Comprehensive Geriatric Assessment in hospital and hospital-at-home settings

a mixed-methods study

Mike Gardner, Sasha Shepperd (Corresponding Author), Mary Godfrey, Petra Mäkelä, Apostolos Tsiachristas, Amina Singh-Mehta, Graham Ellis, Pradeep Khanna, Peter Langhorne, Stephen Makin, David J. Stott

Research output: Contribution to journalArticle

Abstract

Background
The Comprehensive Geriatric Assessment (CGA) is a multidisciplinary process that determines a frail older person’s medical, functional, psychological and social capability to ensure that they have a co-ordinated plan for treatment and follow-up.

Objectives
To improve our understanding of the effectiveness, cost-effectiveness and implementation of the CGA across hospital and hospital-at-home settings.

Methods
We used a variety of methods. We updated a Cochrane review of randomised trials of the CGA in hospital for older people aged ≥ 65 years, conducted a national survey of community CGA, analysed data from three health boards using propensity score matching (PSM) and regression analysis, conducted a qualitative study and used a modified Delphi method.

Results
We included 29 trials recruiting 13,766 participants in the Cochrane review of the CGA. Older people admitted to hospital who receive the CGA are more likely to be living at home at 3–12 months’ follow-up [relative risk (RR) 1.06, 95% confidence interval (CI) 1.01 to 1.10] (high certainty). The probability that the CGA would be cost-effective at a £20,000 ceiling ratio for quality-adjusted life-years (QALYs), life-years (LYs) and LYs living at home was 0.50, 0.89, and 0.47, respectively (low-certainty evidence). After PSM and regression analysis comparing CGA hospital with CGA hospital at home, we found that the health-care cost (from admission to 6 months after discharge) in site 1 was lower in hospital at home (ratio of means 0.82, 95% CI 0.76 to 0.89), in site 2 there was little difference (ratio of means 1.00, 95% CI 0.92 to 1.09) and in site 3 it was higher (ratio of means 1.15, 95% CI 0.99 to 1.33). Six months after discharge (excluding the index admission), the ratio of means cost in site 1 was 1.27 (95% CI 1.14 to 1.41), in site 2 was 1.09 (95% CI 0.95 to 1.24) and in site 3 was 1.70 (95% CI 1.40 to 2.07). At 6 months’ follow-up (excluding the index admission), there may be an increased risk of mortality (adjusted) in the three hospital-at-home cohorts (site 1: RR 1.09, 95% CI 1.00 to 1.19; site 2: RR 1.29, 95% CI 1.15 to 1.44; site 3: RR 1.27, 95% CI 1.06 to 1.54). The qualitative research indicates the importance of relational aspects of health care, incorporating caregivers’ knowledge in care planning, and a lack of clarity about the end of an episode of health care. Core components that should be included in CGA focus on functional, physical and mental well-being, medication review and a caregiver’s ability to care.

Limitations
The risk of residual confounding limits the certainty of the findings from the PSM analysis; a second major limitation is that the research plan did not include an investigation of social care or primary care.

Conclusions
The CGA is an effective way to organise health care for older people in hospital and may lead to a small increase in costs. There may be an increase in cost and the risk of mortality in the population who received the CGA hospital at home compared with those who received the CGA in hospital; randomised evidence is required to confirm or refute this. Caregiver involvement in the CGA process could be strengthened.
Original languageEnglish
Number of pages236
JournalHealth Serv Deliv Res
Volume7
DOIs
Publication statusPublished - Mar 2019

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Geriatric Assessment
Confidence Intervals
Propensity Score
Caregivers
Costs and Cost Analysis
Delivery of Health Care
Regression Analysis
Episode of Care
Quality-Adjusted Life Years
Mortality
Qualitative Research
Health Care Costs

Cite this

Gardner, M., Shepperd, S., Godfrey, M., Mäkelä, P., Tsiachristas, A., Singh-Mehta, A., ... Stott, D. J. (2019). Comprehensive Geriatric Assessment in hospital and hospital-at-home settings: a mixed-methods study. Health Serv Deliv Res, 7. https://doi.org/10.3310/hsdr07100

Comprehensive Geriatric Assessment in hospital and hospital-at-home settings : a mixed-methods study. / Gardner, Mike; Shepperd, Sasha (Corresponding Author); Godfrey, Mary; Mäkelä, Petra; Tsiachristas, Apostolos; Singh-Mehta, Amina; Ellis, Graham; Khanna, Pradeep; Langhorne, Peter; Makin, Stephen; Stott, David J.

In: Health Serv Deliv Res, Vol. 7, 03.2019.

Research output: Contribution to journalArticle

Gardner, M, Shepperd, S, Godfrey, M, Mäkelä, P, Tsiachristas, A, Singh-Mehta, A, Ellis, G, Khanna, P, Langhorne, P, Makin, S & Stott, DJ 2019, 'Comprehensive Geriatric Assessment in hospital and hospital-at-home settings: a mixed-methods study', Health Serv Deliv Res, vol. 7. https://doi.org/10.3310/hsdr07100
Gardner, Mike ; Shepperd, Sasha ; Godfrey, Mary ; Mäkelä, Petra ; Tsiachristas, Apostolos ; Singh-Mehta, Amina ; Ellis, Graham ; Khanna, Pradeep ; Langhorne, Peter ; Makin, Stephen ; Stott, David J. / Comprehensive Geriatric Assessment in hospital and hospital-at-home settings : a mixed-methods study. In: Health Serv Deliv Res. 2019 ; Vol. 7.
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title = "Comprehensive Geriatric Assessment in hospital and hospital-at-home settings: a mixed-methods study",
abstract = "BackgroundThe Comprehensive Geriatric Assessment (CGA) is a multidisciplinary process that determines a frail older person’s medical, functional, psychological and social capability to ensure that they have a co-ordinated plan for treatment and follow-up.ObjectivesTo improve our understanding of the effectiveness, cost-effectiveness and implementation of the CGA across hospital and hospital-at-home settings.MethodsWe used a variety of methods. We updated a Cochrane review of randomised trials of the CGA in hospital for older people aged ≥ 65 years, conducted a national survey of community CGA, analysed data from three health boards using propensity score matching (PSM) and regression analysis, conducted a qualitative study and used a modified Delphi method.ResultsWe included 29 trials recruiting 13,766 participants in the Cochrane review of the CGA. Older people admitted to hospital who receive the CGA are more likely to be living at home at 3–12 months’ follow-up [relative risk (RR) 1.06, 95{\%} confidence interval (CI) 1.01 to 1.10] (high certainty). The probability that the CGA would be cost-effective at a £20,000 ceiling ratio for quality-adjusted life-years (QALYs), life-years (LYs) and LYs living at home was 0.50, 0.89, and 0.47, respectively (low-certainty evidence). After PSM and regression analysis comparing CGA hospital with CGA hospital at home, we found that the health-care cost (from admission to 6 months after discharge) in site 1 was lower in hospital at home (ratio of means 0.82, 95{\%} CI 0.76 to 0.89), in site 2 there was little difference (ratio of means 1.00, 95{\%} CI 0.92 to 1.09) and in site 3 it was higher (ratio of means 1.15, 95{\%} CI 0.99 to 1.33). Six months after discharge (excluding the index admission), the ratio of means cost in site 1 was 1.27 (95{\%} CI 1.14 to 1.41), in site 2 was 1.09 (95{\%} CI 0.95 to 1.24) and in site 3 was 1.70 (95{\%} CI 1.40 to 2.07). At 6 months’ follow-up (excluding the index admission), there may be an increased risk of mortality (adjusted) in the three hospital-at-home cohorts (site 1: RR 1.09, 95{\%} CI 1.00 to 1.19; site 2: RR 1.29, 95{\%} CI 1.15 to 1.44; site 3: RR 1.27, 95{\%} CI 1.06 to 1.54). The qualitative research indicates the importance of relational aspects of health care, incorporating caregivers’ knowledge in care planning, and a lack of clarity about the end of an episode of health care. Core components that should be included in CGA focus on functional, physical and mental well-being, medication review and a caregiver’s ability to care.LimitationsThe risk of residual confounding limits the certainty of the findings from the PSM analysis; a second major limitation is that the research plan did not include an investigation of social care or primary care.ConclusionsThe CGA is an effective way to organise health care for older people in hospital and may lead to a small increase in costs. There may be an increase in cost and the risk of mortality in the population who received the CGA hospital at home compared with those who received the CGA in hospital; randomised evidence is required to confirm or refute this. Caregiver involvement in the CGA process could be strengthened.",
author = "Mike Gardner and Sasha Shepperd and Mary Godfrey and Petra M{\"a}kel{\"a} and Apostolos Tsiachristas and Amina Singh-Mehta and Graham Ellis and Pradeep Khanna and Peter Langhorne and Stephen Makin and Stott, {David J.}",
note = "The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 12/5003/01. The contractual start date was in June 2014. The final report began editorial review in November 2017 and was accepted for publication in April 2018. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.",
year = "2019",
month = "3",
doi = "10.3310/hsdr07100",
language = "English",
volume = "7",
journal = "Health Serv Deliv Res",

}

TY - JOUR

T1 - Comprehensive Geriatric Assessment in hospital and hospital-at-home settings

T2 - a mixed-methods study

AU - Gardner, Mike

AU - Shepperd, Sasha

AU - Godfrey, Mary

AU - Mäkelä, Petra

AU - Tsiachristas, Apostolos

AU - Singh-Mehta, Amina

AU - Ellis, Graham

AU - Khanna, Pradeep

AU - Langhorne, Peter

AU - Makin, Stephen

AU - Stott, David J.

N1 - The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 12/5003/01. The contractual start date was in June 2014. The final report began editorial review in November 2017 and was accepted for publication in April 2018. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

PY - 2019/3

Y1 - 2019/3

N2 - BackgroundThe Comprehensive Geriatric Assessment (CGA) is a multidisciplinary process that determines a frail older person’s medical, functional, psychological and social capability to ensure that they have a co-ordinated plan for treatment and follow-up.ObjectivesTo improve our understanding of the effectiveness, cost-effectiveness and implementation of the CGA across hospital and hospital-at-home settings.MethodsWe used a variety of methods. We updated a Cochrane review of randomised trials of the CGA in hospital for older people aged ≥ 65 years, conducted a national survey of community CGA, analysed data from three health boards using propensity score matching (PSM) and regression analysis, conducted a qualitative study and used a modified Delphi method.ResultsWe included 29 trials recruiting 13,766 participants in the Cochrane review of the CGA. Older people admitted to hospital who receive the CGA are more likely to be living at home at 3–12 months’ follow-up [relative risk (RR) 1.06, 95% confidence interval (CI) 1.01 to 1.10] (high certainty). The probability that the CGA would be cost-effective at a £20,000 ceiling ratio for quality-adjusted life-years (QALYs), life-years (LYs) and LYs living at home was 0.50, 0.89, and 0.47, respectively (low-certainty evidence). After PSM and regression analysis comparing CGA hospital with CGA hospital at home, we found that the health-care cost (from admission to 6 months after discharge) in site 1 was lower in hospital at home (ratio of means 0.82, 95% CI 0.76 to 0.89), in site 2 there was little difference (ratio of means 1.00, 95% CI 0.92 to 1.09) and in site 3 it was higher (ratio of means 1.15, 95% CI 0.99 to 1.33). Six months after discharge (excluding the index admission), the ratio of means cost in site 1 was 1.27 (95% CI 1.14 to 1.41), in site 2 was 1.09 (95% CI 0.95 to 1.24) and in site 3 was 1.70 (95% CI 1.40 to 2.07). At 6 months’ follow-up (excluding the index admission), there may be an increased risk of mortality (adjusted) in the three hospital-at-home cohorts (site 1: RR 1.09, 95% CI 1.00 to 1.19; site 2: RR 1.29, 95% CI 1.15 to 1.44; site 3: RR 1.27, 95% CI 1.06 to 1.54). The qualitative research indicates the importance of relational aspects of health care, incorporating caregivers’ knowledge in care planning, and a lack of clarity about the end of an episode of health care. Core components that should be included in CGA focus on functional, physical and mental well-being, medication review and a caregiver’s ability to care.LimitationsThe risk of residual confounding limits the certainty of the findings from the PSM analysis; a second major limitation is that the research plan did not include an investigation of social care or primary care.ConclusionsThe CGA is an effective way to organise health care for older people in hospital and may lead to a small increase in costs. There may be an increase in cost and the risk of mortality in the population who received the CGA hospital at home compared with those who received the CGA in hospital; randomised evidence is required to confirm or refute this. Caregiver involvement in the CGA process could be strengthened.

AB - BackgroundThe Comprehensive Geriatric Assessment (CGA) is a multidisciplinary process that determines a frail older person’s medical, functional, psychological and social capability to ensure that they have a co-ordinated plan for treatment and follow-up.ObjectivesTo improve our understanding of the effectiveness, cost-effectiveness and implementation of the CGA across hospital and hospital-at-home settings.MethodsWe used a variety of methods. We updated a Cochrane review of randomised trials of the CGA in hospital for older people aged ≥ 65 years, conducted a national survey of community CGA, analysed data from three health boards using propensity score matching (PSM) and regression analysis, conducted a qualitative study and used a modified Delphi method.ResultsWe included 29 trials recruiting 13,766 participants in the Cochrane review of the CGA. Older people admitted to hospital who receive the CGA are more likely to be living at home at 3–12 months’ follow-up [relative risk (RR) 1.06, 95% confidence interval (CI) 1.01 to 1.10] (high certainty). The probability that the CGA would be cost-effective at a £20,000 ceiling ratio for quality-adjusted life-years (QALYs), life-years (LYs) and LYs living at home was 0.50, 0.89, and 0.47, respectively (low-certainty evidence). After PSM and regression analysis comparing CGA hospital with CGA hospital at home, we found that the health-care cost (from admission to 6 months after discharge) in site 1 was lower in hospital at home (ratio of means 0.82, 95% CI 0.76 to 0.89), in site 2 there was little difference (ratio of means 1.00, 95% CI 0.92 to 1.09) and in site 3 it was higher (ratio of means 1.15, 95% CI 0.99 to 1.33). Six months after discharge (excluding the index admission), the ratio of means cost in site 1 was 1.27 (95% CI 1.14 to 1.41), in site 2 was 1.09 (95% CI 0.95 to 1.24) and in site 3 was 1.70 (95% CI 1.40 to 2.07). At 6 months’ follow-up (excluding the index admission), there may be an increased risk of mortality (adjusted) in the three hospital-at-home cohorts (site 1: RR 1.09, 95% CI 1.00 to 1.19; site 2: RR 1.29, 95% CI 1.15 to 1.44; site 3: RR 1.27, 95% CI 1.06 to 1.54). The qualitative research indicates the importance of relational aspects of health care, incorporating caregivers’ knowledge in care planning, and a lack of clarity about the end of an episode of health care. Core components that should be included in CGA focus on functional, physical and mental well-being, medication review and a caregiver’s ability to care.LimitationsThe risk of residual confounding limits the certainty of the findings from the PSM analysis; a second major limitation is that the research plan did not include an investigation of social care or primary care.ConclusionsThe CGA is an effective way to organise health care for older people in hospital and may lead to a small increase in costs. There may be an increase in cost and the risk of mortality in the population who received the CGA hospital at home compared with those who received the CGA in hospital; randomised evidence is required to confirm or refute this. Caregiver involvement in the CGA process could be strengthened.

UR - http://www.mendeley.com/research/comprehensive-geriatric-assessment-hospital-hospitalathome-settings-mixedmethods-study

U2 - 10.3310/hsdr07100

DO - 10.3310/hsdr07100

M3 - Article

VL - 7

JO - Health Serv Deliv Res

JF - Health Serv Deliv Res

ER -