Inpatient consult team in a community hospital led to decreased mortality
ACP J Club. 1993 July-Aug;119:17. doi:10.7326/ACPJC-1993-119-1-017
Thomas DR, Brahan R, Haywood BP. Inpatient community-based geriatric assessment reduces subsequent mortality. J Am Geriatr Soc. 1993 Feb;41:101-4.
To study the effect of an inpatient, community-based geriatric consultation team on mortality, hospitalization, and functional status.
Randomized controlled trial with 1-year follow-up.
A community hospital.
All hospitalized patients > 70 years of age were screened and excluded if they refused, were admitted to the intensive care or coronary care unit, had terminal disease or renal hemodialysis, or lived > 50 miles from the hospital. 132 patients were studied (mean age 77 y, 56% women). Follow-up was 91%.
64 patients were allocated to receive usual care. 68 patients were allocated to receive individual assessments from each member of the geriatric assessment team (a physician, geriatric nurse specialist, home health nurse, medical social worker, dietitian, pharmacist, and physical therapist). The team members prepared a summary report with recommendations that was put in the chart. A copy was also sent to the attending physician.
Main outcome measures
Hospitalizations and functional status (Functional Assessment Inventory and the Katz Functional Activity Rating Scale) were assessed at 6 months. Mortality was assessed at 6 months and 1 year.
At 6 months the patients receiving assessment by the geriatric assessment team compared with patients receiving usual care had fewer deaths (P = 0.01) (Table) and fewer readmissions to the hospital (0.3 vs 0.6 per person, P = 0.02). In an intention-to-treat analysis at 1 year a continuing trend toward fewer deaths occurred (10% vs 20%, P = 0.08) (Table). The groups did not differ for hospital length-of-stay, discharge destination, community service referrals, physician visits after discharge, or overall functional status at 6 months. A trend toward increased functional activity occurred in the assessment team patients (P = 0.07).
Hospital readmissions and short-term mortality were decreased in elderly persons when they were assessed by an inpatient geriatric consultation team in a community hospital.
Source of funding: Not stated.
For article reprint: Dr. D.R. Thomas, Department of Internal Medicine, Saint Louis Uinversity, 1402 South Grand Boulevard., Room M238, St. Louis, MO 63104-1028, USA. FAX 314-771-8575
Table. Assessment by geriatric team vs usual care in elderly inpatients*
|Outcomes||Geriatric Team||Usual Care||RRR (95% CI)||NNT (CI)|
|Death at 6 months||5%||21%||77% (28 to 93)||7 (4 to 23)|
|Death at 1 year||10%||20%||49% (-15 to 78)||Not significant|
*Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article
Few studies have been completed in the value of specialty consultations in hospital (1). Geriatric consultation teams, consisting typically of a geriatrician, a gerontologically trained nurse-specialist, a social worker, and possibly other professionals (therapists, dietitians, and pharmacists), have been developed to improve functional outcomes by addressing complex problems threatening independence. Such teams are easier to implement than specialized inpatient geriatric units and serve to educate health professionals about geriatric care.
Several randomized controlled studies suggest that these teams produce modest but consistent benefits, including increased new diagnoses, fewer medications, and perhaps improved short-term survival and functional status. This study extends such findings to the nonacademic, community-hospital setting, which provides the majority of care to older patients. Unfortunately, little is known about what produces a better outcome: Is it fewer medications, better recognition and treatment of depression, earlier mobilization, or coordinated discharge planning?
There are many reasons why geriatric consultation teams might not be successful in controlled trials. They offer only recommendations, not direct care (2). Instead, geriatric assessment may identify chronic disease and disability, but these problems may not be swiftly remedied (1). Selection based on age alone, such as used in this study, often does not identify the frail patient most likely to benefit from an astute evaluation. Contamination bias may occur when recommendations made for the intervention group are applied to control patients. Finally, community services necessary to prevent premature institutionalization are scarce, fragmented, and priced beyond the reach of many older persons. Such considerations make these modest gains seem even more impressive and underscore the need to better define factors that contribute to success. The team approach itself may be the most important element. As medicine increasingly adopts continuous quality improvement and interdisciplinary care, a closer look at what makes geriatric teams effective could provide valuable lessons.
Joseph Francis, MD, MPH
Veterans Affairs Medical CenterMemphis, Tennessee, USA