Title: How best to deliver Comprehensive Geriatric Assessment in a cost-effective way
Funder: Department of Health (England)

Abstract: BACKGROUND Comprehensive Geriatric Assessment has the potential to both improve clinical outcome (reduce mortality and the need for long-term care) and reduce the costs of health and social care (1). Evidence is needed on how to provide acute Comprehensive Geriatric Assessment (CGA) to older adults in greater numbers with a fixed or shrinking hospital resource. Without this perspective existing models of acute hospital CGA care will become unworkable as the health service deals with an increased number of frail older people with complex health needs. OBJECTIVE To improve our understanding of the effectiveness implementation and cost effectiveness of specialist led Comprehensive Geriatric Assessment (CGA) across secondary care and hospital at home settings. DESIGN We will conduct:(1) A national survey of CGA in community settings and follow-up interview study this will provide data of the different models of CGA in the NHS and data for modelling the costs of CGA care in a hospital and hospital at home setting.(2) An update of the Cochrane Review of CGA with individual patient data meta-analysis and multi-level modelling of cost-effectiveness a survey of trialists and refinement of a protocol logic model to map out the pathways that constitute the mechanism of action of CGA(3) A Delphi exercise with clinicians who specialise in the care of older people observational case studies and interviews with healthcare providers patients and caregivers of how CGA is implemented. SETTING1)A national survey of healthcare providers of CGA in community settings in England Wales Scotland and N Ireland. 2)Randomised data from six countries3)Delphi exercise of providers of CGA in England Wales Scotland and N Ireland.4)Case studies and interview study in England (South Devon) and Scotland (Lanarkshire)STRATEGY FOR REVIEWING THE LITERATURE For this update of the Cochrane Review of CGA we will include randomised controlled trials of CGA. Two reviewers will independently select studies according to the pre-specified inclusion criteria. The quality of eligible trials will be assessed using the Cochrane Risk of Bias criteria and data extraction will be completed independently by two authors. The overall quality of the included evidence will be assessed using GRADE. We will request individual patient data (IPD) from the investigators of the included trials and refine a protocol logic model by using data from a survey and interviews with trialists and data from related studies. Aggregate analyses will initially be undertaken to estimate treatment effects using a random effects model. Regression models stratified by trial will be used to explore the effects of different models of CGA patient groupings and age covariate interactions on the outcomes of interest. Pre-specified factors are age at randomisation level of frailty and cognitive impairment. Two level multi-level regression models will be fitted with patients corresponding to level one units and trials as level two units for the outcomes of interest using the appropriate approach to continuous and dichotomous outcomes. Trial and treatment effects will both be represented by a random effects model. Data on all patients will be included to conduct an intention to treat analysis.TARGET POPULATION Our target population is frail older people who have been referred to hospital for an acute medical event and are eligible for CGA this will include people with a surgical diagnosis. Trials typically recruited patients on the basis of age alone (i.e. all admissions over 75) or on the basis of criteria such as changing functional status prior disability cognitive impairment or classic geriatric syndromes such as falls immobility delirium and non-specific presentations. For the case study and interview study patients for observation will be based on typical and extreme case sampling strategies patients that are typical of those receiving CGA and extreme in that they pose particular challenges for the delivery of healthcare for example on account of cognitive impairment multiple co-morbidities and frailty that will impact on the recovery process.INTERVENTION BEING ASSESSED CGA is a multidimensional interdisciplinary diagnostic process focused on determining a frail older person’s medical functional psychological and social capability to ensure that problems are identified quantified and managed appropriately. A tailored management plan which includes rehabilitation is developed and delivered by a multi-disciplinary teamMEASUREMENT OF COSTS AND OUTCOMESNational survey: implementation (including barriers) of CGA in community settings the cost and outcomes of the different models of CGA and the extent CGA in practice differs from the evidence.Cochrane Review of CGA with individual patient data: the primary outcome is ‘living at home’ (the inverse of death or living in a residential care setting) and cost-effectiveness. Follow up time will be a median of 12 months. Delphi exercise: key dimensions of CGA as researched and translated to a hospital at home setting. Case studies and interview study of patients and their caregivers and healthcare providers: the main findings will be factors associated with the implementation of CGA in inpatient and hospital at home settings. PROJECT TIMETABLE This research is planned over three years. In year 1 we will: 1) conduct a national survey of CGA in community settings with follow-up interviews and conduct modelling of the cost-effectiveness of the different CGA models; 2) establish the collaboration of trialists for an update of the Cochrane Review of CGA start to obtain and clean individual patient data from the trialists conduct a survey of the trialists and refine the protocol logic model. In year 2 we will complete the collection of individual patient data and conduct multi-level modelling of effectiveness and costs and refine the logic model; we will also start the Delphi exercise. In year 3 we will complete the Delphi exercise and conduct the case study analysis and interview study with patients caregivers and healthcare providers. (1) Ellis G Whitehead MA O’Neil D Langhorne P Robinson D. “Comprehensive Geriatric Assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews 2011 Issue 7 Art No:CD006211. DOI:10.1002/14651858. CD006211.pub2


Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE