The effects of outpatient geriatric evaluation and management on caregiver burden

This study investigated the effects of outpatient geriatric evaluation and management (GEM) on informal caregivers' sense of burden. We randomized 568 high-risk, community-dwelling older adults to receive either GEM or usual care for 6 months. At baseline and one year later, we assessed the burden experienced by their informal caregivers (N = 88). Compared with caregivers of participants in the usual care group, caregivers of participants in the GEM group were less than half as likely to report increased burden during the one-year follow-up period (16.7% vs 38.5%, p = .034). The findings suggest that GEM helps protect the informal caregivers of high-risk older people from the increases in burden that often accompany advancing age.     

老年人综合评估的实施

老年人综合评估是全面关注和处理与老年患者健康和功能状态相关问题的重要研究方法.现对老年人综合评估的概念、目标人群、评估内容和实施方法进行介绍,同时介绍老年人综合评估成效的研究结果.     

A randomized clinical trial of outpatient geriatric evaluation and management

OBJECTIVES: To measure the effects of outpatient geriatric evaluation and management (GEM) on high-risk older persons' functional ability and use of health services. DESIGN: Randomized clinical trial. SETTING: Ambulatory clinic in a community hospital. PARTICIPANTS: A population-based sample of community-dwelling Medicare beneficiaries age 70 and older who were at high risk for hospital admission in the future (N = 568). INTERVENTION: Comprehensive assessment followed by interdisciplinary primary care. MEASUREMENTS: Functional ability, restricted activity days, bed disability days, depressive symptoms, mortality, Medicare payments, and use of health services. Interviewers were blinded to participants' group status. RESULTS: Intention-to-treat analysis showed that the experimental participants were significantly less likely than the controls to lose functional ability (adjusted odds ratio (aOR) = 0.67, 95% confidence interval (CI) = 0.47-0.99), to experience increased health-related restrictions in their daily activities (aOR = 0.60, 95% CI = 0.37-0.96), to have possible depression (aOR = 0.44, 95% CI = 0.20-0.94), or to use home healthcare services (aOR = 0.60, 95% CI = 0.37-0.92) during the 12 to 18 months after randomization. Mortality, use of most health services, and total Medicare payments did not differ significantly between the two groups. The intervention cost $1,350 per person. CONCLUSION: Targeted outpatient GEM slows functional decline.     

Effectiveness of acute rehabilitation services in geriatric evaluation and management units

As pressure for cost containment has mounted and the US population ages, causing increased levels of disability among the population and a greater focus on quality of life and rehabilitation after acute illness, the emphasis on acute rehabilitation services has increased. Acute rehabilitation services include many programs, and the field is changing rapidly along several dimensions, some of which are explored. In such a complex and fluid situation, a definitive overview is impossible, but some useful remarks are attempted.     

The costs of family caregiving: implications for geriatric oncology

Older adults with cancer receive considerable care from their family members. The article reviews the types of stressors family members face while caregiving, and what is known about the psychological, physical health, social, and economic costs of caregiving. The benefits experienced by caregivers, and sustained effects on families after bereavement or cancer survivorship are also reviewed. Interventions that are promising in decreasing the costs of caregiving, and implications for research and clinical practice are discussed.     

Fall-risk evaluation and management: challenges in adopting geriatric care practices

One third of older adults fall each year, placing them at risk for serious injury, functional decline, and health care utilization. Despite the availability of effective preventive approaches, policy and clinical efforts at preventing falls among older adults have been limited. In this article we present the burden of falls, review evidence concerning the effectiveness of fall-prevention services, describe barriers for clinicians and for payers in promoting these services, and suggest strategies to encourage greater use of these services. The challenges are substantial, but strategies for incremental change are available while more broad-based changes in health care financing and clinical practice evolve to better manage the multiple chronic health conditions, including falls, experienced by older Americans.     

The effectiveness of cost-effectiveness analysis in containing costs

OBEJCTIVE: Although cost-effectiveness analyses (CEAs) have been advocated as a tool to critically appraise the value of health expenditures, it has been widely hoped that they might also help contain health care costs. To determine how often they discourage additional expenditures, we reviewed the conclusions of recently published CEAs. DATA SOURCES: A search of the Abridged Index Medicus (a subset of MEDLINE designed to afford rapid access to the literature of “immediate interest” to the practicing physician) between 1990 and 1996. STUDY SELECTION: We only included articles that reported an explicit cost-effectiveness (CE) ratio (a cost for some given health effect) in the abstract. DATA ABSTRACTION: From each abstract, we collected the value for the incremental CE ratio and the measure of health effect (life-years, quality-adjusted life-years [QALYs], other). We then categorized the authors’ conclusion into one of three categories: supports strategy requiring additional expenditure, no firm conclusion, and supports low-cost alternative. Finally, we obtained the article and collected information on funding source. DATA SYNTHESIS: Among the 109 eligible articles, the authors’ conclusion supported strategies requiring additional expenditure in 58 (53%) and supported the low-cost alternative in 28 (26%). We then focused on the 65 articles reporting either life-years or QALYs. Cost-effectiveness ratios ranged from $400 to $166,000 (per life-year or QALY) in the 39 articles (60%) in which authors supported additional expenditure, and ranged from $61,500 to $11,600,000 in the 13 articles (20%) in which authors supported the low-cost alternative. Despite identifying similar CE ratios, authors arrived at different conclusions in the overlapping range ($61,500 to $166,000). Of the 10 articles acknowledging industry funding, 9 supported a strategy requiring additional expenditure (p=.01 as compared with those without such funding). CONCLUSIONS: Authors of CEAs are more likely to support strategies requiring additional expenditure than the low-cost alternative. There is no obvious consensus about how small the CE ratio should be to warrant additional expenditure. Finally, concerns about funding source seem to be warranted.     

The effectiveness of a comprehensive geriatric assessment intervention program for frailty in community-dwelling older people: a randomized,controlled trial

This randomized, controlled trial assessed the effectiveness of comprehensive geriatric assessment (CGA) and subsequent intervention in pre-frail and frail community-dwelling elderly based on the Fried Frailty Criteria (FFC) and the Barthel Index (BI) A total of 310 pre-frail or frail elderly from a single community were identified using the FFC. Of these, 152 were randomly assigned to the intervention group for CGA and appropriate intervention by medication adjustment, exercise instruction, nutrition support, physical rehabilitation, social worker consultation, and specialty referral. Clinical outcome was re-evaluated by the FFC and BI 6 months later. Compared to the control group, the intervention group tended to have a better outcome, with an odds ratio (OR) = 1.19, 95% confidence interval (95% CI) = 0.48–3.04, p = 0.71) and 3.29 (95% CI = 0.65–16.64, p = 0.15), respectively, and were less likely to deteriorate, with an OR = 0.78 (95% CI = 0.34–1.79, p = 0.57) and 0.94 (95% CI = 0.42–2.12, p = 0.88), respectively. Although no significant differences were observed, the CGA and subsequent intervention showed a favorable outcome in frail and pre-frail elderly based on the frailty status and BI. Inability to complete the CGA and poor compliance with the intervention program appear to be the main reasons for unfavorable outcomes.