JAMDA 16 (2015) 446e447
JAMDA journal homepage: www.jamda.com
Editorial
Evolving Models of Comprehensive Geriatric Assessment Laurence Z. Rubenstein MD, MPH * Donald W. Reynolds Department of Geriatric Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK
An article in this issue of JAMDA describes an exciting randomized controlled trial (RCT) of a new model of comprehensive geriatric assessment (CGA) developed and tested in Sweden.1 In the program, community-living persons aged 75 and older who had been hospitalized at least 3 times in the preceding year were randomized to receive CGA and follow-up in the ambulatory geriatric care unit or to receive usual outpatient care. Those receiving the outpatient CGA and follow-up had significantly fewer hospital days in the 24-month period after randomization and had a trend toward fewer nursing home days as well. Mortality was lower for the group receiving CGA (borderline significance in the intent-to-treat analysis, but significant when excluding the 11 participants who never went beyond the baseline assessment: a preplanned subgroup analysis). Although health-related quality of life was not significantly affected by the program, patients’ sense of security in care2 was significantly improved. Overall cost of care was not significantly affected; the extra cost of the program was offset by the savings from reduced hospital and nursing home days. These findings join the many dozens of positive RCTs of CGA and follow-up programs that have been tested in many different locales using many different models. The tested models of CGA programs differ from each other in several ways: program location (eg, acute hospital, subacute hospital, outpatient setting, home visitation, nursing home), patient selection or targeting criteria (eg, all persons older than a certain age, high utilizers, post hospitalization, long-term care referrals, specific diagnoses or disabilities), program intensity levels (single versus multiple visit; hands-on clinical control versus consultation only), and length of follow-up (from only a few months to up to 3 years). Although not all trials have produced significant positive results, most have. Moreover, the overall effectiveness of CGA and follow-up programs has been confirmed in many analytic reviews and in several metaanalyses.3e11 From these reviews and analyses we also have learned what program characteristics are associated with the most positive effects. In general, inpatient programs, those targeting persons at higher risk, those providing a higher-intensity intervention, and those with longer follow-up periods have tended to show more dramatic effect sizes.
DOI of original article: http://dx.doi.org/10.1016/j.jamda.2015.01.074 The author declares no conflicts of interest. * Address correspondence to Laurence Z. Rubenstein, MD, MPH, Donald W. Reynolds Department of Geriatric Medicine, University of Oklahoma College of Medicine, 1122 NE 13th Street, ORB1200, Oklahoma City, OK 73117. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.jamda.2015.03.012 1525-8610/Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
So where does this new Swedish study fit within the spectrum of trials of CGA? It was an outpatient program, and most previous trials of outpatient CGA have not shown dramatic effects. But there are some crucial factors in this program that contributed to its success. These include its targeting of high utilizers with multiple hospitalizations and its involvement of proactive hands-on follow-up (including home visitation) for up to 2 years that could be as intensive as necessary depending on a patient’s individual needs. Moreover, this program has some relatively unique aspects that also likely contributed to its success that are worth commenting on: it was based in a “real-world” nonacademic setting within a large municipal health care system, it used a simple targeting approach (ie, previous hospitalizations), it used individualized interventions (rather than adhering too much to standardized protocols), and it was able to make use of clinical and follow-up extracted from a system-wide data warehouse. These features not only made it more likely to succeed but also increased its likelihood of being sustainable within a health care system. We have learned a lot since the early descriptive studies of CGA programs from the mid-20th century, which indicated that CGA could improve diagnostic accuracy and treatment planning in geriatric settings, but that told us little about program effectiveness in improving outcomes.12 Likewise, we have learned a lot since the first RCTs were published in the mid-1980s that proved that CGA could improve multiple health care outcomes, from improved function and survival to reduced institutionalization and costs.13e15 These early trials produced tremendous optimism for CGA, but findings from some of those dramatic early trials were tempered by some disappointing subsequent trials that often involved less-intensive interventions with less-careful patient targeting and that showed less-dramatic, sometimes insignificant, results. Meta-analyses explained some of these discrepant findings, and clearly associated higher-intensity and more carefully targeted studies with more positive results. Nonetheless, many later CGA-based interventions became minimalist because of increasing (and often short-sighted) cost-containment efforts that disincentivized providing payments for CGA, even if costs could be saved over time.16 This has contributed to reducing the potential dramatic value of these programs. Yet, even with our improved sophistication and knowledge of CGA and its limitations, we can remain very optimistic about its importance and ability to produce major benefit in geriatric care settings. CGA has endured and remains our fundamental toolbox for planning geriatric treatment and follow-up and will continue to be an essential part of geriatric medicine.
Editorial / JAMDA 16 (2015) 446e447
References 1. Ekdahl AW, Wirehn AB, Alwin J, et al. Costs and effects of an ambulatory geriatric unit (the AGe-FIT study). J Am Med Dir Assoc 2015;16:497e503. 2. Krevers B, Milberg A. The instrument “Senos Security in CaredPatients’ Evaluation”: Its development and presentation. Psychooncology 2014;232:914e920. 3. Stuck AE, Siu AL, Wieland D, et al. Comprehensive geriatric assessment: A meta-analysis of controlled trials. Lancet 1993;342:1032e1036. 4. Elkan R, Kendrick K, Dewey M, et al. Effectiveness of home based support for older people: Systematic review and meta-analysis. BMJ 2001;323:719e725. 5. Huss A, Struck AE, Rubenstein LZ, et al. Multidimensional preventive home visit programs for community-dwelling older adults: A systematic review and meta-analysis of randomized controlled trials. J Gerontol A Biol Sci Med Sci 2008;63:298e307. 6. Baztan JJ, Suarez-Garcia FM, Lopez-Arrieta J, et al. Effectiveness of acute geriatric units on functional decline, living at home and case fatality among older patients admitted to hospital or acute medical disorders: Meta-analysis. BMJ 2009;338:b50. 7. Van Craen K, Braes T, Wellens N, et al. The effectiveness of inpatient geriatric evaluation and management units: A systematic review and meta-analysis. J Am Geriatr Soc 2010;58:83e92. 8. Bakker FC, Robben SHM, Olde-Rikkert MGM. Effects of hospital-wide interventions to improved care for frail older inpatients: A systematic review. BMJ Qual Saf 2011;20:680e691.
447
9. Ellis G, Whitehead MA, Robinson D, et al. Comprehensive geriatric assessment for older adults admitted to hospital: Meta-analysis of controlled trials. BMJ 2011;343:d6553. 10. Deschodt M, Flamaing J, Haentjens P, et al. Impact of geriatric consultation teams on clinical outcome in acute hospitals: A systematic review and metaanalysis. BMC Med 2013;11:48. 11. Partridge JSL, Harari D, Martin FC, Dhesi JK. The impact of pre-operative comprehensive geriatric assessment on post-operative outcomes in older patients undergoing scheduled surgery: A systematic review. Anaesthesia 2014; 69:8e16. 12. Rubenstein LZ. Comprehensive geriatric assessment: From miracle to reality (Joseph T. Freeman Award Lecture). J Gerontol A Biol Sci Med Sci 2004;59: 473e477. 13. Rubenstein LZ, Josephson KR, Wieland DG, et al. Effectiveness of a geriatric evaluation unit. N Engl J Med 1984;311:1664e1670. 14. Rubenstein LZ, Wieland GD, Josephson KR, et al. Improved survival for frail elderly inpatients on a geriatric evaluation unit: Who benefits? J Clin Epidemiol 1988;41:441e449. 15. Hendricksen C, Lund E, Stromgard E. Consequences of assessment and intervention among elderly people: A three year randomised controlled trial. Br Med J (Clin Res Ed) 1984;289:1522e1524. 16. Fracchia S, Marchionni N, DeBari M. Aren’t thirty years enough to affirm the full maturity of modern geriatrics? J Gerontol A Biol Sci Med Sci 2015;70: 223e224.
JAMDA journal homepage: www.jamda.com
Editorial
Evolving Models of Comprehensive Geriatric Assessment Laurence Z. Rubenstein MD, MPH * Donald W. Reynolds Department of Geriatric Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK
An article in this issue of JAMDA describes an exciting randomized controlled trial (RCT) of a new model of comprehensive geriatric assessment (CGA) developed and tested in Sweden.1 In the program, community-living persons aged 75 and older who had been hospitalized at least 3 times in the preceding year were randomized to receive CGA and follow-up in the ambulatory geriatric care unit or to receive usual outpatient care. Those receiving the outpatient CGA and follow-up had significantly fewer hospital days in the 24-month period after randomization and had a trend toward fewer nursing home days as well. Mortality was lower for the group receiving CGA (borderline significance in the intent-to-treat analysis, but significant when excluding the 11 participants who never went beyond the baseline assessment: a preplanned subgroup analysis). Although health-related quality of life was not significantly affected by the program, patients’ sense of security in care2 was significantly improved. Overall cost of care was not significantly affected; the extra cost of the program was offset by the savings from reduced hospital and nursing home days. These findings join the many dozens of positive RCTs of CGA and follow-up programs that have been tested in many different locales using many different models. The tested models of CGA programs differ from each other in several ways: program location (eg, acute hospital, subacute hospital, outpatient setting, home visitation, nursing home), patient selection or targeting criteria (eg, all persons older than a certain age, high utilizers, post hospitalization, long-term care referrals, specific diagnoses or disabilities), program intensity levels (single versus multiple visit; hands-on clinical control versus consultation only), and length of follow-up (from only a few months to up to 3 years). Although not all trials have produced significant positive results, most have. Moreover, the overall effectiveness of CGA and follow-up programs has been confirmed in many analytic reviews and in several metaanalyses.3e11 From these reviews and analyses we also have learned what program characteristics are associated with the most positive effects. In general, inpatient programs, those targeting persons at higher risk, those providing a higher-intensity intervention, and those with longer follow-up periods have tended to show more dramatic effect sizes.
DOI of original article: http://dx.doi.org/10.1016/j.jamda.2015.01.074 The author declares no conflicts of interest. * Address correspondence to Laurence Z. Rubenstein, MD, MPH, Donald W. Reynolds Department of Geriatric Medicine, University of Oklahoma College of Medicine, 1122 NE 13th Street, ORB1200, Oklahoma City, OK 73117. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.jamda.2015.03.012 1525-8610/Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
So where does this new Swedish study fit within the spectrum of trials of CGA? It was an outpatient program, and most previous trials of outpatient CGA have not shown dramatic effects. But there are some crucial factors in this program that contributed to its success. These include its targeting of high utilizers with multiple hospitalizations and its involvement of proactive hands-on follow-up (including home visitation) for up to 2 years that could be as intensive as necessary depending on a patient’s individual needs. Moreover, this program has some relatively unique aspects that also likely contributed to its success that are worth commenting on: it was based in a “real-world” nonacademic setting within a large municipal health care system, it used a simple targeting approach (ie, previous hospitalizations), it used individualized interventions (rather than adhering too much to standardized protocols), and it was able to make use of clinical and follow-up extracted from a system-wide data warehouse. These features not only made it more likely to succeed but also increased its likelihood of being sustainable within a health care system. We have learned a lot since the early descriptive studies of CGA programs from the mid-20th century, which indicated that CGA could improve diagnostic accuracy and treatment planning in geriatric settings, but that told us little about program effectiveness in improving outcomes.12 Likewise, we have learned a lot since the first RCTs were published in the mid-1980s that proved that CGA could improve multiple health care outcomes, from improved function and survival to reduced institutionalization and costs.13e15 These early trials produced tremendous optimism for CGA, but findings from some of those dramatic early trials were tempered by some disappointing subsequent trials that often involved less-intensive interventions with less-careful patient targeting and that showed less-dramatic, sometimes insignificant, results. Meta-analyses explained some of these discrepant findings, and clearly associated higher-intensity and more carefully targeted studies with more positive results. Nonetheless, many later CGA-based interventions became minimalist because of increasing (and often short-sighted) cost-containment efforts that disincentivized providing payments for CGA, even if costs could be saved over time.16 This has contributed to reducing the potential dramatic value of these programs. Yet, even with our improved sophistication and knowledge of CGA and its limitations, we can remain very optimistic about its importance and ability to produce major benefit in geriatric care settings. CGA has endured and remains our fundamental toolbox for planning geriatric treatment and follow-up and will continue to be an essential part of geriatric medicine.
Editorial / JAMDA 16 (2015) 446e447
References 1. Ekdahl AW, Wirehn AB, Alwin J, et al. Costs and effects of an ambulatory geriatric unit (the AGe-FIT study). J Am Med Dir Assoc 2015;16:497e503. 2. Krevers B, Milberg A. The instrument “Senos Security in CaredPatients’ Evaluation”: Its development and presentation. Psychooncology 2014;232:914e920. 3. Stuck AE, Siu AL, Wieland D, et al. Comprehensive geriatric assessment: A meta-analysis of controlled trials. Lancet 1993;342:1032e1036. 4. Elkan R, Kendrick K, Dewey M, et al. Effectiveness of home based support for older people: Systematic review and meta-analysis. BMJ 2001;323:719e725. 5. Huss A, Struck AE, Rubenstein LZ, et al. Multidimensional preventive home visit programs for community-dwelling older adults: A systematic review and meta-analysis of randomized controlled trials. J Gerontol A Biol Sci Med Sci 2008;63:298e307. 6. Baztan JJ, Suarez-Garcia FM, Lopez-Arrieta J, et al. Effectiveness of acute geriatric units on functional decline, living at home and case fatality among older patients admitted to hospital or acute medical disorders: Meta-analysis. BMJ 2009;338:b50. 7. Van Craen K, Braes T, Wellens N, et al. The effectiveness of inpatient geriatric evaluation and management units: A systematic review and meta-analysis. J Am Geriatr Soc 2010;58:83e92. 8. Bakker FC, Robben SHM, Olde-Rikkert MGM. Effects of hospital-wide interventions to improved care for frail older inpatients: A systematic review. BMJ Qual Saf 2011;20:680e691.
447
9. Ellis G, Whitehead MA, Robinson D, et al. Comprehensive geriatric assessment for older adults admitted to hospital: Meta-analysis of controlled trials. BMJ 2011;343:d6553. 10. Deschodt M, Flamaing J, Haentjens P, et al. Impact of geriatric consultation teams on clinical outcome in acute hospitals: A systematic review and metaanalysis. BMC Med 2013;11:48. 11. Partridge JSL, Harari D, Martin FC, Dhesi JK. The impact of pre-operative comprehensive geriatric assessment on post-operative outcomes in older patients undergoing scheduled surgery: A systematic review. Anaesthesia 2014; 69:8e16. 12. Rubenstein LZ. Comprehensive geriatric assessment: From miracle to reality (Joseph T. Freeman Award Lecture). J Gerontol A Biol Sci Med Sci 2004;59: 473e477. 13. Rubenstein LZ, Josephson KR, Wieland DG, et al. Effectiveness of a geriatric evaluation unit. N Engl J Med 1984;311:1664e1670. 14. Rubenstein LZ, Wieland GD, Josephson KR, et al. Improved survival for frail elderly inpatients on a geriatric evaluation unit: Who benefits? J Clin Epidemiol 1988;41:441e449. 15. Hendricksen C, Lund E, Stromgard E. Consequences of assessment and intervention among elderly people: A three year randomised controlled trial. Br Med J (Clin Res Ed) 1984;289:1522e1524. 16. Fracchia S, Marchionni N, DeBari M. Aren’t thirty years enough to affirm the full maturity of modern geriatrics? J Gerontol A Biol Sci Med Sci 2015;70: 223e224.
