Can Comprehensive Geriatric Assessment make a difference to care home residents?  

03 March 2016

Adam Gordon is Clinical Associate Professor in Medicine of Older People at the University of Nottingham, a visiting Professor at City University London and an Honorary Consultant Geriatrician at Derby Teaching Hospitals NHS Foundation Trust.  He tweets @adamgordon1978.  Here he talks about a new research project considering the value of CGA in care home residents

Comprehensive Geriatric Assessment (CGA) works. At least, it does when performed in an inpatient setting in an acute hospital. This has been shown over numerous systematic reviews and meta-analyses to be the case.  Older people with frailty who receive CGA experience better outcomes in terms of functional status, cognition, readmissions to hospital and numbers of days spent at home.

CGA has been shown to work in a number of community settings as well, although the evidence of superiority over alternative models of care is perhaps more circumstantial in this setting. There are a number of settings where it has not been shown to work, where it might be expected to work.  These include in the context of acute medical assessment, in liaison services and in care homes. This is, in some circumstances, because of a lack of robust RCT evidence. In other circumstances, RCTs have been conducted but have been found after the case to be testing an intervention that fell someway short of the accepted definition of CGA as iterative, multidisciplinary, multi-domain assessment supported by case management and regular review.

I have previously made the case that CGA may have a role in providing health care to care home residents. Yet this is based upon an extrapolation of the evidence from acute care which, for some commentators at least, may be a step too far. The Proactive Healthcare for Older People in Care Home (PEACH) study (funded by the Dunhill Medical Trust) aims to consider how and whether CGA helps in greater detail to help address this uncertainty.

The project started in January 2016 and the researchers are currently being recruited.  A number of pieces of work will be undertaken:

A realist literature review will establish, based upon previous research of CGA, or similar interventions, what seems to work, in what circumstances and for whom.

Quality improvement collaboratives, representing health and social care commissioners, providers, care home organisations, NHS front-line staff and lay representatives will work to align healthcare to care homes more fully with the principles of CGA across four Care Commissioning Groups in South Nottinghamshire.

Concurrent process analysis will describe, in detail, how the quality improvement collaboratives worked and how they changed patient care at the front-line.

Computer algorithms, already under development, will be refined to trawl health databases for care home resident health resource use data (particularly number of admissions to acute care, length of stay, acute hospital readmissions, ambulance calls and, hopefully, GP out-of-hours use).

Individualized resident health-related quality of life data will be collected.  We aim to use a stepped-wedged randomization process to allow some element of robust historical control. This will be methodologically challenging – I’ll report back on how we’re getting on at a later stage.

We will cost the intervention and, depending on the quality of the health related quality of life data, aim to conduct a cost-benefit analysis.

The aim, at the end of this process, will be to describe not just whether CGA can be implemented but also some generalizable principles about how it can be implemented in modern UK health and social care settings and whether it made a difference to patient and service level outcomes.

Ambitious, challenging and exciting – it’ll be a busy couple of years doing all this.  The Dunhill Medical Trust have given us the opportunity to answer some very important questions here. Let’s hope we can do that opportunity justice.  I’ll report back via this blog as the project advances.

The PEACH researchers are: Adam Gordon, John Gladman, Claire Goodman, Julienne Meyer, Jay Banerjee, Tom Dening, Sarah Lewis, Dominick Shaw, Heather Gage, Maria Zubair, Anita Astle, Zimran Alam, Clive Bowman, Pip Logan, Finbarr Martin and David Stott.

Care homes


Working with Dr Gill Garden the newly established Bromhead Frailty team are gathering a detailed evidence base as we work alongside residents of the many care homes across Lincoln.

Are you looking for nursing homes to take part in this research study? We are a practice in Glasgow that looks after a nursing home and this sounds very interesting - would like to learn more!

One of the challenges in the evaluation of CGA is that often we deal with complex patients who have complex problems, implement a complex intervention and then aim to evaluate that with a simple outcome measure (mortality; % transferred to hospital; change in function, etc.). My suggestion is to use suitably complex outcome measurement. For that, take a close look at individualized outcome measures (we've used Goal Attainment Scaling, but there are others). Here are a few (older) references that might help: J Clin Epidemiol. 2003 Aug;56(8):736-43. PMID: 12954465 Age Ageing. 1999 May;28(3):275-81. PMID: 10475864 J Aging Health. 1999 Feb;11(1):96-124.PMID: 10848144 Gerontologist. 1998 Dec;38(6):735-42. PMID: 9868853 A pragmatic study in the Day Hospital setting is Stolee P, Awad M, Byrne K, Deforge R, Clements S, Glenny C; Day Hospital Goal Attainment Scaling Interest Group of the Regional Geriatric Programs of Ontario.A multi-site study of the feasibility and clinical utility of Goal Attainment Scaling in geriatric day hospitals. Disabil Rehabil. 2012;34(20):1716-26. PMID: 22397694 A more critical take on GAS from the Netherlands is in this recent review: Finally, some very interesting work on CGA in long term care is going on by colleagues here in Halifax: Marshall EG, Clarke B, Burge F, Varatharasan N, Archibald G, Andrew MK. Improving Continuity of Care Reduces Emergency Department Visits by Long-Term Care Residents. J Am Board Fam Med. 2016 Mar-Apr;29(2):201-8. doi: 10.3122/jabfm.2016.12.150309. PMID: 26957376 Marshall EG, Clarke BS, Varatharasan N, Andrew MK.A Long-Term Care-Comprehensive Geriatric Assessment (LTC-CGA) Tool: Improving Care for Frail Older Adults? Can Geriatr J. 2015 Mar 31;18(1):2-10. doi: 10.5770/cgj.18.122. PMID: 25825606 I hope this helps, and is not too didactic. Good luck with the study - it is much needed.

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