**Transcript of Cyberseminar**

**Evidence Based Synthesis Program (ESP)**

**Effect of Geriatricians on Outcomes of Inpatient and Outpatient Care: An Evidence Brief**

**Presenter: Mark Helfand, MD, MPH, MS**

**March 20, 2013**

**Effect of Geriatricians on Outcomes of Inpatient and Outpatient Care: An Evidence Brief**

**March 20, 2013**

Moderator:  Today’s presenter is Mark Helfand.  He’s the director of the VA Evidence-based Synthesis Program and the Scientific Resource Center for the Agency for Healthcare Research and Quality Effective Healthcare program, Professor of Medicine and Professor of Medical Informatics and Clinical Epidemiology at the Oregon Health and Science University. 

Our discussants today are Michael Mayo-Smith, who is the network director for the VA New England Healthcare System, Michele Zbogar is VISN 8 chief medical officer, and Kenneth Shay, the director of geriatric programs, VA Office of Geriatrics and Extended Care.  And, Mark, can I turn things over to you?

Mark Helfand:  Sure. You’ve got me queued up here.  Yes, hello that’s better, okay.  So I’m Mark Helfand. I’m going to talk about this evidence synthesis that we conducted in Oregon at the Portland VA. 

First I want to acknowledge the authors and contributors to the, sorry, to the project.  The principal investigator was Annette Totten, who’s a health service researcher here.  And the other research staff are listed on the slide, as well as the project manager, Nicole Floyd, who also is the project manager for the ESP Coordinating Center and a contact for that program as well. 

We have a disclosure for all of these, which essentially says two things, that the finding and conclusions are those of the authors and, second that we don’t have any affiliation or financial involvement that conflicts with the material presented in the report.  I would add to that that I am a VA clinician, mostly in hospital, general medicine hospital care.  So of course I’ve always trying to refer patients to geriatric and rehab in patient services as part of my regular responsibilities.  The older veterans are increasingly receiving healthcare from the Veterans Administration.  Forty-three percent of veterans over age sixty-five will enroll in veterans’ health services in 2013, an increase from 31 percent in 2003.  This is about four million veterans over sixty-five. 

And as we know, health needs change with age and are likely to increase.  Chronic illness, age-related disability, falls, cognitive impairment and multi-morbidity are all major focuses of the geriatric services that we’re going to talk about today.  The VA has been an innovator, a leader in geriatrics, not only in training but also in models of care. Most or all of the models of care that we will talk about today have been used or are developed in the VA at various points.  And we’re still an ongoing leader in the areas of patient care and research in geriatrics.  

And so I think it’s—which I think is important to know.  And I’m sure that many people listening or watching and participating in this know this, but this is, for those of you who have not been in the VA as long as me, I suppose a total of twenty-six years now, the exposure and the interaction with geriatrics here has been remarkable over the years. 

Let me provide some background.  Well we’ll return to this in a minute.  The—what I say when we’ll return to it is that I’m not going to define these terms here, but I wanted to introduce them here that several models of care we keep talking about, models of care, are designed to address complex needs of older adults.  

And these have been categorized here for you, interdisciplinary teams, either inpatient or outpatient; special units or geriatric wards; geriatric consultation services; co-management with other specialists; and geriatric as primary care providers are all some of the roles that geriatricians play, or some of the programs and models that geriatricians work in.  As I said, we’ll return to this a bit later, but I would say these categorizations have been used in the literature.  They’re not necessarily the right terms for all of this, but this is the way that many of the systematic reviews have categorized programs.  As you know, if you’ve been in a program or participated in one it’s not always that easy to make distinctions, but these are some of the distinctions that have been made.  

The objectives of this review, we responded to a request from the Office of Geriatrics and Extended Care and the Healthcare Delivery Committee of the National Leadership Council of VA to evaluate the effectiveness of geriatricians as consultants, co-management providers or individual primary care providers, and to describe specific characteristics that lead to more effective outcomes.  And when we say specific characteristics there, we mean programs or of the patients that would help us characterize under what circumstances these care models are most effective. 

The questions for the review, which we divided up into inpatient, outpatient settings, is what is the effectiveness of geriatric teams, consultative services or geriatric co-management in the inpatient setting?  And for outpatients what’s the effectiveness of geriatric consultation, co-management, or geriatricians as primary care providers.  And then ask if any of these models and settings are shown to lead to improved outcomes, the additional question is whether there are specific characteristics of the patients or the care model that lead to improved outcomes.  

The next few slides, which are the next couple of slides which are about methods hopefully we’ll go over quickly, but they’re in the talk too, as is some of the other materials to document the extent and the nature of the review.  So this was an evidence brief, not a full systematic review.   An evidence brief has a shorter time frame, an abbreviated search, and relies largely on existing systematic reviews supplemented with fair to good quality randomized trials and observational studies that were done since or otherwise not covered in those reviews.  And we have a list there of the outcomes that we had sought information on.  

Usually, in these reviews, what we do is talk to some clinicians and other experts about what would be the important measures.  And so that’s what you see reflected here.  The next slide just describes the search strategies, the quality assessments and also the peer review and technical, yes sort of ways that we got technical input.  

We found ten systematic reviews, five in the inpatient setting, and five in the outpatient setting and twenty-eight primary studies.  The systematic reviews are described in more detail in this slide.  I’m not going to go over all of this, but at least this gives you all of the major references that we relied on, or are relying on when we talk about this systematic review or that one.  The individual studies conducted since these reviews generally were either poor quality or had similar results.  None of the more recent studies overturned the findings of some of these reviews.  I would also add that although the dates on most of these reviews are quite recent, 2011, 2009 and so on, most of the studies they reviewed are older, were conducted before 2005 and even the majority probably before 2002 or earlier.  

It’s easier to see the relationship between these reviews graphically.  The Ellis review, which is the Cochrane review, is an overarching review that was an update of an earlier Cochrane review I think from 2004.  And it divided—that this is again for inpatient care and it divided and categorized the studies as studies in special units or studies with floating teams.  Now, special units are a setting where a comprehensive geriatric assessment is done.  A comprehensive geriatric assessment involves a coordinated multidisciplinary assessment designed to identify medical, physical, social and psychological problems.  And it serves as a basis for a plan of care.  Some of the inpatient geriatric units are known by names such as the acute care for the elderly program or GEM [use] geriatric evaluation and management units.  And programs like that they identified fifteen trials.  

The other model, the floating team model, is another consult to is a more of a consultative model.  And two of the reviews addressed the seven trials in the overall Ellis review and one other systematic review.  For the special units, those could be further subdivided into acute care or post acute or step down as those are somewhat self-explanatory, but acute care would be admitted.  At the time of admission they go right to the geriatrics unit. Post acute is usually after a medicine or surgical admission.  

And so that gives you kind of a picture of where the evidence is in most of these reviews.  In addition, one of the reviews, Conroy, also reviewed geriatric rehabilitation, trials involving geriatric rehabilitation.  Before we go on, and this is really we’re still focused on inpatient, but this comment applies to both inpatient and outpatient.  The main finding of this review is that the effectiveness of geriatric involvement in these various models in patient function and healthcare utilization varies across the different models.  And so a lot of the attention from in this webinar going forward is going to be looking at the different models.  

The next slide we can start talking about the specific results of these reviews.  These comparisons—this slide compares the inpatient geriatric units with the floating team model.  And these findings are that the specific units improved patient function and the likelihood of discharge to home compared to standard hospital care.  

One needs to remember that the time or the duration of admission is not comparable, so you’re talking about standard hospital care discharging patients at a point where they may go to another facility or so on, or and the discharge to home from the geriatric unit is after a period of a longer period of care, but when the patient leaves the special geriatric unit they’re likely to have better function and more likely to be discharged home.  

Co-management by floating geriatric teams, along with a primary ward team did not improve patient outcomes.  And there were mixed results in the studies that the overall conclusion was that they did not.  And neither reduced patient mortality rates.  There is insufficient evidence about the effect of inpatient geriatric intervention on hospital readmission, length of stay, emergency visits or outpatient visits.  

Inpatient rehabilitation, as I mentioned, was a separate group of studies reviewed in this Conroy systematic review.  Inpatient rehabilitation that included geriatricians in the staffing lowered nursing home admissions, improved functions and lowered mortality.  The actual numbers that that review published and those outcomes were quite remarkable. 

For the lower nursing home admissions the relative risk that they calculated at discharge for the lower chances of nursing home admission was a thirty-six percent reduction, a relative risk of 0.64 with a confidence interval of 0.51 to 0.81.  And for after the follow-up period it was still 0.84 or sixteen percent lower chance of discharge to a nursing home. 

The improved function was the most dramatic number.  It was 1.75 was the odds ratio, meaning that at the certain threshold of good function, there was a much higher change of that with the inpatient rehabilitation.  The follow-up was a thirty-six percent increase in the number of, in the percentage of patients that had good function.  And there was lower mortality.  That was a thirteen percent reduction in mortality over the follow-up period up to twelve, three to twelve months.  The patients in these rehabilitation studies were a mixture of patient with specific conditions such as a hip replacement, and other patients sent to rehab for a variety of reasons.  

The next slide talks about a particular outcome, independent survival that was featured in the Cochran review, the review from 2011.  And we thought this deserves comment because the review emphasized, or at least was the main outcome that that review looked at.  Their finding on that was based on a calculation of the estimated independent survival from published data.  So this is what you would call a composite outcome, meaning that they combine the outcomes actually measured in the study in a way that they could try to get a single outcome measure that would have something to do with living, survival and not being institutionalized.  

None of the actual studies measured this, so that they didn’t measure this directly.  This had to be calculated or estimated in some way based on some assumptions in the studies.  And not all studies provided the data needed to make the estimate of this measure.  So there was probably a loss of precision as well as some loss of data in trying to do this.  On that measure they found an improved chance of independent survival from summarizing these studies, and in general an improved chance of less likely to be institutionalized over this time period.  So let me just give you some of the findings that they had featured or less.  Let me go back a step and give some background on what was going on with this measure.  

So I think as many of you know, the earlier studies in the 1990s of geriatric, comprehensive geriatric assessments and related models of care should improve survival for patients in those models as opposed to usual care, but subsequently the VA conducted a large cooperative trial in 2002 which was published in the New England Journal of Medicine.  The first author was Harvey Cohn. 

That trial, which was very well reported, it’s very great, it’s an enjoyable article to read, had a surprising finding of no difference in survival.  And this prompted a sort of a look at the data and a look at the—a reevaluation really of the goals of geriatric, of dedicated geriatric units.  And this, of course, we’re talking about 2002.  Systematic reviews in the years, in the few years after that emphasize survival and a few other outcomes.  And I think what we’re seeing with this review in 2011 over about a decade later is that sort of a movement to sort of define a clearer goal than just survival, one that geriatric care has probably been all along been intended to achieve, and which is probably a more meaningful one in the long run than survival alone.  

The problem with the findings about independent survival are some of those are the ones I already mentioned that they had to calculate this outcome.  It was not directly measurable in some of the studies, so they had incomplete data.  The other problems are that the studies involved in this are all older than seven or eight years ago.  And so their relevance today might be limited.  And that’s because usual care has evolved since the 1990s or the early 2000s.  

In usual care on a medicine ward of course we have multidisciplinary conferences in many VAs almost every day.  That wasn’t the case ten or fifteen years ago.  And usual care may have adopted many other aspects of comprehensive, the kind of comprehensive care that geriatric units pioneered.  

And so this is an important aspect of where we are now with our knowledge of the effectiveness of geriatric units.  We didn’t feel that the recalculation and all of the sort of problems with the data that entails makes this finding reliable.  We think it’s more of an exploratory finding that would need to be confirmed in an actual perspective study, but it gives us a sort of an idea of what future studies really might identify as a primary outcome. 

So with that I’m going to turn to the outpatient setting.  The systematic reviews of the outpatient setting are listed here.  The categories here are complex outpatient interventions to improve function and maintain independence.  And home visits and screening assessments is another category.  The other kinds of studies in the outpatient setting are geriatric geriatricians in teams and in comprehensive models, geriatricians as consultants and geriatricians as primary care providers.  I’m not going to spend as much time on the outpatient as on the inpatients’ side, so we can—but we can summarize the findings rather quickly.  Next slide?

The main findings are that when geriatricians in teams or as consultants and specialists, the results for that were mixed.  We didn’t definitive evidence of the effectiveness or lack of effectiveness of those models.  We also found that interventions in which geriatricians have direct patient care or direct patient contact are more likely to result in better outcomes than those in which there is some sort of indirect role of the geriatrician.  There’s older evidence that geriatrician primary care providers manage medications more effectively for older patients than other clinicians. 

It would be hard to put that in perspective.  Medication management has changed, is changing so rapidly, and remains a huge challenge.  I don’t want to sort of throw in my own sort of opinions just from watching clinically what’s happened over the years, but I’m sure many of you have an opinion on whether medication lists are getting larger or shorter, more complicated or less complicated in general in our patients.  And so this is certainly this is an area where the evidence doesn’t quite catch up to the need for improved management.  And finally there’s no reduction in mortality in these models that compare to care by a non-geriatrician.  

The next thing the complex interventions we may come back to that if somebody has a question about what those models are, but complex interventions involving geriatricians were effective in fewer nursing home admissions, improved physical function and lower risk of hospital admissions.  Interventions specifically targeting the frail elderly, on the other hand, had mixed results.  And finally as primary care providers or outpatient consultants not as well evaluated and quite old literature, we really didn’t find anything sort of strikingly—we don’t—I just have to say we don’t have any insights about kind of which situations and which kind of patients these models would be effective.  

So this area, geriatricians as outpatient consultants, we didn’t find any systematic reviews.  We found some recent studies and we summarize them here.  I don’t want to read through.  I’ll just give you a minute to sort of look at this and say that as you see there are some recent studies.  This is an area that is quite active.  As you probably know there is a lot of technological innovation now in technology for virtual home visits for evaluating behaviors, risk factors, needs of people in their homes rather than having to sort of see the patient in another setting and ask what’s going on, and so on and rely on that or rely on a single home visit.  

So our expectation is that this field here is evolving especially in what you might call the telemedicine or the remote data collection mode.  And this review did not find a literature on that or actually specifically seek a literature on that, but I can tell you that that is a very active and interesting area for the role of geriatricians to get better data on what is actually going on in order to make care plans that are more specific for what actually is happening in the home or the other settings that the patient lives in.  Unfortunately the systematic reviews in this study we didn’t find systematic reviews, but the individual studies here were sparse and didn’t quite get to those new technologies.  

Finally we had the last role of the primary care providers, not a definitive literature on preventive home visits or health assessments.  So let’s talk about the limitations of the review for a minute.  I remind you that these are complex interventions so it’s often difficult to isolate the specific contribution of geriatricians from other services within the complex models of care.  That’s a universal problem in looking at what parts of a—trying to look at what parts of a comprehensive, holistic model, if you will, actually make a difference.  And it may not be the most important thing to do if the models clearly work, but it was one of our tasks to try to look at the contribution of geriatricians.  

And finally there are methodological limitations.  There is no consensus on best practices for doing this kind of review, this evidence brief methodology.  It relies on methods to evaluate the relevance and quality of other systematic reviews.  One would think since there’s such a proliferation of systematic reviews in the literature that we should be able to make use of them.  And an evidence brief is an attempt to make use of them when they come in groups instead of one at a time, but I would say that there’s not as developed a methodology for doing that as there is for doing original systematic reviews.  

And finally the searches didn’t include topic specific databases or extensive efforts to identify grey literature, meaning reports from internal reports and from organizations that may have done research but not published it.  And finally, as I said, we’re dependent on the quality of previous systematic reviews. 

So with that I think we’ll ask for questions.  The new directions I should say—I should have said before asking for questions.  Some of the new directions here, none of the studies or models really showed an important effect on readmission rates.  And I know readmission rates are a concern in every model.  There are a number of intensive primary care models and other sort of non geriatric or sometimes geriatric models that try to address the fact that what people, well all these things that are done doesn’t always reduce the readmission rate.  

And so I’d say that we try to identify like a future direction for some of these programs.  And that sort of struck us that a relationship between in this review, separating inpatient from outpatient in a way kind of begs the question of how do we achieve continuity to prevented readmissions, but also when people are readmitted, and the familiarity with the team and so on that they have worked with before.  How do we promote that?  

And what struck us that sort of in this literature at this point there weren’t impressive results on readmissions and there may need—that it might be an important area for further defining the sort of aims and methods of these kind of panels.  Thanks.  

Moderator:  Great.  Thank you, Mark.  And we actually don’t have any pending questions right now, so as our audience is putting those together and typing them in, why don’t we take this opportunity to hear from our discussants?  That will take a little time while our audience is submitting questions at this time.  

Michele Zbogar:  Well I can start if that’s all right.  

Moderator:  That would great.  Thank you. 

Michele Zbogar:  Yes.  This is Michele Zbogar and I want to compliment the ESP program for delivering this program in the time constraints that the health care delivery really put on them to deliver a product.  

The parameters of this particular evidence brief had to be limited because of the time constraints.  And I think that finding the literature evidence was really helpful.  As an organization as we look to identify best models of care, often programs bring forth a recommendation to either enhance current models, propose new models or decide that expansion of current models needs to occur.  This is a resource question, but also needing support from the healthcare delivery system.  

So as an organization having this evidence-based approach to really look at the evidence of where you put your resources that have—that are supported by the literature as contributing the best to this group of patients is really what we needed to do in this particular case.  I think this research has helped us identify where geriatrics’ contributions have been most meaningful in the areas of medication management, readmission, maintenance of functions and--mortality sort of iffy because of the population itself--but the other two certainly it has helped us identify at this point in time with the medical literature where really geriatricians do contribute, developed attention between [PAC] and geriatric in terms of providing care because [PAC] basically states in primary care we take care of the patient, but in many ways what is the difference. 

And I think that that has helped us identify what is the difference of the care, but also where can this--what kind of model of care is most effective using geriatric sets of models.  So I think that we found some areas certainly in inpatient rehabilitation which seem to have made a difference. 

Other areas in terms of geriatricians as consultants it seemed not to make so much of a difference.  It just is it might still be early in terms of our research to make definitive plans to say this doesn’t work absolutely, or this does work, but this research helps put us on the right road as to how to approach the topic of specialty care, how to approach the topic of models of care using the evidence-based set that this program to help us look at the available literature and the evidence based as we decide to invest our resources into certain requests.  So that’s really what I’ve have to offer, again a lot of time constraints for this, but actually remarkable product and I thank you.  

Michael Mayo-Smith:  So this is Mike Mayo-Smith.  I’m a network director in [VISN 1], and am like Michele on the health delivery committee.  And our commentary I think that’s why we both got invited to comment on this because the original, the origination of this review came from a request from the health delivery committee and where a proposal came to the committee that in an effort to better address the needs of the elderly population. 

There was a proposal to require the establishment of geriatric consultation teams in all our hospitals.  And there was no question everyone was in full agreement about the fact that the care of the elderly is a big issue for the VA, but it was uncertain whether the data supported the requirement that these such programs be established at all VAs. 

And in thinking about this we did ask for an evidence synthesis review.  And one of the things that we found was this evidence synthesis review was very—we really like this approach where evidence-based policy.  It came back.  We had a very nice summary of the evidence and we felt we could make a policy decision with some evidence to guide us.  

In this case the results is a complicated question, but overall the committee after looking at these results did not find evidence that supported that the VA require establishment of such consultation teams like this in all our hospitals.  I wanted to also point to a recent debate or a recent it’s called in the balance a couple of articles in the Annals of Internal Medicine from May 1, 2012 where this topic is debated by national experts.  

And there are two articles in that.  The first article is labeled “Is Geriatric Medicine Terminally Ill?” And the second article is labeled “Treating Our Societal Scotoma, The Case for Investing in Geriatrics, Our Nation’s Future and Our Patients.”  

And the first group raises the question.  And everybody is in agreement that the needs of geriatric population are critical and important.  And geriatric medicine or the elderly are increasingly part of our healthcare population. 

But this, the first one says, and let me just read a couple excerpts that I think it summarizes the point that we’re facing here.  It says geriatrics differs from other medical subspecialties which have developed interventional procedures and medical therapies that have been shown to dramatically improve morbidity, mortality and quality of life.  Lacking such interventions, Medicare reimbursement for geriatricians will not be substantially increased in the era of fiscal austerity unless comparative effectiveness research shows that geriatricians provide higher quality, more cost effective care than other physicians.  Yet evidence, available evidence is limited.  

So that’s one group’s conclusion.  And I think actually our ESR would come to the same conclusion that available evidence is limited.  They went on to say that studies have demonstrated co-management patients with hip fracture by geriatricians and orthopedists can decrease costs and hospital stays, but comparisons with hospitalist orthopedic co-management are not available.  

So is the geriatrician or is it the co-management?  And they talked about the fewer inappropriate medications and better assessed geriatric syndromes than the generalist physicians, but the clinical significance of these findings were uncertain.  

So they—and the other article they both, they state evidence, and this is" Treating Our Societal Scotoma," they say, who are arguing for expanding geriatric interventions as, “Evidence of the effectiveness of these approaches in improving outcomes for older patients is compelling.”

So I think it depends on how you read the literature is where you fall on this spectrum of this question.  And I think that our sort of conclusion was at the health delivery committee was that this is not at a point where it’s right for spreading into all VA hospitals as a requirement.  Mark brought up the question of where are the research questions that might help us get to a point of identifying what is beneficial, and also raises the question, a lot of these interventions are complex system interventions.  And is the role of the geriatricians to help us lead in developing better systems to care for elderly patients, and perhaps not be a focal point of a highly specialized individual who’s required to be a personal participant in the care?

So those are—I add that commentary from one perspective as well.  I’ll stop at the point.  Thank you. 

Kenneth Shay:  Thanks, Dr. Mayo-Smith.  This is Ken Shay from the Office of Geriatrics and Extended Care.  And I also want to commend Dr. Helfand and his team, and Annette Totten in particular for a really excellent product in a very constricted time frame.  And I also want to thank them for really being open to some concerns that a number of folks from my office and associated with geriatrics through VA had with the original presentation of the results, not really the results, but the way they were communicated.  And I feel that they have been very forthcoming in addressing our concerns and communicating them in this cyberseminar in a very fair and balanced way. 

I’d like to frame my comments on sort of three different pieces.  One has to do with sort of the origin of this evidence synthesis.  And Dr. Mayo-Smith related sort of how it came about that I want to modify some of his interpretation of that a little bit.  

Secondly, I want to focus on what I consider really one of the most important findings and seem to be a consistently reported finding, which was the importance of the geriatric team and the geriatrician working directly with the patient as opposed to giving advice in a consulting role and then standing back and allowing the main treating team to do the care.  And then, thirdly, I did want to talk about this issue of the outcome and mortality versus function.  So those three things I’ll take in order. 

The first is the original purpose.  This actually this ESP was actually requested initially by the Office of Geriatrics and Extended Care and was sort of in a queue waiting to be acted on when the healthcare delivery committee asked for really the identical study.  And so I really owe a debt of gratitude to them for asking that question.  

They did so in response to a proposal, as Dr. Mayo-Smith said that was made to the committee, but it’s a bit of a simplification to say that it was a proposal to put geriatric consultation in every VA.  It was a proposal to address the issue of rising numbers of geriatric patients in VA despite the fact that we have a declining number of people with advanced training in geriatrics in the workforce, and that the workforce in general in all disciplines historically has received little to no training as part of their pre-licensure curriculum in geriatrics.  It’s just not a big part of healthcare training.  

And yet you have this growing population.  Dr. Helfand mentioned forty-three percent of enrollees are over the age of sixty-five.  Over fifty percent of VA patients or enrollees who get care are over the age of sixty-five.  So this isn’t just an issue of the elderly.  This is an issue of VA.  It’s our population.  Over fifty percent of them are old.  And that number is going to continue to climb.  And the oldness of the old ones continues to get older.  

And so VA as a system needs to grapple with it now.  The Office of Geriatrics and Extended Care is particularly tuned into that because we have the responsibility for the frailest and the oldest.  That’s really our charge, but really we view that entire demographic as ultimately the group to which we focus our efforts and that we are approached about questions.  

And so the recommendation was really that VA needed to tune up its geriatric workforce through a combination of offering additional training to the full healthcare workforce because over fifty percent of their patients are over the age of sixty-five, but we don’t really have enough trainers. 

And to do that we need to take on additional geriatric personnel.  

And to have additional geriatric personnel you need to have venues in which they can apply their training.  And the question always get asked if you have a specialty that’s relatively uncommon, are you better off just trying to hire everybody in sight?  Or are you better off making them as consultants so one person can leverage his or her knowledge through the actions of others?

And so that was the big question initially.  And the literature we felt, and I think Dr. Helfand’s study has won that out, was that consultants alone really are not nearly as effective as when you actually have the people providing the care that they have identified as necessary.  

So that’s just a bit of the historic perspective.  There was a recommendation for inpatient consulting teams.  And it was for teams, not individuals.  And even the fact that the recommendation was for inpatient teams was one of three recommendations, one having to be do with long-term care and the other having to do with geriatric primary care. 

So I do feel that this, the synthesis has done a very nice job of showing that.  In general the presence and the contributions of geriatricians are positive.  They result in tangible and desirable outcomes.  And as for what particular model through which that should be the geriatric expertise should be delivered, I agree that the findings are not quite that definitive.  

But I think that the overall finding that there is benefit for having the care delivered hands on also speaks to the fact that the general workforce for all of their excellent skills and dedication still do not have the background in many cases to actually deliver the care that has been recommended, whether it’s because of time, which some people contend, or because of just appreciation for the difference of the findings, as in the case of for instance the identification of a functional assessment as part of the workup of the patient.  And the impact of that on the ultimate plan of care is extremely important.  

And yet repeatedly hear in geriatrics and extended care that the [PAC] teams don’t have time to do that.  I think that if they appreciated that that’s far more important and if there were performance metrics that reflected it was far more important than more traditional kinds, parts of the patient assessment, you might get a better compliance and then, yes, you might get superior care from the non-specialists.  But until such time as that occurs, the care that’s recommended by the specialists is informed not only by their background, but also by the level of the emphases they put on different things, knowing that they have more impact on their care.  

The final thing that I wanted to mention has to do with the outcome, so I just alluded to that. 

Dr. Helfand was very good about talking about questions whether mortality is really a reasonable outcome in geriatric studies, and pointing out that early on many studies showed improvements in mortality.  And you have to realize that the use of nursing homes and geriatric care in general has dramatically changed through the ‘90s and beyond because of OBRA, which was a legislative omnibus bill in 1987, which really for the first time started transforming nursing homes and geriatric care into actual care as opposed to custodial maintenance.  

And as a result of that I think the early studies did show enhancements in mortality because you had people who were essentially warehoused.  And yet in the presence of more informed geriatric care they actually were living longer and doing better.  

However, since that time we’ve had a much more sophisticated approach to care of the elderly in general.  Some of this is mentioned in Dr. Helfand’s presentation with the diffusion of geriatric principles throughout the healthcare workforce.  And that’s a very good thing. 

However, as he pointed out, function, and the function ability and the need to or the desire to stay at home to have a patient-centric outcome, to use the current parlance that we’re all becoming more and more accustomed to, is far more important than a change in the mortality.  And really in more enlightened times one might even say that the finding that there is no change in mortality was actually an endorsement of the quality of the care.  

Old people die.  Old people get sick and they die.  And they’re frail.  And interventions that are done in a research mindset have the potential for making them better, but also for making them worse.  And from the standpoint that the mortality did not change that’s an endorsement that the care is in fact it results in better, other outcomes like enhanced function or reduced institutionalization is all that much more powerful for it.  

So I think I’ll be quiet now and let folks from the listening audience weigh in with if they have some questions.  But again I want to thank both Dr. Helfand and Dr. Totten, as well as Drs. Zbogar and Mayo-Smith for making this possible, because I interpret it as very much an endorsement of the importance of geriatrics expertise and an endorsement of the desires of the Office of Geriatrics and Extended Care to really enhance care for all veterans by focusing some additional resources or the rationalization for focusing some additional resources on this very vulnerable and very high cost segment of the population that is also growing.  

Moderator:  And wonderful.  Thank you so much.  We do have a few pending questions out here, but for our audience you can if you do have any questions you can submit them using the Q&A screen in Go to Webinar.  It’s located on the dashboard on the right-hand side of your screen.  If it has collapsed against the side of your monitor, just click on that orange arrow at the upper right-hand corner of your screen to open that back up.  

And the first question that we have here, did the outcomes take into account whether any of these patients were in the adult day healthcare programs or not?

Mark Helfand:  No.  In these I can’t say that there was absolutely no study that had patients in adult daycare and took our account of it, but in general no they did not take account of all.  

Michele Zbogar:  No.  The inpatient studies don’t necessarily role for what was happening in the outpatients ahead of them.  

Mark Helfand:  Right.  

Moderator:  Great.  Thank you.  The next question I have here, I realize that evidence based is based on randomized clinical trials.  However, most research on geriatrics care cannot be randomized.  There is abundant literature using secondary data and population-based data that should also be synthesized.  What are discussions about synthesizing that evidence?

Mark Helfand:  Well actually some of the reviews that we relied on did synthesize that evidence.  And I don’t have the—I don’t think it was in the slides, but it might have been, the list of the reviews that I made.  For instance that little graphic that we used talked about the Baztan review.  That was the special units with acute care setting.  And actually I think about half the studies, or actually a majority of the studies in that review were non-randomized studies, were observational studies.  

There is a I think an important point to make about the use of non-randomized or observational studies in a situation like this.  We’ve referred to these as complex interventions or models.  And the quality improvement kind of data, approach to data is very relevant to these models.  

We’re talking about a situation where the really definitive, beautifully done trial by Cohn and the VA collaborative program was ten years ago, or eleven years ago now.  In that study mortality within one year after discharge from a geriatric unit was about twenty percent.  

There’s many, many numbers that we could be using in monitoring or evaluating changes to these models if we had the data systems and the commitment to do it.  And what I mean by that is the big question now is this question of comparison between modern day hospitalist space in patient care and a geriatric model.  

And several of the speakers have referred to the sort of increasing use of some of the components of dedicated geriatric units in usual care.  And so over time what would one would like to see is if those kinds of outcomes are getting closer, or not getting closer for those with and without these units.  We don’t find and we didn’t find a study that did that in a setting.  

And when I say in a setting of a quality improvement approach to data, what I mean is where you are continuously monitoring these things and showing not just for one group but for both groups what’s happening over time.  So I think observational data could be extremely useful in this. I can’t say—we didn’t really make an attempt to sort of tease out do we need another large trial, or would it be better to rely primarily on measurements over time?

Michele Zbogar:  Yes.  And if I can just say we didn’t exclude trials, or didn’t say we were only looking at trials.  We first searched the reviews and then the additional articles, like the medication management articles are not trials, but so that was we didn’t make the distinction.  We did require that there be a comparison either with [sunlight] or with something else.  So a lot of the descriptive studies were not really triggered.  

Moderator:  Great.  Thank you.  Again that questioner did send in a follow-up comment stating, it is important to be aware that there are methodological challenges in estimating effects on outcomes that are subject to attrition because of mortality.  Literature is only slowly emerging as to how to address these challenges.  This needs to be considered as potential limitations in all the results that are synthesized.  

And that is actually all of the questions that we currently have out here.  If anyone else from the audience does have anything that they would like to share this would be a great opportunity to get that in.  We do have a few more minutes.  We are scheduled to run about another fifteen minutes.  So if you’d like to type it in quick we can get it on here.  If not we will wrap things up a little bit early. 

And it looks like we don’t have anything else coming in.  So I really want to thank our presenter and panelists for today.  We really appreciate the time that all of you put into this and making the time in your schedule to join us for the slide session today.  We really do appreciate everything that you put into it. 

For our audience thank you very much for joining us today.  As you leave the live session today you will have, you will be prompted with a feedback form.  If you could take a few moments to fill that out we really do look at the feedback that you provide to us and use that in our current and upcoming sessions. 

Thank you, everyone, for joining us for today’s HSR&D cyberseminar.  We hope to see you at a future session.  Thank you.  

**[End of Recording]**

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