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      Comprehensive geriatric assessment for older adults admitted to hospital

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          Abstract

          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. 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. 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. 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. 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. 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). 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. What is the aim of this review? The aim of this Cochrane Review was to find out if organised and co‐ordinated specialist care (known as comprehensive geriatric assessment, or CGA) can improve care provided to older people admitted to hospital. Researchers at Cochrane collected and analysed all relevant studies to answer this question and included 29 trials in the review. Key messages Giving older people who are admitted to hospital access to specialist co‐ordinated geriatric assessment (CGA) services on admission to hospital increases the chances that they will be alive in their own homes at follow‐up. What was studied in the review? Older people admitted to hospital may have multiple, complex, and overlapping problems. They are more prone to rapid loss of independence during an acute illness, leading to potential admission to a nursing home. Some of this decline might be avoided if care needs are identified appropriately and if treatment is co‐ordinated and managed. Specialist co‐ordinated care (known as comprehensive geriatric assessment, or CGA) was developed to address medical, social, mental health, and physical needs with the help of a skilled multi‐disciplinary team. The aims are to maximise recovery and to return patients to previous levels of function when possible. In hospital, CGA is carried out on a geriatric ward, or on a general ward that is visited by a specialist geriatric team. What are the main results of the review? Review authors found 29 relevant trials from nine countries that recruited 13,766 people. These studies compared CGA with routine care for patients over 65 who were admitted to hospital. Most trials evaluated CGA that was provided on a specialised hospital ward or across several wards by a mobile team. The review shows that older people who receive CGA rather than routine medical care after admission to hospital are more likely to be living at home and are less likely to be admitted to a nursing home at up to a year after hospital admission. We found no evidence that CGA reduces risk of death during follow‐up at up to a year after admission, and we noted that CGA appeared to make little or no difference in dependence (whether patients need help for everyday activities such as feeding and walking). We found too much variation in cognitive function and length of hospital stay to draw a conclusion. Uncertainty regarding the cost‐effectiveness analysis suggests that further research is needed. How up‐to‐date is this review? Review authors searched for studies that had been published up to 5 October 2016.

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          Most cited references73

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          Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis

          Objective To assess the effectiveness of acute geriatric units compared with conventional care units in adults aged 65 or more admitted to hospital for acute medical disorders. Design Systematic review and meta-analysis. Data sources Medline, Embase, and the Cochrane Library up to 31 August 2008, and references from published literature. Review methods Randomised trials, non-randomised trials, and case-control studies were included. Exclusions were studies based on administrative databases, those that assessed care for a single disorder, those that evaluated acute and subacute care units, and those in which patients were admitted to the acute geriatric unit after three or more days of being admitted to hospital. Two investigators independently selected the studies and extracted the data. Results 11 studies were included of which five were randomised trials, four non-randomised trials, and two case-control studies. The randomised trials showed that compared with older people admitted to conventional care units those admitted to acute geriatric units had a lower risk of functional decline at discharge (combined odds ratio 0.82, 95% confidence interval 0.68 to 0.99) and were more likely to live at home after discharge (1.30, 1.11 to 1.52), with no differences in case fatality (0.83, 0.60 to 1.14). The global analysis of all studies, including non-randomised trials, showed similar results. Conclusions Care of people aged 65 or more with acute medical disorders in acute geriatric units produces a functional benefit compared with conventional hospital care, and increases the likelihood of living at home after discharge.
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            A controlled trial of inpatient and outpatient geriatric evaluation and management.

            Over the past 20 years, both inpatient units and outpatient clinics have developed programs for geriatric evaluation and management. However, the effects of these interventions on survival and functional status remain uncertain. We conducted a randomized trial involving frail patients 65 years of age or older who were hospitalized at 11 Veterans Affairs medical centers. After their condition had been stabilized, patients were randomly assigned, according to a two-by-two factorial design, to receive either care in an inpatient geriatric unit or usual inpatient care, followed by either care at an outpatient geriatric clinic or usual outpatient care. The interventions involved teams that provided geriatric assessment and management according to Veterans Affairs standards and published guidelines. The primary outcomes were survival and health-related quality of life, measured with the use of the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36), one year after randomization. Secondary outcomes were the ability to perform activities of daily living, physical performance, utilization of health services, and costs. A total of 1388 patients were enrolled and followed. Neither the inpatient nor the outpatient intervention had a significant effect on mortality (21 percent at one year overall), nor were there any synergistic effects between the two interventions. At discharge, patients assigned to the inpatient geriatric units had significantly greater improvements in the scores for four of the eight SF-36 subscales, activities of daily living, and physical performance than did those assigned to usual inpatient care. At one year, patients assigned to the outpatient geriatric clinics had better scores on the SF-36 mental health subscale, even after adjustment for the score at discharge, than those assigned to usual outpatient care. Total costs at one year were similar for the intervention and usual-care groups. In this controlled trial, care provided in inpatient geriatric units and outpatient geriatric clinics had no significant effects on survival. There were significant reductions in functional decline with inpatient geriatric evaluation and management and improvements in mental health with outpatient geriatric evaluation and management, with no increase in costs.
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              A systematic review of comprehensive geriatric assessment to improve outcomes for frail older people being rapidly discharged from acute hospital: 'interface geriatrics'.

              many frail older people who attend acute hospital settings and who are discharged home within short periods (up to 72 h) have poor outcomes. This review assessed the role of comprehensive geriatric assessment (CGA) for such people. standard bibliographic databases were searched for high-quality randomised controlled trials (RCTs) of CGA in this setting. When appropriate, intervention effects were presented as rate ratios with 95% confidence intervals. five trials of sufficient quality were included. There was no clear evidence of benefit for CGA interventions in this population in terms of mortality [RR 0.92 (95% CI 0.55-1.52)] or readmissions [RR 0.95 (95% CI 0.83-1.08)] or for subsequent institutionalisation, functional ability, quality-of-life or cognition. there is no clear evidence of benefit for CGA interventions in frail older people being discharged from emergency departments or acute medical units. However, few such trials have been carried out and their overall quality was poor. Further well designed trials are justified.
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                Author and article information

                Journal
                Cochrane Database of Systematic Reviews
                Wiley-Blackwell
                14651858
                September 12 2017
                :
                :
                Affiliations
                [1 ]Cochrane Effective Practice and Organisation of Care Group
                Article
                10.1002/14651858.CD006211.pub3
                6484374
                28898390
                e4e2e1bd-0929-41fe-8d8e-b47d138e0eb4
                © 2017
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