|
The impact of a geriatrics evaluation and management unit compared to standard care in a community teaching hospital |
Stewart M, Suchak N, Scheve A, Popat-Thakkar V, David E, Laquinte J, Gloth F M |
|
|
Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology The use of an acute inpatient geriatrics unit, that is, a geriatric evaluation and management (GEM) unit, for the care of frail elderly patients. The GEM unit was staffed by an interdisciplinary team consisting of a physician's assistant, a social worker, and a group of nurses and nursing assistants skilled in the care of the frail elderly. A geriatrician oversaw the GEM unit.
Economic study type Cost-effectiveness analysis.
Study population The study population comprised patients older than 75 years who required acute care. If patients were older than 75 years but younger than 85 years, other criteria were required:
multiple co-morbid conditions;
living alone, or with only a functionally impaired spouse in the community;
incontinence;
polypharmacy (more than 6 medications);
albumin level less than 3 g/dL;
mental status change, dementia, or a Mini-Mental State Examination score of less than 25;
anticipated self-care or mobility problems;
depression;
functional impairment;
Stage II or greater pressure sore;
history of falls;
recent decline in function;
suspected substance abuse; and
negligence.
Patients who were fully independent or terminally ill were excluded.
Setting The setting was a hospital. The economic study was carried out in the USA.
Dates to which data relate The dates during which the effectiveness and resource use data was gathered were not reported. The price year was not reported.
Source of effectiveness data The effectiveness evidence was derived from a single study.
Link between effectiveness and cost data The costing was carried out prospectively on the same sample of patients as that used in the effectiveness study.
Study sample Power calculations were not reported. A nurse supervisor and the admitting house officer, who were not involved in the study, determined eligibility. An overall sample of 61 eligible patients was identified. There were 34 patients in the GEM group and 27 patients in the control group. The mean age was 86 years in the GEM group and 82 years in the control group. It was not stated whether some patients refused to participate or were excluded from the study sample for any reason.
Study design This was a prospective cohort study that was carried out at a community-teaching hospital, the Union Memorial Hospital in Baltimore, Maryland. The patients were allocated to the study groups on the basis of bed availability. Randomisation was attempted, but it was not feasible because of the lack of control over bed availability in the busy hospital setting. Variability in care was minimised by using only two of four physician medical admitting teams. The patients were followed until hospital discharge. No patient was lost to the follow-up assessment. The outcome assessment was based on data collected by trained interviewers who were not involved in patient care.
Analysis of effectiveness All of the patients included in the initial study sample were accounted for in the analysis of the clinical study. The outcomes estimated were the length of stay (LOS) and change in the number of medications. The study groups were comparable at baseline in terms of age, gender distribution and serological parameters. However, GEM patients had a significantly greater number of co-morbid conditions and a greater use of medications than control patients.
Effectiveness results The LOS was 6 (+/- 0.9) days in the GEM group and 7.1 (+/- 1.06) days in the control group, (p=0.06). This trend in LOS reduction was achieved despite greater baseline co-morbidity in the GEM group.
The number of medications at discharge decreased in the GEM group by one medication, but increased by two in the control group (p<0.001).
Clinical conclusions The effectiveness study showed that, compared with control patients, there was a significant reduction in the number of medications used by GEM patients and also a non significant trend towards shorter hospital stay.
Measure of benefits used in the economic analysis The health outcomes were left disaggregated and no summary benefit measure was used in the economic evaluation. In effect, a cost-consequences analysis was carried out.
Direct costs Discounting was not relevant since the costs were incurred during a 1-year timeframe. The unit costs were not presented separately from the quantities of resources used. The health services included in the economic evaluation were hospitalisation, room, emergency room, operative room and recovery room, laboratory and pathology, radiology and EKG, pharmacy, medical-surgical supplies and blood transfusions. The cost/resource boundary of the study was not reported. The costs were estimated on the basis of charges derived from the hospital billing records. Resource use data came from the sample of patients included in the clinical study and referred to the year post-admission. The price year was not reported.
Statistical analysis of costs The costs were presented as mean values with standard errors. Statistical analyses were carried out to test the statistical significance of differences in the costs.
Indirect Costs The indirect costs were not included in the economic evaluation.
Sensitivity analysis Sensitivity analyses were not performed.
Estimated benefits used in the economic analysis See the 'Effectiveness Results' section.
Cost results The total costs were $6,223 (+/- 765) in the GEM group and $10,042 (+/- 1,308) in the control group, (p<0.01).
Pharmacy charges were $407 (+/- 78) in the GEM group and $877 (+/- 210) in the control group, (p<0.02).
The costs for medical-surgical supplies (including blood transfusions) were $303 (+/- 75) in the GEM group and $1,672 (+/- 588) in the control group, (p=0.005).
Other categories of costs did not differ between the groups.
Synthesis of costs and benefits A synthesis of the costs and benefits was not relevant since a cost-consequences analysis was performed.
Authors' conclusions Acute inpatient geriatrics units, such as geriatrics evaluation and management (GEM) units, used to target more frail and older patients led to cost-savings and reductions in medications in comparison with standard care.
CRD COMMENTARY - Selection of comparators The selection of the comparator was appropriate as it reflected the standard approach for the management of frail senior patients. You should decide whether this is a valid comparator in your own setting.
Validity of estimate of measure of effectiveness The effectiveness evidence came from a prospective cohort study. The authors attempted to carry out a clinical trial but randomisation was not feasible because of bed restrictions. Therefore, the impact of selection bias and confounding factors could not be completely ruled out. The study groups were quite comparable at baseline, although GEM patients were significantly in more severe condition (greater co-morbidity). This disfavoured the intervention patients. A relatively small sample of patients was enrolled and no evidence about the appropriateness of the sample size was provided. Trained interviewers, who did not participate in patient management, collected all the data. However, no blinding was used. The outcomes used in the analysis estimated the indirect impact of the interventions on the patients' health. The use of measures more directly related to health would have been useful. These issues tend to limit the internal validity of the study. The authors noted that caution is required when interpreting the clinical results of the study over the long-term, because follow-up data were not estimated.
Validity of estimate of measure of benefit No summary benefit measure was used in the analysis because a cost-consequences analysis was conducted. Please refer to the comments above in the 'Validity of estimate of measure of effectiveness' field.
Validity of estimate of costs The perspective adopted in the study was not reported and charges were used as a proxy for the costs. A cost-to-charge was not applied. Statistical analyses of the costs were performed for cost comparisons, but the cost estimates were specific to the study setting. No sensitivity analyses were carried out. The choice of the time horizon was appropriate for capturing all relevant resources. The source of the data was reported. A detailed breakdown of the cost items was not provided and no information on the quantities of resources used and unit costs was given. Similarly, the price year was not given, which reduces the possibility of replicating the study and performing reflation exercises in other settings.
Other issues The authors stated that their findings confirmed the results of studies that had shown improvements in drug regimens. However, other studies reported either shorter or longer LOS. The authors discussed some of the possible explanations for the differences between their conclusions and the findings of other studies. The issue of the generalisability of the study results to other settings was not addressed and sensitivity analyses were not performed. This reduces the external validity of the study. The authors noted some limitations to the validity of their analysis, which were mainly associated with the small sample size and the lack of long-term clinical data.
Implications of the study The study results supported the use of GEM for the management of frail older patients requiring acute care. The authors noted that their findings justify larger randomised trials in community-hospital settings.
Bibliographic details Stewart M, Suchak N, Scheve A, Popat-Thakkar V, David E, Laquinte J, Gloth F M. The impact of a geriatrics evaluation and management unit compared to standard care in a community teaching hospital. Maryland Medical Journal 1999; 48(2): 62-67 Other publications of related interest Nikolaus T, et al. A randomised trial of comprehensive geriatric assessment and home intervention in the case of hospitalised patients. Age and Ageing 1999;28:543-50.
Indexing Status Subject indexing assigned by NLM MeSH Aged; Aged, 80 and over; Cost-Benefit Analysis; Frail Elderly; Geriatric Assessment; Hospital Charges; Hospital Units /economics /organization & Humans; Length of Stay; Maryland; Prospective Studies; administration AccessionNumber 22001006134 Date bibliographic record published 30/06/2005 Date abstract record published 30/06/2005 |
|
|
|