Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Annual comprehensive geriatric assessments improved community living

ACP J Club. 1996 Mar-April;124:30. doi:10.7326/ACPJC-1996-124-2-030


Source Citation

Stuck AE, Aronow HU, Steiner A, et al. A trial of annual in-home comprehensive geriatric assessments for elderly people living in the community. N Engl J Med. 1995 Nov 2;333:1184-9. [PubMed ID: 7565974]


Abstract

Objective

To evaluate the effectiveness of annual comprehensive geriatric assessments plus follow-up visits on the rate of disability in elderly persons living in the community.

Design

3-year randomized controlled trial.

Setting

Community-based study in California, USA.

Patients

414 elderly persons (mean age 81 y, 70% women) who were ≥ 75 years and living at home. Exclusion criteria were severe cognitive or functional impairment, language problems, plans to move to a nursing home or out of the vicinity, terminal illness, or participation in another study. Follow-up was complete for survival and health care use.

Intervention

Patients were stratified by age and sex and allocated to an intervention group (n = 215) or to a usual care group (n = 199). Patients in the intervention group received annual assessments in their homes from gerontologic nurse practitioners. Assessments included medical history; physical examination; laboratory tests; and determinations of functional and mental status, oral health, gait and balance, medications, body weight, vision, hearing, extent of social network and support, home safety, and external access. On the basis of consultation with geriatricians, the nurses made recommendations and followed up their implementation every 3 months.

Main Outcome Measures

Primary outcomes were mean functional status score (0 to 100) (combined activities of daily living [ADL]) and rate of permanent nursing home admissions. Secondary outcomes were admission rates for acute care hospitals and short-stay nursing homes and visits to a physician.

Main Results

Analysis was by intention to treat. At 3 years, patients in the intervention group had higher mean functional status scores than patients in the usual care group (75.6 vs 72.7 points, P = 0.03, 95% CI for the 2.9-point difference 0.4 to 5.4). The intervention led to fewer patients being admitted to long-term nursing homes than did usual care (4% vs 10%, P = 0.02). In the second and third years, patients in the intervention group made more visits per month to physicians than did patients in the usual care group (1.27 vs 0.92 mean visits/mo, P = 0.001). The groups did not differ for rates of admission to acute care hospitals or short-term nursing homes.

Conclusion

Annual comprehensive geriatric assessments were more effective than usual care in delaying permanent nursing home admission and improving functional status in community-dwelling elderly persons.

Sources of funding: W.K. Kellogg Foundation; Swiss National Science Foundation; Senior Health and Peer Counseling.

For article reprint: Dr. A.E. Stuck, Morillonstrasse 75, Zieglerspital, Bern CH-3001, Switzerland. FAX 41-31-971-0124.


Table. Annual comprehensive geriatric assessments vs usual care to increase the rate of community living*

Outcome at 3 y Geriatric assessment Usual care RRR (95% CI) NNT (CI)
Admission to long-term nursing homes 4% 10% 58% (12.5 to 80) 17 (9 to 102)

*Abbreviations defined in Glosary; RRR, NNT, ad CI calculated from data in article.


Commentary

Multidisciplinary approach reduced readmissions in patients with CHF

The optimal management of elderly persons after hospital discharge as well as those living independently in the community has generated intense interest. The extensive literature on this subject is complemented by these 2 well-designed studies: 1 tested the hypothesis that intensive follow-up after hospital discharge in patients with CHF will reduce costs and hospitalizations; the other tested the hypothesis that in-home comprehensive geriatric assessments will help prevent disability among elderly persons.

Several points made by the 2 studies invite comment. In both studies, the intervention increased quality of life and functional outcomes, which were primary outcomes of the study by Stuck and colleagues. In this study, however, the rates of admission to acute care hospitals and short-stay nursing homes were not reduced. In addition, organizing a full-scale geriatric outreach program with geriatrician-supervised, specially trained nurse practitioners to visit healthy elderly persons in the community might not be feasible in many locations; it is, however, a novel approach for decreasing the demand for long-term care services. The study by Rich and colleagues, by including elderly persons admitted to the hospital with a serious diagnosis (CHF), showed a substantial decline in the rate of hospital readmissions.

The cost calculations made in both studies are complex and, I believe, fail to make a convincing case that the interventions actually save money. For example, Rich and colleagues base their calculation on a rate of $20/h for nursing care. This is considerably less than the $78/h that Medicare allows in my part of the United States and probably in the area where this study was done. The charge for a routine office visit to a primary care physician is usually less than a home visit by a nurse.

The challenge in interpreting any study that deals with home visits is that many patients, caregivers, and policymakers have already decided that this is a good way to take care of the frail elderly and the disabled. The intuitive belief that home care is beneficial warrants further research that examines the spectrum of home care services available for chronically ill patients while considering the costs that the health care system can absorb (1). In the present health care "market," new systems of care are being created that are supposedly cost-effective—systems that are expensive to operate but are not being evaluated to confirm their intended efficiencies. These authors should be congratulated for rigorously evaluating their interventions, but I would be reluctant to say that the application of these 2 studies would lead to a decrease in total health care cost; rather, it might shift some of the cost to other providers.

Elderly persons use many support services. One study (2) showed that as many as 88% of elderly patients discharged from the hospital required some form of home care. Bull (3) suggests that 2 readily available variables—age and functional ability before discharge—predict whether home care will be beneficial. Solomon and colleagues (4) add educational level, social support, impairment of ADL, and previous home care use as major predictors.

Key to the success of home care or outreach preventive services is the availability of programs that are acceptable to the patient and suited to the environment in which the patient lives. An important goal of any program is to reduce the use of health care services, which includes not only hospital and nursing home admissions but also home care visits. Most elderly persons want to be independent. To the extent that our services allow that to happen, the patient will have a valuable outcome. Simply calling the patient after discharge has been shown to reduce the use of health care services (5). Future research that helps to determine the proper balance of services for each patient will be welcomed.

Dennis L. DeSilvey, MD
University of VirginiaCharlottesville, Virginia, USA


References

1. Cummings JE, Weaver FM. Cost-effectiveness of home care. Clin Geriatr Med. 1991;7:865-74.

2. Hanger HC, Conway C, Sainsbury R. The costs of returning home. N Z Med J. 1993;106:397-9.

3. Bull MJ. Use of formal community services by elders and their family caregivers 2 weeks following hospital discharge. J Adv Nurs. 1994;19:503-8.

4. Solomon DH, Wagner DR, Marenberg ME, et al. Predictors of formal home health care use in elderly patients after hospitalization. J Am Geriatr Soc. 1993;41:961-6.

5. Wasson J, Gaudette C, Whaley F, et al. Telephone care as a substitute for routine clinic follow-up. JAMA. 1992;267:1788-93.