Cost-Effectiveness of Comprehensive Geriatric Assessment Adapted to Primary Care.

OBJECTIVES: To estimate the cost-effectiveness of a pragmatic trial of comprehensive geriatric assessment adapted to primary care, compared with care as usual. DESIGN: Within-trial cost-effectiveness study of a prospective controlled multicenter trial. SETTING AND PARTICIPANTS: Nineteen primary care practices in Sweden. The original trial included 1304 individuals aged ≥75 years at high risk of hospitalization selected using a prediction model. From the original trial, 369 individuals participated in the cost-effectiveness analysis, 185 in the intervention group and 184 in the control group. Mean age was 83.9 years and 57% of the participants were men. METHODS: We obtained health care costs from administrative registries. Community costs and health-related quality of life data were obtained from a questionnaire sent to participants. Health-related quality of life was measured using EQ-5D-3L and quality-adjusted life years were calculated. We analyzed all outcomes according to intention to treat, and adjusted them to age, gender, and risk score (risk of hospitalization in the next 12 months). The primary outcome was the incremental cost-effectiveness ratio associated with the intervention at follow-up after 24 months. RESULTS: The difference in total cost (incremental cost) between intervention and control groups was USD -11,275 (95% CI -407 to -22,142). The incremental effect in quality-adjusted life years was -0.05 (95% CI -0.17 to 0.08). In the cost-effectiveness plane that illustrates the uncertainty of the analysis, 77.9 of the observations were within the south-east quadrant, implying lower cost and greater effect in the intervention group. CONCLUSIONS AND IMPLICATIONS: The results suggests that a primary care comprehensive geriatric assessment intervention delivered to older adults at high risk of hospitalization is cost-effective at follow-up after 24 months. The use of a prediction model to select participants and an intervention with a low cost is promising but requires further study.

Costs and effects of comprehensive geriatric assessment in primary care for older adults with high risk for hospitalisation.

BACKGROUND: The healthcare system needs effective strategies to identify the most vulnerable group of older patients, assess their needs and plan their care proactively. To evaluate the effectiveness of comprehensive geriatric assessment (CGA) of older adults with a high risk of hospitalisation we conducted a prospective, pragmatic, matched-control multicentre trial at 19 primary care practices in Sweden. METHODS: We identified 1604 individuals aged 75 years and older using a new, validated algorithm that calculates a risk score for hospitalisation from electronic medical records. After a nine-month run-in period for CGA in the intervention group, 74% of the available 646 participants had accepted and received CGA, and 662 participants remained in the control group. Participants at intervention practices were invited to CGA performed by a nurse together with a physician. The CGA was adapted to the primary care context. The participants thereafter received actions according to individual needs during a two-year follow-up period. Participants at control practices received care as usual. The primary outcome was hospital care days. Secondary outcomes were number of hospital care episodes, number of outpatient visits, health care costs and mortality. Outcomes were analysed according to intention to treat and adjusted for age, gender and risk score. We used generalised linear mixed models to compare the intervention group and control group regarding all outcomes. RESULTS: Mean age was 83.2 years, 51% of the 1308 participants were female. Relative risk reduction for hospital care days was - 22% (- 35% to - 4%, p = 0.02) during the two-year follow-up. Relative risk reduction for hospital care episodes was - 17% (- 30% to - 2%, p = 0.03). There were no significant differences in outpatient visits or mortality. Health care costs were significantly lower in the intervention group, adjusted mean difference was € - 4324 (€ - 7962 to - 686, p = 0.02). CONCLUSIONS AND RELEVANCE: Our findings indicate that CGA in primary care can reduce the need for hospital care days in a high-risk population of older adults. This could be of great importance in order to manage increasing prevalence of frailty and multimorbidity. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT03180606 , first posted 08/06/2017.

Staff experiences of a new tool for comprehensive geriatric assessment in primary care (PASTEL): a focus group study.

Objective: Comprehensive geriatric assessment (CGA) is recommended for the management of frailty. Little is known about professionals' experiences of CGA; therefore we wanted to investigate the experiences of staff in primary care using a new CGA tool: the Primary care Assessment Tool for Elderly (PASTEL).Design: Focus group interviews. Manifest qualitative content analysis.Setting: Nine primary health care centres in Sweden that participated in a CGA intervention. These centres represent urban as well as rural areas.Subjects: Nine nurses, five GPs and one pharmacist were divided into three focus groups.Main outcome measures: Participants' experiences of conducting CGA with PASTEL.Results: The analysis resulted in four main categories. A valuable tool for selected patients: The participants considered the assessment tool to be feasible and valuable. They stated that having enough time for the assessment interview was essential but views about the ideal patient for assessment were divided. Creating conditions for dialogue: The process of adapting the assessment to the individual and create conditions for dialogue was recognised as important. Managing in-depth conversations: In-depth conversations turned out to be an important component of the assessment. Patients were eager to share their stories, but talking about the future or the end of life was demanding. The winding road of actions and teamwork: PASTEL was regarded as a good preparation tool for care planning and a means of support for identifying appropriate actions to manage frailty but there were challenges to implement these actions and to obtain good teamwork.Conclusion: The participants reported that PASTEL, a tool for CGA, gave a holistic picture of the older person and was helpful in care planning.Key pointsTo manage frailty using comprehensive geriatric assessment (CGA) in primary care, there is a need for tools that are efficient, user-friendly and which support patient involvement and teamwork•This study found that the Primary care Assessment tool for Elderly (PASTEL) is regarded as both valuable and feasible by primary care professionals•Use of carefully selected items in the tool and allowing enough time for dialogue may enhance patient-centeredness•The PASTEL tool supports the process of identifying actions to manage frailty in older adults. Teamwork related to the tool and CGA in primary care needs to be further investigated and developed.

Accuracy of the Cognitive Assessment Battery in a Primary Care Population.

BACKGROUND: There are several cognitive assessment tools used in primary care, e.g., the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment. The Cognitive Assessment Battery (CAB) was introduced as a sensitive tool to detect cognitive decline in primary care. However, primary care validation is lacking. Therefore, we investigated the accuracy of the CAB in a primary care population. OBJECTIVE: To investigate the accuracy of the CAB in a primary care population. METHODS: Data from 46 individuals with cognitive impairment and 33 individuals who visited the primary care with somatic noncognitive symptoms were analyzed. They were investigated with the MMSE, the CAB, and a battery of neuropsychological tests; they also underwent consultation with a geriatric specialist. The accuracy of the CAB was assessed using c-statistics and the area under the receiver operating characteristic curve (AUC) was used to quantify the binary outcomes ("no cognitive impairment" or "cognitive impairment"). RESULTS: The "cognitive impairment" group was significantly different from the unimpaired group for all the subtests of the CAB. When accuracy was based on binary significant reduction or not in one or several domains of the CAB, the AUC varied between 0.685 and 0.772. However, when a summation or logistic regression of several subcategories was performed, using the numerical values for each subcategory, the AUC was >0.9. For comparison, the AUC for the MMSE was 0.849. CONCLUSIONS: The accuracy of the CAB in a primary care population is poor to good when using binary cutoffs. Accuracy can be improved to high when using a summation or logistic regression of the numerical data of the subcategories. Considering CAB time, lack of adequate age norms, and a good accuracy for the MMSE, implementation of the CAB in primary care is not recommended at present based on the results of this study.

Proactive healthcare for frail elderly persons: study protocol for a prospective controlled primary care intervention in Sweden.

INTRODUCTION: The provision of healthcare services is not dedicated to promoting maintenance of function and does not target frail older persons at high risk of the main causes of morbidity and mortality. The aim of this study is to evaluate the effects of a proactive medical and social intervention in comparison with conventional care on a group of persons aged 75 and older selected by statistical prediction. METHODS AND ANALYSIS: In a pragmatic multicentre primary care setting (n=1600), a prediction model to find elderly (75+) persons at high risk of complex medical care or hospitalisation is used, followed by proactive medical and social care, in comparison with usual care. The study started in April 2017 with a run-in period until December 2017, followed by a 2-year continued intervention phase that will continue until the end of December 2019. The intervention includes several tools (multiprofessional team for rehabilitation, social support, medical care home visits and telephone support). Primary outcome measures are healthcare cost, number of hospital care episodes, hospital care days and mortality. Secondary outcome measures are number of outpatient visits, cost of social care and informal care, number of prescribed drugs, health-related quality of life, cost-effectiveness, sense of security, functional status and ability. We also study the care of elderly persons in a broader sense, by covering the perspectives of the patients, the professional staff and the management, and on a political level, by using semistructured interviews, qualitative methods and a questionnaire. ETHICS AND DISSEMINATION: Approved by the regional ethical review board in Linköping (Dnr 2016/347-31). The results will be presented in scientific journals and scientific meetings during 2019-2022 and are planned to be used for the development of future care models. TRIAL REGISTRATION NUMBER: NCT03180606.

Direct Costs of Very Old Persons with Subsyndromal Depression: A 5-Year Prospective Study.

OBJECTIVES: This study aimed to compare, over a 5-year period, the prospective direct healthcare costs and service utilization of persons with subsyndromal depression (SSD) and non-depressive persons (ND), in a population of very old persons. A second aim was to develop a model that predicts direct healthcare costs in very old persons with SSD. DESIGN AND SETTING: A prospective population-based study was undertaken on 85-year-old persons in Sweden. MEASUREMENTS: Depressiveness was screened with the Geriatric Depression Scale at baseline and at 1-year follow-up, and the results were classified into ND, SSD, and syndromal depression. Data on individual healthcare costs and service use from a 5-year period were derived from national database registers. Direct costs were compared between categories using Mann-Whitney U tests, and a prediction model was identified with linear regression. RESULTS: For persons with SSD, the direct healthcare costs per month of survival exceeded those of persons with ND by a ratio 1.45 (€634 versus €436), a difference that was significant even after controlling for somatic multimorbidity. The final regression model consisted of five independent variables predicting direct healthcare costs: male sex, activities of daily living functions, loneliness, presence of SSD, and somatic multimorbidity. CONCLUSIONS: SSD among very old persons is associated with increased direct healthcare costs independently of somatic multimorbidity. The associations between SSD, somatic multimorbidity, and healthcare costs in the very old need to be analyzed further in order to better guide allocation of resources in health policy.

Cognitive impairment and its consequences in everyday life: experiences of people with mild cognitive impairment or mild dementia and their relatives.

BACKGROUND: The aim of this study was to explore experiences of cognitive impairment, its consequences in everyday life and need for support in people with mild cognitive impairment (MCI) or mild dementia and their relatives. METHODS: A qualitative approach with an explorative design with interviews was chosen. The participants included five people with MCI and eight people with mild dementia and their relatives. All participants were recruited at a geriatric memory clinic in Sweden. The Grounded Theory method was used. RESULTS: The following categories emerged: noticing cognitive changes; changed activity patterns; coping strategies; uncertainty about own ability and environmental reactions; support in everyday life; support from the healthcare system; consequences in everyday life for relatives; and support for relatives. The main findings were that people with MCI and dementia experienced cognitive changes that could be burdensome and changed activity patterns. Most of them, however, considered themselves capable of coping on their own. The relatives noticed cognitive changes and activity disruptions to a greater extent and tried to be supportive in everyday life. Degree of awareness varied and lack of awareness could lead to many problems in everyday life. CONCLUSIONS: Perceived cognitive impairment and its consequences in everyday life were individual and differed among people with MCI or dementia and their relatives. Thus, healthcare professionals must listen to both people with cognitive impairment and their relatives for optimal individual care planning. Support such as education groups and day care could be more tailored towards the early stages of dementia.

Neurological assessment and its relationship to CSF biomarkers in amateur boxers.

BACKGROUND: Mild traumatic brain injury (TBI) or concussion is common in many sports. Today, neuropsychological evaluation is recommended in the monitoring of a concussion and in return-to-play considerations. To investigate the sensitivity of neuropsychological assessment, we tested amateur boxers post bout and compared with controls. Further the relationship between neuropsychological test results and brain injury biomarkers in the cerebrospinal fluid (CSF) were investigated. METHOD: Thirty amateur boxers on high elite level with a minimum of 45 bouts and 25 non-boxing matched controls were included. Memory tests (Rey Osterrieth Complex Figure, Listening Span, Digit Span, Controlled Word Association Test, and computerized testing of episodic memory), tests of processing speed and executive functions (Trail Making, Reaction Time, and Finger Tapping) were performed and related to previously published CSF biomarker results for the axonal injury marker neurofilament light (NFL). RESULTS: The neurological assessment showed no significant differences between boxers and controls, although elevated CSF NFL, as a sign of axonal injury, was detected in about 80% of the boxers 1-6 days post bout. The investigation of the relationship between neuropsychological evaluation and CSF NFL concentrations revealed that boxers with persisting NFL concentration elevation after at least 14 days resting time post bout, had a significantly poorer performance on Trail Making A (p = 0.041) and Simple Reaction Time (p = 0.042) compared to other boxers. CONCLUSION: This is the first study showing traumatic axonal brain injury can be present without measureable cognitive impairment. The repetitive, subconcussive head trauma in amateur boxing causes axonal injury that can be detected with analysis of CSF NFL, but is not sufficient to produce impairment in memory tests, tests of processing speed, or executive functions. The association of prolonged CSF NFL increase in boxers with impairment of processing speed is an interesting observation, which needs to be verified in larger studies.