摘要:

In the last decade the concept of geriatric evaluation and management (GEM) has been widely discussed in the literature. Studies of GEM have occurred primarily in three settings: inpatient units, outpatient clinics, and specialized types of home care. We have reviewed the literature, focusing on randomized trials, to determine the strength of the evidence for the efficacy of these interventions. Two single‐site randomized controlled trials of inpatient GEM units have been conducted and indicate that such units that provide care to targeted disabled older patients probably have a favorable impact on subsequent physical function, rates of institutionalization, and mortality. Two randomized trials of inpatient GEM consultation teams have been conducted. The trial that did not target high‐risk individuals showed no benefit while the trial that did target an at‐risk group showed that those receiving the service had improvements in mental status and short‐term mortality. The results of randomized trials of outpatient GEM clinics to date have been unimpressive. Two trials of in‐home GEM by a trained observer tended to show that the service resulted in a reduction in mortalityTo date randomized trials of GEM have been very heterogeneous in terms of the type of assessment and subsequent care, the site in which services are delivered, and the manner in which patients are selected for the studies. This limits the ability to compare and extrapolate across studies. In the future there is a need to better clarify the selection of study participants, the exact structure of the assessment intervention provided, and the elements of successful interventions that may be most critical to insuring a goo

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb05926.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

摘要:

Comprehensive geriatric assessment is a technique for multidimensional diagnosis of frail elderly people with the purpose of planning and/or delivering medical, psychosocial, and rehabilitative care. When comprehensive geriatric assessment is coupled with some therapy, then the term geriatric evaluation and management (GEM) will be used. Following a brief history of comprehensive geriatric assessment, we describe the varied patterns of GEM program organization and review the literature of studies examining GEM effectiveness. Program diversity complicates drawing firm conclusions about GEM effects; however, the vast majority of studies report positive, if not uniformly significant, results. Our analysis suggests that much of the variability in findings is due to sample size limitationsIn order to reach conclusions of program effects across studies and to avoid problems of small sample sizes, we undertook a formal meta‐analysis. In this initial meta‐analysis, we sought to evaluate the effect of GEM programs on a single outcome: mortality. We pooled all published GEM controlled trials into four major groups: inpatient consultation services, inpatient GEM units, home assessment services, and outpatient GEM programs. Meta‐analysis of 6‐month mortality demonstrates a 39% reduction of mortality for inpatient consultation services (odds ratio 0.61, 95% confidence interval 0.46–0.81, P = 0.0008) and a 37% reduction of mortality for inpatient GEM units (odds ratio 0.63, 95% CI 0.42–0.93, P = 0.02). Home assessment services reduced mortality by 29% (odds ratio 0.71, 95% CI 0.55–0.90, P = 0.005). On the other hand, no significant survival effect was found for outpatient GEM programs (odds ratio 0.96, 95% confidence interval 0.61–1.49). Further use of meta‐analytic techniques should be employed to clarify the effect of GEM on other important outcomes (eg, functional status, use of hospitals and nursing homes) as well as to identify program characteristics most effective in achievi

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb05927.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb05928.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

摘要:

A multi‐site randomized controlled trial could most conclusively establish the efficacy of geriatric evaluation and management units, but many questions must be answered to design such a trial. First, the research questions needs to be rigorously specified. This will facilitate decisions concerning the types of patients to be included in the study. Second, the intervention requires a clear definition, including its component parts, to improve replication across multiple sites. Third, the type of randomization (ie, by hospital or by patient) and the timing of randomization (ie, at admission or at some later point during care) need to be considered. Fourth, because this type of intervention cannot be administered in a blind fashion, bias is a critical concern. Outcome measures must be selected carefully so that those least susceptible to bias are given the highest priority. Despite the need to address all of these questions, the time is upon us to conduct a multi‐site trial of geriatric evaluation and management progr

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb05929.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

摘要:

Researchers generally agree that Geriatric Evaluation and Management (GEM) Units are effective only when they are targeted at a specific group of frail, elderly patients who are most likely to benefit. Such patients are those who are neither too sick (eg, severely demented or moribund) nor too well. Various strategies for identifying such patients have been employed by investigators with little consensus on the most efficient targeting criteria. Criteria most often used for inclusion in GEM programs are various combinations of patient age, degree of functional impairment, presence of geriatric conditions (eg falls, incontinence, confusion), particular diagnostic conditions (eg, multiple disorders), and psychosocial conditions (eg, living alone, recent bereavement, low income). Commonly used exclusion factors are severe dementia, inevitable nursing home placement, and terminal illness. Outcome studies suggest that beneficial effects of GEM care are most apparent when patients are selected using specific clinical criteria. Future research on targeting should address the potential need for differing criteria in different settings (eg, inpatient vs outpatient GEM units), simplifications of criteria for greatest ease of application, and prospective evaluation of which criteria best predict functional improvement, longer survival, and reduced health care expenditures in response to GEM care.

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb05930.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb05931.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

摘要:

To maximize the cost effectiveness of geriatric evaluation and management (GEM) programs, criteria need to be established for selecting patients most likely to benefit. A working group was convened to define appropriate patient selection (targeting) criteria for each type of GEM program and to consider research questions for future targeting studies. The group outlined targeting criteria for the spectrum of GEM program types and locations. GEM program types included: inpatient GEM units; hospital geriatric consultation services; GEM programs in nursing homes; outpatient GEM programs for functionally impaired persons; and geriatric community outreach/screening programs for functionally independent elders. For each program type, the group outlined targeting criteria based on current literature and experience.Because research has not yet established the effectiveness of many of these patient targeting strategies, the group drafted a set of research questions, pertinent to targeting, that require attention: (1) For each identifiable population of elderly people, who are most likely to benefit from GEM? (2) How should these people best be identified/targeted? (3) What criteria should be used for targeting? (4) How and how often should population screening be performed to identify persons in need of GEM?

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb05932.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

摘要:

Methods of conducting comprehensive geriatric evaluation and management (GEM) are proliferating in a variety of clinical settings. However, rigorous evaluations of efficacy for this new approach to care of older patients have demonstrated a favorable impact on patient outcome in only a few studies. All of these have been controlled single site studies, and replication is needed. If replication studies show similar results, further studies should be undertaken to define the minimum necessary intervention to achieve the desired outcome.Controlled trials are needed to determine if consultative geriatric evaluation and/or primary patient management is effective. Further innovative work is needed in model development for geriatric assessment and management in outpatient settings. Finally, studies of geriatric evaluation and management in other environments, such as home care or the nursing home, are recommended.

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb05933.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

摘要:

Methodological issues relating to multi‐site studies of inpatient geriatric evaluation and management units were the focus of this working group's deliberations. The group favored a randomized clinical trial in which the inpatient geriatric evaluation and management unit was coupled with outpatient geriatric care. Inclusion of a broad spectrum of patients stratified according to risk for poor hospital outcomes was proposed in order to obtain information on the types of patients that would be most likely to benefit. The need for a detailed definition and description of care in the unit and of “usual care” was emphasized. Serious concerns were raised about including both VA medical centers and private hospitals in the same trial due to differences in the implementation of such a program. Furthermore, fears of contamination of the control group suggested that hospitals could be randomized either to provide usual care or have a GEM unit. However, this strategy would necessitate that hospitals that have already developed inpatient GEM units would be excluded from the trial and could be costly because of the number of hospitals that would be req

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb05934.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

摘要:

Issues related to measuring outcomes of care in geriatric evaluation and management (GEM) units were identified by the outcomes working group of the GEM evaluation conference. GEM units have as a major goal the improvement or maintenance of both physical and psychosocial function. Suggested outcome measures for physical health included survival, restricted activity days, general health perceptions, comprehensive physical function, and miscellaneous specific types of functioning. In the area of psycho‐social function, the working group suggested measuring cognitive function, affect/life satisfaction, social function, and satisfaction with care. The patient's caregiver (eg, spouse or child) is often an important target of GEM care, and the group suggested measuring caregiver burden, life satisfaction, and assessment of patient behavior problems.While the primary goal of GEM units is to improve health status, their effects on the utilization and cost of health care are important to decisions about wide‐spread implementation and funding. The group therefore suggested a comprehensive assessment of these outcomes. Among the large array of recommended outcomes, the most important were thought to be mortality, function, and c

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb05935.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY