Randomised controlled trial of specialist geriatric medical assessment for patients discharged from hospital acute assessment units

Edmans, Judi; Bradshaw, Lucy; Franklyn, Melanie; Gladman, John; Conroy, Sharon

doi:10.1016/j.eurger.2013.07.454

Cited by 11 publications

(35 citation statements)

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“…However the trial showed no benefits in terms of resource use or health outcomes for this intervention [7].…”

Section: Introductionmentioning

confidence: 99%

“…The criteria for participating in the trial have been described in detail elsewhere [7,12]. Briefly, participants were aged 70 or over and identified at being at risk of future health problems, using the Identification of Seniors at Risk (ISAR) screening tool (predictive tool of high acute care hospital utilization and adverse health outcomes) [13] and had a short stay of up to 72 hours in the acute medical unit.…”

Section: Sample Selectionmentioning

confidence: 99%

“…However one concern is that at least half of older patients discharged home from acute medical units are readmitted in the near future [6,7].…”

Section: Introductionmentioning

confidence: 99%

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Comprehensive geriatric assessment on an acute medical unit: a qualitative study of older people’s and informal carer’s perspectives of the care and treatment received

et al. 2016

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Objective: This qualitative study was imbedded in a randomized controlled trial evaluating the addition of geriatricians to usual care to enable the comprehensive geriatric assessment process with older patients on acute medical units. The qualitative study explored the perspectives of intervention participants on their care and treatment. Design: A constructivist study incorporating semi-structured interviews that were conducted in patients’ homes within six weeks of discharge from the acute medical unit. These interviews were recorded, transcribed, and analysed using thematic analysis. Setting: An acute medical unit in the United Kingdom. Participants: Older patients (n = 18) and their informal carers (n = 6) discharged directly home from an acute medical unit, who had been in the intervention group of the randomized controlled trial. Results: Three core themes were constructed: (1) perceived lack of treatment on the acute medical unit; (2) nebulous grasp of the role of the geriatrician; and (3) on-going health and activities of daily living needs postdischarge. These needs impacted upon the informal carers, who either took over, or helped the patients to complete their activities of daily living. Despite the help received with activities of daily living, a lot of the patients voiced a desire to complete these activities themselves. Conclusions: The participants perceived they were just monitored and observed on the acute medical unit, rather than receiving active treatment, and spoke of on-going unresolved health and activity of daily living needs following discharge, despite receiving the additional intervention of a geriatrician.

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“…However the trial showed no benefits in terms of resource use or health outcomes for this intervention [7].…”

Section: Introductionmentioning

confidence: 99%

Section: Sample Selectionmentioning

confidence: 99%

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Comprehensive geriatric assessment on an acute medical unit: a qualitative study of older people’s and informal carer’s perspectives of the care and treatment received

et al. 2016

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“…Interventions must take into account the environment in which they are implemented, or risk poor performance or unintended consequences (242). A recent randomised control trial of specialist geriatric medical assessment for patients discharged from the acute medical unit published no benefit for mortality, institutionalisation, days spent at home and quality of life (243). Critical review suggests the performance of frailty assessment tool utilised was poorer than expected as used in this setting, and that provision of specialist geriatric input via a liaison service may have limited effectiveness compared to a ward-based multidisciplinary approach.…”

Section: Though There Is Clear Impetus For Improvement Interventionsmentioning

confidence: 99%

“…Reliable recognition of frailty is a research priority for acute hospital care (38,48,53,162,173,201,243). It is essential to inform routine clinical decision making and plan appropriate care.…”

Section: Risk Prediction Model Based On Frailty Syndromesmentioning

confidence: 99%

Frailty Assessment in Acute Care

2015

The Gerontologist

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IntroductionFor some people, ageing is associated with the experience of increased co-morbidity, functional impairment, poor resilience and heightened vulnerability to external stressors, resulting in reduced lifespan as well as health-span. This frailty phenomenon poses challenges to health care systems in the form of increased patient complexity and resource utilisation. The acute care setting, characterised by time-pressure and high patient turn-over, is under strain and struggles to recognise and subsequently reliably intervene, to prevent, reverse or halt the decline of this vulnerable cohort. MethodsThis mixed-methods study probes existing evidence and 'real-world' processes with a systematic review of frailty assessments developed or validated in the acute care setting and a survey of contemporaneous clinical practice in London Acute Medical Units. Content validation and understanding of contextual factors for ideal frailty assessment in acute care is explored using Delphi consensus and Focus Group methodology respectively. The resultant model is developed on existing retrospective national Hospital Episode Statistics data, and prospectively tested on observational data in a local Acute Medical Unit setting. ResultsExisting frailty scores are preponderantly biophysical in nature, and have poor predictive power for adverse outcomes in the acute care setting. In clinical practice, single-dimension assessment tools predominate. Frailty syndromes and previous high resource utilisation in the form of a simple, clinically relevant tool useful to the multidisciplinary team gain consensus as optimal assessment for the setting. Retrospective testing of the frailty model displays moderate predictive powers for adverse events (inpatient mortality, emergency readmission and institutionalisation) and prospective testing provides concurrent (Frailty Index, Age, Co-Morbidity) and comparative predictive validity (Frailty Index, Co-Morbidity, 2 admission National Early Warning Score) with existing risk stratification models in this setting. ConclusionsA risk prediction model based on frailty syndromes and previous high resource utilisation is a valid, feasible and useful for the acute care setting.

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