Comprehensive Geriatric Assessment in hospital and hospital-at-home settings: a mixed-methods study

Research output: Contribution to journalArticlepeer-review

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

In: Health Services and Delivery Research, Vol. 7, No. 10, 31.03.2019, p. 1-206.

Research output: Contribution to journalArticlepeer-review

Harvard

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 Services and Delivery Research, vol. 7, no. 10, pp. 1-206. https://doi.org/10.3310/hsdr07100

APA

Gardner, M., Shepperd, S., Godfrey, M., Mäkelä, P., Tsiachristas, A., Singh-mehta, A., Ellis, G., Khanna, P., Langhorne, P., Makin, S., & Stott, D. J. (2019). Comprehensive Geriatric Assessment in hospital and hospital-at-home settings: a mixed-methods study. Health Services and Delivery Research, 7(10), 1-206. https://doi.org/10.3310/hsdr07100

Vancouver

Author

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 Services and Delivery Research. 2019 ; Vol. 7, No. 10. pp. 1-206.

Bibtex

@article{5931a4c341104793a5b9020db61a6e08,
title = "Comprehensive Geriatric Assessment in hospital and hospital-at-home settings: a mixed-methods study",
abstract = "Background: The Comprehensive Geriatric Assessment (CGA) is a multidisciplinary process that determines a frail older person{\textquoteright}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{\textquoteright} 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{\textquoteright} 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{\textquoteright} 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{\textquoteright}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.Funding: The National Institute for Health Research Health Services and Delivery Research programme.",
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}",
year = "2019",
month = mar,
day = "31",
doi = "10.3310/hsdr07100",
language = "English",
volume = "7",
pages = "1--206",
journal = "Health Services and Delivery Research",
issn = "2050-4349",
publisher = "NIHR Health Technology Assessment Programme",
number = "10",

}

RIS

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

PY - 2019/3/31

Y1 - 2019/3/31

N2 - 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.Funding: The National Institute for Health Research Health Services and Delivery Research programme.

AB - 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.Funding: The National Institute for Health Research Health Services and Delivery Research programme.

U2 - 10.3310/hsdr07100

DO - 10.3310/hsdr07100

M3 - Article

VL - 7

SP - 1

EP - 206

JO - Health Services and Delivery Research

JF - Health Services and Delivery Research

SN - 2050-4349

IS - 10

ER -