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


Therapeutics

Outpatient geriatric care improved satisfaction but not health in frail elderly men

ACP J Club. 1997 Jan-Feb;126:14. doi:10.7326/ACPJC-1997-126-1-014


Source Citation

Engelhardt JB, Toseland RW, O'Donnell JC, et al. The effectiveness and efficiency of outpatient geriatric evaluation and management. J Am Geriatr Soc. 1996 Jul; 44:847-56.


Abstract

Objective

To compare outpatient geriatric evaluation and management (GEM) with usual outpatient primary care (UPC) of frail elderly men for health and functional status, psychosocial well-being, quality of care, and use and cost of health services.

Design

Randomized controlled trial with 16-month follow-up.

Setting

Outpatient clinic of a U.S. Veterans Affairs (VA) medical center.

Patients

160 men who were ≥ 55 years of age (mean age 72 y, 95% white). Inclusion criteria were ≥ 10 outpatient visits in the previous year and ≥ 2 impairments on the activities of daily living (ADL) or instrumental ADL scale. Exclusion criteria were psychiatric or cognitive impairments, other interdisciplinary health care in the previous year, or receipt of most health care services from non-VA care providers. Follow-up was 84%.

Intervention

80 patients were allocated to each care group. GEM care included care from a nurse practitioner with input from the team geriatrician and social worker. It consisted of an initial comprehensive assessment, development and implementation of a care plan, periodic assessment, monitoring and updating of the plan, and referral and coordination with other service providers. Patients in the UPC group were seen in a primary care clinic staffed by internists who had nursing support.

Main outcome measures

Mortality, health and functional status (2 scales), psychosocial well-being (4 scales), quality of health care (3 scales), patient satisfaction (1 scale), quality assurance (1 scale), and total use and costs of health care.

Main results

Analysis was by intention to treat. After 16 months, the groups did not differ for death (7 deaths in the GEM group and 6 in the UPC group), health and functional status, or psychosocial well-being. Patients in the GEM group had better scores in the drug utilization review scale, had better continuity of care, were more satisfied with some aspects of care, and reported more positive changes in the stress of pressing problems (P < 0.05 for all comparisons). Patients in the GEM group made more clinic visits (7.0 vs 3.6, P < 0.001) and fewer emergency department visits (P = 0.04). The groups did not differ for costs (outpatient, inpatient, nursing home, or total costs), but the outpatient costs showed a trend toward higher costs in the GEM group (U.S. $5165 vs $4247, P = 0.053).

Conclusion

Geriatric evaluation and management team care for frail elderly men led to greater patient satisfaction but not to improved health status, mortality, or costs than did usual internist-managed primary care.

Source of funding: Department of Veterans Affairs.

For article reprint: Dr. J.B. Engelhardt, Stratton VA Medical Center (151K), 113 Holland Avenue, Albany, NY 12208, USA. FAX 518-463-4984.


Commentary

Comprehensive geriatric assessment, supported mainly by anecdotal and marketing testimony, already has a niche in many health care systems. The study by Engelhardt and colleagues has some limitations: an unblinded comparison, measurement of multiple outcomes, and a restricted patient cohort—men who frequently used VA health care services. Even though women were not included, the study increases our understanding of the effectiveness of comprehensive geriatric assessment programs. Men in the GEM group were more satisfied with their care than were those who received UPC. This increased satisfaction may, however, have occurred because men in the GEM group received greater financial benefits through the VA as a result of their assessments. Most previous studies have not found increased patient satisfaction. Patient satisfaction is important because the willingness of both patient and caregiver to participate in GEM is essential for the program's success (1). The measurement of patient satisfaction and quality of life in such studies as this one is important, but it should be extended to include patient-defined variables (2).

The start-up costs of a GEM program are likely to be high. The costs include the initial evaluation time, establishment of a new relationship between health care providers and the patients and their caregivers, and handling the problems found in the initial assessment. In short-term studies, these costs are often high, and the cost savings obtained from preventing events (e.g., falls), their sequelae, and subsequent resource utilization might become evident only after years of follow-up. Thus, the 16-month follow-up in this study may have been too short to see an important decline. The findings of fewer visits to the emergency department and the trend toward fewer acute hospitalizations underscore the potential for GEM to reduce long-term health care costs and risks. Much work must be done to define the optimal role of comprehensive geriatric assessment in the health care of older adults.

Mark D. Heuser, MD
University of Maryland School of MedicineBaltimore, Maryland, USA

Mark D. Heuser, MD
University of Maryland School of Medicine
Baltimore, Maryland, USA


References

1. Devor M, Wang A, Renvall M, Feigal D, Ramsdell J. Compliance with social and safety recommendations in an outpatient comprehensive geriatric assessment program. J Gerontol. 1994;49:168-73.

2. Gill TM, Feinstein AR. A critical appraisal of the quality of quality-of-life measurements. JAMA. 1994;272:619-26.