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Abstract
Background: Comprehensive geriatric assessment [CGA] is a multidimensional interdisciplinary diagnostic process intended to determine a frail older person's medical, psychosocial, and functional capabilities and problems in order to plan coordinated treatment and long-term follow-up. Numerous clinical trials have explored the efficacy of CGA coupled with treatment in terms of outcomes such as survival, community tenure, and physical function, but experimental programs have varied in their patients, setting and organization. Our prior systematic review suggested that CGA can be effective in relationship to programs' ability to selectively admit "frail" patients, to deliver or control delivery of indicated services or treatments, and to follow patients and their families over the longer term. We did not establish the effectiveness of CGA programs based specifically in outpatient clinic or office settings. However, changes in health care organization and financing have led to a burgeoning of outpatient programs and new trials. Objectives: To examine the effectiveness of outpatient CGA programs in promoting independent functioning and community tenure, and limiting utilization of institutional services for frail elderly people.
Methods: As in prior reviews, we employed explicit study selection criteria regarding study design and types of participants and programs. A comprehensive, multiple method search strategy was undertaken to identify all randomized control and controlled clinical trials. Here we limit consideration to trials wherein the programs' assessment activities are based in the defined outpatient settings (vs. inpatient facilities, day hospitals, or homes), and in which controls are not receiving CGA in alternative forms. Selected studies were abstracted in detail and the following (variable) characteristics assessed: 1. study design; 2. patient characteristics and method of referral/selection; 3. how CGA was accomplished; 4. how treatments/ services were delivered; 5. outcome ascertainment (including endpoints, timing and measurement methods); and ( 6. findings. A trialist survey is presently being fielded to recover unpublished information concerning trial/intervention design, patient characteristics, and outcomes, prior to quantitative evaluation.
Results: Ten completed and two large ongoing R/CCTs meeting criteria were identified, compared to five that had been described in the last published systematic review. The earlier outpatient trials tended not to "target" patient selection, control service delivery, or perform long-term follow-up, and were generally not effective. The more recently tested programs have improved methods of targeting, treatment delivery, and follow-up, and also appear more likely to have shown meaningful benefits.
Conclusions: This preliminary qualitative review appears consistent with prior quantitative findings concerning the association of CGA program effectiveness with targeting the frail, controlling treatment, and longitudinal follow-up. This association will be important if confirmed through further quantitative analysis. For a variety of reasons related to the financing and delivery of health services, implementing CGA in office or hospital outpatient clinic settings may be more feasible than the "effective" inpatient models of the 1980s. Careful identification and promulgation of best practices for outpatient CGA would hold great potential for meaningful improvement of the health and quality of life of frail and disabled older people in the community.
Methods: As in prior reviews, we employed explicit study selection criteria regarding study design and types of participants and programs. A comprehensive, multiple method search strategy was undertaken to identify all randomized control and controlled clinical trials. Here we limit consideration to trials wherein the programs' assessment activities are based in the defined outpatient settings (vs. inpatient facilities, day hospitals, or homes), and in which controls are not receiving CGA in alternative forms. Selected studies were abstracted in detail and the following (variable) characteristics assessed: 1. study design; 2. patient characteristics and method of referral/selection; 3. how CGA was accomplished; 4. how treatments/ services were delivered; 5. outcome ascertainment (including endpoints, timing and measurement methods); and ( 6. findings. A trialist survey is presently being fielded to recover unpublished information concerning trial/intervention design, patient characteristics, and outcomes, prior to quantitative evaluation.
Results: Ten completed and two large ongoing R/CCTs meeting criteria were identified, compared to five that had been described in the last published systematic review. The earlier outpatient trials tended not to "target" patient selection, control service delivery, or perform long-term follow-up, and were generally not effective. The more recently tested programs have improved methods of targeting, treatment delivery, and follow-up, and also appear more likely to have shown meaningful benefits.
Conclusions: This preliminary qualitative review appears consistent with prior quantitative findings concerning the association of CGA program effectiveness with targeting the frail, controlling treatment, and longitudinal follow-up. This association will be important if confirmed through further quantitative analysis. For a variety of reasons related to the financing and delivery of health services, implementing CGA in office or hospital outpatient clinic settings may be more feasible than the "effective" inpatient models of the 1980s. Careful identification and promulgation of best practices for outpatient CGA would hold great potential for meaningful improvement of the health and quality of life of frail and disabled older people in the community.