Comprehensive geriatric assessment for frail older people in acute hospitals: the HoW-CGA mixed-methods study

Abstract

Background
The aim was to provide high quality evidence on delivering hospital-wide Comprehensive Geriatric Assessment (CGA).

Objective(s)
Define CGA, its processes, outcomes and costs in the published literature
Identify the processes, outcomes and costs of CGA in existing hospital settings in the UK
Identify the characteristics of the recipients and beneficiaries of CGA in existing hospital settings in the UK
Develop tools which will assist in the implementation of hospital-wide CGA.

Design
Mixed methods study combining a mapping review, national survey, large data analysis, and qualitative methods.

Participants
People aged 65+ in acute hospital settings.

Data sources
Literature review: Cochrane Database of Systematic Reviews, DARE, MEDLINE and EMBASE.
Survey: Acute hospital Trusts, United Kingdom.
Large data analyses: 1. People aged 75+ in 2008 living in Leicester, Nottingham or Southampton (development cohort, n=22,139). 2. Older people admitted for short-stay (Nottingham/Leicester, n=825), to a geriatric ward (Southampton, n=246) or community dwelling (Newcastle, n=754). 3. People aged 75+ admitted to acute hospitals in England, 2014-15 (validation study, n=1,013,590).

Toolkit development – multidisciplinary national stakeholder group (co-production); field-testing with cancer/surgical teams in Newcastle/Leicester.

Results
Literature search: common outcomes included clinical, operational and destinational but not patient reported outcome measures.
Survey: highly variable provision of multidisciplinary assessment and care across hospitals.
Quantitative analyses: in the development cohort, older people with frailty diagnoses formed a distinct group, and had higher non-elective hospital use. Patients with the highest 20% of hospital frailty risk scores had increased odds of 30-day mortality (OR 1·7), long length of stay (OR 6·0) and 30-day readmission (OR 1·5). The score had moderate agreement with the Fried and Rockwood scales.

Pilot toolkit evaluation: participants across sites were still at the beginning of their work to identify patients and plan change. In particular, the competing definitions of the role of geriatricians were evident.

Limitations
The survey was limited by an incomplete response rate, yet still provides the largest description of acute hospital care for older people to date.
The risk stratification tool is not contemporaneous, although it remains a powerful predictor of patient harms.
The toolkit evaluation is still rather nascent, and could have meaningfully continued for another year or more.

Conclusions
Comprehensive Geriatric Assessment remains the gold standard approach to improve a range of outcomes for older people in acute hospitals. Older people at risk can be identified using routine hospital data. Toolkits aimed at enhancing the delivery of CGA by non-specialists can be useful, but require prolonged geriatrician support and implementation phases.