What is the evidence for the effectiveness of specialist geriatric services in acute, post-acute and sub-acute settings? A critical appraisal of the literature
Day P, Rasmussen P
Record ID 32004000233
To provide the evidence base through the identification and appraisal of the literature on the effectiveness of specialist geriatric services for developing a sound practice framework. The review had three components, with background and methodology, critical appraisal and write-up of primary and secondary research work and thirdly, a descriptive outline of key recommendations from published specialist geriatric services protocols, guidelines and specified expert opinion.
A number of important findings arise from the from the critical appraisal of the literature:
Community care: The literature evidence from this review generally supports the efficacy of specialist geriatric team services, trained in geriatrics with a multidisciplinary collaborative focus undertaking assessment, rehabilitation, and coordinated case management in community settings. Both preventive care and supportive discharge in these settings appear to provide greater benefit over usual care. However, these benefits were not consistent across all outcomes measured and although improvement in outcomes was often apparent, these were not always significant when compared with the comparison group.
Inpatient care: The evidence from the literature appraisal for the efficacy of specialist geriatric services within inpatient settings was more diverse. This was because of the diversity of studies across the continuum of sub-acute, acute, post-acute care in unit or acute ward settings. This resulted in heterogeneous outcomes (both in effect and the particular outcome measured) with only some outcomes showing significance compared with usual care. Specific findings were:
- Integrated comprehensive programmes involving multi-disciplinary care in an acute setting (with follow through from rehabilitation in hospital to rehabilitation in the community) and early supported discharge programmes should be a part of geriatric hip fracture programmes as these achieved significant benefits over usual care for orthopaedic patients in terms of reduced length of hospital stay, return to previous residential status and cost-effectiveness. Such outcomes were not apparent for physically distinct orthopaedic rehabilitation units.
- Stroke units with comprehensive acute and rehabilitation care with multidisciplinary teams, patient/carer involvement, comprehensive assessment and management (and discharge protocols) and early mobilisation showed significant benefits in terms of mortality reduction and discharge home compared to usual care for acute and sub-acute patients.
- Inpatient comprehensive geriatric assessment (CGA) and rehabilitation programmes showed overall benefit across a range of settings compared to usual care, especially those programmes with medical control over CGA recommendations with long-term follow-up management.
The CGA reported in the literature is similar to the model of assessment, treatment and rehabilitation (AT&R) practiced in New Zealand.
- The overall efficacy of multi-disciplinary specialist geriatric team services in general inpatient geriatric acute care unit settings (GEU/GEMU) compared to usual care was more inconclusive although positive outcomes such as improved functionality, discharge home and reduced hospital length of stay were reported up to the first 12 months post-discharge.
- Multi-component interventions for the prevention of delirium compared with usual preventive care showed positive overall results with the incidence of delirium and number of days/episodes with delirium being significantly lower for the intervention group.
Day hospital and outpatient care: The evidence for the efficacy of specialist geriatric services in geriatric day hospitals and outpatient settings was insufficient, with no conclusive evidence that the services in these settings are of greater benefit than usual care. Many outpatient settings were US Veteran Association hospitals and clinics and so of limited applicability to the New Zealand context.
Specialist team service models: The most effective specialist team service models for patients (and caregivers) appear to be targeted comprehensive services tailored to individual need (including training and education in addition to assessment and treatment) provided by a multidisciplinary team.
Limitations of research base: There were limitations in the current evidence base, particularly problems identifying the most effective components of services, identifying important clinical differences in health outcomes between the intervention and control arms in primary studies, methodological problems affecting the internal validity of both primary and secondary studies, and a lack of literature in the New Zealand context, thereby limiting the generalisability of the studies to the New Zealand population and health care setting.
There is a need for further research designed to address these limitations, providing evaluations of the components of service delivery models to better identify those service features which are most effective in terms of outcomes.
English language abstract:
An English language summary is available
- Community Health Services
- Geriatric Nursing
- Health Services for the Aged
New Zealand Health Technology Assessment
Department of Public Health and General Practice, Christchurch School of Medicine and Health Sciences, University of Otago, P.O. Box 4345, Christchurch, New Zealand. Tel: +64 3 364 1145; Fax: +64 3 364 1152;
New Zealand Health Technology Assessment (NZHTA)