NIHR Signal Comprehensive assessment when older people are in hospital improves their chances of getting home and living independently

Published on 21 November 2017

Older people who received comprehensive geriatric assessment when in hospital were slightly more likely to be living in their own homes one year later. Sixty percent were discharged to independent living compared with 56% receiving standard ward care. People who had received this proper assessment were also 20% less likely to be in a nursing home after three months or more.

Older people often have multiple complex conditions combined with frailty and are more likely to lose independence after illness. Comprehensive geriatric assessment is a careful review by a multidisciplinary specialist team of people’s medical, functional, mental and social capabilities. It aims to improve recovery and enable people to maintain function and independence.

This updated Cochrane review covered 29 trials comparing this assessment with routine care for people over 65, excluding those with stroke and orthopaedic conditions. It may save NHS resources, but the quality of evidence was too low to assess this reliably.

This assessment is not carried out in all hospitals, and the mode of delivery varies. Research has yet to answer how best to deliver this assessment to those most in need.

Comprehensive assessment when older people are in hospital improves their chances of getting home and living independently

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Why was this study needed?

The increasing number of adults surviving to old age places a high demand on the health and social care system. In England, emergency hospital admissions increased by 47% between 1998 and 2013, with older people the largest users of hospital care. Older people are more likely to be frail and have several co-existing health conditions, putting them at higher risk of long-term dependence and poor outcomes. The increased hospital admissions combined with often complex care needs makes sustainable care for older people difficult.

Comprehensive geriatric assessment involves multidimensional assessment by a range of health and social care specialists working in a team. It aims to set patient-centred goals for treatment, rehabilitation and long-term support.

This assessment has the potential to improve outcomes for older people and reduce healthcare costs. This update added seven trials to a previously published Cochrane review to see whether this assessment is clinically and cost-effective.

What did this study do?

The review included 29 randomised controlled trials comparing comprehensive geriatric assessment with routine ward care for 13,766 hospitalised older adults aged over 65 years. People with stroke or orthopaedic conditions were excluded.

Most trials were conducted in North America (20), with two from the UK. Researchers from 13 trials completed surveys on the details of this assessments delivery. Most interventions included multidisciplinary meetings and specialist experience, and involved patients and carers in setting tailored treatment plans. The assessment took place on geriatric wards in 20 trials, and teams visited general medical wards in the remaining trials.

Participants and staff in most trials were aware of group allocation. There was also risk of bias around selective or incomplete reporting of outcomes. However, the overall quality of evidence was high for most outcomes.

What did it find?

  • Comprehensive geriatric assessment gave a small increase in the likelihood that patients would be alive and live in their own homes after hospital discharge. Sixty percent were living at home at 3 to 12-month follow-up compared with 56% of the usual care group (risk ratio [RR] 1.06, 95% confidence interval [CI] 1.01 to 1.10; 16 trials in 6,799 people).
  • It did not affect the risk of mortality (RR 1.00, 95% CI 0.93 to 1.07; 21 trials in 10,023 people).
  • The assessment decreased the likelihood that the person was admitted to a nursing home by 3 to 12 months. Fifteen percent were admitted compared with 19% receiving usual care (RR 0.80, 95% CI 0.72 to 0.89; 14 trials in 6,285 people). There was no effect on the person’s risk of dependence (RR 0.97, 95% CI 0.89 to 1.04; 14 trials in 6,551 people).
  • Seventeen trials reported on healthcare costs, but the quality of evidence was too low to allow reliable analysis. Costs of the assessment were on average £234 higher per person (95% CI -£144 to +£605). There were suggestions from three to four trials that the assessment may increase quality-adjusted life years (0.012 QALYs) and life years (0.037 LYs) slightly. These benefits came at costs of £19,802 per QALY and £6,305 per LY. This meant they can be viewed as good value as they have a 50% chance of falling below a £20,000 willingness-to-pay threshold for QALYs, and 89% probability of meeting the threshold for LYs.

What does current guidance say on this issue?

The NICE 2016 quality standard on comprehensive geriatric assessment recommends that services are commissioned to ensure that older people with complex needs can have this assessment started as soon as they are admitted to hospital. NICE says this helps practitioners to develop a long-term plan to meet the person’s needs, may reduce the length of hospital stay and may help the person to maintain independence.

NICE also has a 2015 guideline on older people with social care needs and multiple long-term conditions. This doesn’t cover hospital admission but covers identifying and assessing care needs, preventing isolation and planning social care and support in community settings.

What are the implications?

The evidence supports guideline recommendations that comprehensive geriatric assessment may increase the likelihood that frail older people can be discharged to independent living. NHS England states, helping older people to live independently may reduce their risk of reaching a crisis, requiring urgent support or experiencing harm.

Implementing these types of assessment may be expected to save NHS resources. But there was little information on social care costs in these studies.

It wasn’t possible to determine one format, team structure or delivery setting that was most effective in practice. But, a small survey of lead researchers identified some of the key ingredients of a successful assessment which included: tailored treatment plans, clinical leadership, knowledge and experience, multi-disciplinary team meetings, and involvement of patients and carers in goal setting.

This review is part of on-going NIHR research on comprehensive geriatric assessment, including important studies looking at different models of delivery and how best to implement it given rising demand and cost constraints in hospitals.

Citation and Funding

Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Syst Rev. 2017;(9):CD006211.

Cochrane UK and the Cochrane Effective Practice and Organisation of Care Group are supported by the National Institute for Health research via Cochrane Infrastructure funding.

This project was also funded by the National Institute for Health Research Health Technology Assessment (HTA) Programme as part of a study (project number 14/51/01).

Bibliography

British Geriatrics Society. Comprehensive assessment of the frail older patient. London: British Geriatrics Society; 2010.

DH. National Service Framework for older people. London: Department of Health; 2001.

Joseph Rowntree Foundation. A better life: valuing our later years. York: Joseph Rowntree Foundation; 2013.

NHS England. Safe, compassionate care for frail older people using an integrated care pathway: Practical guidance for commissioners, providers and nursing, medical and allied health professional leaders. London: NHS England; 2014.

NICE. Older people with social care needs and multiple long-term conditions. NG22. London: National Institute for Health and Care Excellence; 2015.

NICE. Transition between inpatient hospital settings and community or care home settings for adults with social care needs. QS136. London: National Institute for Health and Care Excellence; 2016.

Parker S, Roberts H, Bardsley M, et al. Acute hospital care for frail older people. In progress; funded by the NIHR Health Services and Delivery Research Programme (project number 12/5003/02).

Shepperd S, Hemsley A, Ellis G, et al. How best to deliver Comprehensive Geriatric Assessment in a cost-effective way. In progress; funded by the NIHR Health Services and Delivery Research Programme (project number 12/5003/01).

Why was this study needed?

The increasing number of adults surviving to old age places a high demand on the health and social care system. In England, emergency hospital admissions increased by 47% between 1998 and 2013, with older people the largest users of hospital care. Older people are more likely to be frail and have several co-existing health conditions, putting them at higher risk of long-term dependence and poor outcomes. The increased hospital admissions combined with often complex care needs makes sustainable care for older people difficult.

Comprehensive geriatric assessment involves multidimensional assessment by a range of health and social care specialists working in a team. It aims to set patient-centred goals for treatment, rehabilitation and long-term support.

This assessment has the potential to improve outcomes for older people and reduce healthcare costs. This update added seven trials to a previously published Cochrane review to see whether this assessment is clinically and cost-effective.

What did this study do?

The review included 29 randomised controlled trials comparing comprehensive geriatric assessment with routine ward care for 13,766 hospitalised older adults aged over 65 years. People with stroke or orthopaedic conditions were excluded.

Most trials were conducted in North America (20), with two from the UK. Researchers from 13 trials completed surveys on the details of this assessments delivery. Most interventions included multidisciplinary meetings and specialist experience, and involved patients and carers in setting tailored treatment plans. The assessment took place on geriatric wards in 20 trials, and teams visited general medical wards in the remaining trials.

Participants and staff in most trials were aware of group allocation. There was also risk of bias around selective or incomplete reporting of outcomes. However, the overall quality of evidence was high for most outcomes.

What did it find?

  • Comprehensive geriatric assessment gave a small increase in the likelihood that patients would be alive and live in their own homes after hospital discharge. Sixty percent were living at home at 3 to 12-month follow-up compared with 56% of the usual care group (risk ratio [RR] 1.06, 95% confidence interval [CI] 1.01 to 1.10; 16 trials in 6,799 people).
  • It did not affect the risk of mortality (RR 1.00, 95% CI 0.93 to 1.07; 21 trials in 10,023 people).
  • The assessment decreased the likelihood that the person was admitted to a nursing home by 3 to 12 months. Fifteen percent were admitted compared with 19% receiving usual care (RR 0.80, 95% CI 0.72 to 0.89; 14 trials in 6,285 people). There was no effect on the person’s risk of dependence (RR 0.97, 95% CI 0.89 to 1.04; 14 trials in 6,551 people).
  • Seventeen trials reported on healthcare costs, but the quality of evidence was too low to allow reliable analysis. Costs of the assessment were on average £234 higher per person (95% CI -£144 to +£605). There were suggestions from three to four trials that the assessment may increase quality-adjusted life years (0.012 QALYs) and life years (0.037 LYs) slightly. These benefits came at costs of £19,802 per QALY and £6,305 per LY. This meant they can be viewed as good value as they have a 50% chance of falling below a £20,000 willingness-to-pay threshold for QALYs, and 89% probability of meeting the threshold for LYs.

What does current guidance say on this issue?

The NICE 2016 quality standard on comprehensive geriatric assessment recommends that services are commissioned to ensure that older people with complex needs can have this assessment started as soon as they are admitted to hospital. NICE says this helps practitioners to develop a long-term plan to meet the person’s needs, may reduce the length of hospital stay and may help the person to maintain independence.

NICE also has a 2015 guideline on older people with social care needs and multiple long-term conditions. This doesn’t cover hospital admission but covers identifying and assessing care needs, preventing isolation and planning social care and support in community settings.

What are the implications?

The evidence supports guideline recommendations that comprehensive geriatric assessment may increase the likelihood that frail older people can be discharged to independent living. NHS England states, helping older people to live independently may reduce their risk of reaching a crisis, requiring urgent support or experiencing harm.

Implementing these types of assessment may be expected to save NHS resources. But there was little information on social care costs in these studies.

It wasn’t possible to determine one format, team structure or delivery setting that was most effective in practice. But, a small survey of lead researchers identified some of the key ingredients of a successful assessment which included: tailored treatment plans, clinical leadership, knowledge and experience, multi-disciplinary team meetings, and involvement of patients and carers in goal setting.

This review is part of on-going NIHR research on comprehensive geriatric assessment, including important studies looking at different models of delivery and how best to implement it given rising demand and cost constraints in hospitals.

Citation and Funding

Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Syst Rev. 2017;(9):CD006211.

Cochrane UK and the Cochrane Effective Practice and Organisation of Care Group are supported by the National Institute for Health research via Cochrane Infrastructure funding.

This project was also funded by the National Institute for Health Research Health Technology Assessment (HTA) Programme as part of a study (project number 14/51/01).

Bibliography

British Geriatrics Society. Comprehensive assessment of the frail older patient. London: British Geriatrics Society; 2010.

DH. National Service Framework for older people. London: Department of Health; 2001.

Joseph Rowntree Foundation. A better life: valuing our later years. York: Joseph Rowntree Foundation; 2013.

NHS England. Safe, compassionate care for frail older people using an integrated care pathway: Practical guidance for commissioners, providers and nursing, medical and allied health professional leaders. London: NHS England; 2014.

NICE. Older people with social care needs and multiple long-term conditions. NG22. London: National Institute for Health and Care Excellence; 2015.

NICE. Transition between inpatient hospital settings and community or care home settings for adults with social care needs. QS136. London: National Institute for Health and Care Excellence; 2016.

Parker S, Roberts H, Bardsley M, et al. Acute hospital care for frail older people. In progress; funded by the NIHR Health Services and Delivery Research Programme (project number 12/5003/02).

Shepperd S, Hemsley A, Ellis G, et al. How best to deliver Comprehensive Geriatric Assessment in a cost-effective way. In progress; funded by the NIHR Health Services and Delivery Research Programme (project number 12/5003/01).

Comprehensive geriatric assessment for older adults admitted to hospital

Published on 13 September 2017

Ellis, G.,Gardner, M.,Tsiachristas, A.,Langhorne, P.,Burke, O.,Harwood, R. H.,Conroy, S. P.,Kircher, T.,Somme, D.,Saltvedt, I.,Wald, H.,O'Neill, D.,Robinson, D.,Shepperd, S.

Cochrane Database Syst Rev Volume 9 , 2017

BACKGROUND: Comprehensive geriatric assessment (CGA) is a multi-dimensional, multi-disciplinary diagnostic and therapeutic process conducted to determine the medical, mental, and functional problems of older people with frailty so that a co-ordinated and integrated plan for treatment and follow-up can be developed. This is an update of a previously published Cochrane review. OBJECTIVES: We sought to critically appraise and summarise current evidence on the effectiveness and resource use of CGA for older adults admitted to hospital, and to use these data to estimate its cost-effectiveness. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers on 5 October 2016; we also checked reference lists and contacted study authors. SELECTION CRITERIA: We included randomised trials that compared inpatient CGA (delivered on geriatric wards or by mobile teams) versus usual care on a general medical ward or on a ward for older people, usually admitted to hospital for acute care or for inpatient rehabilitation after an acute admission. DATA COLLECTION AND ANALYSIS: We followed standard methodological procedures expected by Cochrane and Effective Practice and Organisation of Care (EPOC). We used the GRADE approach to assess the certainty of evidence for the most important outcomes. For this update, we requested individual patient data (IPD) from trialists, and we conducted a survey of trialists to obtain details of delivery of CGA. We calculated risk ratios (RRs), mean differences (MDs), or standardised mean differences (SMDs), and combined data using fixed-effect meta-analysis. We estimated cost-effectiveness by comparing inpatient CGA versus hospital admission without CGA in terms of cost per quality-adjusted life year (QALY) gained, cost per life year (LY) gained, and cost per life year living at home (LYLAH) gained. MAIN RESULTS: We included 29 trials recruiting 13,766 participants across nine, mostly high-income countries. CGA increases the likelihood that patients will be alive and in their own homes at 3 to 12 months' follow-up (risk ratio (RR) 1.06, 95% confidence interval (CI) 1.01 to 1.10; 16 trials, 6799 participants; high-certainty evidence), results in little or no difference in mortality at 3 to 12 months' follow-up (RR 1.00, 95% CI 0.93 to 1.07; 21 trials, 10,023 participants; high-certainty evidence), decreases the likelihood that patients will be admitted to a nursing home at 3 to 12 months follow-up (RR 0.80, 95% CI 0.72 to 0.89; 14 trials, 6285 participants; high-certainty evidence) and results in little or no difference in dependence (RR 0.97, 95% CI 0.89 to 1.04; 14 trials, 6551 participants; high-certainty evidence). CGA may make little or no difference to cognitive function (SMD ranged from -0.22 to 0.35 (5 trials, 3534 participants; low-certainty evidence)). Mean length of stay ranged from 1.63 days to 40.7 days in the intervention group, and ranged from 1.8 days to 42.8 days in the comparison group. Healthcare costs per participant in the CGA group were on average GBP 234 (95% CI GBP -144 to GBP 605) higher than in the usual care group (17 trials, 5303 participants; low-certainty evidence). CGA may lead to a slight increase in QALYs of 0.012 (95% CI -0.024 to 0.048) at GBP 19,802 per QALY gained (3 trials; low-certainty evidence), a slight increase in LYs of 0.037 (95% CI 0.001 to 0.073), at GBP 6305 per LY gained (4 trials; low-certainty evidence), and a slight increase in LYLAH of 0.019 (95% CI -0.019 to 0.155) at GBP 12,568 per LYLAH gained (2 trials; low-certainty evidence). The probability that CGA would be cost-effective at a GBP 20,000 ceiling ratio for QALY, LY, and LYLAH was 0.50, 0.89, and 0.47, respectively (17 trials, 5303 participants; low-certainty evidence). AUTHORS' CONCLUSIONS: Older patients are more likely to be alive and in their own homes at follow-up if they received CGA on admission to hospital. We are uncertain whether data show a difference in effect between wards and teams, as this analysis was underpowered. CGA may lead to a small increase in costs, and evidence for cost-effectiveness is of low-certainty due to imprecision and inconsistency among studies. Further research that reports cost estimates that are setting-specific across different sectors of care are required.

NICE states that older people are generally considered to be those aged 65 and older, but may include younger people depending on their health, needs and circumstances. NICE recommends that comprehensive geriatric assessment in hospital should be triggered by an older person having any one or more of the following factors:

  • falls
  • immobility
  • delirium or dementia
  • incontinence
  • taking multiple drugs (polypharmacy)
  • in need of end of life care

Expert commentary

We often hear about the “problem” of older people being admitted to hospital, but we hear less about how hospitals can become better places for older people by ensuring that their needs are met to improve the chances of better outcomes.

Multidisciplinary comprehensive assessment is not universally provided for older people admitted to hospital, and there are still questions about who benefits most, in which settings and at what cost.

While further careful research is addressing these questions, is it time to think seriously about making it available on a hospital-wide basis?

Stuart Parker, Professor of Geriatric Medicine & CRN Specialty Cluster Lead, Newcastle University