geographic areas were assessed during the pre-RAI period. In the post-RAI period, 2000 new residents in 254 of the same facilities were assessed.

INTERVENTION

RAI implementation began in October 1990 and continued until October 1991. The RAI includes a structured, multidimensional resident assessment and problem identification system designed to form the basis for residents' care plans.

MEASUREMENTS

All residents were assessed at baseline and at 6 months using the Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS) and its protocols. All data were collected by research nurses employed and trained by the research team.

RESULTS

Implementation of the RAI significantly reduced the rate of decline in seven of the nine outcomes under consideration. Reductions in improvement were also observed in all outcomes. In activities of daily living, social engagement, and cognitive function, the reduced decline far outweighed any reductions in improvement. In mood problems, problem behaviors, and understanding others, however, reductions in improvement were greater than any reductions in decline. Changes in the rates of decline and improvement were not uniform across all residents.

CONCLUSION

The RAI may have improved the quality of care of nursing home residents by reducing overall rates of decline in important areas of resident function. However, this innovation may have generated trade-offs in that it may have reduced improvement rates in some areas of function. The system's implementation also seems to have focused staff's attention on the needs and strengths of specific subpopulations of residents. Revisions of the RAI must assist staff in generalizing their efforts to all residents and to increasing improvement rates, especially in areas related to mood and behavior.

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.