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


Therapeutics

Evaluation and management of geriatric outpatients

ACP J Club. 1994 Mar-April;120:40. doi:10.7326/ACPJC-1994-120-2-040


Source Citation

Rubin CD, Sizemore MT, Loftis PA, Loret de Mola N. A randomized, controlled trial of outpatient geriatric evaluation and management in a large public hospital. J Am Geriatr Soc. 1993 Oct;41:1023-8.


Abstract

Objective

To determine the efficacy of comprehensive geriatric assessment and follow-up care on mental and physical function and subjective well-being in elderly patients.

Design

Randomized controlled trial with 1-year follow-up.

Setting

University-affiliated public hospital.

Patients

Inpatients aged ≥ 70 years, admitted to the medicine service from the emergency department, were screened for randomization until the target enrollment of 200 patients was reached. Eligibility criteria targeted patients at risk for rehospitalization who were candidates for outpatient management of existing chronic conditions. 194 patients (mean age, 77 y) entered the study (6 patients died before discharge). 122 patients completed follow-up.

Intervention

Patients randomly assigned to the experimental group received long-term outpatient geriatric care starting at discharge by an interdisciplinary geriatric assessment team (GAT). The GAT exclusively managed all patients in the experimental group, collected baseline data, completed a geriatric evaluation, and developed a long-term care plan. Patients in the experimental group received appointment reminders, transportation to and from the clinic, and comprehensive care for any medical or social problems. Patients in the control group received follow-up care after discharge by medical residents in the general medicine clinic.

Main Outcome Measures

Mental status measured by the Short Portable Mental Status Questionnaire, physical function measured by the Katz Index for activities of daily living and the 5-item OARS (Older Americans Resources and Services) Scale for instrumental activities of daily living, subjective well-being assessed with the Life Satisfaction Index-Z, and self-perception of health status measured by the OARS Scale.

Main Results

Compared with control patients, experimental patients at 1 year had less impairment in instrumental activities of daily living (P = 0.013), higher self-rated health (P = 0.006) and perceived health improvement during the last 6 years (P = 0.007), and less activity limitation (P = 0.024). Groups did not differ for mental status, activities of daily living, mortality, or institutionalization.

Conclusion

Comprehensive geriatric assessment and follow-up of elderly patients at high risk for rehospitalization had a positive effect on instrumental activities of daily living and on patients' perceptions of their own health.

Sources of funding: Robert Wood Johnson Foundation and Dallas Area Agency on Aging.

For article reprint: Dr. C.D. Rubin, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235-8889. FAX 214-648-9050.


Commentary

Geriatric assessment and management has been promoted as a means to improve the quality of life of frail elderly persons who are often poorly served by traditional medical care. This approach involves multiple disciplines and attempts to center care on medical and psychosocial needs. Rubin and colleagues provide evidence indicating that this approach after hospital discharge can improve certain quality-of-life measures; elsewhere they report their intervention decreased the use of inpatient care (1). The Methods section of this paper is worthy of careful reading because this intervention required extraordinary efforts by the team to coordinate discharge planning, provide accessible and consistent providers, and protect the patient from the centrifugal forces fragmenting care in academic health centers.

Sociocultural factors are important in these studies, because supportive caregivers are crucial to the success of community-based interventions. More patients in the experimental group were Hispanic (13% vs. 3%), a difference that is not trivial, because recent data show that chronic disease outcomes are better in this population (2).

Readers may be disappointed that mortality, institutionalization, and physical and cognitive function were not improved. This may be a "false-negative" result, but a recent meta-analysis of 4 similar trials (combined total population of 1000) also failed to show an effect on these outcomes (3). This should not surprise clinicians familiar with primary care medicine, where dramatic cures are few and success is measured best by patient perceptions and health effects during longer time frames.

Joseph Francis, MD, MPH
Veterans Affairs Medical Center Memphis, Tennessee, USA