title: Impact of a general practitioner-led intervention for people living with moderate to severe frailty in Midlothian, Scotland
Creators: name: Jones, Helen
Publisher: name: The University of Edinburgh
Year: 2021
Subjects: subject: general practitioner-led intervention
subject: people living with moderate to severe frailty
subject: Midlothian, Scotland
subject: Frailty
subject: Primary care
subject: General Practice
subject: CGA interventions in primary care
subject: MidMed
subject: Frailty Index
subject: comprehensive geriatric assessment (CGA)

description: Frailty is a strong predictor of disability, loss of independence and mortality. Primary care has a significant role to play in the identification and management of frailty. However, for it to become an established part of community-based care, specific models of care for frailty need to be embedded within General Practice, building on existing strengths, such as continuity of care and holistic assessment. My overall aim was to evaluate the impact of a new General Practitioner (GP)-led model of care for patients with moderate and severe frailty living in the community. To investigate the hypothesis that GP-run CGA interventions in primary care led to improved outcomes for patients, a literature review using systematic methodology was performed.The review included 13 relevant studies and together demonstrated that these interventions do not have any convincing impact to secondary care utilisation. Primary care consultations were noted to increase, at least in the short term. MidMed is a dedicated GP-led service for their patients living at home with moderate or severe frailty (as identified by the electronic Frailty Index). The aim of the service was to improve the value of care for their frail, older population. One full-time GP performed a CGA, adapted for primary care, and patients received direct access to appointments with the same GP, bypassing the current telephone/online triage system. To assess the impact of MidMed on primary care and hospital utilisation, a quasiexperimental study was performed. Patients receiving the MidMed service (n=290) were compared with similarly frail patients (n=220), who were not yet enrolled in the service (non-MidMed group) from date of enrolment for up to 16 months. Outcomes were measured using routinely collected data. For those with at least one hospital admission, MidMed was associated with a reduction in the risk of further hospital readmission (adjusted RR 0.46 (95% CI, 0.30–0.71)) compared to the non-MidMed group. However, this benefit did not extend to first hospital admissions (adjusted OR 1.10 (95% CI, 0.72–1.69)). MidMed was also associated with higher primary care usage (adjusted RR 1.52 (95%CI, 1.30-1.75)) and better continuity of care compared to the non-MidMed group. A cross-sectional survey was conducted using questionnaire methodology to investigate patient and GP perception of care delivered by MidMed. Patients taking part in MidMed and GPs working at Newbattle Medical Group were asked to complete a survey at two separate time intervals: one before the start of MidMed; the second 16 months later. MidMed has led to a perception of improved care related to the core attributes of primary care, in particular, access, continuity and patient-centred care. Overall, patients and GPs who completed the survey welcomed MidMed and both report high levels of satisfaction. These findings add to those from previous studies showing that GP-led CGA-like interventions for frailty are positively evaluated by patients and GPs but may or may not lead to an overall reduction in healthcare resource use. It must be noted there were several limitations to both studies, and findings would be more enhanced with the use of a matched control group. However, the results do have value for the Midlothian Health and Social Care Partnership as they can inform plans for service redesign for this group of patients who have high health and social care use and may have considerable unmet need. Analysis is now needed over a longer period. The evaluation would benefit from measuring patient-related outcomes and consideration given to its cost-effectiveness.