Can comprehensive geriatric assessment be delivered without the need for geriatricians? A formative evaluation in two perioperative surgical settings

Abstract

Introduction the aim of this study was to design an approach to improving care for frail older patients in hospital services where comprehensive geriatric assessment (CGA) was not part of the clinical tradition. Methods the intervention was based on the principles of CGA, using quality improvement methodology to embed care processes. Qualitative methods and coproduction were used to inform development of the intervention, which was directed towards the health care professionals involved in peri-operative/surgical cancer care pathways in two large UK teaching hospitals. A formative, qualitative evaluation was undertaken; data collection and analysis were guided by normalisation process theory. Results the clinicians involved agreed to use the toolkit, identifying potential benefits including improved surgical decision making and delivery of interventions pre-operatively. However, sites concluded that pre-operative assessment was not the best place for CGA, and at the end of the 12-month trial, implementation was still nascent. Efforts competed against the dominance of national time-limited targets, and concerns relating to patients’ immediate treatment and recovery. Some participants involved in the peri-operative pathway felt that CGA required ongoing specialist input from geriatricians, but it was not clear that this was sustainable. Conclusions clinical toolkits designed to empower non-geriatric teams to deliver CGA were received with initial enthusiasm, but did not fully achieve their stated aims due to the need for an extended period of service development with geriatrician support, competing priorities, and divergent views about appropriate professional domains.

Geriatrician perspectives on perioperative care: a qualitative study

“…At a healthcare professional level, geriatricians perceived their skill set was unique and valuable for the care of older surgical patients. A recent study showed that implementation of a CGA toolkit to help non-geriatricians deliver CGA for older surgical patients was poorly taken up and implemented, despite buy in from surgeons and anaesthetists at the study hospitals [31]. This echoes the geriatricians' view that they have a specific unique skill set that complements the skills of surgeons and anaesthetists.…”

Impact of a Geriatric Intervention to Improve Screening and Management of Undernutrition in Older Patients Undergoing Surgery for Colorectal Cancer: Results of the ANC Stepped-Wedge Trial

“…The place of geriatric teams could be preponderant in order to improve the care of major geriatric syndromes and, more specifically, undernutrition. Previous studies using geriatric outreach teams or aiming to implement protocols that interfere with current practice have had difficulties showing an impact [ 51 , 52 ]. A recent retrospective study on medical and surgical malnourished patients suggested that embedded nutrition-focused quality improvement programs may improve outcomes such as length of stay or 30-day readmissions, especially for surgical patients [ 53 ].…”

Frailty assessment in older urological patients prior to surgery: a systematic review and narrative synthesis

“…[44][45][46][47] Translating this literature into routine clinical care is problematic due to challenges related to an inadequately trained workforce and has been explored in a recent study aiming to deliver Comprehensive Geriatric Assessment, with limited success, by non-geriatricians. 48 Prehabilitation refers to multidimensional interventions aimed at increasing functional reserve prior to surgery, the central tenets being structured exercise programme and nutritional optimisation. Patients with lower preoperative fitness levels have been shown to derive most benefit, 49 but a recent systematic review has concluded that there is a lack of evidence for clinical outcomes in this population, limited by a low number and quality of studies.…”