Comprehensive Geriatric Assessment and Transitional Care in Acutely Hospitalized Patients

Abstract

IMPORTANCE Older adults acutely hospitalized are at risk of disability. Trials on comprehensive geriatric assessment (CGA) and transitional care present inconsistent results. OBJECTIVE To test whether an intervention of systematic CGA, followed by the transitional care bridge program, improved activities of daily living (ADLs) compared with systematic CGA alone. DESIGN, SETTING, AND PARTICIPANTS This study was a double-blind, multicenter, randomized clinical trial conducted at 3 hospitals with affiliated home care organizations in the Netherlands between September 1, 2010, and March 1, 2014. In total, 1070 consecutive patients were eligible, 674 (63.0%) of whom enrolled. They were 65 years or older, acutely hospitalized to a medical ward for at least 48 hours with an Identification of Seniors at Risk-Hospitalized Patients score of 2 or higher, and randomized using permuted blocks stratified by study site and Mini-Mental State Examination score (<24 vs Ն24). The dates of the analysis were June 1, 2014, to November 15, 2014. INTERVENTIONS The transitional care bridge program intervention was started during hospitalization by a visit from a community care registered nurse (CCRN) and continued after discharge with home visits at 2 days and at 2, 6, 12, and 24 weeks. The CCRNs applied the CGA care and treatment plan. MAIN OUTCOMES AND MEASURES The main outcome was the Katz Index of ADL at 6 months compared with 2 weeks before admission. Secondary outcomes were mortality, cognitive functioning, time to hospital readmission, and the time to discharge from a nursing home. RESULTS The study cohort comprised 674 participants. Their mean age was 80 years, 42.1% (n = 284) were male, and 39.2% (n = 264) were cognitively impaired at admission. Intent-to-treat analysis found no differences in the mean Katz Index of ADL at 6 months between the intervention arm (mean, 2.0; 95% CI, 1.8-2.2) and the CGA-only arm (mean, 1.9; 95% CI, 1.7-2.2). For secondary outcomes, there were 85 deaths (25.2%) in the intervention arm and 104 deaths (30.9%) in the CGA-only arm, resulting in a lower risk on the time to death within 6 months after hospital admission (hazard ratio, 0.75; 95% CI, 0.56-0.99; P = .045; number needed to treat to prevent 1 death, 16). No other secondary outcome was significant. CONCLUSIONS AND RELEVANCE A systematic CGA, followed by the transitional care bridge program, showed no effect on ADL functioning in acutely hospitalized older patients.

Supporting at-risk older adults transitioning from hospital to home: who benefits from an evidence-based patient-centered discharge planning intervention? Post-hoc analysis from a randomized trial

“…The HOME intervention was assessed in a randomized control trial (RCT) involving 400 older patients with varied medical conditions treated in five acute Australian hospitals [28]. Consistent with other evidence-based interventions [30,31], no between-group differences were found between HOME compared to the in-hospital occupational therapy consultation on the main outcomes (independence in ADL, participation in life roles, and hospital and ED readmissions) in this trial [28].…”

Comprehensive geriatric assessments in integrated care programs for older people living at home: A scoping review

“…Information provided about the exact content of the instrument varied between CGAs. For five CGA instruments, the content of the CGA was available in (the appendix of) the original study or in a study cited in the original study (Buurman et al, ; Buurman, Parlevliet, van Deelen, de Haan, & de Rooij, ; Fleischer et al, ; Ruikes et al, , ; Stijnen, Duimel‐Peeters, et al, ; Suijker et al, , ). For the other CGAs, the original study did not provide or only partially provided the exact content of the CGA nor referred to other papers describing this information.…”

“…This Dutch program aimed to improve care and support for older people through funding of several research and implementation projects focused on developing a more proactive and integrated health and social care system for frail older people (Hoogendijk, ; Lutomski et al, ). Nine of these projects, with eight different CGA instruments and procedures, were included in this study (Blom et al, ; Buurman et al, , ; Daniels et al, ; Hoogendijk et al, ; Looman et al, , ; Metzelthin et al, , ; Muntinga et al, ; Ruikes et al, , ; Spoorenberg et al, , ; Stijnen, Duimel‐Peeters, et al, ; Suijker et al, , ; Uittenbroek et al, ).…”

Understanding implementation of comprehensive geriatric care programs: a multiple perspective approach is preferred

“…A closer look at the performance of the intervention showed that low treatment fidelity (<50%) played a major role in the ineffective implementation of the PReCaP (de Vos et al, 2013). The results of three other projects within the Dutch National Care for the Elderly Program, in the clinical setting as well as in primary care, demonstrate that multidisciplinary 'evidence based' interventions for frail elderly are executed with limited fidelity and few minor positive effects (Fabbricotti et al, 2013;Asmus-Szepesi et al, 2015;Buurman et al, 2016). Treatment fidelity issues are caused by various factors, such as the complexity of the projects (Metzelthin et al, 2013), limited attention for implementation, lack of geriatric knowledge and inadequate interdisciplinary communication of patient information (de Vos et al, 2013;Hartgerink, 2013).…”