Author
CONROY Simon Paul; et al.;
A systematic review of comprehensive geriatric assessment to improve outcomes for frail older people being rapidly discharged from acute hospital: ‘interface geriatrics’.
Journal citation/publication details
Age and Ageing, 40(4), July 2011, pp.436-443.
Summary
Five, highly varied, randomised controlled trials were included in the systematic review. There was no firm evidence that either of the forms of comprehensive geriatric assessment (CGA) examined, whether nurse-led or geriatrician-led, has any effect on the outcomes reported – including mortality and readmission. Although there is no clear evidence of benefit with CGA in this population, due to the small number of trials identified, further well-designed research is justified.
Context
Frail older people discharged from hospital-based acute care to home within 72 hours of admission have poor outcomes; half are readmitted and one third die within a year. Comprehensive geriatric assessment (CGA) has been found to improve outcomes for frail elderly people when delivered in a community setting, and in the post-acute care period, but the evidence for older people discharged rapidly into the community is sparse. The aim of this study was to systematically review the evidence on models of care, including community geriatric assessment, for elderly people following admission to acute medical units, or emergency departments, and early discharge - a concept termed ‘interface geriatrics’ by the authors.
Methods
What sources were searched?
The following databases were searched from the date of inception to September 2009: Ovid Medline; EMBASE; British Nursing Index; HMIC; Cochrane Library; CINAHL; AGEINFO; ASSIA; National Research Register; NICHSR; DARE, HTA, and NHS EED. Reference lists were examined for further relevant material.
What search terms/strategies were used?
Search terms for acute and sub-acute care, frail older people, geriatric assessment, and a range of outcomes are presented. The terms were adapted to the individual databases searched; details of individual search strategies are not included.
What criteria were used to decide on which studies to include?
Randomised controlled trials of participants aged 65 years and older, which addressed patient care following rapid discharge (within 72 hours) from an acute hospital setting, were eligible for inclusion. The specified outcomes, reported at any time up to one year after discharge, were as follows: activities of daily living, cost related measures, mortality, health status, length of stay, discharge, readmission, quality of life, satisfaction, carer strain, and carer burden. Studies of condition specific interventions, psychiatric care, and trials specifically aimed at reducing hospital use, were excluded.
Who decided on their relevance and quality?
Studies were initially screened on the basis of the titles and abstracts by one named author. Potentially relevant articles were then examined in full by two other authors who also assigned each study with a critical appraisal score using the nineteen-point Tulder scale. Only studies scoring nine or above were included in the review.
How many studies were included and where were they from?
A total of 3,399 references was identified from the search; 55 papers were examined in full, seven papers were subjected to quality assessment, and five were subsequently included in the systematic review. The selection process, including details of how many papers were identified from each database, the number of papers excluded at each stage of the process, and the reasons for exclusion, is outlined in Figure 1. There were two studies from the UK, and one each from Australia, Canada and the USA.
How were the study findings combined?
Data was extracted by two named authors and cross checked for consistency. Outcomes were combined across studies using a fixed effects model, unless there was significant heterogeneity, in which case a random effects model was used. The results of some studies were not combined and are presented within subgroups. Meta-analysis was performed, as appropriate, using Stata, version 9.
Findings of the review
All five studies used forms of comprehensive geriatric assessment; three were nurse-led and geriatrician supported, and two were geriatrician-led. Both of the geriatrician-led trials were multifactorial and focused specifically on falls. There was no significant difference associated with intervention for any of the outcomes reported: mortality (five studies), institutionalisation (three studies), functional outcomes (one study), quality of life (one study), cognition (one study), or readmission (five studies).
Authors' conclusions
The authors ‘found no firm evidence that any form of CGA (comprehensive geriatric assessment) in this setting and to this group has any effect on mortality, long-term institutionalisation, subsequent use of acute care, physical function, quality of life or cognition’.
Implications for policy or practice
None are discussed.