Correspondence
A Controlled Trial of Geriatric Evaluation
N Engl J Med 2002; 347:371-373August 1, 2002
- Article
To the Editor:
On the basis of a trial that showed little effect of geriatric evaluation and management, Cohen et al. (March 21 issue)1 conclude that earlier studies might have overestimated the benefits of this type of geriatric care.2 This conclusion is premature. The blinding of geriatric teams meant that inpatient care and outpatient care were artificially separated, rather than integrated. The outpatient component was of low intensity and could have consisted of a single follow-up visit. The population was selected on the grounds of frailty, rather than on the basis of the presence of modifiable risk factors, and most of the patients were men. Finally, the validity of the Medical Outcomes Study 36-item Short-Form General Health Survey questionnaire for assessing the functional status in frail elderly people is questionable.3
The results of the study by Cohen et al. should not be interpreted as invalidating the results of previous trials that demonstrated substantial benefits of geriatric assessment.4 Geriatric assessment programs are complex, multifaceted interventions that have been implemented differently in different settings. Heterogeneous results are to be expected. The challenge is to determine which components of the intervention are effective and what populations are most likely to benefit. A recent analysis of trials of home visits that aim to prevent functional decline indicates that programs with multidimensional assessments and follow-up do work, particularly if they are offered to older persons with relatively good function at base line.5 A similar analysis of the trials of geriatric evaluation and management is now required.
5 ReferencesAndreas E. Stuck, M.D.
Spital Bern Ziegler, CH-3001 Bern, Switzerland
andreas.stuck@spitalbern. ch Matthias Egger, M.D.
University of Bern, CH-3012 Bern, SwitzerlandJohn C. Beck, M.D.
University of California School of Medicine, Los Angeles, CA 90024-16871
Cohen HJ ,Feussner JR ,Weinberger M , et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med 2002;346:905-912
Full Text | Web of Science | Medline2
Campion EW . Specialized care for elderly patients. N Engl J Med 2002;346:874-874
Full Text | Web of Science | Medline3
Reuben DB ,Valle LA ,Hays RD ,Siu AL . Measuring physical function in community-dwelling older persons: a comparison of self-administered, interviewer-administered, and performance-based measures. J Am Geriatr Soc 1995;43:17-23
Web of Science | Medline4
Stuck AE ,Siu AL ,Wieland GD ,Adams J ,Rubenstein LZ . Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993;342:1032-1036
CrossRef | Web of Science | Medline5
Stuck AE ,Egger M ,Hammer A ,Minder CE ,Beck JC . Home visits to prevent nursing home admission and functional decline in elderly people: systematic review and meta-regression analysis. JAMA 2002;287:1022-1028
CrossRef | Web of Science | Medline
To the Editor:
The discouraging findings reported by Cohen et al. set the stage for a debate concerning the interpretation of the results and their implications for future geriatric programs. Over the course of the nearly 20 years since the introduction of the principles of geriatric evaluation and management,1 usual care may have become more and more like the programs of geriatric evaluation and management described in earlier studies. In the Veterans Affairs system, there have been many formal interventions to improve the quality of care, and the hospitals participating in the trial were selected because of established programs and a record of good geriatric care.
Such general improvement could indicate that the geriatrics mission has been accomplished, at least in these Veterans Affairs hospitals. However, efficacy of the geriatric evaluation and management approach as compared with that of internal medicine or other medical specialties remains untested.2 There are reports of continued and consistent advantages for patients who receive care through programs of geriatric evaluation and management.3,4 On the basis of a recent analysis, home-based programs for the elderly appear to reduce the rates of functional decline, nursing home admissions, and mortality.5
5 ReferencesRoberto Bernabei, M.D.
Giovanni Gambassi, M.D.
Pierugo Carbonin, M.D.
Università Cattolica Sacro Cuore, 00168 Rome, Italy
giovanni_gambassi@rm.unicatt. it 1
Rubenstein LZ ,Josephson KR ,Wieland GD ,English PA ,Sayre JA ,Kane RL . Effectiveness of a geriatric evaluation unit: a randomized clinical trial. N Engl J Med 1984;311:1664-1670
Full Text | Web of Science | Medline2
Rubenstein LZ, Wieland D, Bernabei R, eds. Geriatric assessment technology: the state of the art. Milan, Italy: Kurtis, 1995.
3
Trentini M, Semeraro S, Motta M, Italian Study Group for Geriatric Assessment and Management
Medline4
Bernabei R ,Landi F ,Gambassi G , et al. Randomised trial of impact model of integrated care and case management for older people living in the community. BMJ 1998;316:1348-1351
CrossRef | Web of Science | Medline5
Stuck AE ,Egger M ,Hammer A ,Minder CE ,Beck JC . Home visits to prevent nursing home admission and functional decline in elderly people: systematic review and meta-regression analysis. JAMA 2002;287:1022-1028
CrossRef | Web of Science | Medline
To the Editor:
The results of the trial by Cohen et al. must be interpreted with caution. Only 3 percent of all screened patients were enrolled in the study, 98 percent of them were men, and the mean age was 74.2 years. In our similarly designed study with 545 participants, the mean age was 81.4 years, and 73.4 percent of our patients were women. The functional status of study participants was similar in the two trials, but in our study the interventions were more effective.1 A subgroup of our patients with severe functional impairment (Barthel score, ≤65 points) benefited most in terms of prevention of rehospitalization or nursing home placement. Compliance with treatment recommendations was a crucial issue with respect to the effectiveness of our intervention. The rate of compliance was higher among women than among men (P=0.04). Although the incidence of disability seems to be similar among men and women,2 the effects of an intervention are not necessarily the same.
2 ReferencesThorsten Nikolaus, M.D.
Clemens Becker, M.D.
Bethesda Geriatric Clinic, D-89073 Ulm, Germany
thorsten.nikolaus@medizin. uni-ulm. de 1
Nikolaus T ,Specht-Leible N ,Bach M ,Oster P ,Schlierf G . A randomized trial of comprehensive geriatric assessment and home intervention in the care of hospitalized patients. Age Ageing 1999;28:543-550
CrossRef | Web of Science | Medline2
Boult C ,Kane RL ,Louis TA ,Boult L ,McCaffey D . Chronic conditions that lead to functional limitation in the elderly. J Gerontol 1994;49:M28-M36
Medline
To the Editor:
In the study by Cohen et al., 3 percent of screened patients chose to enroll and 4 percent refused to enroll or did not have a telephone. Perhaps the authors could comment on whether volunteer bias could have affected their results. The eligible patients who declined enrollment presumably were aware that refusal of consent would result in a greater likelihood of admission to the inpatient unit for geriatric evaluation and management than the 50 percent chance provided by this randomized trial.
John Meuleman, M.D.
Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL 32608
john.meuleman@med. va. gov Author/Editor Response
The authors reply:
To the Editor: In response to the remarks of Stuck et al. regarding our conclusions, the greatest difference between our trial and previous trials in geriatric evaluation and management units was in the effects on survival. We concluded that although methodologic issues may have been involved, it is also possible that usual care has evolved (as Bernabei et al. suggest) so that the difference between such care and that provided by geriatric evaluation and management programs has been reduced. The mortality rate of 20 percent with usual care was considerably lower than that in the earlier studies.1,2 We believe that geriatric evaluation and management units provide a substantial benefit in reducing in-hospital functional decline and that the magnitude of the effect of outpatient geriatric evaluation and management is similar to that of the effects seen in most previous studies.2 Although blinding may have affected planning before discharge, there was ample communication between the inpatient and outpatient teams (whose staff often overlapped), so it is unlikely that blinding would have had much of an effect in the long term. There is no reason to suspect that the outpatient programs were of lower intensity than other programs. Patients in all groups averaged between one and two outpatient visits per month. Frailty has been the basis for the selection of patients in most previous studies of geriatric evaluation and management, and we targeted patients with the use of similar generally accepted criteria. We agree with Stuck et al. as well as Bernabei et al. that there may be other types of programs that might be effective and other target groups and outcomes that might be affected. We hope that they will be evaluated in rigorous trials in the future.
The study that Drs. Nikolaus and Becker describe tested a different intervention3 — direct admission to a geriatric center for assessment, in combination with in-home intervention. Their trial demonstrated efficacy in reducing the length of stay in the hospital and the rate of immediate placement in a nursing home. However, as in our trial, there was no difference in survival, and no difference in overall functional status, although the number of activities of daily living for which they were dependent on others was reduced. Their patients also had higher self-ratings of health. As we noted, theirs is an approach worthy of further study.
As Dr. Meuleman suggests, volunteer bias can affect any clinical trial, but there was no indication that a desire to ensure admission to the unit had an influence. If anything, patients more often refused because they did not want to risk having to remain in the hospital longer.
Current programs of geriatric evaluation and management should not have to justify themselves on the basis of a survival advantage. For frail elderly persons, maintenance of the quality of life and functional status are at least as important, and such programs do appear to improve function.
3 ReferencesHarvey Jay Cohen, M.D.
Morris Weinberger, Ph.D.
Veterans Affairs Medical Center, Durham, NC 27705John R. Feussner, M.D.
Veterans Affairs Central Office, Washington, DC 204201
Rubenstein LZ ,Josephson KR ,Wieland GD ,English PA ,Sayre JA ,Kane RL . Effectiveness of a geriatric evaluation unit: a randomized clinical trial. N Engl J Med 1984;311:1664-1670
Full Text | Web of Science | Medline2
Stuck AE ,Siu AL ,Wieland GD ,Adams J ,Rubenstein LZ . Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993;342:1032-1036
CrossRef | Web of Science | Medline3
Nikolaus T ,Specht-Leible N ,Bach M ,Oster P ,Schlierf G . A randomized trial of comprehensive geriatric assessment and home intervention in the care of hospitalized patients. Age Ageing 1999;28:543-550
CrossRef | Web of Science | Medline
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