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.
Within patient-centered care (PCC), the individual is viewed as an active member of the healthcare team. While there has been recent interest in conducting systematic reviews to examine the effectiveness of PCC interventions, various studies fall short in explaining the type of intervention most effective in producing significant changes to desired outcomes. The purpose of this systematic review was to determine the characteristics of PCC interventions that have demonstrated effectiveness in enhancing the quality of care and performance of self-care behaviours. A systematic review of 40 studies that addressed PCC interventions, included samples over the age of 18 years, and were published between 1995 and 2014 was performed. Descriptive statistics were used to delineate study, participant, and intervention characteristics. Results suggest PCC-based interventions are not effective when delivered to individuals living with chronic illnesses.
OBJECTIVE: Psychiatric disorders are common among medical inpatient settings and management of psychiatric disorders can be challenging in this setting. Integrated models of care (IMCs) combining psychiatric and medical specialties within a single service may improve psychiatric and medical outcomes, although evidence for IMCs in medical inpatient settings has not been well described. METHOD: We searched MEDLINE, Embase, and Google scholar for relevant articles. We included all randomized controlled trials or quasi-experimental studies in English that evaluated IMCs for medical inpatients with psychiatric disorders when compared with usual care. We defined IMCs as models of care where psychiatric and medical providers had joint responsibility for all patients within a given service. We extracted information on the characteristics of IMCs and on the effects of IMCs on psychiatric, medical, and health service outcomes. RESULTS: Four studies met the inclusion criteria, thereby including 716 participants overall. All studies differed in the study design, models of IMCs, and outcomes reported. In 2 studies, IMCs improved psychiatric symptoms compared with those admitted to a general medical service. Two studies demonstrated reductions in length of stay with IMCs compared with usual care. One study reported an improvement in functional outcomes and a decreased likelihood of long-term care admission associated with IMCs when compared with usual care. CONCLUSIONS: There is preliminary evidence that IMCs may improve a number of outcomes for medical inpatients with psychiatric disorders. Additional well-designed studies of IMCs are required to further evaluate the effect of IMCs on patient outcomes and costs of care. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
Patient-centered care (PCC) has been studied for several decades. Yet a clear definition of PCC is lacking, as is an understanding of how specific PCC processes relate to patient outcomes. We conducted a systematic review of the PCC literature to examine the evidence for PCC and outcomes. Three databases were searched for all years through September 2012. We retained 40 articles for the analysis. Results found mixed relationships between PCC and clinical outcomes, that is, some studies found significant relationships between specific elements of PCC and outcomes but others found no relationship. There was stronger evidence for positive influences of PCC on satisfaction and self-management. Future research should examine specific dimensions of PCC and how they relate to technical care quality, particularly some dimensions that have not been studied extensively. Future research also should identify moderating and mediating variables in the PPC-outcomes relationship.
BACKGROUND: Old adults admitted to the hospital are at severe risk of functional loss during hospitalization. Early in-hospital physical rehabilitation programs appear to prevent functional loss in geriatric patients. The first aim of this review was to investigate the effect of early physical rehabilitation programs on physical functioning among geriatric patients acutely admitted to the hospital. The second aim was to evaluate the feasibility of early physical rehabilitation programs.
METHODS: Two searches, one for physical functioning and one for feasibility, were conducted in PubMed, CINAHL, and EMBASE. Additional studies were identified through reference and citation tracking. To be included articles had to report on in-hospital early physical rehabilitation of patients aged 65 years and older with an outcome measure of physical functioning. Studies were excluded when the treatment was performed on specialized units other than geriatric units. Randomized controlled trials were included to examine the effect of early physical rehabilitation on physical functioning, length of stay and discharge destination. To investigate feasibility also non randomized controlled trials were added.
RESULTS: Fifteen articles, reporting on 13 studies, described the effect on physical functioning. The early physical rehabilitation programs were classified in multidisciplinary programs with an exercise component and usual care with an exercise component. Multidisciplinary programs focussed more on facilitating discharge home and independent ADL, whereas exercise programs aimed at improving functional outcomes. At time of discharge patients who had participated in a multidisciplinary program or exercise program improved more on physical functional tests and were less likely to be discharged to a nursing home compared to patients receiving only usual care. In addition, multidisciplinary programs reduced the length of hospital stay significantly. Follow-up interventions improved physical functioning after discharge. The feasibility search yielded four articles. The feasibility results showed that early physical rehabilitation for acutely hospitalized old adults was safe. Adherence rates differed between studies and the recruitment of patients was sometimes challenging.
CONCLUSIONS: Early physical rehabilitation care for acutely hospitalized old adults leads to functional benefits and can be safely executed. Further research is needed to specifically quantify the physical component in early physical rehabilitation programs.
Objectives To describe the Acute Care for Elders ( ACE) model components implemented as part of acute geriatric unit care and explore the association between each ACE component and outcomes of iatrogenic complications, functional decline, length of hospital stay, nursing home discharges, costs, and discharges home. Design Systematic descriptive review of 32 articles, including 14 trials reporting on the implementation of ACE components or the effectiveness of their implementation in improving outcomes. Mean effect sizes ( ESs) were calculated using trial outcome data. Information describing implementation of the ACE components in the trials was analyzed using content analysis. Setting Acute care geriatric units. Participants Acutely ill or injured adults (N = 6,839) with an average age of 81. Interventions Acute geriatric unit care was characterized by the implementation of one or more ACE components: medical review, early rehabilitation, early discharge planning, prepared environment, patient-centered care. Measurements Falls, pressure ulcers, delirium, functional decline, length of hospital stay, discharge destination (home or nursing home), and costs. Results Medical review, early rehabilitation, and patient-centered care, characterized by the implementation of standardized and individualized function-focused interventions, had larger standardized mean ESs (all ES = 0.20) averaged across all outcomes, than did early discharge planning ( ES = 0.17) or prepared environment ( ES = 0.11). Conclusion Specific ACE component interventions of medical review, early rehabilitation, and patient-centered care appear to be optimal for overall positive outcomes. These findings can help service providers design and evaluate the most-effective ACE model within the contexts of their respective institutions to improve outcomes for acutely ill or injured older adults.
