Evidence-based Synthesis Program 

(ESP) 

Effect of Geriatricians on Outcomes of 

Inpatient and Outpatient Care

Evidence Brief

Mark Helfand, MD, MPH, MS

Director, ESP Coordinating Center

March 20, 2013
Evidence-based Synthesis Program 

(ESP) 

Acknowledgements 

Principal Investigator

• Annette Totten, PhD

Contributing Investigators

• Susan Carson, MPH

• Kimberly Peterson, MS

• Allison Low, BA

• Vivian Christensen, PhD

• Arpita Tiwari, MPH

Project Manager: Nicole Floyd, MPH
Evidence-based Synthesis Program 

(ESP) 

Disclosure

This report is based on research conducted by the Evidence-based Synthesis 

Program (ESP) Center located at the Portland VA Medical Center, Portland, OR, 

funded by the Department of Veterans Affairs, Veterans Health Administration, 

Office of Research and Development, Quality Enhancement Research Initiative. 

The findings and conclusions in this document are those of the authors who are 

responsible for its contents; the findings and conclusions do not necessarily 

represent the views of the Department of Veterans Affairs, AHRQ or the United 

States government. Therefore, no statement in this article should be construed as 

an official position of the Department of Veterans Affairs or AHRQ. No 

investigators have any affiliations or financial involvement (e.g., employment, 

consultancies, honoraria, stock ownership or options, expert testimony, grants or 

patents received or pending, or royalties) that conflict with material presented in 

the report.
Evidence-based Synthesis Program 

(ESP) 

Background

•Older veterans are increasingly receiving healthcare from VHA 

o 43% of veterans over age 65 will enroll in VHA in 2013

o Increase from 31% in 2003

•Health needs change with age and are likely to increase

o Chronic illness, age-related disability, falls, cognitive 

impairments, multi-morbidity
Evidence-based Synthesis Program 

(ESP) 

VA Role in Geriatrics

•Early innovator in US

–Training

–Models of Care

•Ongoing Leadership

–Patient care

–Research
Evidence-based Synthesis Program 

(ESP) 

Background 

Several models of care are designed to address complex needs 

of older adults

• Interdisciplinary Teams (inpatient and outpatient) 

• Special Units or Geriatric Wards (inpatient)

• Geriatric Consultation (inpatient and outpatient) 

• Co Management with other Specialists (inpatient and 

 outpatient) 

• Geriatricians as Primary Care Providers (outpatient) 
Evidence-based Synthesis Program 

(ESP) 

Objectives 

Response to a request from the Office of Geriatrics and Extended Care and 

the Healthcare Delivery Committee of the National Leadership Council of 

VA

• Primary

o To evaluate the effectiveness of geriatricians as consultants, comanagement providers, or individual primary care providers.

• Secondary

o To describe specific characteristics that lead to more effective 

outcomes.
Evidence-based Synthesis Program 

(ESP) 

Questions for the Review

• For inpatient medical and surgical patients

o What is the effectiveness of geriatric teams, consultative services 

or geriatric co-management? 

• For outpatients

o What is the effectiveness of geriatric consultation, co-management 

or geriatricians as primary care providers? 

• If geriatric care is shown to lead to improved outcomes

o Are there specific characteristics of the patients or the care model 

that lead to improved outcomes?
Evidence-based Synthesis Program 

(ESP) 

Methods

• Evidence Brief, not full Systematic Review

o Shorter time frame

o Abbreviated search and review

• Study Designs

o Good quality systematic reviews

o Supplemented with fair to good quality randomized trials and 

observational studies not covered in reviews

• Outcomes 

o Function

o Health and long-term care services use

o Medications management 

o Mortality 

o Excluded satisfaction and cost
 

Methods

• Searches: 1985 through March 2012

o PubMed, various Cochrane databases

o Reference lists, hand searching, queries to content experts

• Quality assessment 

o Systematic Reviews: AMSTAR criteria

o Individual studies: established criteria based on study design

 Trials: US Preventive Services Task Force

 Observational Studies: Downs and Black

• Peer review

o 5 technical experts

o Topic nominators

Evidence-based Synthesis Program (ESP)
Evidence-based Synthesis Program (ESP)

Results

• 10 Systematic Reviews

– 5 inpatient

– 5 outpatient 

• 28 Primary Studies

– Inpatient 

• 5 fair or good quality

• 6 poor quality

– Outpatient 

• 11 fair or good quality

• 6 poor quality
Evidence-based Synthesis Program 

(ESP) 

Inpatient Care: Included Studies

• Ellis 2011 (Cochrane review)

o Comprehensive Geriatric Assessment, wards or floating teams

o 22 Randomized Controlled Trials (RCTs)

o 10,315 patients

• Baztan 2009 (systematic review)

o Acute geriatric units vs conventional hospital units 

o 5 RTs, 4 nonrandomized trials, 2 case control studies

• Bachmann 2010 (systematic review)

o Inpatient rehabilitation vs usual care

o General geriatric rehabilitation (8 RCTs) or followup for hip fracture (9 RCTs)

o 4,780 patients

• Conroy 2011 (systematic review)

o Narrow focus (patients being rapidly discharged)

o 5 RTs all included geriatricians, 2 geriatrican-led interventions

• Day 2004, (Updated by Ellis 2011 Cochrane review)

• LeGrain 2011 (good quality RCT)

o Consultation only

o 655 patients

Other individual studies: poor quality or similar results to systematic reviews
Evidence-based Synthesis Program 

(ESP) 

Ellis 

(22 Trials)

Special Units 

15 trials in Ellis

“Floating” teams 

7 trials in Ellis

5 trials in Conroy (rapid 

discharge only)

Acute care

Ellis: 7 trials

Baztan: 7 trials, 

4 nonrandomized 

studies, 2 case 

control studies

Post-acute or stepdown care

Ellis: 8 trials

Bachman: 8 trials 

Inpatient Care: Scope of Systematic Reviews

 
Evidence-based Synthesis Program 

(ESP) 

Main Findings

Inpatient Special Units vs. Floating Teams

• Special geriatric units improved patient function and likelihood of 

discharge to home compared to floating teams with geriatricians (Ellis, 

Bachmann, Baztan) 

• Comanagement by floating geriatric special teams did not improve 

patient outcomes (Ellis)

• Neither special units nor floating geriatric teams reduced patient 

mortality rates (Ellis, Baztan) 

• Insufficient evidence about the effect of inpatient geriatric interventions 

on hospital readmission, length of stay, emergency visits, or outpatient 

visits (Conroy, Baztan) 
Evidence-based Synthesis Program 

(ESP) 

Main Findings

Inpatient Rehabilitation and Consultation

• Inpatient rehabilitation including geriatricians 

o Lower nursing home admissions, improved function, and lower 

mortality (Conroy) 

• Geriatricians as inpatient consultants

o Evidence is insufficient to draw conclusions about effectiveness 

(LeGrain) 

 Variation in nature of consultations

 Generally low quality of studies
Evidence-based Synthesis Program 

(ESP) 

• Ellis 2011 calculated or estimated independent survival from 

published data

– Composite outcome: “the inverse of death or institutionalization” 

– No included studies measured this: less direct 

– Not all studies provided the data needed to make this composite: less 

precise 

• May be effort to provide another rationale for these services 

given trial findings

– Large, well-designed trials (e.g., 2002 VA Cooperative Study, Cohen et 

al) found no difference in survival associated with Comprehensive 

Geriatric Assessment

Additional Outcome: Independent Survival
Evidence-based Synthesis Program 

(ESP)

Outpatient Care: Systematic Reviews

• Complex interventions including CGA 

o Beswick 2008

o Community-based complex intervention to improve function and maintain 

independence

o 89 RCTs; 97,984 patients

o Ekland, 2009

o Interventions targeting frail elders

o 9 RCTs

o Kuo, 2004

o Effect of CGA on mortality

o 9 RCTs; 3,750 Patients

• Home visits and screening assessments

o Byles, 2000

o Health assessments

o 21 RCTs

o Huss, 2008 

o Preventive home visits

o 9 RCTs, 3,750 patients
Evidence-based Synthesis Program 

(ESP)

Outpatient Care: Additional Studies

• Geriatricians in team care or comprehensive models

o 5 Randomized trials

o Direct contact with patients (Eloniemi-Sulkava, 2009; Phelan, 2007; Schmader, 

2004) 

o Advised other providers (Counsell, 2007 & 2009; Rubenstein, 2007)

• Geriatricians as consultants

o 3 Randomized trials, 1 observational study

o 2 Direct contact with patients (Fenton, 2006; Monteserin, 2010) 

o 2 advised other providers (Bula, 1999; Li, 2010)

• Geriatricians as primary care providers

o 2 observational studies 

o Compared to generalist physicians on medications management only (AvilaBeltran, 2008; Phelan, 2008) 
Evidence-based Synthesis Program 

(ESP)

Outpatient Care: Main Findings

• Geriatricians in teams and as consultants/specialists 

o Mixed results/some positive effects on older patients’ function, living 

at home, and health services utilization

• Direct care verses indirect/advise others

o Interventions in which geriatricians have direct patient contact are 

more likely to result in better outcomes

• Geriatrician primary care providers

o Manage medications more effectively for older patients than other 

clinicians

• No reduction in mortality 
Evidence-based Synthesis Program 

(ESP)

Outpatient Care

Complex interventions (Beswick 2008)

• Only 19 of 89 trials were of interventions involving geriatricians

– Subgroup analyses of only studies with geriatricians produced the same results

• CGA and community followup led to

– Fewer nursing home admissions 

– Improved physical function 

– Lower risk of hospital admissions 

– No difference in mortality

Interventions targeting frail elders (Eklund 2009)

• 3 of 9 studies included geriatricians in the intervention

– 2 showed no effect on function, 1 found an increase in health services, 1 found a 

decrease in utilization, and 1 reported no effect on hospital days.

CGA as primary care or outpatient consultation (Kuo 2004)

• No effect on mortality 

• No effect across any subgroup analyses including characteristics of the 

intervention, how long patients managed by the team, or studies conducted in VA 

vs not in VA
Evidence-based Synthesis Program 

(ESP)

Geriatricians as Outpatient Consultants

Individual Studies Only-No reviews

• Patients at high risk of frailty had reduced risk of death or admission to 

long-term care if they received a visit from a geriatrician (Monteserin

2010)

• Patients with high numbers of outpatient visits had a lower rate of 

hospitalization if they met twice with a geriatrician (Fenton 2006)

• Two trials of consultation by geriatricians who advised other clinicians (no 

direct patient contact) reported limited impact on function

o Small, non-statistically significant improvements (Li, 2010),

o Delay in dependency only in patients with better function at baseline (Bula

1999)
Evidence-based Synthesis Program 

(ESP)

Geriatricians as Primary Care Providers

Preventive home visits (Huss 2008, meta-analysis)

• Favorable but not statistically significant effects on mortality, nursing home admission 

and function

• Reduction in functional decline if a clinical examination was included in the home visit 

• Analyses stratified results by whether a geriatrician was involved and results did not 

change

Health Assessments (Byles 2000, systematic review)

• 2 trials included geriatricians, had conflicting conclusions about benefit

• Medication management (2 trials Avila-Beltran 2008, Phelan 2008)

• Patients without a geriatrician were more likely to have a potentially inappropriate 

medication
Evidence-based Synthesis Program 

(ESP)

Limitations

• Often difficult to isolate the specific contribution of geriatricians from 

other services within the complex models of care

• Methodological limitations:

o No consensus on best practices for Evidence brief methodology

o Searches did not include topic specific databases or extensive 

efforts to identify grey literature

o Dependent on quality of prior reviews
Evidence-based Synthesis Program 

(ESP)

Questions?

If you have further questions, 

feel free to contact:

Mark Helfand, MD, MPH, MS

Director, ESP Coordinating Center

Portland VA Medical Center

mark.helfand@va.gov

The full report and cyber seminar presentation is available on the ESP website: 

http://www.hsrd.research.va.gov/publications/esp/