Costs and effects of comprehensive geriatric assessment in primary care for older adults with high risk for hospitalisation

Abstract

Background The healthcare system needs effective strategies to identify the most vulnerable group of older patients, assess their needs and plan their care proactively. To evaluate the effectiveness of comprehensive geriatric assessment (CGA) of older adults with a high risk of hospitalisation we conducted a prospective, pragmatic, matched-control multicentre trial at 19 primary care practices in Sweden. Methods We identified 1604 individuals aged 75 years and older using a new, validated algorithm that calculates a risk score for hospitalisation from electronic medical records. After a nine-month run-in period for CGA in the intervention group, 74% of the available 646 participants had accepted and received CGA, and 662 participants remained in the control group. Participants at intervention practices were invited to CGA performed by a nurse together with a physician. The CGA was adapted to the primary care context. The participants thereafter received actions according to individual needs during a two-year follow-up period. Participants at control practices received care as usual. The primary outcome was hospital care days. Secondary outcomes were number of hospital care episodes, number of outpatient visits, health care costs and mortality. Outcomes were analysed according to intention to treat and adjusted for age, gender and risk score. We used generalised linear mixed models to compare the intervention group and control group regarding all outcomes. Results Mean age was 83.2 years, 51% of the 1308 participants were female. Relative risk reduction for hospital care days was − 22% (− 35% to − 4%, p = 0.02) during the two-year follow-up. Relative risk reduction for hospital care episodes was − 17% (− 30% to − 2%, p = 0.03). There were no significant differences in outpatient visits or mortality. Health care costs were significantly lower in the intervention group, adjusted mean difference was € − 4324 (€ − 7962 to − 686, p = 0.02). Conclusions and relevance Our findings indicate that CGA in primary care can reduce the need for hospital care days in a high-risk population of older adults. This could be of great importance in order to manage increasing prevalence of frailty and multimorbidity. Trial registration clinicaltrials.gov Identifier: NCT03180606, first posted 08/06/2017.

Development of an electronic frailty index for hospitalized geriatric patients in Sweden

“…Furthermore, it may be relevant to use other outcome measures than mortality in coming research efforts, although measures related to physical function and cognition are inherent in the FI. Crucial is also to show whether the eFI is able to identify patients that will benefit from CGA (26), and that will respond to treatment tailored from the outcome of the CGA. When implementing these results, it is also essential to include patients’ perspectives and to understand their feelings on frailty (46,47).…”

“…To date, frailty is not yet routinely assessed in all older adults in Sweden, but the CFS has started to be implemented in Stockholm, at least in geriatric clinics. Routine frailty screening can help identifying patients who would benefit most from a Comprehensive Geriatric Assessment (CGA) (26). To reduce the burden of bedside frailty assessment and aid in risk stratification, there is also an increasing need to analyze whether an eFI can be adapted to Swedish context.…”

Dizziness in older persons at high risk of future hospitalization: prevalence, differences between those with and without dizziness, and effect of a proactive primary care intervention

“…Based on the CGA evaluation the nurse-GP team established individual care plans when needed according to their clinical judgment. Examples of actions included initiation of homecare, diet counselling, physical activity advice, referrals to physiotherapist (PT) and/or occupational therapist (OT), and advice/referrals for were to get social support for loneliness and isolation [ 31 ]. A clinical follow-up by a nurse after one year were reported in 345 cases, and out of those 53 (15%) persons had been referred to a PT and 34 (10%) had been referred to an OT during that year.…”

Use and Prescription of Direct Oral Anticoagulants in Older and Frail Patients with Atrial Fibrillation: A Multidisciplinary Consensus Document

“…Based on the idea that a comprehensive evaluation of the patient is the best way to characterize the risk of adverse outcomes, we do believe that the geriatric comprehensive assessment (GCA) could be placed aside to an integrated approach, such as the ABC pathway. Use of GCA has been suggested as an effective way to manage frailty in older adults [ 53 ]. The conjunction between an integrated approach to AF patients’ management and GCA could probably provide an adequate way to evaluate, characterize and stratify risk in AF frail patients.…”