Effectiveness of geriatric care models in hospitalized patients: Should we cross borders between hospital and home?

Impact of inpatient geriatric consultation teams: a review and meta-analysis (M.D. Deschodt): Background: This review and meta-analysis aims to determine the impact of inpatient geriatric consultation teams. Methods: An electronic search of Medline, CINAHL, EMBASE, Web of Science and Invert was performed. Three independent reviewers selected prospective cohort studies assessing functional status, readmission rate, mortality or length of stay in adults aged 60 years or older. Twelve studies evaluating 4,546 participants in six countries were identified. Methodological quality of the included studies was assessed with the Methodological Index for Non-Randomized Studies. Results: The individual studies show that an inpatient geriatric consultation team intervention has favorable effects on functional status, readmission and mortality rate. None of the studies found an effect on the length of the hospital stay. The meta-analysis found a beneficial effect of the intervention with regard to mortality rate at 6 months (RR 0.66; 95% CI 0.52 to 0.85) and 8 months (RR 0.51; 95% CI 0.31 to 0.85) after hospital discharge. Conclusion: inpatient geriatric consultation team interventions have a significant impact on mortality rate at 6 and 8 months postdischarge, but have no significant impact on functional status, readmission or length of stay. The reason for the lack of effect on these latter outcomes may be due to insufficient statistical power or the insensitivity of the measuring method for, for example, functional status. The questions of to whom IGCT intervention should be targeted and what can be achieved remain unanswered. Comprehensive geriatric assessment and intensive home follow-up after hospital discharge: the Transitional Care Bridge randomized clinical trial (B.M. Buurman): Background: Acute hospitalization is a hazardous event for older people. Over 30% of older people experience a decline in Activities of Daily Living and another 20% dies within six months postdischarge. We aimed to study whether an intervention, consisting of comprehensive geriatric assessment and intensive home follow-up after discharge reduced functional decline and mortality in acutely hospitalized older patients. Methods: a randomized clinical trial was set up in patients 65 years and older, acutely admitted for at least 48 hours to internal medicine of three participating hospitals in the Netherlands. Risk for functional decline was assessed with the Identification of Senior at Risk - Hospitalized patients (score (greater-than or equal to)2). Eligible patients were randomly assigned by a computer-generated program to the intervention or control group. Hospital care was equal in both groups, and of a comprehensive geriatric assessment at admission by the hospitals geriatric consultation team. The intervention group was visited in the hospital by a community care nurse who guided the transition and performed five home visits, including a visit two days after discharge. The primary outcome was functional decline six months after discharge, defined as a loss of ADLs at six months compared to ADL functioning two weeks before admission, and mortality. Outcome assessors were blinded to group allocation. Lineair regression analysis was performed to calculate mean decline in ADLs. Logistic regression analysis was performed to calculate differences in mortality. Results: 674 patients were included with 337 allocated to the intervention group and 337 to the control group. Baseline characteristics were well balanced and showed no differences between the two groups. Mean age of the participants was 80 years in both groups and 67% lived independently before admission. We did not observe differences in functional decline between the intervention and control group (mean decline 0.22 vs 0.12, p = 0.55).We did observe a significant lower 30-day mortality in the intervention group compared to controls (11.3% vs 18.4%, p = 0.01). Conclusion: a transitional care program targeted at patients at high risk for functional decline did not reduce functional decline, but did reduce 30-day mortality. A transitional care program seems to improve patient safety in a vulnerable period shortly after hospital discharge. Specialist geriatric medical assessment for patients discharged from hospital acute assessment units: randomised controlled trial (S.P. Conroy): Background: To evaluate the effect of specialist geriatric medical management on the outcomes of at risk older people discharged from acute medical assessment units (AMU). Methods: Individual patient RCT comparing intervention with usual care in two hospitals in Nottingham and Leicester, UK. 433 patients aged 70 or over who were discharged within 72 hours of attending an AMU and at risk of decline as indicated by a score of (greater-than or equal to)2 on the Identification of Seniors At Risk tool. The intervention consisted of an assessment made on the AMU and further outpatient management by specialist physicians in geriatric medicine, including advice and support to primary care services. The primary outcome was the number of days spent at home (for those admitted from home) or days spent in the same care home (if admitted from a care home) in the 90 days after randomisation. Secondary outcomes were determined at 90 days and included mortality, institutionalisation, dependency, mental wellbeing, quality of life, and health and social care resource use. Results: The two groups were well matched for baseline characteristics, and withdrawal rates were similar in both groups (5%). Mean days at home over 90 days' follow-up were 80.2 days in the control group and 79.7 in the intervention group. The 95% confidence interval for the difference in means was -4.6 to 3.6 days (P = 0.31). No significant differences were found for any of the secondary outcomes. Conclusions: This specialist geriatric medical intervention applied to an at risk population of older people attending and being discharged from AMU had no effect on patients' outcomes or subsequent use of secondary care or long term care. Synthesis of the evidence across the three geriatric care models: towards a European research agenda (S.E. de Rooij): Three different interventions have been presented and discussed and they all show some overlap, and real differences between them. Also the outcomes vary between the studies. In this talk on synthesis of evidence these common themes will be discussed and a European research and implementation agenda will be set. The topics that will be covered are: - What outcomes should we focus on in these hospital-based interventions and how can we measure them? - Why is it so difficult to achieve improvement in functioning? - What research methodology is appropriate for these kind of studies on complex interventions? - Are the efforts to improve these geriatric care models sufficient and how can you measure these? - What are the components that are effective and cost-effective and we could start to implement? - How can we collaborate on a European level and set a research agenda on this topic?